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008-1044-30-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM ', Safety and 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)]. Permit Holder's Name: City Village X Township Duckworth, Dennis Eau Galle, Town of CST BM Elev: Insp. BM Elev: BM Description: ~ X1/1 G ' oa , ~ SA TANK INFORMATION ~ TYPE MANUFACTURER ~ ~ CAPACITY Septic ~ x',~ y Dosing ~~~ `.~ O D Aeration P S2 Holding ~, ~. TANK SETBACK INFORMATION TANK TO • P~L ~r1 WELL BLDG. Vent to Air Intake ROAD Septic 7 5l> J~p.~ , ~~ / ~5 ' Dosing 7 Sb ~~s , !5 ' ~S , ..--. Aeration Holding PUMP/SIPHON INFORMATION Manufacturer ~e Demand t ~~ ~~ GPM Model Numner ~ ~o ~K- ~~'rs TDH Li Friction o System Head TDH Ft ~ ~ ~ ~ ~ s ~ Z~ ~ ~ Forcemain Length ~ Dia. ~' Dist. to well ~ 7 ~ 65 Z3U Z S(lll ~RR(~RPTI(~N SYSTEM county: St. Croix Sanitary Permit No: 506192 0 State Plan ID No: Parcel Tax No: 008-1044-30-000 Section/Town/Range/Map No: 15.28.16.225 ELEVATION DATA STATION BS HI FS ELEV. B~~n~ ~ ~ 3.',~ 3 /aU, d Alt. B ~ ZS' O ( a Bldg. Sewer -~ , ~.sb Si. ~ q St/Ht I eta / `^ SG `T _ /,~ ~O'O p-/• ~~ D SUHt Outlet '- Dtlnlet Dt Bottom ~- ~ ~ 77~ q Header/Man. S.~}~P 7.8y Dist. Pipe s~ yip ~7 . Bot. System ~ , ~ t ~ 7 ~~q Final Grade ~ ~~ ~ g, ~4 St Cover /_ ~ ~ (~ ~~, 1033 ~ .~ ro 8 23 9~. ..zhs~ y -~~ . ~ ov.~. ~rrv~- C.d Ll.(CJv BED/TRENCH DIMENSIONS Width 1 ~ Length i 54 . ZS No. Of nche e PIT DIMENSIONS ~ No. Of Pits Inside Dia. ~ Liquid Depth ~ SETBACK N SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR Manufacturer: ~ INFORMATIO Type Of,$ystem A o~ v~-Q/1\ (,~,g' , , L~~ ~ Z~ / /~ ~~/ ~ )1"T UNIT Model Number: r11CTRIRI ITIf1N CVCTFMlr,.. ie Mme. VtL~.1r L.~ Header/Manifold ~ N ~~ ~ Distribution / ~r I! pipe(s) Lj I 1 µ 3Z x Hole Size {~1 ~~ x Hole Spacing ~/ V~t to Air Int ~ q Length Ip4 Dia ` ~ Length ~ r Dia Spacing ® p Z~ Cull !`(1VFR „ ~.. ., c. tea.. ~ n.,r.. .... nn.,~~.,.t nr et_CSraria Rvctemc Only Depth Over Bed/Trench Center ~ / / ~ Depth Over ~ Bed/Trench Edges \ xx Depth of Topsoil 1 ~-~ xx Seeded/Sodded/ ~(YeS No xx fvtulche_d / }~" Yes + Ne r/ a p ' COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 5 / .~~ /~ Inspection #2: / 7 a~ 6!: a~ Location: 2428 32nd Ave. Woodville, WInn54028~{NEn1/4 SW 1/4 15 T28N R16W) 40 acres Lot ~Q Parcel No: 15.28.16.225 ~ ~L'bt Y ~. ~~O""`^~ ~ ~~~ ~~~~' dr t ~ 1.) Alt BM Description = "<.) Bldg sewer length = ~1 ` ~ ~`J"e `til- a\ d ,~.. ,,,~ w ~~ y P 1 ~ rj y„~~tJ~ -amount of cover = ~ ~ _ _ Plan revision Required? Yes No ~ ~ ~ d~ ~ ~ ~ ~ ~ i Use other side for additional Information. Date Insepctor's Si ature Cert. No. SBD-6710 (R.3/97) ' commerce.wi.goV Safety and Buildings Division County ~ ~ 201 W. Washington Ave., P.O. Box 7162 ST CROIX M scons i n Madison, WI 53707-7 162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce 5 Sanitary Permit Application 882 action Number 539 3 In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application o d project Address (if different than mailing address) POWTS are submitted to the Department of Commerce. Personal ' for second urposes in accordance with the Privacy Law, s. 15.04(1){m , Stats ENV 'a ,}~ Z7~ 3Z ~~ ~l "L I. A lication Information -Plea se Print All Information Property Owner's Name ~ DENNIS DUCKWORTH MAY 1 6 2007 Parcel /1 op fl -/b~Y-~'oa~ Property Owner's Mailing Address Property Location ?~S / 2428 32ND AVENUE sT. CROIx COUNTY ~ Govt. Lot ` City, State Zip Code Phone Number NE '/ ,SW 'la, e8tion 15 WOODVILLE WI 54028 715/684-3328 (circle one) W II. Type of Building (check all that apply) Lot ~ T 28 N; R 16 l` Subdivision Name A ®1 or 2 Family Dwelling - Number of Bedroo 3 ~ try i ~ N/A ~ G~~~ , , J~ N/A ~( ^ Block # ~ / t ,` Public/Commercial - Describe Use N/A Ciry of ^ State Owned - Describe Use ~ CSM Number ^ Village of ' $ ~-' s (p , ZS ~o~ N/A ®Town of EAU GALLE III. Type of Permit: (Check only one box on line A. Complete li ne B if applicable) `~' New System ®Re lacement ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System (explain) System B. ^ Permit ^ Permit Revision ^ Change of ^ Permit Transfer to List Previous Permit Number and Date Issued Renewal Before Plumber New Owner ~ ~ / ~Q Ex iration IV. T e of POWTS S stem/Com onent/Device: (Check all that a 1 ) ^ Non-Pressurized In-Ground Pressurized In-Ground ^ At-Grade ®Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil h ^ Holding Tank ^ Other Dispersal Component (explain) ^ Pretreatment Device (exp am ~ ~ ~ ~ z 4 V. Dis ersaUTreatment Area Information: Design Flow (gpd) Design Soil A 'anon Rate(gpdsf) Dispersal Area equired (sf) Dispersal Are roposed {st) System Elevation 450 / 1 . (p 450 ~jp 450 /~~$ 97 VI. Tank Info Capacity in Total N of Manufacturer w Q Gallons Gallons Units ~ ~ U ~ a H New Tanks Existing Tanks ~ ~ lah. ~` w o H F ~ W a d Septic or Holding Tank 1000 1000 1 WIESER ONCRETE ® ^ ^ ^ ^ Dosing Chamber 600 600 1 WIESER CONCRETE ^ ^ ^ VII. Responsibility Statement- I, the undersigned, assume responsibility for installat5on of the POWTS shown on the attached plans. Plumber's Name (Print) Plumbe 's Signature MP/MPRS Number Business Phone Number BENNIE HELGESON ~-- (/ 220292 715/772-3278 Plumber's Address (Street, City, State, Zip Code W12 9 770TH AVENUE, SPRING VALLEY, WI 54767 VI .Count /De tment Use Onl Approved Owner Gi Reason fo ial Permit Fee $ / Ut5 Datesued 5 / $/G 7 Iss ' ent Signature OQ / IX. Conditions of Approval/Reasons for Disapproval 3\ b `~ ~~„~` e. n ~ SYSTEM QWfdER J 1. Septic tank, effluent filter and Go~.l dispersal cell must all be services / maintairied as per management plan provided by pluml5er. 2 .All setback requirements must be tnaint~ned Attach to complete plans For the system antl submit t0 the County omy on paper no[ teas [l[an a u~ x r [ mcnes m stze SBD-6398 (R. 01/07) Valid thty 01/09 t , ~~ ~~ J !I-~ y ///J~~~~ ~~ ~~~ ~~i~~ y.. Q. ~ ~ ~ ~~ ~ ~3 °~ ~' ~ -~_ ~ C~, 1 ~ ~ /~~ _ ' l pgl /L S~: 1 ~rJ'~~ ~. '~r ~, J ~ ~ ~n ~ ~~~ ~ I <, rt ~. 3 ~. __--Y-------_ _.....~... ~ L- -- - - U F=ay ~- C-:~..f i~ ~ ~=~~ 56, i~ ~. ~ k rf'S ,~~ 'r N ~ _ ,, _ - 1 Li =`=s---- ~ - -- _ __ --- - ~' ~ a \\ ,~ :?~ Se -~c 1 paste ra'~~ ~ --- u ~ old Z f+~~s~ 5,~~.;~~ - ~ ,,, ~.k, 5 `~ S ~_, F_ ~c~6 ~~~~ 5 VYc..I r~ `T l~~ C~~ / i ,~+ .- J ! ~ i i '~ / _ ~~y ~`~LL ~ ~3 `~ I ~~~ ~I ~ ~ /~ 1 / / b~ ,. J ~~~~ J - i ~,~~ (\ r ~ oRl $ ~~ ~ ~ ~ ~ ~ ~~ ,/ ' i ~'_ -° ~• 3 ~. 7 ~, 7~ I' - (i N SE' L ~ aS~ T0.'" ` ~'- --, 7 lr ~ ~,~1__ ~ /~c-- i w~ ~~ Poly lek ~?~ ~~ t~.~-~. 9C~,/S f-4R,~.~ S , ~c ~ .; ~l S*~: nw-j ,-- - -~. F_x~~~~~~5 '~ tt~~~~ F;II~ :; I ~ ~/ _.:~. __ __ S ~ ~ ~ ~~ i ~ ~~ ~'' ~y ^, ~~r~s o- ~, ~LL~~LL_ . , commerce.wi.gov i ^ isconsin Department of Commerce Safety and Buildings 4003 N KINNEY COULEE RD LA CROSSE WI 54601-1831 TDD #: (608) 264-8777 www. commerce.wi.gov/sb/ www.wisconsin.gov Jim Doyle, Governor Mary P. Burke, Secretary May 10, 2007 CUST ID No. 220292 BENNIE W HELGESON HELGESON EXCAVATING W 1229 770TH AVE SPRING VALLEY WI 54767 ATTN.' POWTS Inspector ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 05/10/2009 SITE: Dennis Duckworth 2428 32nd Avenue Town of Eau Galle St Croix County NE1/4, SW1/4, S15, T28N, R16W Identification Numbers Transaction ID No. 1393882 Site ID No. 725051 Please refer to both identification numbers, above, in all comes ondence with thew enc . FOR: Description: Three Bedroom Mound System /Replacement construction Object Type: POWTS Component Manual Regulated Object ID No.: 1129665 Maintenance required; 450 GPD Flow rate; 24 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual, SBD-10572-P (R.6/99), Pressure Distribution Component Manual, SBD-10573-P (R.6/99) 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: • This system is to be constructed and located in accordance with the enclosed approved plans and with the component manual(s) referenced above. • A sanitary permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. • The area within 15 feet horizontally down slope of the dispersal cell shall remain undisturbed. Vehicular traffic or soil compaction in this area is prohibited. • 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 Comm 84 product approval conditions. • Comm 83 22(7) - A copy of the approved plans specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. P.U.~~I.T.i. Cr+nE~~t~on~~'J' nFaeoree~ur .,r ...,...._,.,._ BENNIE W HELGESON Owner Responsibilities: Page 2 5/10/2007 • 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. • Comm 83.52(1)(a) -The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(1). • Comm 83.52(2) - A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. 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 chariges 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. Sincerely, ~L~~1 'x~~2~/~' l~ Gerard M Swim POWTS Plan Reviewer, Integrated Services (608)789-7892, Mon -Fri, 7:15 am - 4:00 pm j erry. swim@wiscons in. gov Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 WiSMART code: 7633 cc: Leroy G Jansky, POWTS Wastewater Specialist, (715) 726-2544 ,Friday, 7:00 A.M. To 3:30 P.M. PROPERTY OWNER: INDEX SHEET DEN1vIS DUCKWORTH 2428 32ND AVENUE WOODVILLE, WI 54028 PROJECT NAME: DEIVNIS DUCKWORTH RE~E111~C~ h~qY p 2 2007 SAFE1~ ~ ~'UILD~NG S PROJECT LOCATION: NE 1/4, SW 1/4, S 15, T 28 N, 16 W MUNICIPALITY: TOWNSHIP OF EAU GALLE COUNTY: ST CROIX DESIGN: PRESSURE DISTRIBUTION MANUAL SBD-10573-P(R/99) MOUND COMPONENT MANUAL SBD-10572-P (R 6/99) CONTENTS: Page 1: Plot Plan Page 2: Cross Section and Plan View of Mound Page 3: Distribution Pipe Layout Page 4: Septic Tank & Pump Chamber Cross Section and Specifications Page 5: WLP1000/600-MR ZABLE Tank Specifications Page 6: Pump Specifications Page 7: POWTS Owner's Manual & Management Plan - Pg. 1 Page 8: POWTS Owner's Manual & Management Plan - Pg. 2 Name: Bennie Helgeson Address: W 1229 770th Avenue Spring Valley, WI 54767 Credential Number: 220292 Signed" - ~ 7 Date: May 1, 2007 DIYISiUN OF SAFE~IY AND B4JIlDVNGS SEE CORRE ONDENCE $yntnetic ;overing ,'~ S 1`~~1 ~ 3 Medium Sond -_ Topso(I ~~ :S :~aae of <`:. Distribution PiP` --T'c '7. tD i ` C Orl ~g % Slope i`f~f 2.- 2'z Aggregate -" Cross tiecii ~n Of A Mound Signed: License Number: Date: L J .,~, r'`o-~ G ~ L Force Main ~P~owed From Pump Lcyer ~ ~ Ft. --- E3.~_ ~Ft. Ft. --- L ~~~5_ F t . I //~ 7 F t . id ~~. ~ Ft. D _ I Ft. E ~ ~y Ft . F .,S~L~ Ft. ~;~Ft. H ~ Ft• - Observation Pipe ~ K B __._.~------""~-- ~ r=-_=-~~_______ _ __ _ ___________--__ ~~i ------------------------------_ _ _ J -J --- - - ` ~ ~ ,~ ELI- Of 2~- 2'2 j ~Distribulion ~ pipe A99fe9ote 4~ Observotion Pipe QQ5a Plan View Of Mound "~neLL~~4~Vl1rl ~ ~i ~ia GILUUCi'V'~"~ Cleanout Access Threaded Cleanout ~. ,. r t"a ?~ c7F- ~ .. End Manifold .:N ~~i '.:~~~ Holes Located on Bottom ifi Are Equally Spaced \ Force Main From Pump \ it Hole Next to Manifold F st P ;~~~ ~ R ~v~ S _) ~ '~ ~'=_7 ~~ Y r ~ Hole Diameter _~; Inch Lateral " ~~ Inch (es) Signed: License Number: Date: Perforated Pipe Detail ~ ~ / End Vi~*+ -------- Na~~o~~~~~ , avc -'~o~ Manifold " ~ ~ Inches Force Main " -~ Inches Invert Elevation 9 7a 7 Holes Per Lateral ~~,~ Number of Laterals 3 Total Holes 7~ _ + i i Cleanouts Distribution Pike Layout • (/k7r1'~y'~, ~•ev~v-~5 ~c~,wor-1-1, Page~Of ' SEPTIC TANK E PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS 4 " ~U(,. V ENT PIPE 12" MIN . ABOVE GRADE 6 WEATHERPROOF JUNCTION BOX APPROVED ~ 25' FROM DOOR, WINDOW OR WITH CONDUIT V~i~ WA NP~L FRESH AIR INTAKE OCK / WARNING LABEL • - a______ 4 " MIN . - zy„ s, e. 18" IN • '~~~ 18 MAN. INLET ~~ i GAS- , ~ WATER TIGHT SEALS T TIGHT ~ ~~ ` , /APPROVED FILTER - A SEAL ~ JOINTS KITH t~>i ~ ~' '~ B ~ ~ ALM APPROVED PIPE ' APPROVED PIPE 3' y _ ~~~`_% ~-- ~ ~ ON ONTO 3 SOLID SOIL ONTO SOlIO C I ' SOIL PUMP OFF ELEV . ~•7-O•FT . -~-- OFF D 3 APPROVED BEDDING UNDER TANK „ CONCRETE PAD SPECIFICATIONS _Y~.~t~ t ~~1~ r_ I ~,t~,~.~LS. SEPTIC / DOSE ~ _~~~,'-~~~ -x_~ = ,j ids (~~~~. TANK MANUFACTURER : (~ / SE'~'- TANK SIZES: SEPTIC DOSE ALARM MANUFACTURER: MODEL NUMBER: SWITCH TYPE: PUMP MANUFACTURER MODEL NUMBER: SWITCH TYPE: REQUIRED DISCHARGE e ~~C~ GAL . /~nLl GAL. ~.T ~fc.~-~• /~ t?e I I PN- / i ~C~ ~ ~= LATE ~%. .S~ PM DOSE VOLUME INCLUDING GAL. ,3 5-- ~~ C~~ -> F LOWBAC K :~ CAPACITIES: A = I S~ INCHES = .3C~ b' GAL. B 2 INCHES = ,~~5.-_GAL. C = ~ INCHES = ~CO.S GAL. D = ~_ INCHES = ~E~, ~ GAL. PUMP E ALARM WIRING AS PER ILHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE + MINIMUM NETWORK SUPPLY PRESSURFT/100 FT. FRICTION FACTOR + _~_ FEET FORCEMAIN x a.L 2 TOTAL DYNAMIC HEAD INTERNAL DIMENSIONS OF PUMP TANK: LENGTH WIDTH LIQUID D~I~ ~ '' /G, ~ ~, CY /'~ , S IGNED: LICENSE NUMBER: ~C~~ 7 FEET FEET FEET ~3F E ET DIAMETER _ DATE: i/88 ,~ O U Z ~-' J wa ~ = J Z F ~ ~ Q ~ a N ~ 1 0 Y~ a~ wo o ~ ~ U O O C7 O m ~ ~ ~ .~i~" Z Z a ~ S ~ Q J = ~ i ~Q ( j w J J ~~ ~ O U o ~ ~-N o~ ww ON ~ W O O (VtOm - 0 0 0 ~. r~ ,n Na I.! S m w w ~t\ r~ co O cc a :~~ o ~ ~~Q ~-NQ N~- ' /~ Q N o ~w~~a.~ M~Ntn''dZw~ J U F - ~~~ ~' C~ l4J OD - J .. w O ~. I- O Z ~ U IN O Z vi ..0~==~ ..30= Z J F- w U' O- (~ ZO J=- mY O N Q US O h- ZO d a D r ~ JI-> Z =~~m~~ ~3mv Ze a~rc~ O as.. U C~ z ~• - ~ ~' w J ~ a a O ~ Z ? J J Z W > W .~Z~ e J ct 7 __~~___~_ ~____'__'I. I I. I I I I` I I ' I I I I I I I I , I I ; I t ~ ~: I ~, . I ~ I I I I I I I I • I - i I ~~ I I / ' \\ I I / ~ I . I ; ; ~ ~ ~` i I ~.I I. I I I I . I I . I I . I I .I I' • I I . I 1 I -- I I ~ . `~~ I I I 1 . ~ ~ , I ~ I I . i s I~ W_ / ~ O J ~ U F `e k tUJtf o ~ t ~ J~ ~cD Nd ~ ~'~' ~ ~~ z~ I ~j a 0 ~ ~ \N ~ o I OVd ~]^o °~~ lJ l__J ~ ~ ~ ~ ~ ~" o~ w o W Q J VI v N F- H O qs~ „95 14 t2 t0 x U z 0 J Q 0 U.S. LITERS it ~ ~ ~ W 4 ~~ HEAD CAPACITY CURVE MODELS "140/4140" TOTAL DYNAMIC HEAD~CAPACITY PER MwurE EFFLUENT AND DEWATERING Ft. Meters Gal. Llrs. 5 1.52 91 }44 45 10 3.05 84 }IB t5 4.57 ]6 2B8 40 140 4140 20 6,io 6e zs7 , 25 7,62 59 223 35 SO 9.14 a9 185 35 10.67 38 Iba 30 40 12.19 21 79 13 72 5 19 25 a5 . Lock V°I ve: 4 6' 20 t5 - t~ 5 ALLONS 10 20 30 40 50 60 70 60 90 100 ll0 G tsu 1 ov ~... .,... - ~ FLOW PER MINUTE 010904 CONSULT FACTORY FOR SPECIAL APPLICATIONS • Electrical alternators, for duplex systems, are available and supplied with an alarm. • Mechanical alternators, for duplex systems, are available with or without alarms. • Control a-arm systems are available for 1 phase pumps used in simplex system. See FM0732. • Variable level control switches are available for controlling single phase systems. • Double piggyback variable level float switches are available for variable level long cycle controls. • Sealed Owik-Box available for outdoor installations. See FM1420. • Over 130°F. (54°C.) special quotation required. • Refer to FM0806 for 200° F. applications. 140 Series - 53 lbs. 4140 Series - 73 lbs. 140!4140••' MODELS Control Selection Model Model Volts•Ph Mode Amps Simplex Duplex N140 N4140 115 1 Non 15.0 1 or 1 8 5 2 or 3 8 4_ E140 E4140 230 1 Non 7.5 1 or 18 5 2 or 3 8 4 BN140 BN4140 115 1 Non 15.5 1 or 1 8 5 2 or 3 8 4 BE140 BE4140 230 1 Non 7.5 1 or 1 8 5__ 2 or 3 8 4 .b SELECTION GUIDE 1 I/2 r:/7 SK1524A I t/2 n?i SK152aB 1. Single piggyback variable level float switch or double piggyback variable level float switch. Refer to FM0477. 2. Mechanical alternator M-Pak 10-0072 or 10-0075. 3. See FM0712 for correct model of Electrical Alternator E-Pak. 4. Variable level control switch 10-0225 used as a control activator, specify duplex (3) or (4) float system. O CAUTION All installation of controls, protection devices and wiring should be done by a qualified licensed electrician. All electrical and safety codes should be followed includ+ng the most recent National Electric Code (NEC) and the Occupational Safety and Health Act (OSHAI. RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. -_-- MA/l T0: P.O. BOX 16347 Louisville, KY 40256-0347 Manu/acturers ol. . ~' SHIP T0: 3649 Cane Run Road ~ ~ ® Loutswlle,KY40211-1961 Qua~irrPu/uveS,vcE/9.99 ® ~ ~ PUMP !O. 1502) 7 FAX (502) 773624 -PUMP hKp://www•zoeller.com __ _ __ __ _ _ _ ___- - - ~.P F rr © Copyright 2001 Zoeller Co. All rights reserved. i~li_E INFORMATION DESIGN PARAMETERS pOWTS OWNER'S MANUAL & MANAGEMENT PLAN Number of Bedrooms 3 ^ NA Number of Public Facility Units ~ NA estimated flow (average) 3U0 al/day ~esi;n rlow )peak), (Estimated x 1.51 450 al/day Soil %+r~plication Rate al/day/ft~ Standard Influent/Effluent Quality Monthly average ' Fats, Oil & Grease (FOG) <_30 mg/L Bioi:i~emical Oxygen Demand (BOD51 5220 rng/L ®NA Total Suspended Solids (TSS) 51 50 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand lBOD5) 530 mg/L Total Suspended Solids (TSS) 530 mg/L i~ NA Fecal Coliform (geometric mean) 510° cfu/100m1 fvtaxinrum Effluent Particle Size Yd in dia. ^ NA C ^ther: ^ NA "~'aluas tvPical for domestic wastewater and septic tank effluent. Page _~ of ~_ MAINTENANCE SCHEDULE Service Event Service Frequency ^ month(s) ears) 3 NA Inspect condition of tankls) At least once every: 2 y ® ear(s) (Maximum When combined sludge and scum equals one-third 1Y31 of tank volume O NA ?un,p out contents of tanklsl ~_ __ ^monthls) (Maximum 3 years) ^ NA nspecc dispersal cell(s) ~ ' At least once every: 2 ® ear(s) ®month(sl O NA __ _ 1 Clean effluent filter At least once every: 13 ^ year(s) l3 monthls- O NA _ Inspect pump, pump controls & alarm At least once every: 13 ^ year(s) ^ month(s) p NA _ Flush laterals and pressure test At least once every: 3 ~ year(s) ^ month(s) O NA _ ,(her: At least once every: p year(s) ~ NA I Other: - MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the SePj ge9Serv csng OperatorCatTank r~taster Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; inspections must include a visual inspectioandfscumaand Ito checkrforany backgupror pondngdof effluentton the ground Surface. measure the volume of combined sludge Tlie dispersal cell(s) shall be visually hespondin tofceffluent onfthe ground surface may ndicate a fail ng cond lion and r quires the or effluent on the ground surface. T p 9 h7unadiate notification of the local regulatory authority. ~1,~hen the combined accumulation of sludge and scum in any tank equals one-third 1Y31 or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance. with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment urti:s, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shah be provided to the local regulatory authority within 10 days of completion of any service event• GMW (4/411 Oj^iNER: DENNIS DUCI~WU1~T-i Page 8 of 8 ' ~ S'1'A12T UP AND OPERATION For new constriction, 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 dztected have the contents of the tank(s) removed by a septage servicing operator prior to use. S)•stzm start up shall not occur when soil conditions are frozen at the ittfilVative surface. lluring 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 lazge dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainar to Assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vzhiclzs over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, 1'hz aria within 15 feet down slope of any mound or at-grade soil absorption azea. Rzduction or elimination of the following tiom the wastewater stream may improve the performance and prolong the life Of the POWTS: antibiotics; baby wipes; cigazette butts; condoms; cotton swabs; degreasers; dental floss; diapars; Disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; harbicides; meat Scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. A13ANDONMEN'f When the POWTS fails and/or is permanently taken out of service the following steps shall betaken to insure that the - Systzm is properly and safely abandoned in compliance with ch. Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disco~tnected and the abandoned pipe openings sealed. • The contents of all 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 anoilter 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: ^ 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 and proposed structure, lot tines and wells. Failuro to protect il~e 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 nol 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 azea. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resoR to replace the failed POWTS Mound and at-grade soi[ absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. «W ARN ING» SEPTIC, PUA4P AA'D OTIiER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT ON1'GEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH b4AY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. "~`~, ~._, ADDITIONAL CObihtENTS ' POWTS INSTALLER POWTS MAINTAINER `~ ,. :a: Name HELGESON EXCAVATION INC Nama r` Phone 715/772-3278 •Phone 715 273-5811 ' .~ ~ ; SEPTAGE SERVlC(NG OPERATOR PUMPER LOCAL REGUTATORYAUTHORITY Name J01-iNSON SANITATION A9enoY ST CROIX ,r,~., Phone Phone 715 386-4680 ''~ • 715 273-5811 .....t: ..~_ ,, Tnia document was dratted by the stafls o! tha Green Lake, lvtarquatte and Waushan County Zonlnp and Sartltalltxt iDOtIC(!/. ThN dOalA'Nt$~•..s+~:i}~ fns minimum reQUuementa of ch. Comm 733.22(2)(b)(1)(d)6(Q and 83.54(1), (216 (J), tMsconslnAdmWstroQW COdb UwoflltbdopNp~ItttiONAOi '~ ' 9uannlee the peAorrnanc+ of the POW'fS. ~ ~. -~ ~y RECENED Wisconsin Department of mmerce 2007 S I A O EPORT Division of Safety and Buildi gs M QY Q 2 Page ~ of in accvrvarxe wim omrn~~ . r~arn. ~.oae IY Attach complete site plan n papgftt~~iR~~rz k 11 in hes in size Plan must county ~~. C~'C~~/,/ . include, but not limited to: ertical and horizontal refer t (BM), direction and Parcel I.D. ~i,~,~ percent slope, scale or dim rrow, and location and distance to nearest road. ~/ y y ^ ~ (J Please print all information. Personal information ou rovide ma be used for secondar ur oses (Privac 04 (1) (m)) Law s 15 Revie ed by Date ~~ y p y p p . y y , . . Property Owner Property Location I ' jj ~riv~I ~raCl~(~o~T~~ Govt. Lot ~~ 1 1/4S~,tJ'I/4 S ~S TaB N R I~ E(o W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# ay~S 32Kd Aug., --- -- 6~ .4crt5 Cily State Zip Code Phone Number ^ City ^ Village ®Town Nearest Road ^ New Construction Use: Residential / Number of bedrooms 3 Code derived design flow rate '~i~Sa GPD ~ Replacement ^ Public or commercial -Describe: Parent material L-o ~S s ayelr- '~/~ Flood Plain elevation if applicable ~~, ft. General comments H q ~ e and recommendations: CI~S~a, ~°? S~i11G" G~"~''~P~- of ~er ,CcQ~-~ o ort Coot ~u~- q6• ~ ®~L"l ~ jy ~ ~e~ Fl~v. 4 7. ~-- Bori , Boring # pit Ground surface elev. / 3. ~ ft. Depth to limiting factor ~~_ in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ftx in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ~ (~-- oY 3 ~-- 5,1 ~ ,~ I- ' ~ ~ S a -i o 3 -- S, l ~,,, ~ ~ ,.~ ~ ~ . ~ • 8 3 ~ ro y ~ --- L ,, , ~ w . ~ . 8 d .~ -~3~ C c bf~ ~ ~Y Boring # ^ Bo 'ng pit Ground surface elev. 9~ - ~ ft. Depth to limiting factor a~_ in. Soil Ap lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft~ in. Munsell Qu. Sz. Cortt. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ~ L~~ ~© 3 - /I ~~ c s ~JF . ~ ~ 3 ,S - F l- s b i '~ ;~ /cep ~ . 5 ~ _ ~. SC L. c S6 ~ ~ ' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L `Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name ase Print), Si nature CST Number Address ~ D Evaluation Conducted Telephone Number 7 ~S~/7/~ 7 c f/ Property Owner ~° t f.~L Y~ 1J-1a~~~ Parcel ID rt `--~ ~ ^ Boring - Rnrinn !! i ~ , / Page ~_ of 3 `~ ~ -J I ~Plt Ground surface elev. ~~o • J n. ueptn to ummng tactor d ~ in. Soil A lication Rate rizon H De th Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fl~ o p in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ~ a- foy ~ ~~ ~ Slk ~ ~~- ~s i~~ ~ ~ ~ g ~ --/ o `( y L b- ~~ ~ 1 ~ ~ /y ~~ fo~l(2 ~ L f rf 1~~ ~ ~ ~' ~~ II (v ~(~ 3 S ~ L- E i f / ~ So ._~ Boring # U Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon De th Dominant Color Redox Descrip~ion Texture Structure Consistence Boundary Roots GPD/fF p in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2 Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ^ Pit Soil A Iication Rate H ri th D minant Cobr D Redox Description Texture Structure Consistence Boundary Roots GP D/fF zon o ep in. o Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eft#2 I ' Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L `Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L "1'he llepartment of Commerce is an equal opportunity service provider and employer. If you need assistance to access servtces or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8J30 (R.07/00) _ ___ P9t 3 ~t 3 ~~J a ~ 0. I ~l 7~ n I6 ~ ~t a ~~~e r'_ d /eve v~ ; ,~ ~ )c.~c ~~~0 t- ~"~ ~ ~ ~ ~~~G ~~~ a~°~9~ 1 ~ ~ Bl' l ~ I ~ i ~~11, ~bO~~a ~- ~ I ~ `C"~ l o f t ~„ Q;;c P~ p ~` ~, • ?~ I~ 7~r~ ~ E rJ f 4 S `~t~ r --L rv~-2 I-~e ~e S _-„~ +~. R~~i~ }}~,~ ®~ )c.~s~ SE~~n~ ~ t,~ E~1- ~ ~~~ ~~. -+o ~, ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer ~~ ~,~ ~ ~~c,~ ~~ ©r-~-- - Mailing Address ~~ ~, ~ ~ axed- ~ ue~ u ~e_,. (--e~oc>~ U7 l~ p L~J 1 ~~' ~~ Property Address ~ ~{ 2, ~ ~ ~ti D ~~ ~.~~ (Verification required from Planning & Zoning Department for new constructton.) City/State ~lJOOC~ ~ ~ LLe.., ~ i Parcel Identification Number ~ c4 - !O ~ - ~c~ - aoo LEGAL DESCRIPTION Property Location ~~ '/ , ~~_ % ,Sec. _~_, T _~i_N R j (o W, Town of ~a-ee. ~r 11 ~ Subdivision h[ ! A Certified Survey Map # ~ ~p ,Volume ,Page # Lot # ~. Warranty Deed # `~ 5 5 7 (C~ ,Volume ~ (~'~ ,Page # S~ Spec house D yes ~,no Lot lines identifiable dyes (] 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. 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 _~ SIGNATURE OF APPLICANT(S) ~/~ ~ D7 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) ~ , _ , _ _ __ ~... ~ - ~ ~ ~ - fMte ~~'~A~ ~P~ ~k~ ~` "tea was wwiwsn :ai ~ICaewM+ ~.y ~ ^y. _ wnr ono II rr11II `L~ ' ~i~~R ~ V«~b 1,~..a. ~. ~~ Tl~~t Deed sa-de between ......~.',`.",`'j" ^E;it'+C~ ' ~r ~AO~X OCR, Wf ~ ~ ~~ ..... ................................................................. ..... . : . Ile~'d ~ M~ord "' .................... _.......................................... ..... .. ..... ..... ...... .............. ........................ ............................... (irsnlo:, wrn~s , R...Dudaar~rth a single ltlilTl sad ..... ...............,_...r..... . ... ..........,*....................-----....... ~ F ~ B v 71990 11:00 A. M ...._.:.::~~:: ~ :.:..:::...:::~~:_::::..::::~ _ ...: :.:~::::......:::::~::::::::::::::::::_:::: a ~~ ~lipiMerefO~ ............................................................ .............................. .. (irentae, w1t11888@tl'1, That the u9d Grantor, for a valuable consideration...... .. NY`f ~~.._ Dollars... ($95_t 000_. 00~ . . ... . ~ .. ~~ . .... ... conveys to Grantee the following described real estate in .......... ,,.,,-.__-. e srullM To `` Co;u,ty, Rlate of Wisconsin: Northeast Quainter of Southra~est Quarter (NF}t of SF$1) Of Sl4CtiGn 15, 'lbws 28, RSitge 16 t 8190, Ta: Parcei No .................................. OtatetenGfng at rirarthtil~st oazner of Southeast Qtl2trter of 9ialt2lwast Quarter of Suction i5, Tai 28, Range 16: rta~uling t2lerloe East 40 rods; thence South 12 rods; the~loa nest 40 rods; thence North 12 rods, t0 place of he9i»nincJ• Also,, A strip of land 1~ rods wide on the West side of Southeast Quarter of Nortlliaest Quarter, of Section 15, Town ?8, Range 16; said strip of land being about 34 rods long aryl xtulni.ng from the public highway oam>orlly 3alawn as the Stage Road on the North; 1 the:~oe SOUth to North line of S4~ of SectiCn 15, Zbwn 28, Range 16. . 0~ ~~ This ...........~& ............. homestead property. tis) (ia not) Together with all and singular the hereditaments and appurtenances thereunto belonging; Ann- ---- -.... h].ayd..841x'S:?i... --- -- ................... ......_ - ....- --- ----................_............_..................... warrants that the title is good, indefeasible in fee simple and free and clear of encumbrsncea except and wilt warrant and defend the same. Z O Jan ~ .................. la.... 90 Dated this ---------•--- - - ......-... _- --_..... -- day of -- ---.__ .............~~_....----........ ~~~'Lc-...-......- (SEAL) ............ . . ............................•------.............. (SEAL) r Lloyd ~~ - - ................ ........_(SEAL) -- -.............--- --- --•---..........---......................(SEAL) AUTHENTICATION sianatnre(a) of Lloyd Burch ---- •--------------•------------------.........---•--------...._......_-•-90 this .~.O.day of.....Talll]3Ly.._...-, 19...... PDbert R. Gavic TITLE: ffiE]fIBE}t STATE BAB OF WISCONSIN (It not, ...------•---...------•-•-•--•------•----------------------- atrthorirad by ~ 708.06, Wia. Stets.) ACHNOWLEDOMBNT STATE OF WISCONSIN ~ sa. ----•-----•-•--...-------•-•--...---..County. Personally came before me this ................day of -----------------------•--......---......., 19........ the above named I to me known to be the person ............ who ezecuttd the foregoing instrument and acknowledge the same. TMlel INSTRUMENT WAS DRAFTED BY l~T R. GAVIC Pam Quinn From: Jessie Nye Sent: Wednesday, March 03, 2004 10:52 AM To: Pam Quinn Subject: septic inquiry 'K(r'~2-~ (~ p~r3328 -- 2~2~ 3,L~ ~• ~ (~~c~dv~l~ ~`fbz~ Dennis Duckworth stopped by and was inquiring about the land next to him. he we percing er y for a septic system five feet from his property line and said that was the only place the land was perked. He is concerned that when they put in a septic they will disturb his slopes on the property line. He would like a call tomorrow at 651-747-2201 to see what your procedur of land or anything before approving the ~ Th~and is owned by Pecilunas in Eau Galle section 15. 008-1044-90-000 e~ C~~~ ~~~~° 15.28.16 229 ~ ~`-~ .~ Sd-c.~ - ~ Jessie Nye ~'~ ~~ ~~~ Administrative Secretary ~ ~~~~~ ~~ ~~~~ St. Croix County Zoning Department (715) 386-4680 ~ -~-~Zc~ ~- l~J ~~ s ~ ~~~-s.~ , .~~ 1,-~ ~ ~~, ~~~~ w~~ ~ ~ ~`- .~~ ~.~~) ~~ -Q'~ c`S n S ~~~ -( .~ y _ ~ ~~ ~,avi.a.Q-- ~ ~ ~` 3Zn d ~~ 7 Z - 1 ~~- ~~~ ~ .SG~-„~-~ p ~- l EAU GALLE T.~~~ N-K. Ib W " ~ Jas. t ~y Chac/e,s Circnn .~. v C "°"~ a .PQ/ h : ~~ /¢cde - ~ y` C ~ He /und ~ p Dona/d ~~ ~ ..E -_ ~~ acv s a yc vahn $ Q h ndeitso~ ° L.f/ ~o Gasse E3 '9e;9~.~s ~ h Q \Q bq /.z0 \ 0 q ~ hQ Y 9o q7. ~ 4 L zs /z.~.: •B a9s ~ so A/!a ~ d d hs a ~. C ~ 0 E ~` ,S{ ~ v C B B w' ~ JO h n ka~ ~ry .. 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( 0' ~i • 'A • / C '6 3~ u d A y~a~ p ~ Jj sn ~'r Z~ /~ ~ ~ Gibe/ a/y a s F c.a ' FL ~sso 0.7~ /~6£/ SG.~„ !'tai ~ p\ ~ \ ~ o ~ ~ a w ds %s-o~/ av L~os~oyl ~- ~ ' 0(C V G o ~g~9/ f'L9 Z ~ ~~ ~~ ~' ~? /66a/ ~~D a6i'o ~ d 9 is c ^ay"' g s/i o / ~ ~ r'11a~ .an a u Ma o p ~ : ~ 5'0l~ ~// .au`i~ . o~ a ~J~ ~ >' / • ~ ~ N~' ~ ~ ~ v ~'\ \4 ~ s \ " ~ ~ ~Jny « /~ /-Y o L~ D . . g s n .u J ice/ ~ ~ l o ' • ~ J ~ ~zw /C 9Yd 3.~S ~ (- M LI •2~=N 8Z 1 ~3ni~ Hsn~ ~~ 1~31~1`d/~ 1N`dS`d31d __ ~. ~_ ~ E EAZJ GALLE PLAT ~ ~ T28-N~R16W `` E ~ ~ ne Publishers, Ltd. See Pages 115-116 For Additional Names. Lr ~ i.r BALDWIN PAGE 40 ,~ _ - ..~ A ..,.... .,; m ~ ` .,,.. .. :........ .... t .: ~?--~m . ~ ~) S l: R .. ,..,~R""'* .~`..„.,. _ ....~ :.,. g ~ ~,,._ la t...,, .. ....... Paul & _ Ia)ll~ Kenneth Gerald & James & waM Gossel ' Mar Ann Sharon 10 E J - - - Care 1deTSOn &EBen tPeterson Widilcer M 17 2 11 L7~^ 30 Kerry Nei on 60 . ' Eno 35 :0 90 54 Holmes Donald/ tail- 120 _ _,r....- _ „v _ _ Arthur gt udl Daniel A Don Jon Timothy ~a~n ensen J Pete==^n ~ MarrAnn (~ ~ t 81 Pamela g Rn4n Rodel 36 Iverson 3o G Moulton rust Dennis & ~ + av. 56 4 100e xee,a°,n 77 l40 ~ Na & Kristine a ~ l ~` ..~ ~) a., nWn xia Hillstead ~~ ~`_ ° n '^ c gtrken '123 H H CS 15 2 Vang 137 ~ Isob e ~ Halde~ison ! ~ ~ W 7 2 n Rurt A Elinbetb 1 39 ::. ~ Clvistenson 66 ~ D 20 f 5 BH & Ohn50n .+ ~ : :q ' lbnald ge J imothr X aobe=t a 94 .:..::::.:.:.~ :.. ::. ~ o rr >: Judith 22 b Pamela Michael ~~~ , David & ite~'ar%. ~s g~= ~ ., b~ Trapp x~ ;odes 146 Dec rave 3z ^ ~ Lee "'tea J Y ^ - _ ' rtb 3 `~ °'2 0 38`a«n BC O L&N 20 Trudy Taut 36 '~` 3: Ia obs~on 9 ° thl 32 Dpt 43 tl ~0 Ostlie 94 Reinsch 88 "~~x 3a x ' Dennis , 3 Rffis Glenda Ts _ v~aim em 50th AVE Greg& G~ ass ~ gM 1 n& ffiDiane at stave anal p; Trust. 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Q ~ I ~ '~; 3 Z O O O O = ~p I o D 'o ~ ~ ~ ~ A S ~ 'a ~ ~ ~ I p O '+ n fl. c y y y N O c y y y~ ' ~ `1 °~ N 6 9 O G O N ~ ~ O G Cn O l~ = 7 N .Ni Dl ~ 7 N rr Dl 'O O Vro'/ !\i ~ y N ~ d N N O '.. i j ~ ~ ~ ~ 7 ~ , Q ~ ~ ~ ~ Z N _ o N u o I D D o ~ 0 D ro O I O c ! ~1 I ~ ~ d ~ I ? a tr • 7 ro W ~ N t0 N A tli ~7 ro ~_ N - c 7J m o (V i c ~ c ~ w m °~ m O a Z 3 ro ~ ~ 3 ro m N -~ ` -'1 y ~ > y C > N C ~ p ~ ~ 2 ~D ~ n n N 7 d 6 ro ' ,'p Z O ~ 3 .. ~~ ~, N O I I Z ~ "' cn oo~ W~ Im ~ fD ~ a I a ~ 3 ~ I a Z ~ r: ° I ~ ° ~ ~ o 3 o ; 3 ~ rn ~ N Z N Z1 _ ro ~ ~ A N W N (nD ~ C O~~ X C F O pD, ''. d f~D N ~~ 3 7 a cc D. ~ ,+ i ( p 7 7 a G ' 0 _ ~ N CD ro N O 3 N T C ~~ ~ N T C '. i T ~ N 7 W ~p ~ 'p .~ O. p N ro Z O G Z O d I 3 ~ N y ~~~ 3 roo~ i ~30 -« ~ m N ro Nr.C< C ~ o ro __ cOi ~ ~ m c Q7 ro x ~ ~ I '; y 3 y ~ ~~'=N ~ 4 ~ ~ ro = ~ ro ~`~ N N ro ~ ro ~ ~ y ~- i ~ ~fl-N ~ O ',~ ~ ~, (D n 0 0 f~ fD ~ ~ eD O ~ I I C N ~ O ro CD ti I o I i ' I b ~" > ro I > ro 'I aro ° v~ O I 5e 0 I ', ~ ., A .q o p g o f i ~ ~ ,y~ i p ~. Al „„r Wieoonsin Department of Health and Sooial Ssrvioes F1'o. fj~6T 370 * division of Health SEPTIC TANK PERAfIT APPLIC~'1TION ?YPE or USE BLACK INK A. OWNER OF PROPERTY Name Address (Street, City, Zip Coda) ~~ B. LOCATION O_F_ PROPER_TY WFC'.RE SYSTEM WILL BE CONSTRUCTED. ALTERED OR EXTEA'DED COUN?Y ~~ Chook One: ~ CITY VILLAGE LEGAL DESCRIPTION "7~ y /U/~ ~~o ~ TOWNSHIP / " C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO PERMIT NUMBER D. SEPTIC TANK CAPACITY "~ Gallons. NEW INSTALLATION ~ REPLACEMENT ADDITION PIATERIALSs Prefab Concrete x 'poured in Place Steel Other ' NUMBER OF TANKS ?O BE INSTALLED: E. TYPE OF OCCUPANCY ~heok One: One or Txo Fami]y Residence Commercial Industrial Other Speaify Number of Persons to be Aocommodeted Number of Bedrooms F. APPLIANCES, ETCs Food Wsste Grinder YES NO Automatic Clothes Washer :~ YES NO Dishwasher YES NO Automatio Potato Peeler YES NO Other (Speaify) G. MASTER PLUMBER MAKING INSTALLATION Name:, T •;,~ ~' ••T I ., ..r ,. a ~. ,~ ,: Address=;:: +~ :, 'Lloenss Number: MP Signature of Applicantrs. ~`~'~'-`".~•. """' (`~,-`•~-'-~.°-.~-~•~.'"""""• MP RSW; ~'t r Address s t.,.; ~ . '! • ( ~.:~, r> ... , ~ ~..~ ~=- .., .:~-.-.- H• (?o be Completed by Issuing i~.gent) / Data of Applioation ~ ` ~ d - ~~ Fee Paid t- _~ Permit Issued (date) ~ _~ v - ~~ permit Humber ,r'. ~ /=_~ _ Ageat (Name) ~ -~ 6 (~ ~,., Fors _~~ ~~ ~! 'i. '~ Towr., Village, City, CountycT-etc. • (Speoity) -Notes The applloation cannot ba ..nsidered for filing until all oP the above questions are answered and the tee paid. Agents will foresard application, the fee of $i.OG for each sep+.ic tanK and the third oopy of the permit (canary) to the Division of Health. Checks and money orders.ahould be :~.de payable to •' the Division of Health. Do not write in space below - FOR DEPARTMENT USE ONLY `` ~;~. ~ / I. DATE RECEIVED ~ `= '' ACCEPTED BY t""J RETURNED (Initials) (Date) See Corres.) FEE RECEIVED ~ .VALID. No. ~ ~~~ PERMIT N0. r'~ / es or No REVIEWED BY APPROVED DATE (Inltials) -Yes or No COMPLETE 0?I.Eic S•i0'E' r .. „r SEPTIC TANK PERM(? N0. %/~? ~ ~ ~ R E P O A T 0 K S O I L P >Z R C O L A T I 4 N ?EST AND SOIL BORINGS ~~CEIV~~ TO DIYISION OF HEALTH • PLIxIDING SECTIbi! MAY 1 4 ~ J j P.O.Box 309, Madison, Wis. 53701 ClVIS10~1 n^ ;~ z4~'cJ Pursuant to H 62.20, Wis. Adainistrative Coda p,,;, ~~ ` 6 EAJ C RB PERCOLATION TES T Teat Depth Character of Soil •Hours Water Test Time Dro in Water Level Inches utes Number Inches ?hSoknoss in.Inohes Since Hole in. Hole Interval Second to Next to Last o Fall 1st Wetted Overni t in Minutes Last Period Last Period Period Ono~In^h Example 4 36-~ T o .:Soih 10~ - C "P6µ' • ` 25^~ Yes- ar No 30 1 2 1 2 1 2 60 i .j r /~ ~ RECORD DATA FROM MINII'ttlM OF 3 TEST HOLES Compute size of absorption area in accord with H 62.20 Wis. Administrative Code. , SOIL BORINGS • Minimum 36" Below pro osed Abso Lion S atom Boring ?otal Depth De th to Ground ~Tater De th to Bedrock Number Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches Exanpls B - 0 72" 72" ~ H Black To Soil 12" C1 18" Sand 18"• Gravel 24" I ~. L ~f' N r, ~ ., , vC .7dnP it " S, 1 ;ice ~'jY..rV sy C1:s .r. -tii. 'L . ~ ., .. ~ y~ 3~'' ~ ~~ •~ ., ,, y' ., .y~ ., ,,3,,. RECORD DATA FROM MINIMUM OF 3 BORE HOLES PE OF OCCUPANCYs RESIDENCE: Nua-ber of Bedrooms _~_ OTHER= (Specify) ~ Number of Persons ~-- D WASTE GRINDER= Yes No ~'i.~ Dishwashers lea No ~_ Automatic 4lothes hashers Yes _~'~ No • FFLUENT DISPOSAL SYSTEMS NET ~ EXTENSION ADDITION REPLAC£i~IENT Tile Size ti' ~ No.Lin•Feet .;.~ Trench Width 1 Depth ti'S~ ~ Number of Lines Seepage Bads Length Width Depth ?ile Size No. Lines ~~ ......... Seepage Pits Inside D'..xmeter Liquid Depth _ I~ the undersigned, hereby certify that the percolation tests repai•ted on this form were made by ma or under my su er- p vision in acaord xith the procedures and method specified in Chapter H 62.20 (13 ), Wisconsin Administrative Code, and that the seta recorded :nd location of test holes are correct to the best of my knowledge and be11eP. NAME ~- '~,= ' i ~' - ; ~y !I.r /Z S r -v: TITLE Type or print REGISTRATION N0. , .1 /~.'; i :.t, tI 'L `, or MASTER PLUMBER LICENSE N0. .ADDRESS ;,., !. ~ x /r. _" !~ ,'-~, a? w, n.• v t S F' ~/~ ~--- ~- DAtE ,7i~,', r~ 3 ~ ~ ~cJ h / SIGNATURE ~'T- ~'-_~-~".s~ `,`j- _ /' C~:.~-^~ , a - .1