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HomeMy WebLinkAbout008-1028-20-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety a ~ Building Division +~ ~ INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 'ermit Holder's Name: City Village X Township Pedersen, Eau Galle, Town of ;ST BM Elev: Insp. BM Elev: BM Description: t SANK INFORMATIONINFORMATION _ J,X'p, ',l', I' E NATION DATA 7 .4~ TYPE MANUFACTURER. r CAPACITY Septic ~ 1 ~~- ']:,~ / .~ CJ ~ ~ AJ ~ Dosing ~ d nJ~ ~ ~ T 95~ / J Aec2l+eF, I V ~ L. J'`- Pa i a~ C~ ~/ t c> Holding TANK SETBACK INFORMATION -TANK TO P/ So~~-~ WELL BLDG. Vent to Air Intake ROAD Septic ~7 ~35~ /5b~ /50' Dosing , ,.~ ~ / ~7~! / W ~~/ ~s~ / '_' Aeration Holding PUMP/SIPHON INFORMATION ~~ Manufacturer r~, o ~/oJ~ S Demand GPM Model Number ~~ ~~ ~,~ 1 TDH L~f~ p~J, '' Friction; os~ . System Head T~ r ~~ Forcemain Length / Z ~}~ Dia. i/ L Dist. to Well /?~ ~ V Coll ARC(lRPT1f1A1 SYCTFM county: St. Croix Sanitary Permit No: 506171 0 State Plan ID No: Parcel Tax No: 008-1028-20-000 Section/Town/Range/Map No: 10.28.16.1420 STATION / B~ . / I, FS ~ L~EV.C Benchma ~ / ~ ~~~ ` Alt. B ~~ ~-OJ ~ . ~~~?/~ Bldg. Sewer ~ . Z'~ 99~, 8!v SUHt Inlet I~. I / ~ I ~~ SUHt Outlet ~ Dt Inlet ~ ~„ Dt Bottom /~' S ~C r~ Header/Man. ' el~ ~ ~ , Dist. Pipe ' q~ !! /~~ ` Bot. S stem f,,7 ` ./ ,~q~, Ce.~ Final Grade ~f Id ( iaz . St Cover 1~ / v C~ ems... Q ~ ~ ~.y 2 ~irwL 3. ( z . 7 Boa . ~ BED/TRENCH Width / Length 1 No. Of Trenc PIT DIMENSIONS No. Of Pits ~ Inside Dia. Liquid Depth DIMENSIONS ~~ "7f ~P \ ~ ~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer. ~ CHAMBER OR INFORMATION Type Of~y tem: ~ ~ ~~~ / /"\_ UNIT Model Number: ~~ IIiCTDIR11T1~1A1 CVCTGI-A ~~ .LI Header/Manifold 1 J) Distribution ~ ~~ - , , ~ x Hole Size .1 x Hole Spacing ~ ~ Ve o Air I ke / Z ~ Pipe(s) 7Z /6 ~ ZS 3 4 th Dia ~ S acin L `I~ a$ J Length _ Dia p g eng Cnll rn\/FR ., o.-.,~~.,.e c.,~re..,~ n.,i., w Mniinrl nr Ot-C;rade Systems Only . 1 Depth Over (~ Bed/Trench Cent ~ / Depth Over ~ Bed/Trench Edges ~ xx Depth of ,~ 1 Topsoil ~ J'1 xx Seeded/Sodded Yes No xx Mulched Yes ~ No ' ~ + I ~l Q , 'Ly~lf /~ 3~ ~, //.]~ COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:. / /__ Location: 491 Cty Rd BB Woodville, WI 54028 (NW 1/4 NW 1/4 10 T28N R16W) NA Lot Parcel N/o~ 10.28.16.1420 1.) Alt BM Description = / ! Ov~...~aw~ 2.) Bldg sewer length = t ~ ~ G~,4,~,"S 6 ~. ~~~ ~\~ ~~~ - amount of cover = ~ / ~ a~ Plan revision Required? 'Yes '~""~ No Use other side for additional information. SBD-6710 (R.3/97) ~-~ s~.~ 7 3 ~ b7 _ ,~ ~o ~ Date Insepctor's nature Cert. No. / commert:e.Wi.gov Safety and Buildings Division County ~ ~ Gf ~ ~ w 201 W. Washington Ave., P.O. Box 7162 : at seo ns ~ n Madison, WI 53707-7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce d (p ~ '~ Sanitary Permit Application State Transaction Number !n aceordance with s. Comm. 83.21(2). Wis. Adm. Code, submission of this form to the appropn mental ~ Z Z 3 a5 ~ _ unit is required prior to obtaining a sanitary permit. Note: Application forms for st -owned TS Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be for se ry u ses in accordance with the Privac Law, s. 15.04(1)(m), Stats. ~ 7 ~ 2 / rc7 1. A lication Information - Plca 'nt All Information Property Owners Name ~ Parcel # `` d ~ D ~~ Z ~ "~ C-CJ Property Owner's Mailing Address Property Location ~- ~, i~z ~- OUNTY Y91 ~. B~ Govt. Lot City, St t Zip Code hone Ntunber ~- ~ ~ /a, ., Section ~ ~/ + ` 1 circle o N; R ~ E o~W T ~ II. Type of Building (check all that apply) Lot # _ ' ` E ~1 or2 FamilyDweling--Nun~herofBedroon7s Xt5 ~n f~---- _....... Subdivision Name _ _._ Block # - ^ Public/C'ommercial - Describe l(se ~ ^ City Of ^ State Owned - Dcscrilx Gsr CSM Number ^ Village of ~ ^ Town of ~ ~e /0 X 7 to O ,~ n. III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ^ New System Replacement System ^ TreatmenVHolding Tank Replacement Only ^ Other Modification to Existing System (explain) B. ^ Permit Renewal ^ Permit Revision ^ Change of Plumber ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. T e of POWTS S stem/Com onent/Device: Check all that a I ~ ^'' ov ^ Non-Pressurized In-Ground ^ Pressurized In-Ground ^ At-Glade ^ Mound > 24 in. ofsuitable soil Mound < 24 in. of suitable soil ^ Holding Tank ^ Other Dispersal Companent (explain) ^ Pretreatment Device (explain) V. Dis ersal/I'reatment Area information: a ~ Desi n Flow (gpd) Design Soil Application Rat~pdsf) ~ Dispersal Area Required t) Disp rsal Area Prop d (sl) z System Eleva[ian g 7/, r0 7~ 0 a zsa zo5 /01. YI. Tank Info Capacity in Total # of / /~ an[ytacjurer/r~ ) L ~L F" ' ~ ° Gallons Gallons Units / e L~ / / t 6 ~ t? , ~ y New Tanks Existing Tanks ((( ~! ~ (IWl ~ ~ n. U r? `s in H to ,15' = w C7 R n, Septic or Holding Tank ~ ~ 1 X Dosing Chamber ~ T / V1I. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plu ber's Name (Prin Plumber's Signature RS Number M P u Bu ~'~ lw` ~~ ~ ~~ Plum is dress (St eet, City, t .Zip Cod ~ r---- ~ ~ ~.~ ~ 61~ ~~~ f v ~ Vli .Coon /De artment Use Onl Approved ^ D~ P - Permit Fee Date Issued Issuing A t Signature $ `"' ~ OD ' 5 ~ ~7 ^ O. even Reason for Denial " IX. Conditions of Ap rovaUReasons for Disapproval 3\ 61 5 5d.'e~ SYSTEM t~WNER J ~ Q ebQ 1. Septic. tank, ef}IueM filter and n,- ~~~ `~~ dispersal ceH must all be services /maintained (f • as per management plan provided by plumber. n ~ t ~~~ ~rja--q.~,~ ~~~ f ~ ~~ ~ ~ `~~ L '~ o,~,e 2. All setback tequirerYtents mtast be maintained ' ° °a F+p WM4il!!M!=tbtlbtRpl2tt~{1ldNS~he system and submit to the County only on paper not tens than a trz x t t mcnes m size SBD-6393 (R. Oll07) Valid thru 01/09 ei+~wf.~-1 Safety and Buildings Division County m ` 201 W. Washington Ave., P.O. Box 7162 I ~~O~~, ~ Madison, WI 53707 - 7162 Sanitary Permit Number (to be flied in by CoJ i (608) 266-3151 Department of Commerce Sanitary Permit Application State Plan LD. Num er In accord with Comm 83.21, Wis. Adm. Code, personal information you provide may be used for secondary purposes Privav`y I~w, s15.04(Ixm) Project Add (if different than mailing address) I. Application Information -Please Print A11'Inforttihfion " .s° Property Owner's Name ~' ~ Parce Lot # Block # Property Owner's Mailing ress perry Location Section '~• ~~' City, State Zip Code Phone Number > ~ (circle one) T N; R E or W e of Building (check all th apply) T II yp . Subdivision Name CSM Number ^ 1 or 2 Family Dwelling - Number of B rooms De c ibe Use (C i l bli ^ P ommero a - s r c u ^ State Owned -Describe Use ^City ^Village ^Township of III. Type of Permit: (Check only one box o line A. Complete Tine B if appli ble) A' ^ New System ^ Replacement Syste ^ Treatment/I-Iolding Tank eplacement Only ^ Other Modification to Existing System B. ^ Permit Renewal ^ Permit Revision Change of Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration P tuber weer IV. T e of POWTS S stem: Check all that a ^ Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soi ^ nand < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized Io-Ground ^ Holding Tank Peat Filter ^ Aerobic Treatment Unit ^ Reciroulating Sand Filter ^ Recirculatin S thetic Media Filter ^ Leaching Chamber ^ Dri Ia ^ Gravel-less Pipe ^ Outer (explain) V. Dis `rsa!/Trea meat Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Di rsal Area equired (sf) Dispersal Area Proposed (sf) System Elevation VI. Tank nfo Capacity in Total Num er M ufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of its Concrete Constntcted Glass Na+x Existing Tanks Tanks Septio or Hokding Tank Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the as igaed, assume responsibility for in e P WTS shown on the attached plans. Plumber's Name (Pent)„ Plu bar's Signature M Basin ~,P1hone Num P umber's Address (Street, City, S e, p Code t ~~ t /~~~ S U risf VIII. Coun /De artmen roved ^ A ^ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued issuing Agent Signature (No Stamps) pp Surcharge Fee) ^ Owner Given Reason for Denial IX. Conditions of Approval/Reasons for Disapproval .. ..r Attach tOmplete pram tro me wunry onryr nor ~~ sya~cm w pnpcr uua .cas w~...aa.~., ...+ .wr•~a ••, ..r.~,.. 't7: ita '.t " `' SBD-6398 (R. 01/03) 1 1 0 a~ _u ~ ,~ -o ~~ ~ ~~ ~ ;~~p.~ h 1b i\ ~ ~~~ L ~~ `4 ~ h ~ o Z, ° ~ c~, a 4. '" ~ 9 ~, ~. } -~ ~ ~~ ~c ~ .~ •'3 s . e ~ d s ~. +` O J ~ t 4 ~w ~ Lt !!AA "4 c ~, .r ~~ ~. ~ ~ ~ ~"'V ~~ ~4 3 ~ ~ ° ~ ~ ~' ~ ~ ~ ~; ~ ~ ~ ~ - Q . ~ ~ ~ '= ~ t ry~ I '`~ ` ~ ~ ~ ~ s O~ ~ Y 6 ~ `{.. ~ ~ ~ I a ~M s ~ ' \~c i ~~ ~'~ o I r ~ S S L ~ ~ ~: f. ~ c,y ~= ,; ~, ~ l t ~'- OL s " `i ` '~ e F p- U '~ i ~ ` ~ `~ i f ~~ ~ V ~ ~ ~ `` ~ ~ -~ ~ ~ o ~ r. <~ ~ ~~~~ ~ o~~ uT~_S ~ -L~ mob ~- ~~ ~~ 2 ~~" 1 ~. i J /\ s~ Y +O O ~ ~ '~ 1' ~ ~ o ~y 0 0 ~ ~. ~v ~ (7 ~ ~ ~ .u s ~ i` ~ ~ \ _I c "\ ~~ `~~~i ~ ~' ~" ~ ,~ ~V~ ~F ~~ b 4 ~ e max. ~ ~ ~ o ~ yt '~~ ~-j> „r $ e v v s M 5 er i ~ ,~ ~ ~ .~ V T Cj ~ ~~ ~ ~ \ ~ h ~ ~~ ~~ `~ ~ `O ~ ~ ~~ 'jl .~ ~ ~"~ ~ ~ ~~ ~ a I~ Q ~o /~ ~-~ rY~~ ~d G~/p~.L 4J ~ ~ CS ~~ ,~ O~ '."p -~M ~"(' ~(7 Ly n r} ' ~, / _f~J~ LJC ~tl -~- p ~~,~ ~~ S' a "'~ ,; z "w,1 ~ ` o ` ~~ ;,~ q ~. F '~ _ ~o _ ~ ~ ~ ~ ~ ~ ~ ti e~ ~ ~~ ~~ °\ ~ ~ ~ ~~ ~ ' ' t ~ ~ ~ ~ c~ b ~ ~, ,p~ S C I}f O ~ ~J ~ 6 ~ ~J I (I V ~ ~ 0 ~ ~ J ~ t ~ ~ ~ \ r 1 '~ ~ ~ ~? 4 y,, ~~ ~~ .~ r 0 ~ ~,^ ~ ~ ~i w a ~ w ' ~ p ~ "\~ i t~ _S o ~ ~~ G ~~ ,~' e~ w ~- C.~ `9 ~ ~ ~~ c Z \ ~ [3 ~ ~ ` ~ y ~ t ~~ ~ r ~` _s~ ~ e ~` ~, _ ~ ~~ _ ~ ~; '~- ~' - ~ o 'i, 'g ~ ~ Y ~ ~. 4 ~ r u 1 - k ~ ~ ~~~ - '~ ~ ~~ ~„ ;r x ~./ ~ 4 `S V ~~ ~ a o: ° ~ ~~ ., • Wi~rconsinl)epartmentofCommerce OIL EVALUATION REPORT Division of Safety and Buildings in accord wit i Attach complete site plan on paper not less than 8 1/2 x inche inGude, but not limited to: vertical and horizontal reference ~ t percent slope, scale or dimensions, north arrow, and location a Please print all information. Personal informatlon you provide may be used for secondary purposes (P~ Property Owner ,p ~i I~I~ f ~? ~~1-~ ? ~: Property Owners Mailing Address 4:. ~/ ~ City State Zip Code Phone Number must and o 'ounty S'}• Parcel .D. ~ ~ Q Revie ed by Page ~ of Coo rX Date I /ZIL~/5 Law.~T*S'Dd't"r~m7Q I~/o d4'Yi;`~~ I t~f L i.? ~®e~..v I (%/`~ ~~U `C-~f f {.,l ~I A$ Govt. Lot N y,/ 1/4 P/tAf 114 S /Od T ~ ~ N R /{ W ~-4or Lot # Block # Subd. Name or CSM# ^ City ^ Village Town Nearest Road ~'aw Ga llc -_. ~ c R _ _ gB ^ New Construction User Residential / Number of bedrooms ' ~ Code derived design flow rate ~ 7.~0 GPD Replacement ^ Public orcommercial -Describe: Parent material w~~t a • ~ f T"; /,~ Flood Plain elevatioon if applicable /~'~ _ `'• General comments - ~ 'u < : e., ~4.~4~ p ~ ~ ~ ~/ ~ ~~` p'~r~r. y~ ~ z~,. s t~.~. ~,- ~~, ~~ ~.. I ~ tiU«se ,s 3d~.-~. and recommendations: ,~~-~ ~~, ~ AGW F~ ~~ ~, //~,,, ~u~ t'' wow, ~ ~.~~ ahs~~ory . Boring Boring # '~~ ~ Pit Ground surface elev. ft. a' Depth to limiting factor in. oil A ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots G P D/fP- in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eft#2 ~ rJ- - /D ~v ~R 3l3 -°- s T ,l ~ ,,, r ;. ~ ~ H S ~' h. C~_ 6 ~• 8 3 ~ ~-~a fC) ~d? .S-!S ~c~ ~,~,~~Sf$ ~• ~~ ~ ~. m a/, ~ h, ~ ~' C w ~ ~ f. 4 f~- I / 1 ~'~. r~ ' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L 'Effluent #2 = BOD < 3t7 mg/L and i 55 < su ~c CST Name (Please Printj Signature CST Number Ch a~-%r•f ~.€'"e6~r li~Cs~ ~ /~/ ~.~J 673 Address ,, ,r p .Date Eval/nation Conduded_ - Telephone Number t:" f ~ ~T. ~ ~ ~`~ t ` :? "`_,~' L~~[SGV o r7~'h r1F' ~ .~'~ f7 f / I ~ / .' ~'J ~ ~l.s'..2~ S'-,5 ~ 3 p Boring # ~ Boring ~~. ~ `~ Pit Ground surface elev. ~ ft. Depth to limiting factor / Soil A lication Rate Horizon Oepth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munseil Qu: Sz. Cont. Color Gr. Sz: Sh. 'Eff#1 `Eff#2 .. ~6-.~~. ,~~~~ s~'~ -~~d ~ s ~-~ ~~~ ~ c 1 ~ ~, a dK ~, ~'~ C ~ z ~' ~. ~' o. ~' ~~-`~ ~ 7s~~e ~~6 ~ ~ 7r s~f .~ ~ ,~ ~ a6K ~ ~'w -- - a . ~ ~. 3 Property Owner ~ ~" ~~-~~v1 ~'~ Boring # ~ Boring Parcel ID # p ~ ~ -~~~~ ~ ~p ~~~ Page ~ of - ~ ~l Pit ~rouna surrace elev. - 6 n. uepin to umlung 7ac:wr 6 v 111• Soil A lication Rate Horizon Depth Dominant Color Redox Oesaiption Texture Structure Consistence Boundary Roots GPD/ff'- in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Effn 2 / p ~- t ~-^, ~%=~ Zre- ~ 611` 6~~j ~S C/i J ~ ~4 ~ ~ LtiC~ C Le q! ^ro ~n_ O" GL 7, t'). '~ ~ ~ .-~a~ ~ ~ ~T ~D C»+ ~ F ~ / S ~ ~-' '><-k ct `j u.-c. odd s /r cif- J~- c~ sn c !`n a~ ~~r ~` Boring # 0 Boring _~ U Pit ~rouna surrace elev. n. veprn ro uminng racwr m. Soil A IicaGon Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fiz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Effm2 Boring # ~ Boring U Pit VI VUI IU JUI Iai;G GIGV. Il. VGFJII I lV IIII Illll IIJ. IOI.IVI ~• .,. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Effn2 -. 'Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ''Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or 'need material in an alterriate format, please contact the department at 608-266-3151 or TTY 668-264-8777: SDD-8330 (R.07/00) f ~ s>;r ~:r~.. ~ C /3 ~ .B ~~ ~~ `~ D Q ra ,~ ~ ~ n ~ ~~ ~ ~ ~ ~ Y ~ ~ $ ~ A ~ s ~ ~' ='1 ~ =' ~' t 1. ~' r ~ ~ a ~ :\. ~ ~ ~ = t ~ 7) y ~ : ^ ~. ~., v. ; ', ~, ~+ \ 2 o ~ '+! \ ~+ ~ ~ ~ ^ ~ n ~' ~4 1 Y ^ { ~O ~ ~b 1 3 o ~ , ~ ~ o ~ ~ ~ ~, ~, ° .~ , ~, G 0 ~ ' T ~ ~ ~ 4 , ~~ b ~ f 0 c,~ ~ S o C~ gas '~P 3 =, ;~ ~ ~ ~i ~. k pew °~ q s~6~~ 0 F Z ~ i ,, ~ ~ ~ ~ 0 ppvi^ N~ fl. j Q a; ~ Q -r+ ^}.. -P 0 ti S i I r 0 r y n e 0 "b r- ~" S C h`~ ~, " F 0 A `• ~ ~. .~ r N ~` ~~ ~ v T F A `^ ~~ ~ ~ ~ ~ `~, n ~ ~j a ~ ~'',~ ~ ~ ~ ^ ~ ' S Q (Tt y. W l~ ~J --}---~ z commerce.wi.gov isconsin Department of Commerce Safety and Buildings PO BOX 7162 MADISON WI 53707-7162 TDD #: (608) 264-8777 www. commerce.wi.gov/sb/ www.wisconsin.gov Jim Doyle, Governor Mary P. Burke, Secretary December 19, 2005 OUST ID No. 220673 CHARLES L WEBSTER WEBSTER EXCAVATING, INC. N5815 770TH ST ELLSWORTH WI 54011 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 12/19/2007 SITE: Tim Pederson -Dwelling 491 CR BB Town of Eau Galle, 54028 St Croix County NW1/4, NWl/4, S10, T28N, R16W ATTN: POWTS Inspector ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 Identification Numbers Transaction ID No. 1223057 Site ID No. 708338 Please refer to both identification numbers, above, in all cones ondence with the a enc . FOR: Description: Replacement Mound System / 750 gpd Object Type: POWTS Component Manual Regulated Object ID No.: 1055776 Maintenance required; Replacement system; 750 GPD Flow rate; 16 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual -Version 2.0, SBD-10691-P (N.O1/O1), Pressure Distribution Component Manual -Version 2.0, SBD-10706-P (N.O1/Ol); Biofilter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: P•~. Conde --~ This system is to be constructed and located in accordance with the approved plans and with the component manuals listed above. DE A copy of the approved plans, specifications and this letter shall be on-site during construction and open to D1bIS ~ 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. SEE CQ(ZR~ In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence maybe made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. CHARLES L WEBSTER Sincere . ~/ eter E Pagel Private Sewage Pl Reviewer ,Integrated Services (608)266-2889 , M - F, 0630 - 1500 Hrs pepagel@commerce. state. wi.us Page 2 12/19/2005 Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 WiSMART code: 7633 cc: Leroy G Jansky, Wastewater Specialist, (715) 726-2544 Webster Soil Testing Ft Sewer System Design Charlie St Kris Webster, owners N5815 770`h Street, Ellsworth, WI 54011 Telephone: (715) 273-3430 Fax: (715) 273-4181 WI Licenses: MP220673, ST220673, ST 261669, PE1880,~,~CE'VE~ POWTS Indez Sheet ~~G 1 6 2005 Page ly~~.~, & B~pGS o!V Mound System fora 5 Bedroom Residence Property Owner/Project Name: Tim Pederson NW'/ NW'/, S10 T28 N R 16W Town of Eau Galle, St. Croix County, WI Contents Pa ge 1 of 8 Index Sheet Pa ge 2 of 8 Plo_n Pag e 3 of 8 Plan View Cross Section Pag e 4 of 8 Distribution Pine Layout Pag e 5 of 8 Punning Chamber Layout Pag T e 6 of 8 ~ w w ..~ Pumu Performance Curve I' GiARLES l.. ~_ "~'~'` WEBSTEfl = ~ E-18803 i ~ ~ :~ ELLSWOR7M ~ ~ WIS. '~ 2- S, '•... .. a~ ,~~ ~• s~'o N A~r•E~~~iy`. ,,•~ r911~'C/~' ~.~,lt Comaonent manual used• Name: Mound Component Manual for POWTS Version: 2.0 SBD-10691-P Date: January 30, 2001 Name: Pressure Distribution Manual for POWTS Version: 2.0 SBD 10706-P Date: January 30, 2001 ~f ~~~ ~~ T,s ~~a~y r - f /dn View CraS' s Sec •f'for1 Approved Synthetic Covering ~-s~-v~ G 33 Distribution. Pipe Medium Sand _ Topsoil ~ H _ _ G .--„= -_ F Elev ~' y O L- -J I E ~~ ~ D 3 ~ u - b . ~ % ,Slope Bed Of ? 2 2 Force Main Plowed Aggregate From Pump Layer COh.towh. E.,~= /D~ l E 1. g 7. Ft ~ zz ~~a:p.~ Cross Section Of A `Mound System Using . ~' F a ~- Ft. ~ 9 r~~:h~ . A Bed For The Absorption Area G h .~ Ft . A ~~ Ft. H 1-O Ft. Linear- Loading Rate= 9. 9 GPD/LN FT 6 ~ ~ .~Ft. Design Loading Rate=®.3fGPD/SQ FT j ~ ~ ~ Ft. J~Ft. K '! a,. Ft . r c fim- c e.. I'-~ ~ ~K / h'e~ i I w ..: 8. Ft ~-~~-s~ ~ ~ ~ Observation .Pipe tl ~ ~- g ~ K ~---- - - --- --- - - - --- - - r - l s I ------ - ~ ------ --- ---- ---~--_•~ A - ~ ~ --------- ~ - ------------------.i w ~;_ i ~ ---- ------ -- ~ ~ -- -- -- -~$to~0istribution Bed Of 2~- 2:2 c_ Pipe A re ate I ~b B f`3 lltea.~ f S~ 99 9 Observation Pipe ~' ,a``~S8°w"'t~ (aachbz securely) ~S~e~r,~-GC~o _@~ p,~pe /° Pte. da~`di/S"{~eC't, ,~ 6Gs'e4 y,~t:~~. ~.~oc,~' to l2~(/e. ~'~:~,k..,a vrid/.,efL~. a, ~ ~~HGh@s 6e Prvyl~al~.d wi 7'~+ of w~tL'.- l~~~f co11b/ 111~/C T/iC b.~'.o~, ~ii~G~~' S/o ~E al $` f ~. ~ "! c 4., d SC 6.. p,,.,, /~~ ~h 1'a1~ T~''l / ~~ L~' ~Q.s'L~N Perforated Pipe Oetoil l1 Eod Yiew ~erforoted ~VG Pipe ( / sec o~c'~d:` / ~ jf~ ~ _ J~ l~ • ' 1 ~iStnJUti1 ~ / Pig! /~ ~ ` ~ J ~ See ,~~.~ dcfid~~ a' ~_=a ~ ~.~ Holes Locoted On Botlom, I-re Eeauollr Spoced P ~~ Ft. ~O ri~G~• Distribution Pipe, layout S 3 Ft. tl` ~ hc~ l~ .,s /,,,i~i^z s o_4/~~,,~ ~? ~"= e, ,rat X 3~;,r. Inches M~~•:~w« s ri~•ei,~ ~~ Y 3v;~- Inches Hole Diameter ~ Inch Lateral ~ ~~ Inch(es) Manifold oz Inches . Force Main " ~ Inches ~ -" •~ ~ of holes/pipe ~'4' otccesS b.X ~ !a 3 *ti~<<d!d pi4,~ Invert Elevation of Laterals ~ Ft_ ~" /.~ te• j / I P,~os e,? d a/et~•i Place lst hole /~in•' F`o,,, eKd~d;~~;~q;~e1~ with .succeeding holes at ~~'ir;. intervals . ~ ~~ •~ ~ d ~_ ~s /9~h- ~'•-~ e,.d ulE' d.~sf ~,°d ~:.~, c e //. Flo ti~. ~ .sc ~,, p!d ~ ~. ~. TiM ~E'p~ ~sv~l (No Scale) •Approved Locking Manhole Covers With Warning LabelSAttached Weatherproof -y.t.:~/y~,r/c% ~ Junction Box ~~ ~__ ~ Page ~ Of {~ Pj~s r:~ reat P~~v e,~~ jo~~ ~ d %r I<ylke Approved _ Vent Cap r~ -~ 12" Minimum _ ~..~ r I 4 -Minimum Quick l8" Minimum ~ Disconnect - -- ~ t 8.., ~.~.~ ~ 1 /4•' Weep .f~~dk.a~ Ce,va4 ~~` y~0 Baffle ~ i Hole ~ ~ Pafy !g~'s'.t~ ~ Alarm ~ 0 n 6, B t t t B~•~ e C ~-P~ w.'t<-•K~g:~~~ *APPROVED Off ~ ~ /'" ~0'3 off'-coyer t, JOINTS WITH P`°v'°~~°'°~'J APPROVED PIPE p *° P""'~° 3' ONTO Conc. Block SOLID SOIL 3" of Bedding Under Tank -f ' ;d~cL~ ~wn~P ~~/azr.b, n/! se.~a c~hat'l'~ ci y"eia.+'*.S' Number of Doses: ~- 4'Per Day Gallons Per Day/~of•-Dose 1tG3 Gallons Yol ume of Backfl ow:-!~3~.36~+ s~ 7 Gal l ons Tank Manufacturer: ~:~~.- ~'~o~ ~+-~~-~`~-~ Total Dose Yolume:........= l Zs-- Gallons Tank Size-Septic/Pump : ~~`yS SS'o ~ P Ga ons nl arm Manufacturer: .L evelllay~, Model Number: ~ C- y Capacities: A z/ inches or ~"~~ Gallons Switch Type:. rr~¢ / ,~~ ~/ ~ + B ~ inches or so Gal 1 ons Pump Manufacturer: 6~.,.1n/ + C~ 7 inches or / 7„~ Gallons Model Number: P s-/ + D~-inches or .duo Gallons Minimum Discharge ate: ~ 9- Tota1.....= 3 ~ inches or ,sp Gailons vertical Difference Between Pump Off and Distribution Pipe: l2-~ Feet hti nimum Required Supply Pressure:......... ~.-.Q.~!~?~:~~...+ mss- Feet 36'c~ Feet of Force Mai n x /. 37' Friction Factor/100 Feet: + ~. j feet ~. Inch Diameter Force Main Total Dynamic Head:...=~~-Feet Internal Tank Dimensions: Length+~~/~}'%/n; Width/o~;~.; Liq/uid Depth1~'p° ` ~/4. ~~~ ~ ~'31'~ta ~ij. ~fty..~ C~e~•~b~ C'p~~PG'I '~~~5~~ P/ y - ~ ~~ Submersible Effluent Pump ~,~ ~p~~ PE APPLICATIONS Speaally designed for the following uses: • Mound Systems • Effluent/Dosing Systems • low Pressure Pipe Systems • Basement Draining "~,_. - • Heavy Duty Sump/ Dewatering ~e.~ ate. ~ ~ ~ 9.3''~f,r„ ~ ,~,.~ - ~ ~fi'- METERS FEET 10 Q x V Q r 0 F of SPECIFICATIONS MOTOR FEATURES Pump -General: • Discharge:l'h" NPT • Temperature: 104°F (40°C) maximum, continuous when fully submerged. • Solids handling:'/z" maximum sphere. • Automatic models include a float switch. • Manual models available. • Pumping range: see performance chart or curve. PE31 Pump: • Maximum capacity; 53 GPM • Maximum head: 25` TDH . PE41 Pump: • Maximum capagty: 61 GPM • Maximum head: 29' TDH PE51 Pump: • Maximum capadty: 70 GPM Maximum head: 37` TDH General: • Single phase • 60 Hertz • 115 and 230 volts • Built-in thermal overbad pro- section with automatic reset. • Class 6 insulation. • Oil-filled design. • High strength carbon steel shaft. PE31 Motor. • .33 HP, 3000 RPM • 115 volts • Shaded pole design PE41 Motor. • .40 HP, 3400 RPM • 115 and 230 volts • PSC design. PE51 Motor. • .50 HP, 3400 RPM • 115 and 230 votes • PSC design ~ ~ ~ ~ ~ - i MODELS: PE31, PE41, PE51 ~ - -- 2 GPM ~ :i_ __ r_ ' 1 FT : _ ._ _ ~ --4 ~ .,. , 20 : . 4 ~ ~ -- 15 I i ~ ._ _ _+ ~ I i -r- -i-- }-_ I ~ _ i i - _1- i _ _ _ + 10 ~ - -- - - ~ i , ~!- '--~ -1- ~-._.l ~-. 5 ~ ,-1- - - - ~1-+-t-! - - ~-t- _ -H _ 0 0 1 0 2 0 3 0 4 0 5 0 6 0 7 0 c,PM 80 0 5 10 15 m3/h G4PAQTY ® 2004 ITT Water Technology, Inc. Effective June, 2004 BPE31/41 ^ Corrosion resistant construction. ^ Cast iron body. ^ Thermoplastic impeller and cover. ^ Upper sleeve and lower heavy duty ball bearing conswcdon. ^ Motor is permanently lubricated for extended service life. ^ Powered for continuous operation. ^ All ratings are within the working limits of the motor. ^ Quidc disconnect power cord, 20' standard length, heavy duty 16/3 S1TW with 115 or 230 volt grounding. plug. ^ Complete unit is heavy duty,' portable and compact. r Mechanical seal is carbon, ceramic, BONA and stainless steel. ^Stainless steel fasteners. AGENCY LISTINGS s~® C US Tested to UL 778 and CSA.22Z 108 Standards By ~Il~rl Stdrldild5 ASSOOadOn Fde #LR38549 Goulds Pumps a KO 9001 Registered. Goulds Pumps ~~~' ITT Industries ~; POWTS OWNER'S MANUAL 8c MANAGEMENT PLAN Page ! of FILE INFORMATION owner T ~•r,., ~e a/ ey s c h Permit # DESIGN PARAMETERS Number of Bedrooms ~"' ~ ^ NA Number of Commercial Units NA Estimated flow (average) ..So © aUda Design flow (peak), (Estimated x 1.5) ~,~"fi' al/da Soil Application Rate ~'? ~' aVda /ftiz Influent/Effluent Quality Monthly average' Fats, Oil 8 Grease (FOG) 530 mg/L Biochemical Oxygen Demand (GODS) 5220 mg/L Total Suspended Solids (TSS) 5150 m /L Pretreated Effluent Quality ^ NA Monthly average'* Biochemical Oxygen Demand (BODS) 530 mg/L Total Suspended Solids (TSS) 530 mg/L Fecal Coliform (geometric mean) .510• cfu/100m1 Maximum Effluent Particle Size Y inch diameter SYSTEM SPECIFICATIONS Septic Tank Capacity /-.~'o vr'' al ^ NA Septic Tank Manufacturer fLj~G,- C'o~, ~`~ ^ NA Effluent Filter Manufacturer ~o / f./" ^ NA Effluent Filter Model ,~'~-S` ^ NA -Pump Tank Capacity qS~O al ^ NA Pump Tank Manufacturer cd,~esc~ Co~,ee~?~ ^ NA .Pump Manufacturer ~o.,. / ^ NA Pump Model p~' ,.~'/ ^ NA Pretreatment Unit NA ^ Sand/G,ravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other. Manufacturer Dispersal Cell(s) ^ In-ground (gravity) ^ In~round (pressurized) ^ At-grade ,ilk Mound ^ Dri line ^ Other • Values typical for domestic (non-commerGaQ wast®water and septic tank effluent *• Values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every ^ months (year(s) (Maximum 3 yrs.) Pump out contents of tank(s) When combined sludge and scum equals one-third (X,) of tank volume Inspect dispersal cell(s) At least once every ~ ^ months year(s) (Maximum 3 yrs.) Clean effluent filter At least once every 3 {months . ^ year(s) Inspect pump, pump controls & alarm At least once every ^ months year(s) ^ NA Flush laterals and pressure test At least once every ^ months ^ year(s) ^ NA ~SNedo~ other. At least once every ^ months ^ year(s) ~'NA other. At least once every ^~ months ^ year(s) ~NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer, Septage Servicng Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing c~ndition and requires the immediate notification of the local regulatory authority. When the combined accumulation of ~udge and scum in any tank equals one-third (Y) or more of the tank volume, the entire contents of the tank shall be rerltoved by a Septage Servicing Operator and disposed of in accordance with ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatment components, and any other maintenance or monitoring at intervals of 12 months or less shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event STARTUP AND OPERATION. For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. . M ~ ~ K ~ P/d ~ ~'d>^, 7~;~ P ~ p~~Q.S~'~ .- ~a~ ds ~ ~, ~ h ~ Pfd H - -- Page ~ of System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, .overloading the cell(s) and may result in the backup orsurface discharge of effluent To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or~elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; dgarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications;' oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONM F j,~T ~. •~ When the POWTS faiL~ and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with ch. Comm 83:33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of atl tanks and pits shall be removed and~properly disposed.of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: , O A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing erect proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement-area. Replacement systems must comply with the rules in effect at that time. ^ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ^ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitebie replacement area. I tf no replacement area is available a holding tank may be installed as a last resort to replace the failed POWT ~ ' ,~ Mound and at-grade soil absorption systems maybe reconstructed in pia, following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply wit~t the rules in effect at that time. «wARNtNG» .. 1 SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER AMY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY B~ DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name ~,,, dpi Lr cd~at.9`r'.~- Phone ~'/S - 2~ - 9 ~' S°' POWTS MAINTAINER GL~ tea ~ ~''` Name •Phone SEPTAGE SERVICING OPERATOR PUMPER (~h ~rwa LOCAL REGULATORY AUTHORfTY Name Agency - S'* ~.-o : ~ Co, ~ ~ 2~0~ .,l Phone ~ Phone ?/, j` a 3 ~ 6' - 9- 6' ~' CJ This document was dratted by the staffs 4f the Green Lake, Marquette and Waushara County Zoning and Sanitation agendes. This document meets ;he minimum requirements of ch. Comm 8322{2)(b)(1)(d)b(t) and 83.54(T), (2) ~ (3), Vlrisconsin Administrative Code. Use of this document does not guarantee the performance of the POWTS. GMW (2/01) v01. 1~48PAGE Jc~70 STATE BAR OF WLSCONSIN 1''uKM f - IYYB WARRANTY DEED Document Number This Deed, made between William L . Kitahnsr and Cieo M. Kirchner, husband and wife Grantor, and Timothv R. Pederson and Jennifer L. Pederson, husband and srifo Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in st . Croix County, State of Wisconsin (the "Property"): sea Attached 61159 Y.ATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO. , iiI RECEIVED FOR RECORD 10-0~-2000 11:00 AN MARRAkTY DEED EXEKPT k CERT CORY FEE: COPY FEE: TRP.HSFER FEE: 408.00 RECORD?NG FEE: 12.00 RAGE5: 2 i ~'- Together with all appurtenant rights, title and interests. Name and Retwn Address _ (~ ^ l ~ Lr1~r.11S~~cJ~SC, ~~~'Y~lS1J~V I„1~-~l',~-~qf\/I s-lots-so-ooo 8-1027-95-000 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except easements, roadways and restrictions of record Dated this::,~i.~>'t `- day of *William L. Ki~chne/r *Cleo M. Kirchner AIITHENTICATION Signature(s) authenticated this day of TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stets.) THIS INSTRUMENT WAS DRAFTED BY Michael H ForecXi Attornev Eau Claire Wisconsin (Signatures may be authenticated or acknowledged. Both are not necessary.) ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. St - Croix County P So I came before me this day of the above named William Kitchnrar Cleo M Kitch*+er to me known to be the person who executed the f ing instrument acknowledged the same. r/ * Tra rn Y Notary Public, State of Wisconsin My Co 1 ton is pe ent. If not, state expiration date: Tracy L. Turner aNames of persons signing in any capacity must be typed or printed below [heir signature. JLake "' " "--" STATE BAR OF WISCONSIN WARRANTY DEED FORM No. t-1998 ProduCeO w8n ZipFOrtn ^' by Vertiaan Mlc. 18025 FMeen MYa Roatl, ellMOn Towrvhip, Michigan 48035, (900)383-9905 Attorney MichaN H Foredci I Bl0 Brackett Ave, Eau CSaerc WI 347014627 Plwne' (713) BJS-7029 Fu (713) 83341 t2 ~~~ 1548p~t;E 399 That certain parcel of land located in the Northwest Quarter (NW'/,) of the Northwest Quarter (NW'/,), of Section Ten (10), Township Twenty-eight (28) North, Range Sixteen (16) West, Town of Eau Galle, St. Croix County, Wisconsin, more fully described as follows: Commencing at the Northwest corner of said Section 10, thence S.02°59'54"E., (assumed bearing on the West line of the NW%. of said Section 10) a distance of 361.73 feet to the Point of Beginning, of the parcel to be herein described; thence N.87°32'55"E., 738.22 feet; thence S.02°59'54"E., 413.07 feet; thence 5.87°32'55"W., 738.22 feet; thence N.02°59'54"W., 138.93 feet on the West line of the NW% of said Section 10; thence N.90°00'00"E., 220.30 feet; thence N.02°59'54"W., 226.31 feet; thence N.90°00'00"W., 220.30 feet; thence N.02°59'54"W., 47.83 feet to the point of beginning. AND The South 226 feet of the North 635 feet of the West 220 feet of the Northwest Quarter (NW'/.) of the Northwest Quarter (NW'/.), Section Ten (10), Township Twenty~ight (28) North, Range Sixteen (16) West. For Reference Only: 8-1028-20-000 8-1027-95-000 491 County Road BB Woodville, WI 54028 va. va~va<a vv vi.a a SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owne uyer P~~1e~~ Mailing Address ~~f ~ 1~ Property Address ~ ~(~ ~ /~ ~~Ft ~~ ~ ~ ~LL°~ l~r`.C~ L~i(Gf ea ~ S~ (Verification required from Planning & Zoning Department for new City/State , J~ L~J t t, Parcel Identification Number LEGAL DESCRIPTION p, n J Property Location '/4 , ~~ `/4 ,Sec. ~~ , T ~Ci N R ~~ W, Town of li( V L Subdivision ,Lot # ~ . Certified Survey Map # ,~ ~ ~ C 0 l ,Volume ~~_, Page # Warranty Deed # ,Volume ,Page # Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, 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 Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms ~r Q 6 SIGNATURE OF APPLICANT(S) /~/~~ DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) /~ v~ ,~ a rN~ ti cb ( 3 ~~ c9 ~ o. s pEC 2 61996 JAN ~ 3 1,~~7 ~ ~ ,~~H.w~-S~ ~RgJt~°CA«~ ~l Sl: CROIX COUNTY 553662 ~, ~' ~ ~uRVEYOR'S RECORD c' CERTIFIED SURVEY MAP ROBERT TORGERSON Part of the Northwest 1/4 of the Northwest 1/4 of Section 10, Township 28 North, Range 16 West, Town of Eau Galle, St. Croix County, Wisconsin. NW COR. SEC. / 0, T 28 N , R / 8 W, N //4 CO R. SEC. /O, T 28 N, R / 6W, f BOUNTY SURVEYOR'S MO N.1 UNPLA TTED LAND S /R.~A/Z'RO'AO'SP/KE FOUNDI 1 - N LINE NW//4 N90.00'00"E 2644.90' ~ ' /322,43' a~ b ,/ /322.43' I p-._ ~ /} N 90.00' 00"W /289.37' 'A O i~ IN ~ O ~ N ~._. - - ~ -_ - --- --'-' - - -- - -'-- -- - --M -- d i~^ ~ i Owner's Address: Q Ii bIh I 2358 50Th Ave. v J M ~ Woodville, WI 54028 ~ 4I ~3 ~N ~ Y I I o I ~ rti '^ ~ S 87'32'33"W 738.22' m 3. O' ~ 703.22' ~ y I ~ ~ ~ ~ o J ~` o I V ~ ' - ~ ~ LOT/ ~~ 3 ~~/~~.PLA T-TED LANDS 3 ~ N ' ~ .-y ~-L~..- _ .... 7 N I i -~~°~_--~ ~ 33.073 ACRES a h h /,440, 676 SOFT. ~ W I3g 3 • • 3 /. 239 q CRES EX C. ROAD R. O. W. q O q N ~ p f m I ~ rl / O /, 36/, 629 S0. FT. N „ 4II ~~ ~ 9 2 ~ " 2 0 705.22' ~ 0 QII N 3. 0' 3 I N B7 • 32' 33 " E 73 8.22 ' `,~~t111111/~~~ c~ ,~~ ~0 WII " I ~ ~ ~'s ~ i ~' I , i , . ' :,. II N o Note : ~ '~LAl1REN E': ~ v Q z I^ a I No suitable area fora ~ m ~ ~ MU H~(~ °G ~ J a W se tic system has been found ,;, ~ o ., 3 ~ I a h ~r ~ ,~i~ i s time . = ~ ~` " a .;.~' ~ N ~ E ALLS,,:' Jot r°r ~ r ~ • I ~ ,~ AAL I v~ y ~ o ~'~~ ~ ~ ~7~t~ Laurence W. Murphy I4S 43'I ~ ~ R gistered Land Surveyor -•r- o--yi ~ , i . +"I^+(:tX CQUfITY 3' 1 3 -~--,~-V ~ ~,.o~~;"-;.,i-w?t1StVr~ ~Ic17bf71p73.73' 1 `Sr~eB~'~^ '/9 "W 1320. 79' S L /NE NW //4 N W //4 -fij-~^-f^- N,;::~ ~aa~~n~er.tee T A, REF. COR, FOUND 3'02.33'40"E 8.53' l~, ~ B I s Z' UNPLA /. TED LAJyOS BECAUSE OF LARGE ROCK P/LE Q '` ALL BEAR/NGS REF. 9kYJt.,71NE*4VD741'iNL/NE OFT/,~E o Indicates 1" X 24" iron pipe ® li i o Nw//4 of sEC, /o, r;~a-,11.~~/~~/,.S~ASSUMED weighing 1.13 lbs./lin. ft. ~ m ~ Nso•oo'oo"E ~ set. `' ~ Indicates 1" iron pipe found. ~ ~ 'o ~ ~' SCALE200' '~~~' Indica.tes fenceline_ ~ ~ O 23' 30' /00' 200' 300' 400' 300' 600' ~^ J H ' ~ ~ ~r~ o This instrument drafted by Laurence W. Murphy ~ SHEET 1 OF 2 3 Volume 11 Page 3197