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HomeMy WebLinkAbout040-1059-50-000 ,Wisconsin 9epartmentofCommerce PRIVATE SEWAGE SYSTEM County: St. Croix oa~qty and Binding Division INSPECTION REPORT Sanitary Permit No: 538712 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: John, David O. & Anita Troy, Town of 040-1059-50-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: GS 15.28.19.227D TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic r Benchmark 1 /aoo LA, B 116 Y, /oa Dosing Alt. BM d b V 7 ~p ~6" 17. ~p Io Bldg. Sewer 112 .0 Holding St/Ht Inlet 1Z 57. St/Ht Outlet TANK SETBACK INFORMATION TANK TO , P/L 4 WELL BLDG. xent to Air Inta e R D Dt Inlet Septic Lb Dt Bottom Dosing Header/Man. S 7 TZ V ' Aeration Dist. Pipe Holding Bot. System 2 . PUMP/SIPHON INFORMATION Final Grade Manufacturer Demand St Cov ~q 202 (0-, GPM t u S~Z-- /t tP Model Number 1 1:51 siC TDH LFriction Loss System Hem TD , ~t 6,. ArA- Forcemain Length'! Dist. to Well / `-G- SOIL ABSORPTION SYSTEM BED/TRENCH Width Length I / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth r<t DIMENSIONS .740 SETBACK SYSTEM TO P/L BLD WELL LAKE/STREAM LEACHING Manufacturer: ,/k '9 I INFORMATION CHAMBER OR Ty6~IjQ : + , UNIT Model Number: 4ad / DISTRIBUTION SYSTEM y-/ . . W Header/Manifold Distribution x Hole Size` x Hole Spacin~ VenfW4 ' Length _1 Dia Pipe(sLength) Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth G, xx Seeded/S dded xx %lched Bed/Trench Center / Z Bed/Trench Edges ` Topsoil \ Yes ® No Yes Rfl No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: / / Location: 696 Glover Rd. ver Falls, WI 54022 (SE 1/4 NE 1/4 15 T28N R1 9W) metes & bounds Lot Parcel No: 15.28.19.227D 1.) Alt BM Description , 5 ~~aer~ G(J-1- d -rimes 2.) Bldg sewer length = 34 av-lu_ 'k G?tQ['r?~Q - amount of cover = J e_" C5 Plan revision Required? M1 Yes No Use other side for additional information. Date Ins ctor's S' ature Cert. No. SBD-6710(R.3/97) b~a d~y~ l~~-v r: ` ~ r.vA, ,may- - - 1 f F~VI U, co"111111TI10rce-W1.90V Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 j y- ~Ro i sco n s i n Madison, WI 537 A D Sanitary Permit Number (to be filled in by Co.) Dpafnt of Cotmnerre f) Sanitary Permit Application State Transaction Number 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 forms for state-owned POWTS are Pro' Addreis differentthan marling address ~t (if ) submitted to the Department of Commerce. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15. 1 m Stals. L Application Information - Please Print All Information RECEIVED I Property Owner's Name Parcel # G,~ r- Property Owner's Marling Address Property Location z !4 L1LouE2 /D, ST. GROIX COUNTY 11 CJOVL Lot city, Zip Code , S£ Section /iL dE.e Ix-,us, a T SS10.2,2 15 S'a7S- 4 yY9 (circle one T~N, R-Z -?.ca W i H. Type of Building check all that apply) Lot # Ior2Family Dwelling -NumberofBedrooms 3 wks- Subdivision Name Block # &'A ~ ❑ Public/Commercial - Describe Use ❑ State Owned - Describe Use CSM NumberiEfage of Town of ~-Xoy III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owneri ^`j IV. T ofPOWTS m/Com onent/Device: Check all that apply) ,WNon-Pressurized In-Ground ❑ Pressurized In-Ground At-Grade ❑ Mound > 24 in_ of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Hokling Tank ❑ Other Dispersal Component (explain} Pretreatment Device (explain) V. Dis rsaMeatment Area Information: S 3' Design Flow (gpd) Design Soil Application Rate(gpdsf) peisal Area Required (sf) Dispersal Area posed (sf) System Elevation 3;SO ' 1 . -5-1 113 y 93. o VL Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units o B New Tanks Existing Taoks w i;Um. u i " y e. 8 ra c N w U in w to iz. C5 CL Septic or i:Ioldieg Tack ~00 O DOO / l✓/,62rEa o.JCiccrE Dosing Chamber G o O _ /001 / VII. Responsibility Statement- I, the anderskeed, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print)Plumber's igna re MP/ Number Business Phone Number To ,J 715 G 7e7- S 4 Plumber's Address (Street, City, State, Zip Code eo? 98 r✓Y. ATS" u1[ .o.V)o 4/S Sy73~ VIII Coun /De artment Use Only Approved ❑ Disapproved Permit Fee Date I ued Is` s ❑ Owner Given Reason for Denial IX. Condition s ofApprovaMeasous for Disapproval SYSTEM OWNER: c.(I i"1YO 1 Septic tank, effluent filter and (S ~U?if h7 dispersal cell must all be serviced / maintained y a"W-'/ as per management plan provided by plumber. All setback requirements must be maintained W-'1- ~'w✓ {7,p-n 7v as per a pp I ica bl9'#stdb/ .for the system red submit to kly only on paper not less than 8 1/2 x 11 io size ~6l 5 >o~ SBD-6398 (R. 02109) Valid thin 02111 \31 4 kJ 0y Q n: h Q V Q h O b?~ cQ 'u ry O Q ~ 'h Q O V ~H d ~a ~ ~ 4 ~v V ~o ~ ~ \ v ~ G V ~J K tV a~ o ~ V ~ ~ • tii \ 'Z1 `l a o a V o v. - ~ v v ~9 i ao Z p ~ ~ ~ Vv` p ~ 3¢ ~ M J O V ry a" oz ~ i ~ Q ~ u We ~ y 4 V a `'1 W~I v O t' O ~i v I a ~ ~ > a 0 n J v it orl e ~ x~ ~ N h o r o Ole N ~U v M ~ I~ Private On-Site Wastewater Treatment System (POWTS) Index and Title Sheet Owner. ~~4v~,o J aNN Project Name and System T • t ifr YPe- 04vio -Te,y.✓ - 3-e4 /n/6~low,✓.0 boars &,v.srorio.~ Location 96 Ito~~~-~ ~o Street Address ~SE' /V£ /s, p?8 ~V /9 t✓ Legal Description o~r.✓ aF ~ ny ~r ~/lo~x ~o Township/County ' Contents: Page l:_ Jii/,oEX ~if'i~ J.{/fEr Page 2: d'1o r Page 3: Page 4: ,G'u~rP ~Ei[Fo~t~.v~► ~iirvf Page 5' QoGr r-c ~w.✓e'.es,✓~...c t.✓.~t~.~.~,~:- 61s.✓ Page 6: all Page 7: Page 8: Page 9: Attachments: _ ,So-~~ yviao r.1.w ,06AAr PlumberlBesier -T,y„i Signed: Credential Number. dam/3314 Date: ~o~/,lEal1-io„/q~ ~D!✓PS ~D/7,~0Ncr,✓T 4,,lew SBD- /os~ 7 -oO cW. ~i99J n ~j IJ 1~0 v, x- ?F fir- - 14 1. ~ t F\~~ uo 0 v Q ~ 3 ~ a ~ N' Wy It o o a 2 It a ~ 6~° C1 ~W ~v o vi o I y O ~ ~ ~ O C - K M~ .1 n a v ry Q it q v ll ~ 1 Q a o ~O v y1 I V ~a o > a 0 1 J 41 "R tj j T v v 14, 4j N N 6, 14 1. e \ e ~ Q `V Page 3 Of -SEPTIC TANK F,'PUMP CHAMBER CROSS SECTIOW AND SPECIFICATIONS 4" CI. VENT PIPE 12" MIN. ABOVE GRADE 6 WEATHERPROOF y /O' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE - TWITH CONDUIT MANHOLE COVERS W/ PADLOCK ~lv~I-rvra y WARNING LABEL a .r...-4" MIN. 18" IN. _ ~ e# INLET WATER TIGHT SEALS GAS- TIGHT, ; A SEAL vAPPROVED JOINTS WITH APPROVED = - - LM APPROVED PIPE PIPE 3' B i ON 3' ONTO 'ONTO SOLID SOLID SOIL SOIL PUMP OFF ELEV. 88.o FT. -f-- OFF RISER EXIT D PERMITTED ONLY IF TANK MANUFACTURER HAS APPROVAL, 3" APPROVED BEDDING UNDER TANK CONCRETE .PAD SPECIFICATIONS SEPTIC./ DOSE TANK MANUFACTURER: ///ES~ic Lanl~~tCrE NUMBER DOSES PER DAY: 9 as Yp) 11V3 +J3= TANK SIZES: SEPTIC /ooo GAL.* DOSE VOLUME INCLUDING DOSE Goo GAL_ - FLOWBACK: 1174 GAL. ALARM MANUFACTURER: _S. T. L-" ~.darr~a_s CAPACITIES.: A = _ao INCHES = _ 33G ' GAL. MODEL NUMBER: 37414,r ~91E.ti' SWITCH TYPE: z%f4- umr B = 2 INCHES = .33.G GAL. PtlMP MANUFACTURER: ZOELLE.C C = `'7 INCHES = 1174 .GAL. MODEL NUMBER: SWITCH TYPE: D.= _ 7 INCHES = GAL. REQUIRED DISCHARGE RATE _as GPM PUMP ALARM WIRING AS PER ILHR 16.23 WAC VERTICAL•DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE ~.D FEET + MINIMUM NETWORK SUPPLY PRESSURE . . FEET + o FEET FORCEMAIN _-X 1:~. S-FT/300 FT. FRICTION FACTOR - : 3 FEET TOTAL DYNAMIC HEAD = 4.3- FEET 41 INTERNAL DIMENSIONS OF PUMP TANK: LENGTH 53# ; WIDTH 7,9 ; DIAMETER - LIQUID DES 36 ' TOTAL DYNAMIC HEAD/FLOW PUMP PERFORMANCE CURVE PER MINUTE MODEL 15111521153 EFFLUENT AND DEWATERING 56 14 153 MODEL 151 152 153 12- Feet Meters Gal. Liters Gal. Liters Gal. Liters o 35 5 1.5 50 189 69 261 77 291 = to 452 10 3.0 45 170 61 231 70 265 U 30- 15 4.6 38 144 53 201 61 231 c 8 2 451 20 6.1 29 110 44 167 52 197 25 7.6 16 61 34 129 42 159 0 6 20 30 9.1 - - 23 87 33 125 35 10.7 - - - - 22 85 45 40 12.2 - - - - 11 42 4 Shut-off Head: 30 ft. (9.1m) 38 fL 01.6m) 441E (13.4m) 10 ola5ose 2 5 X 0 Mo e1151 Models 152 / 153 10 20 30 40 5o 60 70 86 90 100 GALLONS - 67132 67132 LITERS 0 40 ab 12o 180 200 240 280 320 360 3718 4 518 3 718 45M FLOW PER MUTE 014508A e CONSULT FACTORY FOR 37 _ 3718 SPECIAL APPLICATIONS ® a ® 3718 3718 I I • Timed dosing panels available. - • Electrical alternators, for duplex systems, are available and { supplied with an alarm. • Variable level control switches are available for controlling single phase systems. r • Double piggyback variable level float switches are available for variable level long and short cycle controls. - I • Sealed Qwik-Box available for outdoor installations. See 1111116 12118 FM1420. i -I I • Over 130°F (54°C) special quotation required. 41316 sire 15111521153 Series SK2444 SK2604 15111521153 MODELS Control Selection Duplex Model Volts-Ph Mode Amps Simplex N151 115 1 Non 6.0 1 2 or 3 BN151 115 1 Auto 6.0 Included 2 or 3 E151 230 1 Non 3.2 1 2 or 3 BE151 230 1 Auto 32 Included 2 or 3 "Easy assembly" N152 115 1 Nat 8.5 1 2 or 3 (pump 8 discharge pipe BN152 115 1 Auto 8.5 h1nduded 2 or 3 not included.) E752 230 1 Non 4.3 2 or 3 BE152 _230 1 Auto 4.3 2 or 3 N153 115 1 Nan 10.5 2 or 3 BN153 115 1 2 or 3 E153 230 1 Non 5.3 2 or 3 BE153 230 1 Auto 5.3 Included 2 or 3 SELECTION GUIDE 1. Single piggyback variable level float switch or double piggyback variable level OPTIONAL PUMP STAND P/N 10-2213 float switch. Refer to FMO477. Reduces potential clogging by debris. 2. See FM0712 for correct model of Electrical Alternator E-Pak. Replaces rocks or bricks under the pump. • Made of durable, noncorrosive ABS. 3. Variable level control switch 100743 used as a control activator, specfy duplex Raises pump 2" off bottom of basin. (3) or (4) float system. Provides the ability to raise intake by adding sections of 1 or 2" PVC piping. A CAUTION Attaches securely to pump. Ali installation of controls, protection devices and wiring should be done by a qualified • Accommodates sump dewatering and effluent applications. licensed electrician. All electrical and safety codes should be followed including the ! \ most recent National Electrical Code (NEC) and the Occupational Safety and Health NOTE: Make sure float is free from obstruction. Act (OSHA). RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. © Copyright 2008 Zoeller Co. All rights reserved. POWTS OWNERS MANUAL & MANAGEMENT PLAN page- S of FIE INFORMATION SYSTEM'SPECIRCATIONS Owner dl~/o ~oy.J Septic Tank Capacity /000 at .0 NA Pemhit # Septic Tank Manufacturer 0 NA ~✓IESEti o.~cRE-r6 DESIGN PARAMETERS Effluent Filter Manufacturer ~ES r 0 NA Number,of Bedrooms 3 . E3, NA Effluent Filter Model 1,47_14 0 NA "Number of Public Facility Units 0 NA Pump Tank Capacity, ,0<9 al 0NA DNA Estimated flow (average) Soo gal/d Pump Tank Manufacturer N//ESE2 " o~JG. Design flow (peak), (Estimated x 1.5)" 5/ O gal/day Pump. Manufacturer ZoE~t E2 0 NA Solt Application Rate . - y - avd . tw Pump Model 0 NA Standard influent/Efftuent Quality Monthly average* Pretreatment .Unit NA Fats. OE & Grease (FOG) 530 riig/L ❑ Sand/Gravel Fher D Peat Fitter Biochemical Oxygen Demand (BODai 5220 mg/L 0. NA 0 Mechanical Aeration 0 Wetland Total Suspended Solids (TSSI 5150 mg/l. 0 Disinfection 0 Other: Pretreated Effluent Quality` Monthly average Dispersal Cell(s) 0 NA Biochemical Oxygen Demand (BODJ 530 mg/L ln-Ground (gravity) 0 In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L 0 NA 0 At-Grade 0 Mound Fecal Coliform (geometric mean) 51Wpfu/100ml . 0-Ddp4jne 0 Other. Maximum Effluent Particle Size )e in dia.. 0 Other 0 NA Other: 0 NA Other: 0 NA ''Values types for domestic wastewater and septic tank effluem. Other: 0 NA MAINTENANCE SCHEDULE Son we Exam Service Frequenay 3 a s) (Mmilintim 3 years) 0 NA inspect condition of tank(s) At least once every: D month(s) Pump out contents of tank(s) When combined sludge and scum equals one-third-(YJ of tank volume 0 NA Inspect dispersal cell(s) At least once every: 0 month(s) (Maximum 3 years) 0 NA -3 year(s) At least once every: /I/ N month(s) 0 NA Clean effluent filter © year(s) controls & alarm At least once every: 0 month(s) ONA Inspect pump, pump 3 . ye(s) Flush laterals and pressure test At least once every: 0 month(s) NA D year(s) Off. 0 month(s) 0 NA At least once every:-, 0 year(s) Other. 0 NA MAINTENANCE UNSTS anomS inspecdons of tanks and dispersal cads shall be made by an individual carrying one of the following licenses or certifications: Ma 9W Plumber; Master Plumber Restricted Sewer. POWTS Inspector, POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, (measure the volume of combined sludge and scum and t0 check for any back up or pondmg of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface.- The ponding of effluent on the ground surface may indicate a falling condition and'requkes the immediate nodfWa don of the local regulatory authority. When the Combined- accumulation of sludge and scum in any tank equals one-third 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, Wwconsin Adminis trative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized a nests, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority wrthm 10 days of completion of any service event. START UP ANO oPERATwN Page of ' For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting Woducfs or other chegnicels that InaY lonPSde the treabnert PrOOGGS and/or damage the dispersal cep(s). If high concentrations are detected have the c.orntamts of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface`' g" During power outages pump tanks may IN above normal tnighwater levels. When power is restored the excess wastewater will be discharged to the dispersal cells) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the cohtethts of the pump tank removed power to the effluent pump or contact a 'Pl unber or POWTS -MaiMaloer to assist in manually operating~p ~ restoring prior to punV restore normal levels within the punk tank. (enrols .to Do not drive or park vehicles over tanks and dispersal cells. Do not drive or Park within 15 feet down slope of any mound or at -grade over, or otherwise distwb or compact, the area -grade sop absorption area. Reduction or elimination of the following from the wastewater stream may inprove the performance and Prolong the We of the POWTS: MTUWKydw. baby wipes; cigarette butts; conda7hs; cotton ; mss; dental floss: diapers; disinfectants: fat; foundation drain (suurnp plump) water. frcdt and vegetable peelings; gasofune. grease; herbicides; mast= scraps:'rnedications; op: Painting products; pesticides; sanitary napkins; tampons; and water Softener brine. .ARANDONNIIB iT When the RNM fails mWw is permanently taken out of service the following Steps shag be taken to insure that time systern is properly and ad* doidoped in complance with chapter Comm 83.33, Wboonsin Administrative Code: . • All piping to tanks and pits shag be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and Pita Shall be removed and properly disposed of by a Septa Serviolng -Op . • After pungA g, all tardcs and pits shag be excavated and removed or their covers removed and the void space fled with sou, gravel or another inert solid material. CON ILCY PLAN If the POWTS fags and cannot be repaired the following rn6esures,have.been, or rust be taken, to provide a code ooinplant repliacen" system: A suitable replacement area has been evaluated and may be utifrced for the location of a replacement sop absorption sV*Wn,. The replaceinag area should be protected from disturbance and compaction and Should not be infringed upon by required setbacks from existing anil -DroPobed structure, lot Ghes and wells. RA" to protect' the replacmnent am will . result in the need for a now soli and site evaluation to establish a suitable nwheerient area. Replacement sySterns roust comply with the ndes in effect all that tine. D A sufteble replacerrierht area 15'110t avaiable due to setback and/or Sol britations. Barring advances in POWTS technology a hoidng tank may be installed'as a last resort to replace the fried POWTS. . The clot has not been evaluated to identify a Suitable replacement area, Upon falwe of the POWTS a =1 and sits evokintion nmst be performed to-locate a Suitable replacement area, If no replacement area is avageble a holding tank may be ihMaNed as a last resort to replace the felled POW TS. O Mound and, all-grade soil absorption systems may be reconstructed in place following removal of the biomst at the infitradve surface... Recoh>st3thrgtions of such systerns.oxm comply with the rules in effect at that Mime. SEPTIC. PUNp AND OTHE1t TREAT aMr TANKS MAY CONTALN LETHAL GASSES ANDIOR IIT OXYGEN. DO NOT ENTER A SEPTIC. PUMP OR OTHER TREATRUM TANK UNDER ANY t XROSTANCES. DEATH MAY RESULT. RESCUE OF A rERSON FRDM THE NTMW OF A TANK MAY BE DFFIC XT OR 09098 BLE. ADDmONAL COMMENTS '-POWTS NSTALLER POWTS MAINTANIER Narrne / Nafne _7 o .r ~t,r EL~L'E dUIVd 1•✓6 Phone S G 7,?- Sa?6 Plane SEPTAOE SERVICNG OPERATOR OVMM) - G,i✓ No•v,J LOCAL REGtILATORY AAUTHORRY Name Name a~X ~t" GE . Phone Phone /S- 38G y680 This docxment was wafted in compliance with dmprw Caawn 83.=Z(b)(t)(dWf) and 83.54(!). (2) & (3), Wier, r iorosi eve Cale- - 4-r ZS JU6 m u v tia'a`x • - i ' - - a O ar i vi w - d if - tf r d vai V~i ~ a0.. 41 4- z Q ~ i VI ~ w mr N ~•V.4 (a v z } w~ A cn - o $ t~ v0 CY - to m G 3 ?~Y ( -;5r s+ O s L 0 3 2 w E tit X_- 4w _ me a m~ > CL 02 f 4-4 5: Jr ui Q. %4..4 7E 2 /"1 a1 c w ' u! ~C as r- £ -3 - ca V 221 tV m 47 tit > g Ea 4~ cm CL. eCO m 4. m - TL Z ~ v V ~ ~ C V V ar E V= G'OY~ m _ m E r 3 EE z Q i`~~`C i~ v N >s CL C~ Esp= to aEiQCC a5« ~i E? 1 ao>- v$iso M C d 87 ' C Q a Tt V1 10 O. V= . N Q ~i « 4p o 0 m m O 2- io w CL s ~ ~ O q oar w V t ~ ~ ~ ar O ro ar m m Or 1 a~ m v c A 2 `o0 of our ~ ; - - 3 ~ « a/ M E 0. 75 CL Q X al r:Y! +Oir C umi 3 O O 14 t O M_ Y' t:.: 0 I S ar r N 'O E N W f ] V O. a7 Ct R ~ _ 1ypa w L a~ a ri o T _ ON L w C \ 111 V m- m Z - ~.y -Dmy~O~ ~'taD S 1 G. O C Y % = I Q D~.• rn rQ O, t; !~1 4 ~ m~ N d~ m G. J m~ ~i Q m 'o u E 3 cc 10- - - ° V - > mr~~ _ i-+ 77 EQ aai 2! E 0 r ; ~ ar v m = i-+ CLE 4v M 4--A M L A! m wQ. o « m Nr i~ Jym Myv~c ~,,-~3 H vvisc o sin Department of Commerce SOIL EVALUATION REPOR PAID Page / of 3 Division of Safety and Bindings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 812 x 11 inches in size. Plan must r ~/IOJ X include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel tD. percent slope, state or dimensions, north arrow, and location and distance to nearest road. Please print aA information. by Dale Personal mfbmu m you prwride may be used Law, 15.04 (1) (m)). - (D ~D Property Owner Location 01,0 ~1 o*') dpvt Lot se- 114,V C 1M S I.,F- T .?8 N R /9 j (or jo Property Owners Mailing Address # Blodc # G ub a or CSW G 9G lalo~~.c - CityyJ State Zip Cade iiii e~Fillege ® Town Nearest Road to `G/UE2 x'; LLS CJT Tito GLovE ! ❑ New Construction Use Residential / Number of bedrooms -3 Code derived design flaw rate GPD (311ent ❑ Pub k or commercial - Descrbe: Parent material Ou r-AMS11 Flood Plain elevation if applicable H.Q ft. General con rwft and ~/dG ~ou,rD X40 s"S~ r fif r LoROi.✓t IZAr- L/,~r s ro rio.✓ cair t .ate recommendations: ~ EEd ED /lECO.y.yE~o .5: F-/1 Boring # ❑ Boring ® Pit Ground surface elev. 97 8 ft. Depth to limiting factor - 160 in. Sod AviAcation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munseti Qu. Sz. Cont. Color Gr. Sz. Sh. -EW -Eff#2 / D- oy2a / .J3ry ~ S v G 8 3 SZ-o /o/,( x/4 fM SO el S /.D 21D, 3, /i Q Boring # ❑ Boring 0 Pit hound surface elev. 96-Z ft. Depth t0 limiting factor > 8 y in. Sod Appllc;abon Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. -001 -Eff#2 / o -/8 ioYz .71a - S11 ^1 oi.~ 'V4' 449 le IC a ley, e 3 - s, l - 3 1,77-33 a r s l -F sdk 4/ - 3 - /o Ya s - s ~ - • Eliluerd #1= BOD >.M:5 220 mg& and TSS >30 < 150 ' Effluent #2 = BOD < 30 mgIL and TSS < 30 mglL CST Nape rem Print) - CST Number ~ ~ ssErr ~ 97 y 'Address ate Evaluation Conducted Telephone Number 150-? /P/W tJ4 Y ~t' LCAN G L A/.rE L✓Z- .5-317-0/I 9 /~-/D 7~S 835/- 8610 Pmp" Omw -_Vwy/,o ,real y Pamd Page -1 cf~_ 0 B«ig# ° Boring ® pit Grratardsrrrfaoeelev. 2,~G it Dept to rrragiacbor ' in. sai Rats Norfaan Depth Damkw*Cokx Redox Desrripion Tetkrre SUudeYe -ConddOnos Boundary Rods GPON ir. Ntsrset Qo. Sz. Cunt Color Gtr. Sz Sh. -EM1 -EM2 O - a y a6,~ C 6qI✓. M O R S S S ✓ n ,~J S 8 14Ya S y s s M y Bonxg # ®~9 , ❑ PR QUXWSrrtfaaselev 98. Z ft Dept, fo WON factor 00 " Sot AmIcOon NO florizon Depth Do Aw* Re&K Demx%* n Texuale _ Stfuch a CbnskW a Bounty Roofs _G POW im Munsel CkL Sz Coat C*r Or. Sz. Sh. OEM *EW ~ O -3 o rz ,t l 2 38 -s- o Y 3 519-77- /o Y,t A- 6 .72- /o - f Q Bm ft # 80rtlg ~ Grar.,dsr.faceeie+►_ -ft Depth bfirriirgfacfor in. Sat ApOcalon Raba Hwr mr Deo DomkmntCOb RadomDesaipflorr Texture Sf<wkm Cmahmrtoe Boundary (toots GPM in. Nrrnsel Qu. Sz. Cow Color GE SL SL 'EM! 'E2 T :~Ruent#1=EIOQS>30<220egglL.aadTSS>30<13E3ragil - ~~-80Osc~~,~~c30~ The Df;p~ent ofCc~oenx is an equal opportrmiEy service ~aod eo~loyer. Ify~ need assistance>n access services or. need mrtW in an aftmft fib please cow" ffic &Wumea at 608-266-3152 or TTY 6a8-2648777_ s C t~'1 H H C4 0 o Z1 L'~ - o o °p a Z o ti Z "t rv A 0 7 ~ 7. y r c a S O 0 a 1~ 0 4 N V` D o ~r ~ ~ w c " a ~ ~~h M ~ ~ N h p 0 z 3ti 7 a 7 ~u N v t ell c QP A p Z o a^ r N. ~ e n % IN I a 0 W ~a 10/20/20 PM 0 03:01 ' ' Parcel 040-1059-50-000 P ~ PAGE E 1 1 OF 1 Alt. Parcel M 15.28.19.227D 040 - TOWN OF TROY Current 0 ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner 0 - JOHN, DAVID 0 & ANITA DAVID 0 & ANITA JOHN 696 GLOVER RD RIVER FALLS WI 54022 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 696 GLOVER RD SC 4893 RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 1.530 Plat: N/A-NOT AVAILABLE SEC 15 T28N R19W 1.53AC PT SE NE COM 167 Block/Condo Bldg: 1/2 FT W OF E1/4 COR SEC 15,TH N 443 1/2 FT, W 150 FT, S 443 1/2 FT E TO POB Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 15-28N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 413/639 2010 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 11/09/2009 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.500 50,000 140,300 190,300 NO Totals for 2010: General Property 1.500 50,000 140,300 190,300 Woodland 0.000 0 0 Totals for 2009: General Property 1.500 50,000 140,300 190,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 121 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ST. CROIX COUNTY 'SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/ er D- Mailing Address Property Address S~iy►~ j~ (Verification required from Planning & Zoning Department for new construction.) City/State 1 ~ &L- J &L-f, (UL7 Parcel Identification Number 5D LEGAL DESCRIPTION Property Location '/4 ,Sec. T 4 N RW, Town of / Subdivision Plat: i Lot # Certified Survey Map # , Volume , Page # Warranty Deed # (before 2007)Volume , Page # V3 Spec house yes /ho Lot lines identifiable key 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 ( I ) 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. 1/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedroom o4- SIGN RE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) Sic ` r f5trx' S p,R NI6LFPG9•, MiLWi4KfL r~ •.;Gs:. ,:•F : cep` ".t, aka , p ;s•,,:L..... ; ~ ' '3++ ~r~< sw:,. " . '9 4t 'rFs 's s~,x u, S4?+firo'i.ky k :•FT. _ t the year, t7 RE iNT .7 ~yr~l ,~a.'.%L'"t. ~t ^ F~% y>`~:f£'•TF:`,~' y ~.,3. .+1,..j~`°#:t • I l a• 3' rv" a 1• n a 1:. s;._ ,;'.M•. band and wife, b h of AeRR„ ffP Ril a a:^C+ c e7h. x: R 777 k ~<~i ~,A'~`.•x, y...k•'.:,a5;ds. A;... ..MM, ire, i.- i vi t. E•I. .2" „y•. FF,,1' f.FF ~dy .F,. 11._.y fw;{I'';' n`ai.•7'C.t.iE•.1 ,'the firat part, 'iAi A', • ~ t. Ar.. ; u^ ~MQg.. of T, v, yea.fTeRe•ssuxc lT'sJNnf'w,eHlfnRq.na+!'urp•''!s}nti+nu.na.*mrlT/sjew;Y+9Rns~ 77 77' dfHP .rw IF'~''ytr t,. „n<} ' rya"• w.:.. 'zh}.<' ,~i^ . ,•ti" "n•'s" i.r E .ss... husband and wife, as joint tenants, parties of the second part, Witnesseth, That the skald part,iPA........ of the first pact, for and in consideration of the sum of One thousand rred and,,,, ,N0~100 ~.~~~aF#at~#..3~ #~F. Dollars tive"..hup5k to..... th~R? ..,,..in hand paid by the said parties of the second part, the receipt whereof is hereby o fessed and ve d aiid donfirined,'and.by acknawled ed, ha „ ; iven, granted bargained, sold, remised, released, aliened, conveye these presents do...... give, grant, bargain, sell, remise, release, alien, convey and confirm until the said parties of of St. roixr_ the second part, as joint tenants, the following described real estate, situated in the County ..and State of Wisconsin, to-wit; A parcel 'of land located in the Southeast Quarter of the Northeast Quarter (S 1/4 NF 1/4), Section 15, Township Z8 North, Range 19 West, Town of Troy, St. Croix County, Wisconsin, more fully described as follows: Cornrnencing at a point on the South line of said Southeast Quarter of Northeast Quarter, which point is South 890171 West 167.50 feet from the East quarter corner of said Section 15 and the POINT OF DEGINNINQ; thence North 00431 West 443, 50 feet; thence South 89017' West 150 feet; thence South 00431 Fast 443, 50 feet to the South line of said Southeast Quarter of Northeast Quarter, thence North 890171 Fast along the South line of said Southeast Quarter of Northeast Quarter 150 feet to the point of beginning. ` Said parcel containing 1. 53 acres including Town Road R/W, 3 R is • l Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise apper- j taining; and all the estate, right, title, interest, claini or demand whatsoever, of the said part..l.ee._.of the first part, ' either in late or equity, either in possession or expectancy of, in and to the above bargained premises; and their heredita- ments and appurtenances, To have and to hold the said premises as above described, with the hereditaments and appurtenances, unto the said parties of the second part, as joint tenants. vole !