Loading...
HomeMy WebLinkAbout040-1320-00-008 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT sanitary Permit No: (ATTACH TO PERMIT) 556335 0 GENERAL INFORMATION 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: Miller, Vincent and Carolyn Bates Troy, Town of 040-1320-00-008 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: y1~\ I 24.28.20.2155 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURE S CAPACITY STATION BS HI FS ELEV. 3.95 1 3, 5 It C-6 Septic T Benchmark d W: e , rDd~ y 3 142-3 Dosing AI BM J Air ~ J S G 7q Aeretiefl- Bldg. Se er Holding St/Ht Inlet ` TANK SETBACK INFORMATION St/Ht Outlet TANK TO , P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Pl~ Dt Bottom Dosing / J /i Header/Man. 11A- Z. 3 Aeration Dist. Pipe z .53 /a!• 37 Holding Bot. System 3.3Y /6G 57 Final Grade PUMP/SIPHON INFORMATION l1 5 7 /GZ . 3, Manufacturer Demand St Cjqver y~ 6GS 1. ( GPM F, r) if 5"40 ' .7 • 7ct Model Number :36, a1'a"f S• 35 yT 55 TDH LFriction Los System Head DH C L F 16 71 , 7 DI &I .56 - -(I P c~ ID 4~. Forcemain Le1710 Dia. i Dist. to Well Z JA- SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of T en he PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / ~5 {4 t SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type f ystem: CHAMBER OR Model Number: Ma- / g A114- DISTRIBUTION SYSTEM Header/Manifold f Distribution / at Jr r/ / x Hole Size 1 i x Hole Spacing Vepito Air Intake Pipe(s) -7 J Lengthy Dia 2 Length Dia / Spacing 'T 204 SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only e% Depth Over Depth Over xx Depth of //mar xx Seeded/ odded xx M Iched Bed/Trench Center BedlTrench Edges Topsoil Yes No es No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: g / 27/ y Z' Inspection #2: /Z p f-66 Location: 286 Cove Rid Drive Hudson, WI 54016 (NE 1/4 NE 1/4 24 T28N R20W) Cove Ridge L t 8 Parcel No: 24.28.20.2155 1.) Alt BM Description = PL 65"V. In c; : n 3 Pit 2.) Bldg sewer length = z 5 - amount of cover = `I &A4 ~ PAA, Plan revision Required? ®Yes No Z ~T /6 iS Use other side for additional information. SBD-6710 (R.3/97) Date Insepct s Signatiff Cert. No. a~"ar"avT County Safety and Buildings Division St. Croix 201 W. Washington Ave., P. ox 7162 Sanitary Permit Number (to be filled in by Co.) P Madison, WI 53707 2 335 r w to Transaction Number 5 hermit Application 1037 In accordance with SPS 383,21(lj, Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Services. Personal information you provide may be used for secondary Gam. X purposes in accordance with the Privacy Law, s. 15.04 1) m , Stats. 86 ( 4e Ridge Drive 1. Application Information - Pleas t All Information Property Owner's Name Parcel # `\J Vincent Miller & Carol Bates 040-1320-00-008 Property Owner's Mailing Address Property Location Govt. Lot City, State Zip Code Phone Number NE NE Section 24 (circle one) Chippewa Falls, WI 54729 715 xxx-xxxx T 28 N; R 20 E or W II. Type of Building (check all that apply) ok. eh Lot # El 1 or 2 Family Dwelling - Number of Bedrooms 3 Subdivision Name 178) Cove Ridge ock # El Public/Commercial -Describe Use ❑ City of Na ❑ State O Inalis ca wned - Describe Use CSM Number ~J V ill ge of ~ LKTown of TioV C Na ~ III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. New System ❑ Replacement System ❑ TreatmentlHolding Tank Replacement Only ❑ Other Modification to Existing System (explain) List Previous Permit Number and Date Issued B• ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New Before Expiration Owner IV. Type of POWTS System/Component/Device: Check all that a 1 ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil 9.6.und 124 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treat ent Area Information: Symtech STF-100 effluent filter Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Requir (sf) Dispersal Area Propose sf) System Elevation 1.0 gpd/sq.ft. ASTMC-33sand is 100.67' at 20" above 450.00 Gpd 0.6 d/s .ft. native soil 450.00 sq. ft. 450.00 Sq. Ft. 3 99.00' contour VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units y o $ o New Tanks Existing Tanks n `7 ! w a Y Y YQ wl w U v~ y rn w C7 ci. Septic or Holding Tank 1,000 0 1,000 1 Wieser Concrete X Dosing chamber 600 0 600 1 Wieser Concrete X VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature / MP/MPRS Number Business Phone Number William Schumaker MP 227990 (715) 386-2131 Plumber's Address (Street, City, State, Zip Code) 1070 Scott Road, Hudson, WI 54016 VIW, County/Department Use Only Y_,Approved reapproved Permit Fee Date Issued Issuin ent Signatu $ pb Cj Owner eason for Denial / l z' IX. CondiqMt,W"WReasons for Disapproval 3> Go A' j S~a rat DD ~tJo ~G G 1. '$eptic tank, effluent filter and J ~ dispersal cell must all be services / malntained re n G lr`t~~leC~ w ernes 1~ as per management plan provided by plumber. 2. All setback requirements must be,rrtalntaifidd as per applic" code/ounces: Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size SBD-6398 (R. 11/11) i ~./e.✓a/ua.t'on~~~ ~ EXisv"~y ~ra.de 2(ev~ • ~Jro/ae/E~ 5~.~ ZSG ernix~ d c lr: Propoxd Lotaw y ` erncrte Ply/4m-.,{,~ 0 tdson, u7/. s~Dl6 ' 6m4-Gon S.T P.c w( lot 8 /~~s oFC'v~e eid~+~, Aly-,-oA-'A efr-'Awtmt4 4 e.- e-t s. T.' ot,,tl. i. iQ 1 v , c~ T-1. °►e7'rnny, aFEv.,~on~ so/,al9rby.o! d S! 'ff.ST. 30311 S7 94Cre-S ~7Ki /d:~~ ,Seu7u ~ 5f1' -~'sOr7 ~ar4y~ _8anc-~ rK&:(,E' o = l~.a? Al la 9,0XV C. -r-, .5 6A.6e 4f ~ ~ ~crce.recu~t.- ~u. S.G.S ~,(ev!-= ~o is'i97~ P~uPosed I 3 64f- drCo,,., 'P~'s~denee ~ I ~ i t I i~ .4 I`x'ooi IIl` Propose ormo441 ai, ol:~oc/scc/ CSI/.7'wo (Z) .r diStfr'i bu,&,o la,6r-r&~S 4--/- 1,AP r 73, KSySf'+,m et~~ Abe /oo.G~'ef • r , I 1 C'o~ 9$SO'r< <~'dP? d-re; x Ae,dye Tod t~rl'v e- lof. sf~ rF'e. ,4ssu,r cam/ a lc.vA - 93n. ozz ~z' CLL( - de - Sac- P9.8 or` 9 ozy3~Eea aTMF~ Safety and Buildings boo PO BOX 7162 D P MADISON WI 53707-7162 ` K Contact Through Relay 3 ~ S l P S y www.dsps.vA.gov/sb/ yd -mow www.wisconsin.gov A~Oss~oNP Scott Walker, Governor Dave Ross, Secretary September 12, 2012 CUST ID No. 227990 ATTN: POWTS Inspector WILLIAM C SCHUMAKER ZONING OFFICE SCHUMAKER PLUMBING ST CROIX COUNTY SPIA 1070 SCOTT RD 1101 CARMICHAEL RD HUDSON WI 54016 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 09/12/2014 Identification Numbers Transaction ID No. 2146372 SITE: Site ID No. 783717 Vincent Miller & Carolyn Bates Please refer to both identification numbers, 286 Croix Ridge Dr above, in all correspondence with the a enc . Town of Troy St Croix County NE1/4, NE1/4, S24, T28N, R20W Lot: 8, FOR: Three Bedroom Mound System / 16 inches to Limiting Condition Object Type: POWTS Component Manual Regulated Object ID No.: 1390747 Maintenance required; 450 GPD Flow rate; 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.01101); Effluent Filter L 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 and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. 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: Reminders • This system is to be constructed and located in accordance with the approved plans and with the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems Version 2.0" SBD- 10706-P (N.01101). • This system is to be constructed and located in accordance with the approved plans, and the "Mound Component Manual for Private Onsite Wastewater Systems Version 2.0" SBD-10691-P(N.01/01). Reminders • 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. • 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. WILLIAM C SCHUMAKER Page 2 9/12/2012 • The area within 15' downslope of the dispersal cell shall remain undisturbed. Vehicular traffic, excavation or soil compaction is prohibited in this area. • The existing POWTS shall be properly abandoned per SPS 383.33, Wis. Adm. Code. • The upslope edge of the dispersal cell aggregate shall be aligned along the 99.0' contour for as long as possible. If backhoe pits encroach into the basal area, care shall be taken to make sure that it is completely back- filled. • Piping material throughout the entire system must satisfy the proper ASTM specifications as required SPS384, Wis. Adm. Code; (see the Tables in SPS 384.30-1 through 12). 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. A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. 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. Sincerely, Fee Required $ 250.00 Fee Received $ 250.00 Balance Due $ 0.00 Robert Kanter UDC Engineering ConsultPhtegrated Services WiSMART code: 7633 (608)261-6541 , Monday-Friday 8:OOAM - 4:45PM robert.kanter@wisconsin.gov cc: Charles L Bratz, POWTS Reviewer Il, (608) 789-7893, 7:45 am - 4:30 pm Monday - Friday MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Vincent Miller & Carolyn Bates bedroom residential mound Estimate Owner's Name: Vincent Miller & Carolyn Bates Owner's Address: Site Address: 286 Croix Ridge Drive Legal Description: NE1/4 NE1/4, Sec.24, T.28.N., R.20W. Township: Troy County: St. Croix A-. . Subdivision Name: Cove Ridge Lot Number: 8 Block Number: Na a t;"E t-.it3 ll_ Parcel I.D. Number: 040-1320-00-008 Plan Transaction No.: C;d~~rNCE Page 1 Index and title Page 2 Data entry Page 3 Mound drawings !RECE'VED Page 4 Lateral and dose tank 1 2012 Page 5 System maintenance specifications AEG Page 6 Management and contingency plan ~LDINGS Page 7 Pump curve and specifications SAFE & gU Page 8 Site Plan Page 9 Attached soil evaluation report Designer: Bill Schumaker License Number: 227990 Date: 08/20/12 Phone Number: (715) 386-3121 Signature: Designed Pursuant to the Mound Component Manual for POWTS Version 2.0 SDB-10691-P (N. 01/01), and both SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST-SAS (01/81) and Pressure Distribution Component Manual Ver. 2.0 SBD-10706-P (N. 01/01) Version 5.1 (R. 06/06) Page 1 of 9 Mound and Pressure Distribution Component Design Design Worksheet Site Information (R or C) R Residential or Commercial Design Note: Sand fill (D) calculations assume a 300.00 Estimated Wastewater Flow (gpd) Table 83-44-3 in-situ soil treatment for 1.50 Peaking Factor (e.g. 1.5 = 150%) fecal coliform of - 36 inches. 450.00 Design Flow (gpd) 5.00 Site Slope 99.00 Contour Line Elevation (ft) 16.00 Depth to Limiting Factor (in) 0.60 In-situ Soil Application Rate (gpd/ftz) Distribution Cell Information 75.00 Dispersal Cell Length Along Contour (ft) = 6.00 Cell Width (ft) 1.00 Dispersal Cell Design Loading Rate (gpd/ft2) 1 Influent Wastewater Quality (1 or 2) Are the laterals the highest point in the distribution Y Pressure Disribution Information network? Enter Y or N (C or E) E Center or End Manifold 3.00 Lateral Spacing (ft) If N above, enter the elevation ft 2 Number of Laterals of the highest point. 0.125 Orifice Diameter (in) 2.00 Estimated Orifice Spacing (ft) = 6.08 ftz/orifice 2.00 Forcemain Diameter (in) 220.00 Forcemain Length (ft) Does the forcemain drain back? ~ Y 82.00 Pump Tank Elevation (ft) Enter Y or N 6.50 System Head (ft) x 1.3 35.89 Forcemain Drainback (gal) 18.38 Vertical Lift (ft) 67.38 5x Void Volume (gal) 4.39 Friction Loss (ft) 103.27 Minimum Dose Volume (gal) 0.00 In-line Filter Loss (ft) 30.48 System Demand (gpm) 29.27 Total Dynamic Head (ft) i Lateral Diameter Selection Manifold Diameter Selection in. dia. options choice in. dia. options choice 0.75 1.25 x 1.00 1.50 x x 1.25 2.00 1.50 x x 3.00 2.00 x 3.00 x Gallons/Inch Calculator (optional) Treatment Tank Information r~ 603.36 Total Tank Capacity (gal) 1000.00 Septic Tank Capacity (gal) 36.00 Total Working Liquid Depth (in) Wieser Concrete Manufacturer 16.76 gal/in (enter result in cell B49) Dose Tank Information Effluent Filter Information 603.36 Dose Tank Capacity (gal) Pol Lok~ Filter Manufacturer 16.76 Dose Tank Volume (gal/in) PL-525 Filter Model Number Wieser Concrete Manufacturer Project: Vincent Miller & Carolyn Bates bedroom residential mound Estimate Page 2 of 9 Mound Plan and Cross Section Views 1/10 B J Observation Pipe K s:; ti ~y•JlL ; 5 . ti L..,.ti..,;::~ :1 A W B - :Q : I 41 L - Mound Component Dimensions A 6.00 ft E 23.60 in H [Aft ft K 10.83 ft B 75.00 ft F 9.50 in 1 ft L 96.65 ft D 20.00 in G 0.50 ft J W 25.22 ft 450.00 (ftz) Dispersal Cell Area 1312.50 (ft) Basal Area Available 6.00 (gpd/ft) Linear Loading Rate 7.50 (ft) 1/10 B Obs. Pipe Placement Mound Cross Section View Aggregate Dispersal Area Finished Grade 102.46 (ft) 0 ♦ H ,rrrr„r„ G 1 r,:,...r..:,:rr I F Dispersal Cell 101.17 (ft) Lateral 100.67 (ft)-l- - Invert Dispersal Cell [ Elevation D Y ) i l •4 ~,.ita1. q},~~~~ • y.. ;.,544 i L....,:.. ~ x 4..:1,,z ,~•_z. YL:L. . x . a ~ i~•S'S Contour Elevation 5.0 % Site Slope Geotextile Fabric Cover Shading Key d Dispersal Cell See lateral details on 1 Topsoil Ca 1.5 ft • Page 4 for number, size, p Subsoil Cap y c and spacing of laterals. ,rrr,,,. Laterals are equally ASTM C33 Sand spaced from the 4•<. Tilled Layer H 0.5 ft Typical Lateral © ,f,••f.'r~ ~ distribution cell's Aggregate o centerline in the } A distribution cell (AxB). Project: Vincent Miller & Carolyn Bates bedroom residential mound Estimate Page 3 of 9 End Connection Lateral Layout Diagram aw scoweredovofth irnension ♦.Turn-upvibsllvslworciosnoutplu9 ,I AN Ulwab us i *mwal IF x Mol es drilled on dN bouom of the lueral *waft spaced Fog** amiin oonnoction vii loo or Goss to m4v4old x'&nf poNM- Laarals 6 force main of PVC Soh 40 (per COMM Table 84.30.5) Number of Laterals 2 Orifice Diameter 0.125 in Lateral Diameter 1.50 in Orifice Spacing (X) 2.04 ft Lateral Length (P) 73.44 ft Orifices per Lateral 37 Lateral Spacing (S) 3.00 ft Orifice Density 6.08 ft2/orifice 7 Lateral Flow Rate 15.24 gpm Manifold Length 3.00 ft System Flow Rate 30.48 gpm Manifold Diameter 1.50 in Total Dynamic Head 29.27 ft Forcemain Velocity 3.11 ft/sec Dose Tank Information Locking cover with warning label and locking device and sealed watertight Electrical as per NEC 300 and No Comm 16.28 WAC 4 in. min. Disconnect Tank component is properly vented Alternate outlet location MForcemain diameter Wieser Concrete Manufacturer 2 in. Capacityl 603.36 Gallons Volume 16.76 gal/inch A Weep hole or anti- Dimension Inches Gallons B siphon device A 18.34 307.35 B 2.00 33.52 C Pump off elevation (ft) C 6.16 103.27 82.79 D 9.50 159.22 D Total 36.00 603.36 Do♦ se tank elevation (ft) I 3" Bedding un er tank. 82.00 Alarm Manuafacturer LevelArm Alarm Model Number DLV Pump Manufacturer Goulds Pump Model Number WE05H Pump Must Deliver 30.48 gpm at 29.27 ft T D H Project: Vincent Miller & Carolyn Bates bedroom residential mound Estimate Page 4 of 9 Mound System Maintenance and Operation Specifications Service Provider's Name Bill Schumaker Phone 715 386-3121 POWTS Regulator's Name St. Croix County Zonin De 't. Phone 715 386-4680 System Flow and Load Parameters Design Flow - Peak 450 gpd Maximum Influent Particle Size 1/8 in Estimated Flow - Average 300 gpd Maximum BOD5 220 mg/L Septic Tank Capacity 1000 gal Maximum TSS 150 mg/L Soil Absorption Component Size 450 ft2 Maximum FOG 30 mg/L Type of Wastewater Domestic Maximum Fecal Coliform >10E4 cfu/100 mL Service Frequency Septic and Pump Tank Inspect and/or service once eve 3 ears Effluent Filter Should inspect and clean at least once eve 3 ears Pump and Controls Test once eve 3 ears Alarm Should test month) Pressure System Laterals should be flushed and pressure tested eve 1.5 ears Mound Ins ect for ondin and seepage once eve 3 ears Other Miscellaneous Construction and Materials Standards 1. Observation pipes are slotted and materials conform to Table Comm 84.30-1, have a watertight cap, and are secured in as shown in the mound component manual. 2. Dispersal cell aggregate conforms to Comm 84.30 (6)(i), Wis. Adm. Code. 3. All gravity and pressure piping materials conform to the requirements in Comm 84, Wis. Adm. Code. 4. Tillage of the basal area is accomplished with a mold board or chisel plow. 5. The mound structure and other disturbed areas will be seeded and mulched to prevent soil erosion and help reduce frost penetration. Lateral Turn-up Detail Finished Grade 6-8" Diameter Lawn Threaded Cleanout Sprinkler Valve Box Plug or Ball Valve Distribution Long Sweep 90 or Two 45 Degree Bends Same Diameter as Lateral Project: Vincent Miller & Carolyn Bates bedroom residential mound Estimate Page 5 of 9 Mound System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General This system shall be operated in accordance with Comm 82-84 Wis. Adm. Code, and shall maintained in accordance with its' component manuals [SBD-10691-P (N.01/01), SSWMP Publication 9.6 (01/81), and Pressure Distribution Component Manual Ver. 2.0 SBD-10706-P (N. 01/01)) and local or state rules pertaining to system maintenance and maintenance reporting. No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tanks are no longer used as POWTS components. Septic or pump tank manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8-inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into a tank or component. Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Slats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code. The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of a triennial assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such products are used they shall be approved for septic tank use by the Department of Commerce. Pump Tank The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary. Mound and Pressure Distribution System No trees or shrubs should be planted on the mound. Plantings may be made around the mound's perimeter, and the mound shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic (other than for vegetative maintenance) on the mound is not recommended since soil compaction may hinder aeration of the infiltrative surface within the mound and snow compaction in the winter will promote frost penetration. Cold weather installations (October-February) dictate that the mound be heavily mulched as protection from freezing. Influent quality into the mound system may not exceed 220 mg/L BOD5, 150 mg/L TSS, and 30 mg/L FOG for septic tank effluent or 30 mg/L BOD,5, 30 mg/L TSS, 10 mg/L FOG, and 104 cfu/100 mL for highly treated effluent. Influent flow may not exceed maximum design flow specified in the permit for this installation. The pressure distribution system is provided with a flushing point at the end of each lateral, and it is recommended that each lateral be flushed of accumulated solids at least once every 18 months. When a pressure test is performed it should be compared to the initial test when the system was installed to determine if orifice clogging has occurred and if orifice cleaning is required to maintain equal distribution within the dispersal cell. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner, and any levels above 6 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component(s) shall be immediately repaired or replaced with a component of the same or equal performance. If the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or replaced in its' present location by increasing basal area if toe leakage occurs or by removing biologically clogged absorption and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. See Page 5 of this plan for the name and telephone number of your local POWTS regulator and service provider. Pretreatment Units The information and schedule of mananagement and maintenance for pretreatment devices such as aerobic treatment units or disinfection units are attached as separate documents and are considered part of the overall management plan for this system. Project: Page 6 of 9 GOULDS PUMPS Submersible Effluent Pump ll 1 3885 PROSURANCE AVAILABLE FOR RESIDENTIAL APPLICATIONS. APPLICATIONS ■ Shaft: Corrosion-resistant Single phase: ■ Bearings: Upper and stainless steel. Threaded • Built-in overload with lower heavy duty ball bearing Specifically designed for the design. Locknut on three phase automatic reset. construction. following uses: models to guard against • All single phase models ■ Power Cable: Severe duty • Homes component damage on feature capacitor start rated, oil and water resistant. accidental reverse rotation. motors for maximum • Farms Epoxy seal on motor end • Trailer courts starting torque. ue. ■ Fasteners: 300 series 9 q provides secondary moisture • Motels •'/3 and 112 HP- 16/3 SJTOW ~ • Schools stainless steel. barrier in case of outer jacket • Hospitals ■ Capable of running dry with 115, 208 and 230 Volt damage and to prevent oil three prong plug. wicking. Standard cord is 20'. • Industry without damage to • 3/4-2 HP -14/3 STOW with • Effluent systems components. Optional lengths are available. bare leads. ■ O-ring: Assures positive ■ Designed for continuous Three phase; g' SPECIFICATIONS operation when fully • Overload protection must sealing against contaminants submerged. be provided in starter unit. and oil leakage. Pump • Solids handling capabilities: • 112-2 HP - 14/4 STOW with 7." maximum. MOTORS bare leads. AGENCY LISTINGS • Discharge size: 2" NPT. ■ Fully submerged in high- ■ Designed for Continuous • Capacities: up to 140 GPM. grade turbine oil for lubrication Operation: Pump ratings are Tested to UL 778 and • Total heads: up to 128 feet and efficient heat transfer within the motor manufacturer's CSA 22.2 108 Standards . TDH. recommended working limits, By Canadian Standards ■ Class B insulation. Association • Temperature: can be operated continuously CM us File #LR38549 104'F (40°C) continuous without damage when fully 140~1` (60°C) intermittent. submerged. Goulds Pumps is lso Soot Registered. • See order numbers on METERS FEET r ( 7 SERIES: 3885 - 9 P p - 130 SIZE:'/,' SOLIDS ecific voltage sl haserand RPM s 40 - SEEIE: lzol o a available. F- R RP i 1 35 110, WE2QH i i I SGPM _ r T 30I 100 f FEATURES _ FT I _ 901 WEt$H ■ Impeller: Cast iron, semi- V F I 1- r 801 z open, non-clog with pump-out E7 H = 25! vanes for E0H al 70 a 20 j r , Balanced for Z protection. 60 smooth operation. Silicon ° w o a 151 bronze impeller available as o 50 E H - - an option 40;.._... - I i ■ Casing: Cast iron volute type7-bhf 2"rNPTxd schae eaency. 51 20 WE03L g 10 ■ Mechanical Seal: SILICON o~ ol- 3 40 50 - 6o io~so CARBIDE VS. SILICON o 10 20 90 100 110 120 130 140 150 160 GPM CARBIDE sealing faces. 5"- - j -_L - - 0 15 20 25 30 35 m3/hr Stainless steel metal parts, CAPACITY BUNA-N elastomers. 30-VSCAr! mini,nury 5141d-°r Goulds Pumps 2002 Goulds Pumps ITT Industries Effective October, 2002 WWW.goulds.com ~~rr~~JJ jJ i/y ~ SaY Wa/ua ~'on /o, E • EXis~:ny ra.de Zlev., • /Oro~atlEy S&E s r/,r~G¢rrt ~jl/NL '~ly p~oposcd ~ates~r 2841 CIOV dyc !fir Cwnbinc.~s arr P. e; w/ Lot B ~~ir.~ oF~'v~f dot,/y4aAlArssse E ~Eyy.le,',V s 4,.2V T'.284, "suC. ~d,4Je ;,7 l dui` gyp. s v u~, 71 arC77~0% aFEa,,,ron so/,d~~»y►d_ d .S~•eraiX a; u~l. ~ /oe:l. ~osto-/dZo-vo..c~a8 yr.,4.ST. ~r(, 303 7 j,. S/9QcrCs bk: /d:n~ SewN Co n 5t 1, won ~a4yC BA nCk =Ad: ad 0 ~ Pia ascd ~c~rcrwta;vl. (ct. S.G.S ¢lec)- 'Aye ~si97~ P 3 btGdre r ~isrdetice ~ ~ ~ -g proposedMou.ndQ,i. 0 3, ; s'su1 x9G.G1.;1 G"rrs' aQ FPO, 99.SO~ aVOix k,dye e lc.v~ - 930. oz2 yz Cc,- -cde- Sac.- P9.O oF9 4 Wlsronsin Department of Commerce OI L RVAMv~.i R ORT Page 1 of 3 Division of Safety and Buildings *hofizorda Cantu 85 Wis. Adm. Code A P_ 9 ~ ST. cROi3c Attach complete site plan on paper n81/2 in size. include, but not limited to: vertical an(BM), direction and ParI.D. percent slope, scale or dimensions, row. a arxfi ~ IN a grpad. Please print aN iMorma . Re by Date . 11 Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location BIn El OMAR HEIGHTS, LLC SE 1/4 SE 1 Z.2 S 13 T 28 N R 20 E (or) W Property Owner's Mailing Address Lot # # Stjbd. Name or CSW 6810 Brookhill Drive 8 - (Pending) ( City State Zip Code phone Number []Village own Nearest Road Salt Lake City, UT 84121 ( ) NK South Cove Road T4PQY N@w owAimm UNIj l i f 9f M1 4 t "MR faw fa No @P® ® R"lacement Pubic or commercial - Descift: Parent material till Flood Plain elevation if applicable IAA ft. General comments Mound System /I q. sand fill - 0.6 loading rate and recommendations. To be designed by designer or installer using a long, narrow design (If pre-treatment system - ft. mound sand) (-1 n Boma ' A ' BoriN # u ' u Ground Q Pit surface elev. RS4. 43 ft. Depth to tanilirg factor 16 in. Soo Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/FF in. munsell Qu. Sz. Corti. Color Gr. Sz. Sh. -Eff#'i '01102 1 0-4 7.5YR2.5/1 - sl 3fabk mvfr cs 3vf-co 0.6 1.0 2 4-12 7.5YR3/4 - l 3fabk ds cs 2vf-co 0.6 0.8 3 12-16 7.5YR3/4 - scl 3fsbk mfi cb 2vf-co 0.2 0.3 4 16- - - lsbr - - - - - - F-] B Boring # ❑ Boring 17 ✓ Pit Gmurid surface elev. t . b ft. Depth to limiting bCtar in. Sol Awlicatiori Rate Horizon Depth Dominant Color Redox Desc iption Texttare St u&m Consistence Botutdary Rods GPDW in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. "E11#1 'Efr#2 1 0-6 7.5YR2.5/1 - 1 3fabk mvfr cs 3vf-c o 0.6 0.8 2 6-13 7.5YR2.5/3 - 1 2fsbk ds cs 2vf-co 0.6 0.8 3 13-17 7.5YR3/4 - 2fsbk mfr cb 2vf-co 0.6 1.0 4 17- - - tsbr - - - - - Horizon 3 has 35% rock fra#meats. Eftkxx t #1 = BOD > 30:5 220 nglL and TSS >30 < 150 mg& ' Eflklent 11x2 = BOO < 30 mgA- and TSS < 30 mglL CST Name (Please Print) - - nature CST Number Mary Jo Hollister Z 224832 Address Date Evakration Conducted Telephone Number W9875 690th Avenue, River Falls, WI 54022 10 - 21 - 05 (715) 426 -1775 O BOMAR HEIGHTS, LLC (Lot 8) Parcel ID # (Pending) Page 2 of 3 Property 11 0an"9 16 / in. [71 Boring # Ground surface elev. 837,73 ft. Depth to limiting fades Pit Sol Rate Horizon Depth Donwrant Color Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munsell Qu. Sz. ConL Color Gr. Sz. Sh. '001 'Eff#2 1 011 7.5YR2.5/1 - sl 3fabk mvfr cs 3vf-co 0.6 1.0 2 48 7.5YR2.5/2 - sl 3fsbk mfr es 2vf-co 0.6 1.0 3 8-16 7.5YR3/3 - 1 3fsbk mfr cb 2vf-co 0.6 1.0 4 16- - - lsbr - - - - - ❑ ~ pn t Ground surface elev. ft Depth to "Brig factor in. Sod ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roofs C411M in. Munsefl Qu. Sz. Cont. Color Gr. Sz Sh. 'Eff#1 'Eff#2 Boring Bodn9 # F-1 laPit Ground surface elev. ,L Depth Writing factor in. Ram Sol Application Horizon Depth Dominant Redox Description Texture Structure Consistence Boundary Roots GPDW i9: Mlll 011: @: D®fA: Effluent #1 = BOD3 > 30:5 220 mg& and TSS >30:5 150 mg/L ' Effluent #2 = BODS < 30 mg/- and TSS < 30 ng/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 alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBI"330Ted (R07/W) Plot Plan for Cove Ridge Page 3 of 3 Town of Troy, & Croix County, Wsconsin Lot 8 I" = 50 ft. Legal Description s~A vF -rte seAs3ec. iza, 2,t. contours T28N,,,,~ = Backhoe pit A.4~ O . BENCH MARK: TOP OF 1 1/4" IRON PIPE 25.11873' U" Q qI: 938. 6- a 8 1:939.42639' A SCALE:1 "=50' q1:937. 816' / BENCH MARK. TOP OF 1 1/4" IRON PIPE 4U / Q ~ 1:93 . "-7A O / AEI: 939.12221' ' Plot Plan for Cove Ridge Page 3 of 3 Town of Troy, St. Croix County, N'' sconsin Lot 8 I" = 50 ft. Legal Description sm A of - Yu, 5Z fl. contours - ~ - Backhoe pit -f28 N •RZOv~I 17 RONPFE I:93- 5 1873' i ELI: 938 ' G 1:939.42639, T Zo RB-8A t1LC. -,u 1: 937 2816' MARK: J TOP 1 1 " M2 PPE O 1:93 ' 1:939.12221' 00 / Parcel- 040-1320-00-008 04/09/2008 08:42 AM PAGE 1 OF 1 Alt. Parcel 24.28.20.2155 040 - TOWN OF TROY Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 07/31/2006 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - BLH DEVELOPMENT CORPORATION INC BLH DEVELOPMENT CORPORATION INC 502 2ND ST STE 204 HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 286 CROIX RIDGE DR SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 1.519 Plat: 11-008-COVE RIDGE 040/06 LOTS 1-13 SEC 24 T28N R20W PT NE NE; BEING COVE Block/Condo Bldg: LOT 08 RIDGE ('06) LOT 8 (1.519AC) i Tract(s): (Sec-Twn-Rng 401/4 1601/4) 24-28N-20W NE NE Notes: Parcel History: Date Doc # Vol/Page Type 07/31/2006 830969 11/008 PLAT 05/02/2006 824187 WD 12/07/2005 813723 2940/194 QC 08/02/2005 802065 20/5033 CSM more... 2008 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 08/24/2007 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.519 273,000 0 273,000 NO Totals for 2008: General Property 1.519 273,000 0 273,000 Woodland 0.000 0 0 Totals for 2007: General Property 1.519 273,000 0 273,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 )SED DRIVEWAY LOCATION. -900~%" ;T BUILDING OPENING ELEVATION ABITABLE STRUCTURES. ``hex )USLY RECORDED INFORMATION. °f A4~ ,f ~•e•'s, oa ~ Q 1.693 ACRES .4 73,757 S.F. NE 114 -NE 114 SE'CRON 24 All* / •O, Q' f f 1.516 ACRES 41. 66,'I' 63 S.F. Sip .*N Ile (0 k ~p f.~. ~ w ~ F rr. • ~M. w wn"w w w~rl• w .~yw.Y w ~kwwl x ~qRM v ~ w tiq. 224.76' Grp ~ •k..ww.....~........~... wrw,.. _ ~ . iz, 1.455 ACRES aa~¢ t.. 63,389 S.F. • a Rte.,, R=8®` 0001 Cll w 95.07° 195.07' `Od-•-°''"~. O~6` w w 00.00, 40 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Ownerl8uyer i,'rl t. tai ~ 1 ~ I. Mailing Address 7&P01- 70 S Property Address--- 2 qb In i 1'R1 ix r ~iz- (Vafficahon required from Piamtrng & Zoning Department for new construction.) City/State M UP f r.=tj, Parcel Identification Number`{ c I ~3 2 t`~~ €a LEGAL DESC OTION Property Location -Ii Ur r/ Nis Y- , Sec. T ~_N R ~ W, Town of Tr+tr Subdivision Plat: t_._.e-q u Lot # *5 . Certified Survey Map # Volume S , Page # f 2 7 Warranty Deed # (before 2007)Valume , page # Spec house[? yes xno Lot tines identifiable i~ Q no SYSTEM MAINT'ENANN A" QV ER CERTIFICATION kmproper use and "'intenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists "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 heatment stage in the waste disposal system. Ownerr maintenance responsibilities are specified in Womm. 8352(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The properly owner agrees to submit to SL 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 213 full ofsludge. Uwe, the undersigned have read the above tegnirernents 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 Resomres, state of Wisconsin. Certification stating that your septic system has been m inmined mast 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 amlare the owner(s) of the PraPertY desanW above, by virtue of a warranty deed recorded in Register of Deeds Office_ Number of edrooms SIGNATURE OF APPLICANT(S) DATE """Any information that is misrepresented my result in the sanitary permit being revoked by the Planning & Zoning Depattnent. Include with this application a recorded warranty deed from the Registrar of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 09AM i 8 0 5 7 0 8 6 State Bar of Wisconsin Form 1-2003 Tx:4042503 WARRANTY DEED 956513 BETH PABST I Document Name REGISTER OF DEEDS Document Number ST. CROIX CO., WI THIS DEED, made between Kevin P. Mergens, a single person 05/16/2012 12:22 PM ' EXEMPT#: NA REC FEE: 30.00 ("Grantor," whether one or more), TRANS FEE: 832.50 Vincent T. Miller and Carolyn A. Bates, as tenants in common PAGES: 1 undivided half interests without right of survivorship ("Grantee," whether one or more). Grantor, for a valuable consideration, conveys 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 Recording Area needed, please attach addendum): Name and Return Address Alliance Title, LLC Lot 8, Plat of Cove Ridge in the Town of Troy, St. Croix County, 610 Main Street North, Suite 11 I Wisconsin. Stillwater, MN 55082 Attn: Kami Telschow .4 Mar l*-A. 1)f_X`gtr lL-Ch"6&ft4_ Q w- C~1 040-1320-00-008 i J Parcel Identification Number (PIN) This ,1 ~ 167 homestead property. .(+a) (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except: roadways, easements, restrictions and rights of way of record. Dated Mayi, 2012 (SEAL) (SEAL) * K P. Mer ens (SEAL) (SEAL) * AUTHENTICATION ACKNOWLEDGMENT Signature(s) kIt yo STATE ) authenticated on &°I- C~LINTY ~ ss. came before me on Ma 0 2012 * Personally , TITLE: MEMBER STATE BAR OF WISCONSIN the above-named Kevin P. I ergens, Grantor (If not, authorized by Wis. Stat. § 706.06) S4eenntt in o Ito be the person(s) who executed the foregoing and acknowledged the sa KAMt T1:LSCHOWTHIS INSTRUMENT DRAFTED BY: COMM. #616091;6Redmon Law Chartered (Richard Lau) o ary u is 17 DiA W. l..;! + + sota 401 Second Street, Suit 200, Hudson, WI 54016 Notary Pu , tate of Wisconsin My Corrmrvssior Exotres 1131(2016 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. AtANTY DEED © 2003 STATE BAR OF WISCONSIN FORM NO. 1-2003 1Type name below signatures. CC M a g ~ CfA~V J Q C Co r N O $a l it 111ilt Will II)'! 111m co ~ i co I Q I I U ! m 5 Y n N ~ I T,g-- 0 E -T: - - - - , I -77 a= ~6 .rso a . a .ns a~ ~ g II A-ce a .r I d 9 a 'l$ ate, CC ) € o o a U) r c m o t 3-0 CY) C C N in O # N 0 t+I CO Q 111t.t hIm 111111 hIm him m ° z m U LL III ~ Al yql I I _ ®l T a s.. .«ef-.. aRCN.m a « l_, R~: I O a„ . r g, E Q b b O C 'O s as® N a 2 zCL k m d m I m g ~ 0 b ~ - - - - - se a a~, da - 1s U a=, o- I c Y n N rai ~g I ~ ~ 3 E wl=' 11 0 m , R o y 6 Fii C n - - L a m cm U) R R V 7 I <nn ~rNi 0 .9 LD a o~~ o~ z°a..a cas~o ~ NSoo co 8 J a ON «r SC O ~N M O N 2 C-4 a =in co CO Lo X CD 4 T° I I ~ ~ I I i i I I ' B b ff: b i s:. e a s zc L a ~ c ® s' J g m -_-~N_---tea s a. $ N m~\ 4rl m ~ I C U - c OE -s ~ ~a IQ--, g mC~ m _ cat~p m o ~ ~ ~ cy (n ~ N U W Q V N y CN7 ~ ~ W 0 ~ 93! i5 € i# ¢ e Job! I ~IL Q' I I I I I I , I I I I I I I 1 j 1 II I I I I I I I I 1 I I I - I I I I I I I b I , Ig I I I I I I I I II I I II I I I I i 1 I ~ § I ~I I I I I ~Y I I v N ¢§g 9 § 0 8 e Qp0 m Z Y N C ~ O Y m to U) ti v a~i U) m Q g J C CpN - O I u N 0j CO W a 1111.1 Will 11m 11m Will m N°n U) ~I ~ I g ~I ~I ~I gl ~I ~I HT l I, I I 'I I I, I q II I I I i N y § C N Y C it ~~p~ppp y V yN7~ U p Q J C pC N 888 C O ~N ~ch 4~ :3 CM co 17 I I I I I 8 V° Ise •~o°- ~ ~I I I I ~ I 17 I I ~ I I I I I I I I I I I I II I I I I° I i I I I I ' I i, I I I I ' I I f I I I I e~ i I I ~ ~ I n i~ n-n i- I [EDE I° Ici I s<« e I I I I ~ I I I I I I I ~ I r _ ~le 8~ ~Im g b I. ~Ib- b ~ I µ~{x~`' b ~ b I I I ~ I C I I , kk ~s I A,-:,: jig L I I I Oa~3~EPARTT STATE OF WISCONSIN a ` i~ Department of Safety and Professional Services SPS Fiscal Plans PO Box 8602 9 p~ Madison WI 53708-8602 ° 5SIONP~ Governor Scott Walker Secretary Dave Ross Payment Voucher Transaction ID: provided by S&B; can be located on web scheduler confirmation notice. If you have not received an ID number, S&B staff will provide one when plans are received.) Check #Dollar Amount: 250.00 Payer Name: William Schumaker Payer Business Name: Schumaker Plumbing Payer Address: 1070 Scott Road Payer City: Hudson State: WI Zip Code: 54016 Phone 715-386-3121 Plan Submitter Name Same (If different from Payer) 1. Mail your check and this completed form to: DSPS Fiscal Plans PO Box 8602 Madison WI 53708-8602 2. Send a copy of this completed payment voucher form along with your plan submittal documents to the office that you select below. Plans submitted to: (circle or check one of the offices) Madison ❑ Hayward ❑ Holmen ❑ Green Bay ❑ WaukeshaK Madison S&B Hayward S&B Holmen S&B. Green Bay S&B Waukesha S&B 201 W Washington Ave 10541 N Ranch Rd 3824 N Creekside La 2331 San Luis PI 141 NW Barstow St. 3nd Floor 53703 Hayward WI 54843 Holmen WI 54636 Green Bay, WI 4"' Floor PO Box 7162 54304 Waukesha WI Madison WI 53707-7162 53188-3789