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008-1091-70-000
Wisconsin DQpartment of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division ~ INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide maybe used for secondary purposes [Privacy Law, s 15.04 (1)(m)). Permit Holder's Name: City Village X Township Rost, Lon A. Eau Galle, Town of CST BM Elev ~ Insp. BM Elev. ~ BM Description: / Ob~ J' SOD ~~' S `7o a~ ~~. . iKNK INFUKMHIIUN TYPE MANUFACTURER CAPACITY Septic Dosing .~Ph~ na•~.33 Aeration Idi ry/ /'~ n'nA 36oV TANK SETBACK INFORMATION TANK TO /L / C ~/ WELL BLDG. Vent to Air Intake ROAD Septic Dosing Aeration Hoiding ~ ~ / ~ 5 of 2 r) ~.~/~ ~-e.~ ids Q.w ~l! PUMP/SIPHON INFORMATI N Manufacturer ~ Demand GPM tv"odel Number TDH Lift Friction Lo System Head TDH Ft Forcemain Len Dia. Dist. to Well SOIL ABSORPTION SYSTEM A 1 / /~ CLCVHIIVIV LHIH c°unty: St. Croix Sanitary Permit No: 514814 0 State Plan ID No: Parcel Tax No: 008-1091-70-000 Section/Town/Range/Map No: 32.28.16.4856 STATION BS HI FS ELEV. Benchmark .~5' 1r~3 ~ goo. a Alt. BM is o- 5 Bldg. Sewer ~ D3 y ~~~ to3,o .~ .a. ~/. 0~ St/ t I et 7w X1.3 fl. 73 St/Ht Outl t Dt Inlet t Bottom Header/Man. Dist. Pipe Bot. System • Final Grade t Cover ~ ~ D~/ /D~• ~~ BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STR LEA Manufacturer: INFORMATION BER OR Type Of System: Model Number DISTRIBUTION SYSTEM /`~/ A' Header/P~lanifold Distributi n x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length ___, Dia _____ Length Dia___ Spacing__ S(~II C(~VFR „ oro«~~ro e.,~ro.,,~ nn~., ,.,, Mnnnti nr At.[~rade Svctems (]nlv Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ~ Yes ~ No [~ Yes [~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:__~__/~QQ/U Y Inspection #2: / / Location: 42 230th Streeta~B~aldwin, WI 54002 (NE 1/4 SE 1/4 32 T28N R16 )metes & bounds Lot (~ Parcel N6o: 32.28.16.,,4/8,5,6_ 1.) Alt BM Description = ~"" ' b~jJ-Yl st~t,{Yj ~Glrlti-~,6n Cf~UI'V4~-~ Q- ~' ° "`'' ~r~G~yGe v~~ 2.) Bld sewer length = ~, ~ / `~ ~e ~ ~/ Z4' c/ ~L /st1.~. g b -do- u C~-~ ~o -~~- • ~~ ~' ~ - amount of cover = ! Plan revision Required? [~ Yes i`~ / / Use other side for additional information. ~ ~ Q ~ ~ ~' ~~'`~ _ Clil~[`~ D~~ Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) t;ommerce,wl,gov Safety and Buildin vision County ,~ a ~ / 201 W. Washington Av . B x 7162 j ~~ C~3 n ~ ~ ~ ^ ^ Madison, W 370 Sanitary P~ Number to by f le in by Co.) 1?epartment a f C ommerce / / Sanitary Permit Application State Transaction umber hi accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate emmental ~~ ~ Y / ili dd iff h unit is required prior to obtaining a sanitary permit. Note: Application ~., an ma ng a ress) erent t Project Address (if d submitted to the Department of Commerce. Personal information you p ovide Yi dary u uses in accordance with the Privac Law, s. ! 5.04(1)(m), Stats. ~~' yn,L L A lication Information -Please Print All Information , Property Owner's Name ~ Parcel # Property Owner's Mailing Address ST. CROIX COUNTY Property Location ~ + , `pt ; R 7 0 J r<~ -~- c~~ ~ ?j ~ ~ ~ ~ 0 ING OFFICE Govt. Lot City, State Zip Code Phone Numb er ~_ y,, S F /, Section ~~ ~~ Q.~ ~~ Lc. ~? ..'~ ~' ~ ~ ~ ~ ~[~ ~~ ~/1~ 7 p 1 t 5 ' ~ / ~ ' ~e.(~ ~ (circle one) E or W N; R ~ T Il. Type of Building (check all that apply) Lot # -_ _ ,,_,~ lli If3'1 F il D N b f B d ~ 2 _ c ~~' ~ ~~ Subdivision Name we or am y n - um er o rooms ___ e .. - ~ `-~x-"` 7.4'Ft4~ j ~ /~ ~ ~1~. ~ ~i!/.J,~ ~(.G0` ~ L,fyiylr- Block # ~~ ^ Public/ .ommercial -Describe use _ l~~ ~.~ ~ / / V ~- ^ City of ~~ ^ State Owned -Describe lice~ ~ti~~n ~~i ~ CSM Number ,^,, Village of ~~^^ /' ~l f CT4~l ~~..., U'~L°L.~ ~ --tom owno LN GGii~ [II. Type of Permit: (Check only one box on lin .Complete line B if applicable) A. ^ New System Replacement System ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System (explain) B. ^ Permit Renewal i ti B f E ^ Permit Revision ^ Change of Plumber ^ Petmit Transfer to New Ow List Previous Permit Number and Date Issued ].~~,~ ( j ~ ore xp ra e on ner ~ /A r~ ~ ~ WZ~• IV. T e of POWTS S stem/Cum onentlDevice: Check all that a 1 Non-Pressurized In-Ground ^ Pressurized In-Cn~ound ^ At-Grade ^ Mound > 24 in. ofsuitable soil ^ Mound < 24 in. of suitable soil ^ . ,/ i!7 Holding Tank ^ Other Dispersal Component (explain) ^ Pretreatment Device (explain) V. Dis ersalfCreatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdst) Dispersal Area Required (st) Dispersal Area Proposed (st) System Elevation ySd a u @ v VI. Tank Info Capacity in Total # of Manufacturer c Gallons Gallons Units ~ ~ ~ N T k i i E T k ~ c ~ D ~ R ew an s x st ng an s a. U ~ ~ ~ rn w C7 a Septic or Holding Tank O©~ ~ .rv~/1 ~.~.~Cl / { I ')1 ~S ~~ / ~~ ~ ~~ Q VlJ l.. Dosiub Chenibc~ VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Prin ) Plumber's Si azure _ = ~-- .. MP/MPRS Number Business Phone Number P umber's Address (Street, ty, State, Zip Code) VIII, ount IDe artment Use Onl pproved ^ Disapproved Permit Fee Date Iss d [sling Agent Sig ture ^ ~ ~ ~ ~ ~ ' Owner Given Reason for Denial .! l_.._.-- _ IX. Conditions of Approval/Reasons for Disapproval ~1 ~,{ ~`ri , ~- ~ G ~~l- ~t~„~?GC~2_ G ~--~ ` ~ ( G SYSTEM OWNEf~: ,~ I' J~ , ,~/J ~q ~ { ~j - ~qI ` ` L ~L ~LG'• l~ a. ~fLi7~'~ .,r ~ !/~ -~~i/u j~-"rte. C~1'~,..l lfr~'l ~ ~ ~ .... ,,,(` _" - U .~eFSal-sell~ast all be serviced /maintained as per management plan provided by plumber. r~c{~i /.Z ~,El~''7-t:'/ ~°C.'"'~~~~ i °' ~"`'`~'~ftac t f coi lete plans for the system and submit to the County only on pa er not less than ri to x 11 inches m size as per applicable co e~orc~{nances ~ ~~~ ,. , /;'i SBD-6398 (R. 01/07) Valid thru 01/09 y(G~;'~t ,..¢~'rS ~h `~ Private On-Site Wastewater Treatment System (POWYS) PLOT PLAN FILE INFORMATION PROPERTY LOCATION Pg 1 of -L Owner ~ ~.G` ~~ ~~, '/a, ~ ~ '/4 ,Section ~~ , ~~ ~ T~N, R ~~ E o>~ ~ PIN # OCity, OVillage, LWTown of ~o~ ~ ~ E~ 9~0 - ~~5 = 583 Wisconsin Department of Commerce SOIL EVALUATION REPORT _~"'~ Page ~ of r7ivision of Safety and Buildings in accordance with Comm tt5, wis. Aam. troae ~urny ~/ Attach complete site plan on paper not less than 8112 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and -7 parcel I.D. Q 6 $ - /jf 9l~ /d - ~ north arrow, and location and distance to nearest road. scale or dimensions percent slope , , Please print 11 inf~~~VEp Reviewe y Date . Personal information you provide may be used rsecondary purposes (Privacy Law, s. 15.04 (1) (m)). ~~ 3 a ~ Property Owner NOV ~ 8 2007 ©~ ~ opertyLocation rr~~ ovt. Lot ~~ 1/4~~ 1/4 .C T ~ ~ N R ~(p E ( W Property Cvuner's Mailing Address ~~ S . CROIX COUNTY ^-~ NING OF of # Block # Subd. Name or CSM# ~~ ~ FICE ~l State Zip Code Phone Number City ^ City ^ Village own Nearest Road / ~o~ tt~1 ~~b~~ (/Si y9~ -~S ~' Ql ^ New Construction Use: residential / Number of bedrooms ~_ Code derived design flow rate sC~ GPD [~eplacemeht ^ Public orcommercial - Describe: Parent material ~ Dr 5 t O ( E'r~ / ' ~~ ~ Flood Plain elevation if applicable tt• ~ ~ j ~ ~ , y~,( }j ~ General comments ~ ~ l ~~ D ~~j„ ~~ fy J /~ ~ ~- ~`"~""~~ and recommendations: f - ~ ~ 1 d` ti" ~( (CS/ `1 c~ 1 U Boring Boring # ~--~~ ~ Pit Ground surtace elev. 9a• ~S ft. Depth to limiting factor in. Soil A lication Rate T t Structure Consistence Boundary Roots GPD/fP Horizon Depth in . Dominant Color Munsell Redox Description Qu. Sz. Cont. Color ure ex Gr. Sz. Sh. *Ef f#1 *Eff#2 f r~^ / ~ - b 6 C ~~ r-- ~ ~ i ~ c s6 / r ~, ;;cJ r' ~~ ~ D . ~ O , 3 Boring # U Boring ^ Pit Ground surtace elev. a,~~ ft. Depth to limiting factor ~~ in• Soil A lication Rate ti i D Texture Structure Consistence Boundary Roots GPD/flz Horizon Depth in. Dominant Color Munsell escr p on Redox Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 / (oylZ - ~ ~ S ~J i ~ ~ ~ ~ / ~~ U `l ~ ~Oj r ` ;,J / ~ D C~ y~ .P / c ~ C~Srb h1-~1 U ~ ~ 7 * Effluent #1 = BOD ~ 30 < 220 mg/L and TSS >30 < 1 bU mgiL - ~muern w~ - o"~ . ~~ ~ ~ ~a~ ~ ~~ ~~ ~ ~~ . -- • • •~• - CST Name (P se Print) - r Si nature CST Number <' Yl ~ ~ ~-t P.SO h ~~~ ~~ Address D to Evaluation Conducted Telephone Number L~f~9 ~~o~ ~v. ~~~, ~~(-~ w~ ~~- mss- o~ >>~ -.~~~n„~m~..,~~. s~ ~.~ 7 Property Owner < C7 h R~ 5 ~ Parcel ID # Page ~_ of 3 Boring # ^~ Boring c°- LJ Pit Ground surface elev. ~ , 7 ~ ft. Depth to limiting factor ~ J in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/tF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ~ ~ ~ /pY~2 ~ ~' ~~ ~ r-~ /~ , ,6 - f e Yf2 ~ S y2 Sic r uc s~k ~ ~ ~ ~ , ~ 3 ^ Boring # ^ Boring ^Pit Ground surface elev. ft. Depth to limiting factor in. Soil Ap lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ^ Pit Soil A lication Rate Horizon Depth Dominant Cobr Redox Description Texture Structure Consistence Boundary Roots GP D/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 'Effluent #1 =GODS > 30 < 220 mg/L and TSS >30 < 150 mg/L 'Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.07/00) e'er-~- ~©VL 1 \OS~ `_ _ ~ ST. C~eot~Ir Cateh'~~ ~~ a~ 5~ 5~~~ ~~ T~8 RIB l.J ~ rt'd~ r~ o ~ ~~,~ ~~ l ~ `~,rl. lc~c~ ~~- ~o~-~t~1~c~-~-~o ~ I ~3 O ~ ~~'rt~" ~~~ NOLUING "TANK AGREEMLNI' Document Nuulb~r .-lgrcemcnt late I l his agreement is made between the... ~~./~fD~ ----------------------------------- Count~• or Local Governmental Unit and the ~ Holding "hank (hvner(s~ LI ~71 ~'l) IIL~%r tJf~ . \4'e :ICknowledee that application is being made for the installation of (a) holding tank(s) nn the fi~lluwine roperty. {Pro ~ de le>~al land description.) ll]tQ Nor 2!p y.0 ~C~~-`c.~ fie. Sdu~ 855. ~~.~ ~~1~ ~QS~ iGsS:O _ ~ ~ I ~~L-tau ~ 1-ti,+ ~ --~ or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. Comm 83, Wis. Adm. Code, Ch. 145, Slats. and Chapter 191 General Code of Pierce County. As an inducement to the Count of5'~'. ~:x to issue a sanitary permit for the above described properly. we agree to do the following: 1 Ovmer agrees to conform to alV applicable regwremenis of Ch Comm 83, Wis. Adm. Code and Chapter 191 General Cade of Pierce County relating to holding tanks. If the owner fails to have the holding tank properly serviced in response to orders issued by the County to prevent or abate a human health hazard as described in s. 254.59, Slats., the governmental unit may enter upon the property and service the tank or cause to have the tank fo be serviced and charge the owner by placing the charges on the tax bill as a special assessment for current seNices rendered. The charges will be assessed as prescribed by, s. 254.59 (2). Slats. t~{'-/01/-7d G~~ Parcel [dentitication Number (PIN) 2 The owner agrees. pursuant to Section V. D. of the holding tank component manual, to have a water meter installed in all buildings or Structures. Water meter shat! be installed by a plumber authorized by the State to conduct such installations, with said installation complying with State regulations and manufacturers specifications. The owner agrees to be finally responsible for the purchase, installation, maintenance, and repair of the water meter, and agrees to allow the governmental unit to enter the above described property on a regular basis to read and/or inspect the water meter. 3 Owner agrees to pay all charges and cost incurred by the governmental unit andlor County for inspection, pumping, hauling, or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank. The governmental unit shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In tha event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges may be placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law. a The owner agrees to contract with a person who is licensed under Ch. NR 113. Wis. Adm. Code, to have the holding tank serviced. 5 The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code, who shall submit to the County a report in acwrdance with Chapter 191 General Code of Pierce County for the servicing of the holding tank. The County may enter upon the property to investigate the condition of the holding tank when pumping reports and meter readings may indicate that the holding tank is not being properly maintained. 6. This agreement will remain in effect only until the County certifies that the property is served by either a municipal sewer or a soil absorption system that complies with Ch. Comm 83, Wis. Adm. Code. In addition, this agreement may be canceled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 7. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit the agreement to the register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be determined by reference to the property where the holding tank is installed. C)~~'nerts} Name(~(Print~ ,.. `~ i O~~ier~s) ~ign:itt~~) ~ ~ ~ y Subs d an~~r~~PJ e ~ on~s~ !.-~ ^ L~ Guverumeutal Clt~ticial Name (Priru) ~ Go~ernmeutal Ofticiat Signature: Governmental Official Title (Print) ~ yr- ~-.~ Nu:rIY1 G1// , Drafted f3}' (print & sign) LrS~ t ~J Printed Name ~- .a /? I.IL; ~~~nalUfe tuft` w .. u.s ..~.. ±t,~f'`~u~^.'-~ ate el y^JI~n6tri f,r G;'rrr!,~:a~4 ~; Lx:;ire5 Oct i7, 2010 ~~u~~Itl~VUUiri~ri~~i~V~~ui~~INUU~iI~~l . ' ` ;asezos ' . KATHLEEN N. WALSH REGISTER Or= DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 12/05/2007 03;50PM HOLDING TANK AGREEMENT EXEMPT a REC FEE: 11.00 PAGES: 1 Area yz z3o~`' sr. ~-L ~ w ~nf , !~~- ~ S~G~i L 1 of 7 commerce.wi.gov i ^ ~scons~n Department of Commerce Safety and Buildings 4003 N KINNEY COULEE RD LA CROSSE WI 54601-1831 TDD #: (608) 264-8777 www. com m e rce. wi. gov/sb/ www.wisconsin.gov Jim Doyle, Governor Jack L. Fischer, A.I.A., Secretary November 29, 2007 CUST ID No. 220292 BENNIE W HELGESON HELGESON EXCAVATING W1229 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: 11/29/2009 Identification Numbers Transaction ID No. 1488471 SITE: Site ID No. 732903 Lon Rost Please refer to both identification numbers; 42 230TH Street above, in all corres ondence with the a enc . Town of Eau Galle St Croix County NE1/4, SE1/4, 532, T28N, R16W FOR: Description: Holding Tank /Three Bedroom Object Type: POWTS Component Manual Regulated Object ID No.: 1163660 Maintenance required; Replacement system; 450 GPD Flow rate; System: Holding Tank Component Manual, SBD-10571-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: Reminders • This system is to be constructed and located in accordance with the enclosed approved plans and with the "Holding Tank Component Manual for Private Onsite Wastewater Systems" SBD-10571-P (R.6l99). • The existing POWTS must be properly abandoned per Comm 83.33 Wisc.Adm. Code. • A service drive or road is to be provided to the service access opening or pump out port. The minimum measured distance required is 25 feet. • 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. ~ ~~" ';h ' a. ^EFaRFF;rtF OF -~ eF FtEY Sf:E CG{sZ~ESP • Inspection of the POWTS 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. Stat • Comm 83.22(71 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 BENNIE W HELGESON Page 2 11/29/2007 Owner Responsibilities: • Comm 83.52 Responsibilities. 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. • Comm 83.55 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. All permits required by the state or the local municipality shall be obtained prior to commencement of constructionf instal lationloperation. 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 to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, ~,,~~~ ~ Charles L Bratz POWTS Reviewer II ,Integrated Services (608)789-7893 , 7:45 am - 4:30 pm Monday -Friday Charles. bratz@wisconsin. gov Fee Required $ 60.00 Fee Received $ 60.00 Balance Due $ 0.00 WSMART coder 7633 cc: Leroy G Jansky, POWTS Wastewater Specialist, (715) 726-2544 ,Friday, 7:00 A.M. To 3:30 P.M. ' ~ ECEIVE~ INDEX SHEET Nov 2 g 2007 SAFETY & BUILDiwGS PROPERTY OWNER: LON ROST 42 230TH STREET BALDWIN, WI 54002 PROJECT NAME: LON ROST PROJECT LOCATION: NE 1/4, SE 1/4, S 32, T 28N, 16 W MUNICIPALITY: TOWNSHIP OF EAU GALLE COUNTY: ST CROIX DESIGN: HOLDING TANK COMPONENT MANUAL (SBD-10571-P 6/11/1999) CONTENTS: Page 1: Plot Plan Page 2: Holding Tank Cross Section and Specifications Page 3: Wieser Concrete W3000- MR Tank Specifications Page 4: Tank Anchoring Calculation Page 5: Holding Tank System -User's Manual - Pg. 1 Page 6: Holding Tank System -User's Manual- Pg. 2 Page 7: Holding Tank Management Plan Name: Bennie Helgeson Address: W1229 770th Avenue Spring Valley, WI 54767 Credential Number: 220292 Signed s4~ Jr~ "} ~R~7 Date: November 27, 2007 ~ ~sERC~ GS `NOENCE Pg ~_ of -L Private On-Site Wastewater Treatment System (POWYS) PLOT PLAN FILE INFORMATION PROPERTY LOCATION Owner ~ ~ '/4, ~_ '/4 ,Section 3~ , ~d~.S ©1~1 i T-~ N, R ~,~ E o>~ PIN # OCity, OVillage, (Town of y~ x ,...-~ ~r . ; _ , ~tu5 JJ r i V e ~~ ~_~ To,~ o~ I,t3e l l ~E~t`..t,3ex,; 3 S No,M..~ ~M , 100.8 .s t~rn~e ~cxw.~~ o~ I 9~. C~ ~,L ' ~-~--~ fir' f ~'U? 7~ i ~ _1 u~ ~~ 3o~ao G-~.! , Ghoc~~.c2. E-I~t~~,~ T~(~ ~of~ ~~~~ ~x~s~,1y . a~.©~ s~--~f- ~ s~ ~,~ 7«Y- k blcQ 7'o B~ P~,.„ ~ ~ G~. aY.ot. t-, I I F ~ u ~ ~ ~`~~ ~~~ ~c~a.. f ~ ~ ~/' 7 U r ~o f S~z-~ ~ b l as ea ,F~ypDroX, ~ ,AC~P~ i ~,~.~ OWNER: LUN ROSY pg 2 of 7 Private On-Site Wastewater Treatment System (POWYS) HOLDING TANK CROSS SECTION & SPECIFICATI( 1S ~~a®o-,MR Colder with warning label 4" rain. above surrounding grade or ~ above Watertight junction box and lock if access opening is establiished regtanal Hood elevation, unless greater than 8 inch di'a. atxe~s port i~t+~ater and gastight n Went ~/c~J. ~~- $ inch ~ ~ ~ ~ ' min, dia. .~ - Power source ,q-~r•oy~ ~'--- 5 : S'Gove~- ~c~-er Building sewer ,. .i '`'R Maximum alarm on level set ' at 12" below tank inlet invert ' Alarm float or 90~ of the liquid capacityr of the tank below the tank inlet invert ~~ ~ ~,,t,i, 3 " ~3~GPd1~.~s (If needed, insert different drawing to illustrate elevations, etc.) I ~: ~ w 0 M H O z O a w z 3 O are-ooo£M~3va 9St~8-SZ~-008 1002 AadflNtlf :31V0 05L45 W1 'HOOa N301VYY 'OL.IMH Sfl 9LL£M 1MS:AE NMtlao 31389~D~ ~~S~~m ~31V0 'ON A3a ,te„4/L ~3lVDS W J Z W ~. O Z m J ~ Z O J J ~ O W a C O Q Z N V • N ~~ W J O W O Z D: Q ~ W p H O Q 0_ ~ O ~ V °a J m ° ~ as Z `~ ~ L'`-' Z ~ chi ~ v O ~~ O' waQU Q WO N O~ ~ ' I1 e N O ~~ m JWW ~ ~M ~ ZO \ O W i'c~ o ° i~~'' a ~oLn ~ ~~ _ ~' ~ Gi z NiA~ W W t/~ NO_J ~O~OF:J~~--~ ~N~ N Wa ~ OQ W O M ; ~-=~w~OD~Z~m~ ~,! ANN ~ _~ z ~ 3Y viNO Lr~~~..30= oQ oow a aWa W =~ m Z Z J L~- j Z C0 0~ O J C0 O l.) D U 0= 0_ I- O cii D G_ Q ~ N3°m c°.~~=~3m~~3 aa~ a~° ~ Zo¢ z z~ a ~ vWi w ~ ~ ° 9 a ~ Y W Z ~ J ~ Z Z ~ _ ~ ~ ~ 3 u 5~ aw O t..~ U b00Z 'Nb'f '~3a ldflNb'W OIld3S aw-ooosM W H W D: U Z O U Q' N W U H Z O U W N O f- U f%) Y Z ZQ ~ U ~~ W Y N_ Z ~ ~. O H U W 5~ ~I a U to \ O 0 Z W W ~' O W n N N_ I U N Q D W W U X w 0 F- W W O O W F=- U Q LL Z Q W D' Q V) Y Z Q H „LL OWNER: LON ROSY pg 4 of 7 Private On-Site Wastewater Treatment System (POWYS) TANK ANCHORING CALCULATION 1'er Comin 83.43(8)(g), Wis. Adm. Code, all tank(s) must be anchored whenever they are at risk for being installed in an area where they may be located in saturated conditions all/part of the year. Using soil as the anchor has become an acceptable alternative to concrete. Flotation potential is the displacement of the tank calculated by its volume in cubic feet. Line A: Calculate cubic feet of tank. 9$7~"3sc 6 ~ inches high, x ~~inches wide, x inches long, = cubic inches. Divide this number by 1728 to equal~7l. S'cubic feet. Line B: Convert the displacement to the weight of water. ,~//, $- (from line A) cubic feet x 62.4 (weight of 1 cubic foot of water) x 1.5 (safety factor) _ .$~ lbs. of lift potential. line C: Calculate weight needed to counter buoyancy. s3~2~/lbs. (Displacement weight from line B.) - bs. (weight of tank per manufacturer) =tbs. of soil needed to anchor tank: lbs. 33~Ea . y ~" Line D: Weight of the soil media including safety factor needed over the tank to anchor the tank adequately. "Tank cover width ~_ inches x tank cover length / 8'~ inches, divided by 144 = ~i acs /3/3 square feet x 0.083 (1 inch in foot decimal) _ ~ cubic feet (volume of 1 inch of space over the tank cover). Line E: Calculated weight of 1 inch of space over entire cover. cubic feet of space (from line D) x 1001bs./cubic foot of =/O g~.~lbs./inch_space above cover . Line F: Calculate inches of soil needed to counter buoyancy. '3~;;,_ylbs. (from tine C) divided by/C~ ,tbs. per inch of soil (from line E) =inches need over tank cover. OW~;1~R: LUti kUST ' pg S of 7 Private On-Site Wastewater Treatment System (POWYS) HOLDING TANK SYSTEM -USER'S MANUAL A. SYSTEM OPERATION: The holding tank system serves to contain wastewater on a site until the contents are pumped and hauled to a proper point of disposal by an individual certified under Wisconsin Administrative Code Chapter NR114. Wastewater from your interior plumbing system enters the building sewer that terminates at the inlet of a prefabricated concrete holding tank system. The tank system has a switch that is set to activate when the liquid level reaches a point 12" below the tank inlet. The switch activates a high water alarm located inside a tank alert box that is installed on a pedestal or inside the dwelling. When the tank is full of wastewater, the switch will be activated and cause an audible alarm to sound. A switch located on the tank alert box can turn off the audible alarm. The liquid waster carrier contracted to service the holding tank system should be called immediately after the alarm is switched off. 'There is only a limited reserve capacity left in the holding tank system after the alarm has been activated. Q. DESIGN rLOW: "I'he holding tank system has a total wastewater capacity of 3000 gallons. Servicing intervals cannot be predicted, as every household has varying water use habits. Use of water conserving fixtures and water conserving practices will increase the number of days before the tank needs to be serviced by a liquid waste carrier. C. WARNING: 1=allure to have the holding tanks serviced on a timely basis may cause wastewater to back up into the dwelling and/or discharge from the holding tank's manhole cover. The discharge of sewage to the surface of the ground is a public. health hazard and subject to enforcement action by Pierce County. Soi 1 settling around the tank perimeter may occur after it has been backfield. All depressions caused by soil settling should be filled with soil material to prevent surface water collection. Depressions left unfilled may allow surface water to freeze and cause frost damage to the manhole riser ring joints or the other tank components. Uo not drive over or near the buried holding tank system with any vehicle or construction equipment. This action may result in a cracked tank(s). This type of damage may allow groundwater to enter the holding tank(s) and increase the frequency of pumping. Many disease-causing viruses, parasites, and bacteria are present in the holding tank's wastewater. Even the slightest exposure to wastewater may adversely affect ones health and increase the risk of serious illness. Please note that the owner of this POWYS must provide the septic servicing operator with reasonable access to the tank(s). This may include (but is not limited to) construction of a designated drive or servicing pad to within 25 horizontal feet and/or to within 15 vertical feet to bottom of the tank(s), foot traffic over and through property, or vehicle traffic over and tlu•ough property. D. TROUBLE-SHOOTING 1. Wastewater backs-up or overflows manhole cover: a. High water alarm not working. b. Tanks not pumped. 2. High water alarm not working: a. Tank alert box not plugged into electrical outlet. b. Audible alarms switch on silent mode. c. Tank switch installed improperly or defective. d. Tank switch electrical connections faulty. e. Electrical line to switch defective. 3. Groundwater entering tank: a. Tank manhole riser ring joints leaking. b. Tank sidewalls or base cracked. ' 'OWNER: LUN ROST Pg 6 of 7 E. MAINTENANCE: 1. The tank alert box 11as a test button that should be pushed once a month to assure the high water alarm system is working properly. 2. The float containing the high water alarm switch may need to be cleaned whenever scum or solids build up on its outer surface. Accumulation of solids on the float may interfere with switch activation. 3. All manhole covers padlocks should be oiled or greased periodically to ensure free movement of lock components. 4. The locking device should be inspected after each tank servicing.to prevent unauthorized entry. F. CONTINGENCY PLAN IN THE EVENT OF FAILURE: A badly cracked holding tank may need to be replaced depending upon the amount of damage and the crack's location, The tank manufacturer should be contacted to make a determination as to whether the tank can be repaired or needs- --eplacement. Groundwater may enter the cracked tank requiring more frequent servicing by the contracted liquid waste carrier until the tank is repaired or replaced. G. CONTACTS IN THE EVENT OF COMPONENT FAILURE REGULATORY AGENCY: ~. Croix County Zoning Office, 1101 Carmichael _Road, llutison, W3 540x6 ,__-- 715-386-4680 _. _ -.____ -------_...._.__-- NAME OF INSTALLER: Name: HelgQson Excavation Tn -Bennie Helg~son Address: W1229 77Uth Avenue Spring ValleX, WI 54767 Phone: 715-772-3278 TANK MANUFACTURER: Name: Wieser Concrete Address: N3716 U. S. Hwy lU riaiden Rock WI 54750 Phone: 8{JO-325-8456 EIIGH WATER ALARM SYSTEM MANUFACTURER: Name: Ed==Electro Systems Address: ^ Su..poly 'o sati ~,,,,,~~ ~* Eau Claire WI 54Z-~- ' Phone: 80U-236-9793 • ~ U6tii`i~;R: LON ROSY pg 7 of 7 Private On-Site Wastewater Treatment System (POWYS) HOLDING TANK MANAGEMEl~T PL~-N This Private Onsite Wastewater Treatment System (POWYS)-has been designed, and.is to be installed and maintained according to Comm 83, Wis. Admin. Code, the Holding Tank Component Manual (SBD-10~TI-P 6/ 1 1 / 1999), and the St ._ Croix County Sanitary .Code . 1. This POWYS is designed to accommodate all wastewater generated by a 3 bedroom residence. 2. The owner of this POWYS is responsible for system operation and maintenance, including allprovi ions in the attached Holding Tank Servicing Contract and Maintenance Agreements. ' 3. Each time the wastewater in the tank reaches 90% of the tank(s) capacity or a level of 12" below the inlet (at which time the alarm will activate), the pumper listed in the current Servicing Contract must b called to empty the tank's contents and dispose of them in accordance with NR. 113, Wis. Adm. Code. 4. At each service event, the service provider should visually inspect the condition of the tank, risers and manhole cover(s) and verify that the alarm system functions and manhole locking devices are present. Discrepancies are reported to the owner in a timely manner for corrective action. All. corrective. actions shall comply with the county sanitary ordinance and Comm 83 and 84 Wis. Adm. Code. All service events or inspections of this POWYS shall be reported to the county within 10 business days.. 6. The owner may not remove any of the wastes from the holding tank(s), or cause such wastes to be removed by any person not authorized to do so under Ch. 281, Wis. Statutes. The discharge of wastes tank to the ground surface, including intentional discharges and discharges caused by neglect, constitutes a failing POWYS and may result in issuance of correction orders or a citation by the county or state. 7. No one should enter a holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within these tanks may contain lethal gases, and rescue of a person from the interior of the tank maybe difficult or impossible. 8. In the event that this POWYS fails and cannot be repaired, a code compliant replacement holding tanl€ maybe installed in the same location (a new sanitary. permit is required for such a replacement). Connection to municipal services would also be considered at this time if they are:deemed available to the property. 9. If this POWYS is replaced, or its use discontinued, components no longer in use it shall be abandQned.ih accordance with Comm 83.33 Wis. Adm. Code. 10. If there is a problem with, or question about this installation, the following persons should be contacted: a. Installer: Bennie Helgeson Phone: 715-772-3278 b. Service Provider: _ Darrell's Septic Service Inc _ Phone: 7.1 5-425-] 025 c. Regulatory Agency: St. Croix Count y Zoning Office ;Phone: 715-386-4680 Private On-Site Wastewater Treatment System (POWYS) • HOLDING TANK SERVICING CONTRACT CONTRACT DATE 12 ~5~~ 7 This contract is made between the Holding Tank Owners(s) Name(s) and Pumper's Name 1 We acknowledge the installation of a holding tank(s) on the following property: (Provide legal descriptions:) 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the access road or drive so that the pumper can service the holding tank(s) with the pumping.equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. The pumper agrees to submit to the local governmental unit which has signed the pumping agreement required by s.Comm $3.55(1)(x), Wis. Adm. Code, and to the County, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. Ixt the event of a change in .this contract, the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the local governmental unit and the County named above within ten (10) business days from the date of change to this service contract. Owner(s)Name(s) (Print) Owner's ature(s) Subscribed and sworn to n thi date: " "" ` ~ ~ Today's Date: ~~ ~n 1~~a7 ~mper's Name (Print) Pumper's Signature Notary Pu lic ignature: /G,/'~~/ Pumper's Registration Number Drafted by Commission Ex iration: ~~~"`"""'°~ ~;^~ GBL1 G •y2~~.~' '~.,,~ WISC~N•``~ ~a--uu~t~~`` ------------------------------------------------------------ 1. The owner agrees to file a copy, of this contract with the local governmental unit that has signed the pumping . agreement required in Ch. 83.54(3)(c), Wis. Adm. Code and Section VII of the Holding Tank Component Manual with the County of 5t~ (m;; x. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerlBuyer ' ~~ n Mailing Address ~ ~ ~30~~' ~~~ ~~ Property Address ~ ~, ~ ~ `1"~ ~-r e~~ (Verification required from Planning & Zoning Department for new construction.) City/State ~~1 d ~~ ~ ~ } t Parcel Identification Number LEGAL DESCRIPTION ~ ~ y~s ~~ Location Pro ert IU' E '/ 5 1~ '/ T ~N R / ~ W, Town of ~ a.u Sec ~ ~~~ ! 1 ~ p y , , . _, Subdivision ~~'tx~=2- ~ ~G'?~~n ~-~ ,Lot # Certified Survey Map # Volume ,Page # Warranty Deed # ~ ~ ~ Z~ ( ,Volume ) ~ / G, ,Page # ~/~ Spec house ~ yes ~ no Lot lines identifiable es ~ 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 5t. 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 arn/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedroo s ~ 1 ! S SIGNATU PPLICANT(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) " ~ f e iic .'ti a ~T~Var~~yyVtiiii3i g~li'~~ ~p+y4 Q~v a~BYVYIV~ p p p y~ tlA• Fi,Et?t i ~aYS ~T~CL ~~$E~v~D 1fARRAbi'~Y D88D FOR RECORDIldt3 DATJa This e~ea,+rada peewees ?~~d~eW ,I Maki and Susan G Maki tlusbansi and w ~`~ ._ © Griuator, and L,on.~~~st .- authenticated 7995. §fitneasetfi, That said Grantor, for a vetuable consideration conveys to Grotrtsa the fot/owing deacribad real estate in St. CroiX Colnty, State of ulecanstni S"~ ~tX C~., t^~ ii6crd tar fTer. ]ic1 A~' R 3 1995 ~y~fi~.s..,,~. W~,t..¢,., FiopiBtar of On_rdas The North 264.0 feet of the South 855.1 Peet oP the East 165.0 feet oP the NE4 oP &E4 oP Sw^.t.ion 32, Township 28 North, Range 16 West, St. Croix County, Wisconsin. 1._i'i-~ ~i. ~.:~ . This ~ hoswstoad property. Together with all and sinwular the horrditements and appurtenances thereunto belonging; ArX! Grantor warrants that the title is gocd, indefeasible in fee simple and free and clear of ancurt6rancea oxcept eaS2ri1@n'~S, restriCtiOnB and roadways of record, and sill warrant ana dofend the lama. t Datod this ~:;~~ ,,,_ day of ~~41.~"C%~? i~95. ~_tSEAL) ~ ~) ~~ ?~nCL.I~-, (SEAL) * -"• _ dr_~nd+-a..r .-r_ {{ ski) •• ,, ,, __.__tSEAt) 1.c9(L7 -~.r~) • ~~~/ t:1.il. _/ (SEAL) * * Susan Maki AD''1'HENTICA~Y'YON SignaLUre(s) of this day of air Grsntae, ACKNOiiLEDCi2~tENT STATE i7F WISCONSIN County ..~ Personally came before me this T995. the eiwve named And ss. r.y:. _? '_ ~ Lo me known to tae the person(s) ~' instrument end acknowy4dgenthe same, TITLE: NENSER OF STATE 8AR OF HISCONSIN (tf not, authorized by §706.06, His. Slats.) TNiS iNSTRUilENT DRAFTED BY THEDINGA LAW FIR1~I (WHT) ~,; r ~ - •'r tar• Public, _ County, Hiaconsirt Hy coemission is permanent- ~ `~02 ~~ (tf not. state expiration dat¢: ~ ) (Signatures may be authenticated or acknowledged, both are not necessary.) ~Ne!ces of persons 6fgning in any capacity should be typed or printed below their signatures- TATS BAR OF 1YISCOriBII~} BORM NO. 1 ' ~` A`•1-34Q SH016 r~ N1TH OPTIONAL S' DORMER, SD'ISBI,RST PEDIA4EI3TS & WINDOW GRIDS (BRICK 1'r'~SCOT BY OTHERS ) ~t ,~„{ <,~ ticti ~~ __ 19~I SQ. FT. (OUTSIDE FLUOR) _ , - _ ,_ '-l ~~c} ~ ~ IIIP ~1TR)nPIiLLVL'f5 'l l~IOC~U~a~ y ~ ~ ~ ~ ~ ~.~I ~~' GF.i'vi77-. Sl%I 92 SLl f; ~ /' 1 1 '~~, OPTIU:N'AL , ~~VIO ~ .••LLL.. 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