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HomeMy WebLinkAbout012-1013-30-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 552385 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Ni oldt, Lyle J. Erin Prairie, Town of 012-1013-30-000 CST BM Elev: Insp. BM Elev: BM Description: Sectionlrown/Range/Map No: l~ INl 1 n?^ 04.30.17.59 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. ~-fv . 5 /63.5 co A6tts Septic Ad 1Benchmark Dosing GQ~-W6 Pv 1 Al a#., asr S; aQr .-f5- DL 1;6 Bldg. Sewer Aa~ 11' + Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION \ \ TANK TO P/L WELL LD Vent to Air Intake ROAD Dt Inlet \ ~f Septic ! _4 ~ 'F6 45 r_ Dt Bottom -5 T7 xl ~ f 7 Dosing >c~ © / 67 (7 Header/Man. g 9 6 7 ..JCS 7 ~ Aeration Dist. Pipe Holding ~ Bot. System PUMP/SIPHON INFORMATION Final Grade 3 M 7 Manufacturer Demand St Cover y L, l~ a j GPM~~. III 5.7 T7 ' Model Number ~ 11A /CAL /T Ca~~~ r 6.7 4s~ 7 TDH LiftFriction ~os System Head TDHZ Ft Forcemain Length Dia. Z i ffio well 76 SOIL ABSORP.~TII~ON SYSTEM BEDITRENCH Width Length No. Of QTre hes PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 19 7 ` 1_~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of,Jystem: ,1 ) UNIT Model Number: O j &G /v/~' DISTRIBUTIONSYSTEM G`/' 7 Header/Manifold ,I Distribution ! L f x Hole Size ► f x Hole Spacing, Ve/~to Air Intake Pipe(s) I / [rJ Length 4 Dia Length Dia Z Spacing 3 j lD Z u 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 S[ Bed/Trench Edges Topsoil Yes O No Yes ❑ V t'T No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: / / Location: 1760 170th Ave Galt, ichmond, WI 54017 31/4 SE 1/4 4 T30N R17W) 40 acres Parcel No: 04.30.17.59 = 15` L et o0 1. Alt BM Description 2.) Bldg sewer length = No to j~ i f to cover= 0i1 3~ r~ter- !j ,6 - aba.1- L431IJ pt,e.ti o `4'2., Plan revs ' n Required? fl Yes No ( q / L/ her side for additional information. 1D Z / ~ 7 Date ISign a Cert. No. SBD-6710 (R.3/97) commerce.wl. ce, Safety and Buildings Division County r C E60' W. Washington Ave., Y.O. Box 7162 tOPO Madison, WI 5370 7-7 1 62 O 1 i Sanitary Permit Number (to be filled in by Co.) Sauhaa 5 Permit Application State Transaclion Number to accordance with s. Comm. 83.21(2), Wis. Adm 1~Fii6ission of this form to the appropriate governmental 269 unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POW TS are Project A ess iling address e - ta} submitted to the Department of Commerce. Personal information you provide may be used for secondary u ses in accordance with the Priy law, s. 15.04 1 m , Stats. L Application Information - Please Print All Information OLL Alt, Property Owner's~e Parcel # Property Owner's Mai Address Property Location/ 36 16YY Govt. Lot City, State Zip Code Phone Number -r- "f Section / ✓t.(~Ifr V ''11 c cle ~ :For W U. Type of Building (check all that apply) Lot # T G~ - N; R r 2 Family Dwelling- Number of Bedrooms Subdivision Name 6 1# -7 6 Block # r 1 0 E] Public/Commercial - Describe Use 1C~. - ❑ City of _ ❑ State Owned - Describe Use CSM Number ❑ Village of Town of t 0 /eLrP~~I~f ~Qj G M. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System Rep acement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal 11 Permit Revision El Change of Plumber 11 Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. Type of POWTS S stem/Com onent/Device: Check all that apply-4 to - ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil / i ❑ Holding Tank El Other Dispersal Component (explain) _ ❑ Pretreatment Device (explain) /Z V. Dispersal/Treatment Area Informatt - Design Flow (gpd) Design Soil Applic on Rate dsf} TDi Requir (st) Disper Area Propose (st) 5ystem Elevation IV' A/217 VI. Tank Info Capacity in # of Manufacturer Gallons Units o New Tanks Existing Tanks w o & fl U in rim i% C7 0. Septic or Holding Tank Dosing Chamber -Al n ~ - VIL Responsibility Statement- I, the undersigned, ass espoasibility fur installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumb lgnature MP/MPRS Number Business Phone Number q, -7 Ilk Plumber's Address Street, City, State, Zip Code Z Ltd / J I I. oun /De artment Use Only VII Approved isapprov Permit Fee Date Is ed Issuing t Signature IQ o rven Reason for Denial Z~ V Z~ Z IX. ContlilReasons for Disapproval 3 'I. 'peptic tank. efflWWitnfflltet anrt C~ tcet~r- GJ~ t s : . dispersal Ceti must all be ve ! mairdalned as per tnanagtatnent plan provided by plull)ber. I 2: AM"suck regteritents must be,maintaintd 4111 pk, `code/ Attach to complete plans for the system and submit to the County only on paper not less than 8 12 x 11 inches in size ? 6A SBD-6398 (R. 02/09) PLOT PLAN PROJECT Lvle NiDnoldt ADDRESS Site Address of 1760 170th Ave SW 114 SE 1/4S 4 /T 30 N/R 17 W TOWN Erin Prairie COUNTY ST. CROIX SYSTEM ELEVATION 97.0' BEDROOM 3 CONVENTIONAL AT-GRADE CONVENTIONAL LIFT HOLDING TANK MOUND )00( SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 630 HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 456 # of chambers BENCHMARK V.R.P. Top of nail in tree ASSUME ELEVATION 100° Filter BEST GF10-8 ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark 1320' Property Line Scale = 1/4„ = 10, Tank is to be properly bedded and 40 Acre Parcel provided with lockdown covers with approved warning labels Huffcutt Combo Tank 8-1 El 4ree 15' below system is to remain undisturbed 4% Slope 0~. S00' Existing 3 )ld system is to be 4rea 15' below system is Bedroom pumped and buried ko remain undisturbed Ho use 0 'Hell g-2 96.5' 96'5 5.95' rad i ng is to be done to divert run-off sway from system 170th Ave AR I b'IV Safety and Buildings ytit' \ 3824 N CREEKSIDE LA o~ P HOLMEN WI 54636 3 O S K Contact Through Relay P S www.dsps.wi.gov/sb/ www.wisconsin.gov ~0 srorsScott Walker, Governor Dave Ross, Secretary June 21, 2012 CUST ID No. 226900 ATTN: POWTS Inspector SHAUN R BIRD ZONING OFFICE BIRD PLUMBING INC ST CROIX COUNTY SPIA 1432 120TH ST 1101 CARMICHAEL RD NEW RICHMOND WI 54017 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 06/21/2014 Transaction ID No. 2097 IdeD No. 2097 umbers 867 SITE: Site ID No. 780710 Lyle Nippoldt Please refer to both identification numbers, 1760 170TH Ave above, in all correspondence with the agency. Town of Erin Prairie St Croix County SWIA, SETA, S4, T30N, R17W FOR: Description: Three Bedroom Mound System / 4% slope Object Type: POWTS Component Manual Regulated Object ID No.: 1377895 Maintenance required; Replacement system; 450 GPD Flow rate; 32 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual -Version 2.0, SBD-10691-P (N.01/01), Pressure Distribution Component Manual - Version 2.0, SBD-10706-P (N.01/01); Effluent Filter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed P.O.W.T. and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. pndition The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code l~ requirements. pp p RO No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.0 , stats. DIVISION OF FETY AN The following conditions shall be met during construction or installation and prior to occupancy or use: ' Reminders SEE CORRES • A sanitary permit must be obtained from the county where this project is located in accordance with the requirements of See. 145.135 and 145.19, Wis. Stats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. • A state approved effluent filter is required. Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. Access to the filter for cleaning must be provided per SPS 384 product approval conditions. • The area within 15' downslope of the dispersal cell shall remain undisturbed. Vehicular traffic, excavation or soil compaction is prohibited in this area. • All POWTS piping component material shall be SPS 383, Wis. Adm. Code. • The existing POWTS shall be properly abandoned per SPS 383.33, Wis. Adm. Code. • 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. SHAUN R BII2D Page 2 6/21/2012 r Owner Responsibilities • The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and maintenance manual and/or owner's manual for the POWTS described in this approval. • The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. SPS 383.54(1). • In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. • The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Since ely, Fee Required $ 250.00 Fee Received $ 250.00 Balance Due $ 0.00 er M S nn POWTS Plan Reviewer, Integrated Services (608)789-7892, Mon - Fri, 7:15 am - 4:00 pm WiSMART code: 7633 jerry.swim@wisconsin.gov Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Safety & Buildings will be x. modified. Code references with prefixes starting with "Comm" will be replaced with "SPS" to recognize the ;relocation of the Division of Safety & Buildings from the former Dept. of Commerce to the Dept. of Safety & Professional Services. Additionally, all S&B codes will be renumbered and addressed in a "300" series. For future reference, the, Wisconsin Commercial Building Code will be addressed by SPS Chapters 360-366. k SHAUN R BIRD Page 2 6/21/2012 Owner Responsibilities • The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and maintenance manual and/or owner's manual for the POWTS described in this approval. • The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. SPS 383.54(1). • In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. • The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracldng purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise maldng them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 250.00 Fee Received $ 250.00 l Balance Due $ 0.00 k*rmS POWTS Plan Reviewer, Integrated Services (608)789-7892, Mon - Fri, 7:15 am - 4:00 pm WSMART; code: 7633 jerry.swiin@wisconsin.gov Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Safety & Buildings will be rte, modified. Code references with prefixes starting with "Comm" will be replaced with "SPS" to recognize the ',,relocation of the Division of Safety & Buildings from the former Dept. of Commerce to the Dept. of Safety & Professional Services. Additionally, all S&B codes will be renumbered and addressed in a "300" series. For future reference, the Wisconsin Commercial Building Code will be addressed by SPS Chapters 360-366. I r Cover Page CEIVEj JUN 1 1 2012 ;-FTY & BUILDINGS Shaun Bird Bird Plumbing Inc. 1008 192nd Ave New Richmond Wi 54017 715-246-4516 Date: 6/ 7/12 Owner:Lyle Nippoldt Location:SW1 /4 SE1 /4 S4 T30 N,R17 W 1760 170th Ave Erin Prairie System type: Mound System Manuals Used: Mound Component Manual Version 2.0 (01/31) Pressure Distribution Manual Version 2.0 (01/31) Page# 1. Cover Page 2. Mound Plot Plan ally 3. Mound Cross Section ID 4. Pipe Cross Section/Pipe Layout BUILDINGS 5. Pump Chamber Cross Section 6. Pump Curve JDENC.-E~ 7-8. Maintance and Contigency plan 9-12. Soil test 13. Filter Specifications and s section Shaun Bird Signature License number 00 PLOT PLAN PROJECT Lvle NiDnoldt ADDRESS Site Address of 1760 170th Ave SW 1/4 SE 1/4S 4 /T 30 N/R 17 W TOWN Erin Prairie COUNTY ST. CROIX SYSTEM ELEVATION 97.0' BEDROOM 3 CONVENTIONAL AT-GRADE CONVENTIONAL LIFT HOLDING TANK MOUND XXX SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 630 HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 456 # of chambers BENCHMARK V.R.P. Top of nail in tree ASSUME ELEVATION 100° Filter BEST GF10-8 ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark 1320' Property Line Scale = 1/4" = 10' Tank is to be properly bedded and 40 }acre Parcel provided with lockdown covers with approved warning labels Huffcutt Combo Tank ~-1 # rea 15' be I ow system is to remain undisturbed 4% Slope ZON B-3 S00' F.M.* 114 Existing 3 Jid system is to be area 15' below system is Bedroom pumped and buried to remain undisturbed House 0 'He 11 F-2 96' 95.5195' .3rading is to be done to divert run-off sway from system 170th Ave Mound System Cross Section and Plan View J 1 Dimension Feet I a A 1 B T 1 f ~ A ► f D E W 1 f - jjj F 1' 1 1 1 c _ 3 s H 1 1_ c) 1 1 l - - 1 1 K / s K Z L Slo e % =Topsoil = ASTM C-33 1 + sand fill Clean a ggre ate 4 in. sch. 40 pvc Cap Material g 0 = W.`.~ /z to 2 /Z in. dia. observation pipe Geotextile Fabric G ' H Ft D 'E Plow Ft Contour ed Surface Slope Direction GENERAL INSTALLATION: The mound area is staked out along the design contour. Existing vegetation is mowed and raked off the site. The mound basal area (L x w) is plowed with a moldboard or chisel plow. Plowing may not proceed if the soil is wet enough at the plow depth to form a %4 inch soil wire when a sample is rolled between the palms of the hands. ASTM C-33 quality sand is placed immediately after plowing. Sand is placed with a tracked machine keeping 12 or more inches of sand under the tracks or is placed overhead by a backhoe. Special care must be used when placing sand of less than one loot thickness to minimize compaction of the plowed surface. After the topsoil cap is placed, the entire mound is seeded and mulched to promote vegetative growth, limit erosion and protect from freezing. The observation pipes are slotted in the lower b inches and secured in place with rebar or a closet flange. 10/07 lgj Page of . Pressure Lateral Layout Two Laterals - End Manifold 0 Threaded 9 Manifold L`} a Lateral Turn-up G Plu out old g M t X Force Main 1' Long Sweep r 0 ~ Bend iameter In. rF-orceMainn ution Network S ecifications Pressure System Construction Diameter ,4 In. Laterals are constructed of Schedule 40 PVC iameter .6 In. pipe. Orifices are drilled perpendicular to e S acin In. the pipe with a sharp drill bit and face down. l Length) Ft. Lateral turn-pups terminate with a threaded old Lenaflil Ft. cleanout plug and are enclosed in a 6-8 inch in Diameter In. diameter lawn sprinkler valve box accessible in Length Ft, from finished grade. Grade j: 6-8 I nch Lawn Sprinkler Valve Box 031051gj Page ol'_--_- s i Septic-Dose Tank Gross Section And Pump Perf ornance 5peclficati0n, Tank Mane Ptun Matiu r Tank Model Number CJ d Pam Model Number Total Tank Capacity Alarm Manufacfiuror Max. Bury Depth Alarm Modal Mtm ber ~e w Type Filter Manufacturar Total WElevadeft o Head Filta Model (TDH) - Feet Head I7iatal Fs+ass~tu+s• 0 Netwscrh LOSS Minimum Puutp'+ot~ Required itorae Mein Loss aP Ft TDH Total Outlet Manhole 11+itt. 4"Above Grade With Looking mice, Inlet Manbole Manhole Min. 4" Above Grade < 6" Below Sew WdC dOW Securely Mounted With Looking Device •06 Finished Grade rr yunodon Boll - Vent Min. 12" Disconnect Above Grade Means Widii "Want Cap 'a' ira► -33-►{.f,•►a,.,a►f►a.YrY~~1f~ f:a:a~{~ rf'••►1'/~d{►{far ► ►Y s►.4►r♦ra r4 { + Autlct Filter Inlet Wet Baffle 14 a►i► A k'+ Switch S and Reserve Capacity v,~ Tank. Volume QrPi ti.; Weep : B Hole Dimension Inches Volume Gal. (reserve) A.' (alarm B!' 2. (W Elevation C a;r Bottom (dead) D D Elevation Total ~z nG Ft •.'•..<<. a. ••Y •~a a+ ra s•aa aa. a. Y<a. sa. a••a•ia'r'•. r•lai as <a to Yal{a{•+ •aY+ •fY •.f Y•••{~ r'i r'r►rrY'a'i►~ Yf►f{ i r►i V {►►►Y►{►r~l►r►{~r'/►+ YfY'f~/~r'{~r~i'a'a►Yr{~1~Y►i/•►a' Kira►{r•/•►~ 1..a►afa'a~{i►af{►a►a►/f• ~ifafi►Y►vhf►//tfr~Y►{►.►{►a►►ffl'Y'arr a'a'•r•' GENERAL INSTALLATIONS: The septictdow task to bedded =d 'b@* tithe in waorrJance with the manufacturer's product.approval sstpe~ifications3. Maximum. depth of briny as, spociiled. by the manufacturer may not be exceeded without prior Iippraval.. Ma►tilole covers 000eed to Wade have an. a bivve looking device (padlock) installed. Piping at dw inlet and outlet is of approved material, connected to the tank with watwtight fittings, and laid on stable soil to p mVent sting or naffing. The fotre main is slowed 'kuith 4" Sob. 40 PVC to bridge the tank excavation and the.deave. is swded.dwatertiglut. -Electrical:servica eompl* with IEC300 and Comm 16.23. 42/05 Vie. of YP LaserJet 311110; 1 lib =4 rid'!! ~ O rdx-a-llfs d.:Jw rNf k~.. r-r~ N ■ ! r V IL 9EH SERIES SUMPfLP' "iU rw'T' P*UhP ass cc) all Ilr~ aont lla NOW MR it tienii mm aywr a WO o t ~ 4s t+ f 7W Mal tel m tMi ad III MOM 308810 MM Os 280 79 51 56 It 82 13.8 W !1 B.ff ~111BIatb sw ss wou i0 H 55 41 42 1718 ar K 8.h ~us1.aM >1Dt~n<s 50N60 UIMBA 4K0 115 3M Ito fUiID 81 rA 11 9 112.8 IV 111 to I111MSa 1 H fa 41 A2 so SUM WO ~OItl110U81DrhRp~/ ifNh6iedYwaabw~trpualpsiatailWca+f~wauodombo asM S..*Wft'h hp 27 Lit vjjAdmo r1DeMMiDIg8M1Ni.' FLOW- LITtR$fF9MR 1tY o WOO 200O 3000 Motor Ho t' Coated Cast Iron _ImpellerMawlial Poi C'arbof 30 to tin _UIn' CIOtOSI ViigO volute _ +s Power Cor -A ~ao M dmitatl Shall See! Nitrile with oarbon and ceramic fu W keeletiE(s S"tainh t FAMW . 2.3 Shaft . ~l. elpt t Bearmp Upper Simve and lower u o Flap 8aariasR o a0 io 60 No FLOW- GALLONSYNOWTE PUMP PERFORMANCE CURVE OCULFA 1115V 6004 Lltuc abut ft-mo c• ~ ems ftinw pMal~na c11q~, o 'nss► gtWW-Lltt:leQldmtftmp.d vm " raa ~3 tarn ovbass-o~AS i POWTS OwmZR'S MANUAE.. & MANA(;EMVXT PLAN .:I go 8eptbTaerk 0 M p >be 3ftTlu~ric 0 WA. Mmd PIitRAit~'1,1 FB irk s T ati~ V WdotFINr'MW 6F -Owl gwi otcamawdo , UlItts PuttWpTtirMC 63~ p rta 3an 9, PkWenp To* M~Irttt~trolle~+t~r- D NA .,rM w saw (fWWi~irile? /00 . Pu lrhu~t s aA APP9e0e111 fie 0 pump mom lJtdk rcrlluenOfl3Awrrte]Y mono* F t Jk Mr+ease; (Pao sW mgA.. ©ifitr~ !°Atsr ©Peplt raw Ct fUtsatiard AWasOfr ©VY'www IMaedrerreiasl t~iq~}eur Dsrmw (DOW s= mgA_ ❑ Db n 13 Odor_ Prab~rabd ~Itrnt i1tuN lYA OisKs) Q initotmd ovum~ efonHS vftaA GMpn W: wrAnd goo mgJL 0 l C0 ~Ka nd Tobt OAPW dsd SSWII (TIM S~ IUD to OIlMC s1 otW'f 1 moamu a BWJWAPatae $ irralrtftarrre6sr v~ensan~ a s~«~...~.~.~ ayrebtsnrcMeMr~. 1I~Iws" lbromo alNlrrakwMINt I~WM'CENNKCB ~sMc+r fvsnt 91ecv be FMQW t W 3napmtoondoon of IsnKS) At No" once every ~ tnaytt#re s) «3 YM•) Pump out aorttsnte of tt~nk{s) when combined studge and scum 44ub oeu•dtled NO of tank volume At least once every a rreorrttre r(s) (fYWerdmwm 3 yes.) ~Cisari reretfl Attest azure every ! ©n 1 s sj inlp~rer~ putap, pump eaontbals s etsrm At tenet once snnsry D tneuetlls e►) NA r"lse,rte ieltietete end prwuM tWIt At Wait cane every 13 rraecWddt e) 0 NA Omw_ At Walt once every Q m=ww L'i ystrEsj Q M o a,.r At hmot once awwy Q nW4hs 13 3a+a(s) O NA aasnw or ftftwkV 1 peosor<xr~ 0- anet aleperee0 COM 11"t tae ertgde by an kldiaiderell aeu:ylnF emet of 0A8 Meow Phm*w. Meelar Pluowsbw PWwWieftd l*ww. POW M WrieyO110r. POW TS WdNk"bw; 9W&W Swvaft 1'ank bwpo liaeie tmwt kukids a vbuM Insp@Won Cit gn teer gM tm idwdhV WW ndeettrg or b kon hwdwane, kIWdMy OW eerie M. r Usldl. nwamnsibe VQkMw of as Med Mudge SM atueer send 0"' ' for wry boink up or pondirrg e t atAiwr~t rxe 0111 gnxww &raw - They diiij tt osil{s) snail bs vbWft w o Is t1 n * d1t sMuw t b'wW - n ttw obeeraion mom and two ishmik I br ~ P of s fkw t an ft orotWttti tltN~- TI~t pWW"p ~ elikrent on 1 to ~ ► Indimllit s 1md ctilq rise t10et Immni Mb rAdM INIS err of #0 w w npertMNY - ?11tW ft Onbho aocaCjwft en ai"skadiit old smrm in any Tank dQIWb 0104" (V armat oft to UK* vokam, t `a et9lr~ af'dM Mlflc W !ie► Af1EtW " b!0 t ! ~ ~ ~ ~ +"Aholr. i3, W<~oc TOt ~ldnifnbtra166 CoChI. snd WY t]Ie $Oftm of fts. li'lMi~lAOW or pr r POWM Car"powak FWOU! '"sm'°a's n' Odwa seer half "kV at i of 12 iriot~ths CO M. bs ~srf by t °Ot !°d P . smt A "t*nIPW sindi'be P n idl ibo tWS IOW mguw+Y su tt * whin 10 t Of MyWbdM OW mw axisbsbu W, pd r 10 nor Sf VW POW TV dW*. tsWS) for 10 P"' :.tsarrOieMs t1'~t rttotr 6tt jtitMi ills ~ D ~ 1!` h~}h tut~olh i8 the OOAIf1 per: fi(t) tee TWV W by 41 S"MgO .se;tr+,rt00tn8 openeior ' Lti 1a~ y' shall not [IptlWf VMW ma modrhons atis6own at tht on Sysvn elect up safaw _ no fiats. v►thetr X18 Dudre_i pmW PUMPUMS e g may tt>rf9t in the wa brauesrvdii be discharipod to then dkpWOW stop(s) in sat!'~lge de* k ovrerfoao 19 by a bac3o ~P nor salrowe &e hatge of . TO avoid Wo affiadan havs*m comatenbF ~ to**f ! b ~ Swwas SenAchm C0 stats+r' l~fl~f' fNiX1l ~►''r' W riltt 0006-Odnt P aM p or C0r10K**1% Or 3 assist in (rNalr dy opera ft go PAP t" Iftle to fasw* tweno b ws within the p W. w 6wL Do n11l:diiffl orparkv~P19 AM s ' s soli &8PWQ1 t8S {b notdnve orpxc taw or'dw*imdit*or=npac L the Sodas wi dh 15 beat down stops att>Ilmy tmowid or at-grade sdTl abs6rpaon an3s- Redi cOm or-aWni9lfloll aft le 1011arktg from Ow wasbiom ter stteam MRY impriM the pel# nnanGe and Pm1mg the Be of ihta POWTS ~;1> tUa butts; condoms; oothn swabs; degl ; de W ftoas; diaper dslWi l alter W fou dh (XiiinP FMP) water, fn* and vegdtIble Peed B QMOW. hates; meat scxaFe ; medicadorls; as !eft Produft--11895ddss; sanitary napkins: tampons; -and water saftner brine. ABAN(k3N0MWr vilhw the PtaVV'M fens andtar to PW111W OW.Men out of service the following stain d1alt he taken to insure that the system is Pm Pedy arld asibly abartdoned in compliance with ch_ Comm 83.33. WIscoonsin Add Code. AN P11*9 to tanks amid pits shelf be disconnected and the abandoned pipe openkVs sealed- Tans coak-is of aft tanks and pft shall be removed and prop" disposed of by a Septagre •ServfV ©pe iator_ ' Lamar PuraP ng. all' tanks and Pits shall be excavated and removed or choir Coysrs rnmawed.t ttn0 acid epees Iffedwith WC gravel oranoff rinertsolid material. CON-MIGIRICY PLAN If the 14:)WTS faits and cannot be reps ued the failovdrig measures have been. or must be lateen, to provide a (ode c=Pfiantt Arnentsysttan 0 A suitable replacerneWarea has been evaluated and may be utilized for the k as bon of s replacement soil absorption systsm- The replaournentarea show be protected from diairbance and COMPaadon and sh Wd not be inidnged upon by requ7red sefbadcs from existing and proposed structure, lot Mgrs arx! wells. Faure to protect the replacement area vW0 v cult in the need for a new soil and site wmiualion lb establish a suitable rieplacement arena- Replacement systems must comply with the rules in effect at that time_ Ci A suitable rspiaoementarea is not available dose to setback and/or soil limitations- Barring advances in POWYS teahmok gy a holding tank fmW be kwtailled as a last resort to replace the failed POINTS. the site has not been evailsaded to identify a suitable replacement area. Upon (allure of the POWYS a snil.and site evaluation must be Oerlormed to locate a' suitable replacement area, if no mPlacsrnsnt area is avaiiable a / 1oldirtg hank [nay be in*Wkd as a last resort to replace the failed POWT'S_ >t ~1AouM and stoode staff ab&xptton systems may be r~nstruaed in place fiollooing removal of the ~bior mt at '~1 "fie lrfiftraffmaurfW& RecCnst actions of such systems must comply with the rules in eMied at that time. <<WARh1NG>> SEPTIC, PUMP AND OTHER TRFATMEHNT TANKS MAY CONTAIN LETHAL GLASSES ANL7Il4R INSUFFICfEmr OXYGEN. 00 tHUr ENTER A SEPTIC, PUMP OR OTHER TRE-ATMENT TANK UNDER ANY CIRCUMSTANCES- DEATH MAY RESULT- . RESGUE.OF A PER$ON FROM TINE INTERIOR OF A TANK MAY BE DIFFICULT OR IN IPOSSISL.E. ADDITIONAL CO UFWS POW1rS INSTALLER POWTS MAINTAINER Name Name Phone 7)15"_ nZ Phorre SEP"T-AGE iERVICING OPERATOR PLlIKP LOCAL REGULATORY AM011I7 Y Name 7-,,,,. l'~? Agencl, / . -.c _ DLt J~ V Phone i Phone f7°- 77ris Qoa rnenawas rliveor by, the ! of Ow Qwn L aim. AtaMunde and Worm' are Count/ Zoning anti SmAnfi n agoldw This darYSnwd m80ts ma rr+ir6norrr r of ch. Ceram 83.ZZCZ0X1()(d)&M and 83.5x(7), (2) & (3). Wisconsin Codt- Uas of this doownent does a% guarantee LNe pvfMnaram of the POWTS. {,NAW (Z1i0t) P(~f'E 07.I 1 PCJL.K 20111 H( FAX f ~~it Idiny~ Q ^4' - 1 1f.19 rt' PC1. ,,a rC. r anc Kle1, 4;iv ,Irr a ,n, CFaaaRC'? . (~o 9 f ralail~jr _ c.\ q l p tk ~a. h COtnf1Y IC' i;i _ >11? On b J 1!1fu(1111A1 4'Bfr'+4~f!f'Fl ilnfit (FFvI) ti n~~n 1e47n ~Anc) , i^ot-~1~~~ ~ S/~ rllf i!t"J'RISnC, ,i~ ~r_ 1 r nf,{LIC! .~lJt ri Cie ~.^+nC.E=xn 1167S"P..B%p7E.{. nate at rm, scala or 9il _ . ons, r ort) e T nr, flJl~i !ot n .Inr hrr_r~nr_ - fie .nee 10 Ram ~~rv~~R a64 uat~rsra~ftr 1 1 a nnl+ Per unnd n' : ~.c ondaey nn }a! ,cart (E r6 m(y 4^'! n 1 OP ii) (n)}. - .,.r ^ ~t, t~rl,frirmallor m~ p "l,J at`I'i,~YOr,~il(.)P1 Ern , rc7~hmrr ! - ?,1li, T36 ~ V~ .r_ (fir k 1, 76hd mime qr G+)111# 1 0 ""il : (7Wn I~IPr3fE:lt S'CO~:I~. I - (35fd('nt. 1 t Mt 11711,Pi U` I I;,Chpllfn5 ~iN ~J riOn~t SlC,Yidt ~ 1gPt y ' _t - ft- l np r urlElltl ~ r F,!r«~raho❑ 'tF ~ I1:r.Ihle htrla~l2i,l m-'~'"-__1--- -ti ~ lives r~,~.~~.„ 9~.. ~79 44 J` ~ 4' 6- 7.L7 I n~ rernn-~rnenrla;lorar, ~J6.5~-~ C? N ~ "nslnr. ^ ,nll Ap41UCS~tt • i P711n0 ~~♦O~ ~apV~ trn I!Inlgll^aAz4N!e A In - III 1"'ll. C Fn lJn 1~PCn e 1P . .,.__-.....,.W..- Roots _ _ - 1 ~n r,~neu Rr rry S+nul3dar~ L- I t~x,Ie!s C e ~rl~il nr ~ lc{,.r ,>>~Ir1111 t^pir,,~rl Rr~ kY~z ~ t~z,chl~ Ic,J ~ _ - ' Co n ' 1231~q ~ IL -o rto" F 1 1. - - ' ~ ~ R3CIr!t11 2 ~ F ~r !h a IrbtlPlnr ~~t, _ SC~iI A _ n P; w'nln'~ ~'I;-~^A~FPtir~af~ ,=Alar-, I 5 ut, ,,h nsls4enek" I Dot) Jary ?arts L_ OFD- hh~rlson rial'}4'~ Dn nm 1 .oiurl Ior rk9 rI > + r sl b ~A I - t SL F'l F7 i ` I ; I I l 30 m41L and S:y 30 Fns ar,ah Rue. i.vr MA CST ~ ~ I )etlc :'vrflwr9iq!rl.;cnal.at.Rt~rl loieph!~n41'•I;.ITb4f -/I ;.4£31592x-46 I'f.Jl._K ZU l-11'1(a F(~i P_ . ACA -d lk~~ PraPn'tY C3"u I ( Am a 2~ nrin F! r,rt L3rrmr d ~g,.trfaca elev. 1.93 f t')eph to limiting Tartar in. yu._ SGil Application Rate Horizon Depth Dominant Colo d~ Red'or.Leaurlption ~ tPyiIV i Strur'iure CoriMsi rioa Boundary Roots PDfft I';. Mtansell 'dtt. L l.:d~.e t 0IC3C 4 d:it all *'Fnl °•IEW2. 1 -3 1- n~ FJai Boring irlc~ # 0- pit Ground 'ufAce elev.- i., Deptli to !imlting facia! in Sail A~a~llcation orate }lorizcn UeiyRtr Dominant Color Ftodohsr iptlo~ ( rr-.rxtuitirrurfratr 4oniistcn k f~cundztiry~ JfZoota _ (3P fJ/H' In Munsell Qw, SZ, (oM Color G r az $ ~ ! ~ w7.1f)t1 ~f(at7 d d I ii w f gorinr-l g l:3ardng # C;rr~uritl qur ere e9ev. fl:. i]eptl ;r. irniting PaCtUr _ i;r. ' t-1wizon Dtj)ln rMrnharvtC;olar R dt'x tnAdLlr,~ t^orl.i tenr,e Boundary T Roots CFoff in Munsol l"4'u Sx Cora Color ~d S '~3 *EtPlkt F 7_ t T . Effluent #•l = ROD, > AO- ,7.211 m, qA, and 4`S:y ~Ji! v5O. rnt, /L. ~~{{luc+nk 3E:: = 1090,. 30 rt9fjll_ 2nd Y SS m5 ~f1 1110A n'te Department of CoMmerce, is an eqrial oppocwl,liC'p ucI-v-lce Providor ird owpioyer. If yo-Li need assi71,0nr.e to ncccSS Krrvit:crr nr ncut Material in a',l, a4tercLaS forma.!, please rrrtt;it`I ihc,' rle.rr rYltYrerai at 008-266-315'1 cw '>i 'y x;08-264-8777, »rti,, c 7_r, rco> I (:lf_I: OI,;:iHG C'A:< PAGE J. i 4e_ r propefly OwrIM page of "r Baring Eivrmg ~ [ 3 Q rcc Ground dutfsiCe elev.. Depth to limiting factor 7~ to SoiNr Horizon Depth Dominant Color Redox Description ~ Tpxh,ro Structure Cgnsistana? Boundary Roots M. MiAnsell qu Sz. Cont. Color _ Gr. Sz. Sh. *EfWW SAO F Fa 1 .~-1 Bl,r;nq E3orlrig# Y 1 pit tt Depth to,irrllln~] facraY in Grartnd yrarface elev. - _ Soil Ilcation Rate - !Koala CIPQNP Lff Hnrtzor t7epth Uominanf Color Rodoh 02sc`.rllsflon 'Tr-xture SYruGtut'e Gcstric Bouncle(y ~El +82 In Monseu Qu Sz. Conf Cdor C;r 5z. Sh ._...._.__..._r._~..._.._._- F_- I.10'Int~a Borg # Graufid stlridCe elev. ft. E7epth, t^ !irrlitln fBStU+._ in. 41on E~~te h10flZpn Gt{allt C)orninarR Color ---RCCIWf Cyaccuxrtinn r xUuR~ SirurJurr GonsistenCB Bound~fY Routs GPa Munsell Sz. Cant. Color Gr. Sz. Sh:. *EfFtt9 "l:fl2 Effluent #1 = BOU, 30,<21u n, 9A. and ~3() 100 my/L 'i{luc+nlX. = SOD, ~ 50 mgll_ and TSS :j in rrgtl Fhe Department of Commerce is an equal o;ppa°tunity aarv;ce providct sand emp.ioym,. Tf You need asststanL;c to aecxss sarvicco or need material i__,, an aitcmate formaL. ,lease contact the department at 609-)66-1) 51 or TTY 608-264.8777. I tw p Uo. j ~ o ~ o~ P ~ n rn~p -17 3 s 0 r~ o Jt• .fob OP4 VOW 93 o► S 4_4 - ~M1 I i I I i I i L - i i I I : i I I , IL I i I i I ~ I - _ j I I :G - >4 L vi U. - - , 'a 5 C ilk, la r Y" of O - /J I 10-P r ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 0 41C~ Mailing Address ~kt N Property Address (Verification required from Planning & Zoning Department for new construction.) City/State Parcel Identification Number. LEGAL DESCRIPTION ~~11Property Location 5c.J %a , 5 G '/a , Sec., T vii R W, Town of r/lr Subdivision Lot # Certified Survey Map # Volume Page 1 Warranty Deed # Volume , Page # r- 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. I/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a watranty deed recorded in Register of Deeds Office. Number of bedrooms SIGNAT PLICANT(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) II IIII IIIIIIIIIIIIIIIiII II I Ill 4 5 2 State Bar of Wisconsin Form 3-2003 8 0Tx44032501 4 QUIT CLAIM DEED 947249 Document Number BETH PABST Document Name REGISTER OF DEEDS ST. CROIX CO., WI THIS DEED, made between Lyle J. Nippoldt, a single person 12/14/2011 12:05 PM EXEMPT*: 16 ("Grantor," whether one or more), REC FEE: 30.00 and Lyle J. Nippoldt as Trustee of the Lyle J. Nippoldt Revocable Trust dated PAGES: 4 March 29, 2011 ' ("Grantee," whether one or more). Grantor quit claims to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property") (if more space is needed, please attach Recording Area addendum): Name and Return Address t SEE ATTACHED ADDENDUM Jennifer A. O'Neill ONeill Elder Law, LLC 900 Crest View Drive, Suite 220 Hudson, WI 54016 SEE ATTACHED ADDENDUM Parcel Identification Number (PIN) This is homestead property. (is) (is not) Dated March 29, 2011 (SEAL) * Lyle J. ippoldt * (SEAL) * (SEAL) * (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) Lyle J. Nippoldt, a single person ft STATE OF WISCONSIN ) au 7tic, ed on M 2011 ) ss. COUNTY ) * tenoffir A. eill, a Law Personally came before me on TITLE: MEMBER STATE BAR OF WISCONSIN the above-named (If not, authorized by Wis. Stat. § 706.06) to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. THIS INSTRUMENT DRAFTED BY: Jennifer A. O'Neill - ONeill Elder Law, LLC Hudson, Wisconsin Notary Public, State of Wisconsin My Commission (is permanent) (expires: ) (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. QUIT CLAIM DEED ® 2003 STATE BAR OF WISCONSIN FORM N0.3-2003 • Type name below signatures. 1 of 4 ADDENDUM TO QUIT CLAIM DEED GRANTOR: LYLE J. NIPPOLDT GRANTEE: LYLE J. NIPPOLDT AS TRUSTEE OF THE LYLE J. NIPPOLDT REVOCABLE TRUST DATED MARCH 29, 2011. PARCEL ID NUMBERS: 028-1006-95-000; 012-1025-60-000; 028-1006-40-000; 012-1025-00-000; 028-1013-30-000; 012-1023-90-050; 028-1013-10-000; 012-1025-40-000; 012-1013-00-000; 012-1024-00-000; 012-1013-30-000; 012-1025-10-000; 012-1012-90-000; 012-1025-50-000; 012-1012-40-000; 012-1026-40-000; 012-1013-20-000; 012-1026-90-000; 012-1013-40-000; 012-1026-50-000 LEGAL DESCRIPTION: Parcel 1: The Southeast Quarter of the Southeast Quarter (SE 1/4 of the SE 1/4), located in Section Two (2), Township Twenty-eight (28) North, Range Seventeen (17) West, Town of Rush River, Wisconsin. Parcel 2: The Northeast Quarter of the Southeast Quarter (NE 1/4 of the SE 1/4), South of Interstate Highway 94, EXCEPT 4.98 Acres of Certified Survey Map in Volume 3, Page 705, located in Section Two (2), Township Twenty-eight (28) North, Range Seventeen (17) West, Town of Rush River, Wisconsin. Parcel 3: North half of the Northwest Quarter of the Northeast Quarter (N 1/2 of the NW 1/4 of the NE 1/4), located in Section Eleven (11), Township Twenty-eight (28) North, Range Seventeen (17) West, Town of Rush River, Wisconsin. Parcel 4: North half of the Northeast Quarter of the Northeast Quarter (N 1/2 of the NE 1/4 of the NE 1/4), located in Section Eleven (11), Township Twenty-eight (28) North, Range Seventeen (17) West, Town of Rush River, Wisconsin. AND 2 of 4 Parcel 5: The Northeast Quarter of the Southeast Quarter (NE 1/4 of the SE 1/4), EXCEPT the North 8 rods of the East 20 rods; and Parcel 6: The Southwest Quarter of the Southeast Quarter (SW 1/4 of the SE 1/4); and Parcel 7: The Southeast Quarter of the Southwest Quarter (SE 1 /4 of the SW 1/4); and Parcel 8: The Northeast Quarter of the Southwest Quarter (NE 1/4 of the SW 1/4); and Parcel 9: The Northwest Quarter of the Southeast Quarter (NW 1/4 of the SE 1/4); and Parcel 10: The Southeast Quarter of the Southeast Quarter (SE 1 /4 of the SE 1/4); All in Section Four (4), Township Thirty (30) North, Range Seventeen (17) West, Town of Erin Prairie, Wisconsin AND Parcel 11: The Northwest Quarter of the Southeast Quarter (NW 1/4 of the SE 1/4); Parcel 12: The Northeast Quarter of the Southwest Quarter (NE 1/4 of the SW 1/4); Parcel 13: The Northwest Quarter of the Northeast Quarter (NW 1/4 of the NE 1/4), EXCEPT that part to the Certified Survey Map in Volume 18, Page 4787; Parcel 14: The Northeast Quarter of the Southeast Quarter (NE 1/4 of the SE 1/4), EXCEPT the North 208.71 feet of the East 313.10 feet; Parcel 15: the Southwest Quarter of the Northeast Quarter (SW 1 /4 of the NE 1/4); Parcel 16: The Northwest Quarter of the Southwest Quarter (NW 1/4 of the SW 1/4); 3 of 4 Parcel 17: A parcel of land located in the Northeast Quarter of the Southeast Quarter (NE 1/4 of SE 1/4) of Section Nine (9), Township Thirty (30) North, of Range Seventeen (17) West, Town of Erin Prairie, being further described as follows: Beginning at the East quarter corner of Section Nine (9); thence South along the section line, 208.71 feet; thence North 89 degrees 56' West, 313.10 feet; thence North 208.71 feet to the quarter section line; thence South 89 degrees 56' East 313.10 feet to the point of beginning. Said parcel containing 1.5 acres of land, EXCEPT the Easterly 55 feet being used for highway purposes. All in Section Nine (9), Township Thirty (30) North, Range Seventeen (17) West, Town of Erin Prairie, Wisconsin AND Parcel 18: The Northwest Quarter of the Northwest Quarter (NW 1/4 of the NW 1/4); and Parcel 19: The Northwest Quarter of the Southwest Quarter (NW 1/4 of the SW 1/4); and Parcel 20: The East half of the Southwest Quarter of the Northwest Quarter (E 1/2 of the SW 1/4 of NW 1/4); All in Section Ten (10), Township Thirty (30)North, Range Seventeen (17)West, Town of Erin Prairie, Wisconsin. i 4 of 4