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002-1090-10-000
,'Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Saff;ty.an Budding Division M INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 'ermit Holder's Name: City Village X Township Lorenz, Julie L. Baldwin, Town of ;ST BM Elev: Insp. BM Elev: BM Description: ao g ~ ~ -~ TANK INFORMATION /1. TYPE MANUFACTURER CAPACITY Septic i w~e~ , ~~ Dosing L/CYK~b ~+~~ ~ ~~~ Holding ~--_ --`- TnNK SFTF3ACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic / / 7 /aj ~9 ~ •~ g`3 ~' Dosing ~ ~ /~~ c / C / 7~5 -- Aeration _ ~___. Holding ~ PUMPISIPHON INFORMATION -1 Manufacturer Demand Q V ~ s GPM Model Number pE ~ ( L"~ ~+ TDH Lif~ ~ Fricti~ Los System Headt ~ TDH~~ , Ft ~ • J • (~ Forcemain Length i Dia. rt Dist. to Well ~ IbO SOIL ABSORPTION SYSTEP.9 BEDITRENCH DIMENSIONS Width / 75 3 Length ZQ ~ No. Of Trenc es 7 X1 PIT DIMENSIONS ~"~ No. Of Pit=~ Inside Dial" Liqui Depth . l . SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR Manufacturer: ~ INFORMATION Type Of S tem: ~ ~ .~ w l oz / 35 ~ ~ l~ ~ A ;' ~ / ~J UNIT Model Number: ~\ V.V . ~ ~ •v~~ v ~ v ~ HeaderlManifold ~... • Distribution x Hole Size ~ ( x Hole Spacing Vent to Air Intake Pipe(s) /q l ~ ~ th' Dia • Spacing L V ~ [ ~.( ~ ['. I ~ ~C1 Length Dia eng _ /1 ~.. .+w~ n Depth Over / ~ Bed/Trench Center / Depth Over BedlTrench Edges ` xx Depth of Topsoil I ~ xx Seeded/Sodded Yes ~ No u c Yes ~ No , .~ D~ COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~ / JO/ ~ o Inspection #2: / / Location: 2691 Hwy 12 Woodville, WI 54028 (NE 1/4 NE 1/4 36 T`9N F~16W~metes & bounds Lot 5 ~ Parcel No: 36. 9.16.512A 1.) Alt BM Description - 4 C~+'~i P'Ot,.1 2.) Bldg sewer length = ~t ~ ~+~~ Q ~ 134J 6l~'~.. W -amount of cover = ~ Plan revision Requidditional i^nformatio~No ~~~ I! 3~ I ~'~ -- J - _--- -- ~ - l' iL ~~~~~~ Use other side fora Date Insepctor's ignature Cert. No. SBD-6710 (R.3/97) tLtVAIIVIV UAIA county: St. Croix Sanitary Permit No: 514932 0 State Plan ID No: Parcel Tax No: 002-1090-10-000 Section/Town/Range/Map No: 36.29.16.512A STATION BS HI FS ELEV. Benchmark Alt. BM ~,,,.t~-- Lam. 3 53 X63. ~~ , ~ Bldg. Sewer ~ /a 3, ~ SUHt Inlet 1D, C • aG ,/ o I SUHt Outlet ` ~. Dt Inlet Dt Bottom ~ ~3- Header/Man. ~,~ / D2 1, ~i Dist. Pipe + ~ •Z ~. / / / f~3 ~ f~ Bot. System ~~ ~ /3 f DZ . !J. Final Grade ~ Z. ~ a~• St Cover WN~ 3.~• o~.~~r 3.5 ~~ f` ~. Commerce.wi.gov Safety and B ' s Division Washington Box 7162 201 W County ST e~0 1 X I S C O n S I n . Madison, 1537 162 Sanitary Permit Number (to be filled in by Co.) m 5/ ~ ~3 Department of Commerce Sanitary PeI-mit Application State Transaction Number (n accordance with s. Comm. 83.21{2). Wis. Adm. Code, submission of this form to the appropriate go mental re ~ 555F3o Project Address (if differentthattmailin8address) unit is required prior to obtaining a sanitary permit. Note: Applica submitted to the Department of Commerce. Personal informatan v u prov~~t/Or~l~i1Qi11second ry u ses in accordance with the Privacy Law, s. ! i.Od{ 1 (m). Slats. CC L~".r/ !G~ ~~+ ~ ~I ~f r /~ l/L~~, ~/ /~ I. A lication Information - Pleas n t A{I Information Parce! a Propeny Owner's Name f z JUL 17 2008 Lo2E J ~D2 .. /090 » !~ - ~' x vt<c E Property Owner's Mailing Address ST. CROIX COUNTY / Property l~ocatton / ~ 5 / Z /~ s~~0 ~ ~W y ~ ,Z ZONING OFFICE Govt. lot ` l Ciry, State Zi Code P Phone Number Q L %. NE %. Section ~ /V Gq~ac~v~ w/ 5~V2g' ?I5-(o98-22/ r~_N: R /~ ~ w II. Type of Building (check all that apply) 3 dot z Subdivision Name ~I or 2 Family Dwelling - Number of Bedrtx~ms t Bock st ^ Public/Commercial-Describe Use l ~ Cin~ of CSA7 Number ^ Village oC ^ Swte O.yrred -Describe Use / _~ Town of ,(3A G~ !~ //1/ 3 . ~S ~ ZU III. Type of PermiC (Check only one box on tine .Complete line B if applicable) A' ^ New System Replacement System 0 Treatmrnt/Hokfing Tank Replacanem Only ^ Other Modific~itxt to Fxisttag Sysuta (explain) B. ^ Permit Renewal ^ Permit Revision ^ Change of Plun#ter ^ Permit Transfer to New List Previous Permit Ntanber aad Date lssrred / Retort Expiration O"'"~ IV. T of POWfS SvstcmlCom onent/Dc.-icr. Check all that a I t/ d < 24 ire of smote soil ~ M oun ^ Non-Pressurized he-Csnpund 0 Pressuized In-Ground ^ Ai-Grade ^ Mound > 24 ro. ofsu~abie soil ^ Voiding Tack ^ Other Dispersat Cott~ottmt friptain) ^ Pretreatttxm Device (ecplatn) V. Dts ersal/I'rea ent Area information: Design Fbw (gpd} Design Soft Application tc(gpdsf) Dispersal Area Required (s Dispersal Area ProposeJe {Sf! System 17e~i~ 5a ' ./ O 2 ~ J ~ . / 225a 4 Jr~ , 2 2 2 50 VI. Teak Into Capacity in Gallons Towl Galltms ~ of Units Manufacttser .c ~ ° ~ U 4 ~ ///~~~ New Tanks ~cistmg Taroks ~ ~ / /~~ vJ~firf/r ~^I 0.v ~ ~ ~ B ~ ~ Septic or Ftoldws Tmk O'YJ"t~ / ~,S O~ Dosing r ,fC G 5v ~ ~ _ VII. Respotuibility Statement- !, the nndersigncd, assume responsibility for installation efthe POIYfS shown on the attached plans. Plttmi?er's Name lprintl .„n,F,er'g Cio..~ture MP/:L1PRS Number t Business Piwrx irumoer ~ f {~ ZG?`l85 ~?15~ZG5-~j//5 ii 1 ~ ~erS ,.e„~1., l .~ ., . ' '~ t ?itemlxr,< Atierers t~t2et. E, iiv. Jtate. Grp ~OL'et LriII..r".rttnt~;'^.eia,-tiitcnt u5[ ve'ei'i _ ilet•m;t Cod uut.°, :. ...~ - :«~:..., n .. C{...,,>...e S '~pgTf3S`et3 I ~ l7 ...6 ~.b ,..5........- S ~ ' ~ ~ O j ^ ~en Reason for crtiai ~ IX. Conditigt~t~t~xaso»s for Disapproval ~ t f S~`~. ~ ~J~ (~ 3~ ~ r f °K'S f~' J ~ e S tllut3nt finer and f. eptic tank,. dispersal cell must all be services/maintained `L ~ n e.~v~ faJ ~~ .~ p e~ ~~ • ~ •s per management plan provided by plumber. ~/ 1 ~. MN ae'~at~tr6egtk~ethertta must be irtkintained '~ ,t1` /1~ X11 ~1. ,~c~^,e.,u.. ~ ~ ~G a. e sanem and sabm' a the Coeety eniv on _ eel tens tiMn t tRp 1 i iaeAes is ase SBD-6398 (R. Ott07) Yalid thnt Oi109 ~COPy ct.LCE l.o~,~.j ~. 3 A t,~w ~~ `~a-w,~Stf~t ~' S-t', C'Cc.c~-ts~ Cuv,~ 7y gml = ~~-o.~~ b1= /oa+o' j32 = loo, ~' 63 = ~oa• o " l00 p . _ ~PF -.N ` - ~ ~ _ --off' '(~~EG-5 -6" ~ ~ a<, ~ ~ ,~~ ~ ~ ~~ N°''S~ ~~ ~~ ~P,~hC ---~. _.,--- __ ~a~vEu~~+`f _ €Jt(S~'iN6 n. T~~1~tS ~h~~Q.~ ~ 2 ~'~ ~~ Scr-~-c,~ ("= ~ ~~ rn P rC 1' t '. y ~ cc.l, t E r',o ~. .3aL~~~~ `~a-w~t~t~ S-f, C'tzt~-~x Cuu N ?Y ,(,~1~( I ~ /~~r~' ~Da~o' ~2 - ~oo,Q' 63 ~ /oa, o ' b~l= 9~~' ~12~ `P~ C ~i F~ ~vl s P~ j° foo, o ` .~`- _ -- ~rSfii~G T~~1~tS ~.,~ ~.~..a-e.l ~` I~t-~.~~.r.~ t'h~~Q~ ~' Z (~'~ ~~ S cr~c.E ("= `f~ //~,, 41, .Ti N r. ' s commerce.wi.gov i ^ ~scons~n Departmerrt of Commerce Safety and Buildings 141 NW BARSTOW ST FL 4TH WAUKESHA WI 53188-3789 TDD #: (608) 2648777 www.commerce.wi.gov/sb/ www.wisconsin.gov Jim Doyle, Governor Jack L. Fischer, A.I.A., Secretary July 08, 2008 CUST ID No. 267985 MICHAEL J MYERS NORTHLAND PLUMBING INC E1556 STATE RD 64 BOYCEVILLE WI 54725 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 07/08/2010 SITE: Julie Lorenz 2691 Hwy 12 Town of Baldwin, 54028 St Croix County NEl/4, NE1/4, S36, T29N, R16W ATTN.• POWI'Slnspector ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 Identification Numbers Transaction ID No. 1555180 Site ID No. 704324 Please refer to both identthcation nun~bcrs, above, in al#correspondenee with the a enc . FOR: Description: Mound, 3 bedroom Object Type: POWTS Component Manual Regulated Object ID :1189335 Maintenance required; Replacement system; 450 GPD Flow rat~'H-in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual -Version 2.0, SBD-10691-P (N.O1/O1), Pressure Distribution Component Manual -Version 2.0, SBD-10706-P (N.O1/O1) 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 the 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: This system is to be constructed and located in accordance with the enclosed approved plans and with the "Mound Component Manual for Private Onsite Wastewater Systems VERSION 2.0" SBD-10691-P (N.O1/Ol) and the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems VERSION 2.0" SBD-10706-P tN.01/O1). In the event this soil abso tion y po p ~ rp system or an of its com vent arts malfunctions so as t ~~rd, the property owner must follow the contingency plan as described in the approved plar~~ r must comply with the operation, maintenance and monitoring duties as describ 'n secti~b~b f d component manual. A copy of this information must be given to the owner upon co letion o~'4 ct. ~~~ ~,~~ \ ~~. All holding/treatment tanks are to comply with Comm. 84.25(7)(a). ~ ~L; ` ~` frw Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. Access to the filter for cleaning must be provided per Comm 84 product approval conditions. ti~ MICHAEL J MYERS Page 2 7/8/2008 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 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. 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. 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. Si ly, Julia Lewis-Osborne POWTS Reviewer 2 ,Integrated Services (262) 397-6005, Fax: (608) 283-7481 julia.lewis@wisconsin. gov Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 WiSMART code: 7633 ,, ,~ Mound System Cover Page ~9, ~ s WIENER CONCRETE Project Name: Lorenz-Mound Owner's Name Julie Lorenz Owners Address 2691 Hwy 12 Woodville, WI 54028 Legal Description ivE • '/., NE • %. Sec 36 T 29 N, R 16 w _~ Township Baldwin county Saint Croix • RECEIVED Subdivision JUN 2 5 2008 Lot# SAFETY & BUILDINGS Parcel ID# Table of Contents P9~ 1 Cover page 2 Mound Sizing Calculations 3 Pressure Distribution Layout and Dynamics 4 Dose Tank 5 Management and Contingency Plan 6 Plot Map ~v nT ~ C[~/e VC- total # of pages: 6 Designer Name: Michael J. Myers MP/License #: 267985 Date: 6/17/08 Ph. #: 715-265-4115 Signature: Mound System Design Methods Used per "Wound Component Manual For Private Onsite Wastewater Treatment Systems" (Version 2.0) SBD-10691-P (N.01/01) per" Pressure Distribution component manual for Private Onsite Wastewater Treatment Systems" (Version 2.0) SBD-10706-P (N 01/01) '. ;;~~,F ~~~~'es ::, ~v~~C F ~ernent.c:orrr N12466 220th St, Boyceville, WI 54725 Ph: 715-643.6068 email: ,' Project Type: 1 or 2 Family Dwelling ~ Slope: 4 # of Bedrooms: 3 Depth to limiting factor: 6 in. Absorbtion rate of fill material: 1 gaUftz/day Absorbtion rate of in-situ soil: 0.2 gaUftz/day Effluent quality Eff#1 • Max BOD effluent value: 220 mg/I Max TSS effluent value: 150 mg/I Mound System Mound Sizing Calculations Project Name: Lorenz-Mound Site Conditions Page 2 of 6 Design of Entire Fill Cell depth at upslope edge (D): 30.0 in. Cell depth at downslope edge (E): 31.8 in. Distribution cell depth (F): 9.5 in. Cover thickness over edge (G): 6 in. Cover thickness over center (H): 12 in. End slope width (K): 13.1 ft. Fill length (L): 146.2 ft. Upslope width (J): 10.2 ft. Downslope width (Toe) (I): 15.0 ft. Fill Width (W): 29.0 ft. Design of the Distribution Cell Basal Area System Design Flow: 450.0 gal/day Basal area required: 2250 ftz Distribution cell widttl~: 3.75 ft Basal area available: 2250 ftz Distribution cell length (B): 120.0 ft Area of Distribution Cel~ 450.0 {~ Observation Pipes Contour Elevation of Mound: 100.00 ft Location from end of cell (Z): 20 ft System Elevation of Mound: 102.50 ft Final Grade of Mound: 104.29 ft Mound Plan View ~ Observation Pipes ~ ~ Z-~I K~ Distribution Cell B ILK Tilled ArealFill Material E~ L Mound Cross Section Final Grade ~,~.~ Synthetic Fabric Distribution Cell System Elevation 6n: a d Cover Material Cetera Fill Material Im~ert ~'~ Slope -~O~ bserva#ion Pipe G ~s 3 Tilled Area ~Forcemain System Contour Notes: Fill material to consist of ASTM C33 Sand Distribution cell aggregate to comply with Comm 84.30(6)(1) Synthetic Fabric covering on cell per Comm 84.30(6)(8) Distribution Cell to have minimum 6" aggregate below lateral and 2" above. Mound System Pressure Distribution Calculations Project Name: Lorenz-Mound Lateral Layout Lateral elevation: 103.0 ft Rows of Laterals: i ~ Manifold type: center ~ Orifice diameter: o.lz5 ~ In. # of Laterals: 2 Distal Pressure: 5 ft Lateral Length: 59.5 ft Orifice Spacing/Distribution Orifice spacing (X): 14.42 Inches Orifices per lateral: 50 Avg. ftz/Orifice: 4.50 ft2 Lateral Side View ~ Lateral Manifold Lateral Len Lateral Plan View -- Lateral Length Orifices on bottom of lateral equals spaced Clean Out Detail Clean-out plug Grade `or ball valve ~Nater tight cap or plug Sprinkler Box Long Sweep 90 or two 45's-.~ Page 3 of 6 Lateral/Manifold Design Lateral diameter: 1'/~ ~ In. Lateral spacing (S): uft Lateral to cell edge: 1.875 ft Lateral discharge rate: 20.60 gpm System discharge rate: 41.19 gpm Manifold diameter: 1~~ ~ In. Manifold length: 0 ft Forcemain Friction Loss Forcemain length: 80 ft Forcemain diameter: 2 ~ In. Friction loss in forcemain: 2.788 ft Tum-up wlbaW vahre or deanout pkag PVC laterals and forcemain to comply with specifications per Comm 84.~(2nej Observation Pipes 6" Minimum Lateral Note: Closet Calar may be used in place of 3I8" tsar ~3I8' Bar Mound System Septic, Pump and Dose Tank Project: Lorenz-Mound Tank Information Pump tank manufacturer: Wieser Concrete Pump tank size/model: wlooo/65o-rtR • Pump tank gaUinch: 17 Actual Pump Tank Volume: 646 gal Tank bottom elevation (inside): gg ft Septic tank size/model: W1000/650-MR ~ Pump and Filter Pump Manufacturer. Goulds Pump Model: PE51 P1 Effluent Filter: Polylock Note: Access opening of sufficient size to be provided to allow removal of filter. Opening to terminate at or above grade. Pump Tank Diagram Watertight Locking Cover 4 Inch ~j With Warning Label; Attemnte ~ - I ~Q' Outlet L~ Location Elect per Comm '16.28 and ~ NEC 300 Weep Hole A orAnti- Siphon 6 Device D Pump must be capable of: 41.2 GPM and head pressure of: 22.7 Feet Page 4 of 6 Dosage Volume Forcemain drains back to tank? QQ Yes O No Lateral void volume: 12.6 gal Dosage to absorbtion Cell: 62.9 gal Forcemain volume: 13.9 gal Total dosage: 76.8 gal Total Dynamic Head Are laterals highest point? y if not, enter highest elevation: p ft System head (distal x 1.3) 6.50 ft Vertical Lift ("D" to lateral) 13.33 ft Friction loss in forcemain: 2.79 ft Pressure loss from filter: ~p {{ Total dynamic head (TDH): 22.82 ft Dose Tank Levels In. Gal A Reserve 23.5 399.2 B Pump off to Alarm 2.0 34.0 C Total Dosage 4.5 76.8 D Effluent depth for pump 8.0 136.0 Total Capacity: 38.0 646.0 Mound System Management Plan pursuant to Comm 83.54 W. A. C. page 5 of 6 Owner's Responsibility: The component owner is responsible for the operation and maintenance of the component. The county, department or POWTS service contractor may make periodic inspections of the components, checking for surface discharge, treated effluent levels, etc. The owner or owner's agent is required to submit necessary maintenance reports to the appropriate jurisdiction and/or the department. Septic Tank: Septic tank(s) are to be inspected routinely and maintained by department approved individuals when necessary in accordance with their approvals. The use of chemical/biological "treatments" is not required or recommended. If such additives are used, make sure they are approved by Department of Commerce, Safety and Buildings Div.. Effluent filters are to be removed & Leaned as necessary, with provisions to keep solids from passing the septic during removal. No more than 1/3 of the usable tank volume may be occupied by sludge/scum. 3 year inspection: If tank has greater than 1/3 volume sludge, tank contents must be emptied and disposed of in accordance with NR 113 Wisconsin Administrative Code by an approved individual. If the inspector does not recommend pumping of the septic tank, then the owner must be notified of when pumping should be done as to not exceed 1/3 sludge volume. Septic tank should be routinely inspected to be watertight and of good repair. Pump/Dose Tank If an effluent filter has been installed in the pump/dose tank, it must be removed & Leaned as necessary, with provisions to keep solids from passing to the mound component during removal. The pump, float switches and alarms must be inspected at least every three years for proper operation. Pump/dose tank should be routinely inspected to be watertight and of good repair. Mound and literal System The mound system component must remain free of ponded surface water prior to pump operation. If 4 inches or more water level is detected in the observation pipes, the owner must be notified of possible problems/failure. The designed daily flow capabilities of the component should never be exceeded. Trees and any other deep rooted vegetation should never be planted, or allowed to grow anywhere on the component. Activities OTHER than mowing/maintenance (i.e. excessive walking, pets, vehicles, etc...) could compress the component and reduce it's absorbtion capabilities and/or possibly cause it to freeze in winter conditions. Lateral distribution pipes should be flushed out/tested every 18 months using the deanout points at each end of the component to remove scum that may Gog orifices. Performance Monitoring: Performance monitoring must be done at least once every three years following the installation or at the time of a problem, complaint, or failure. Contingency Plan: If the septic tank, pump tank or any of their components therein (including floats, alarms, pumps, etc) become defective, the defective tank or component must be replaced immediately to ensure that the system can operate as designed. If the mound component cannot accept wastewater or ponds wastewater to the surface, the component must be repaired or replaced in it's current location by either. extending basal tce to provide added absorbtion area; or by removing the Dogged bacterial mat,aggregate cell, and distribution piping within the mound and replacing said components in order to return system to proper working order as required. i ~ . , ITT APPLICATIONS Specially designed for the following uses: • Mound Systems • Effluent/Dosing Systems • Low Pressure Pipe Systems • Basement Draining • Heavy Duty Sump/ Dewatering SPECIFICATIONS Pump -General: • Discharge: 1'/z" NPT • Temperature: 104°F (40°C) maximum, continuous when fully submerged. • Solids handling:'/z" maximum sphere. • Automatic models include a float switch. • Manual models available. • Pumping range: see performance chart or curve. PE31 Pump: • Maximum capacity: 53 GPM • Maximum head: 25' TDH PE41 Pump: • Maximum capacity: 61 GPM • Maximum head: 29' TDH PE51 Pump: • Maximum capacity: 70 GPM • Maximum head: 37' TDH GOULDS PUMPS Residential Water Systems MOTOR General: • Single phase • 60 Hertz • 115 and 230 volts • Built-in thermal overload protection with automatic reset. • Class B insulation. • Oil-filled design. • High strength carbon steel shaft. PE31 Motor: • .33 HF 3000 RPM • 115 voltr • Shaded pole design PE41 Motor: • .40 HF 3400 RPM • 115 and 230 volts • PSC design PE51 Motor: • .50 HI? 3400 RPM • 115 and 230 volts • PSC design AGENCY LISTINGS sP'. Tested to UL 778 and CSA 22.2 108 Standards BY Canadian Standards Association 30 ~-PE41-- - -- i ±--- -- 1 ~ -- ~ __ _ ~ -- {--- o a i ' Pr31 ~ , ~ ~ __ i _. ___ u ~ I i '. z 20 i i o ~ ~ I C ~ t5 1 I -- - - -- , - ------ - i - - - _- - _..- - . _.. O . ~ 10 . -. - I ~ -- -- i 5 ' ~ I 111 -+ --- - - --1------: 0 0 I _ __ .._._ 0 10 20 30 40 S O 0 70 GPM 8 0 0 5 10 15 m3/h CAPACITY METERS FEET File #LR38549 40 ~_ ' _. __ __ __-_ _. __ PESY ~ ~ ! lMODELS: PE31 PEd1, PESL ~ ~ ~~ ~ li HP:.33, .d0 50 3 -- - __ ----~ 1 o i ~ ~ ---~ 2 GPM Goulds Pumps is 150 9001 Registered. ~. ., • commerce.wi.gov i~c~nsin Departmerrt of Commerce Safety and Buildings 10541 N RANCH ROAD HAYWARD WI 54843 TDD #: (608) 264-8777 www. commerce.wi,gov/sb/ www.wisconsin.gov Jim Doyle, Governor Mary P. Burke, Secretary September 19, 2005 CUST ID No. 46672 MARK W IVERSON PO BOX 155 HAIvIMOND WI 54015 CONDITIONAL APPROVAL PLAN APPROVAL EXPIItES: 09/19/2007 SITE: Julie Lorenz 2691 Hwy 12 Town of Baldwin, St Croix County NE 1/4, NE 1/4, S36, T29N, R16W A7TN.• POWTS Inspector ZONING OFFICE ST CROIX COUNTY SPIA -1101 CARMICHAEL RD HUDSON WI 54016 Identification Numbers Transaction ID No. 1193081 Site ID No. 704324 Please refer to both identification numbers, above in all corres ondence with-the a enc . FOR: Object Type: Soil Saturation Determination Regulated Object ID No.: 1038924 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. The following conditions shall be met during construction or installation and prior to occupancy or use: 1. Approval is hereby granted pursuant to s. Comm 85.60(2), Wis. Adm. Code, to estimate the depth to seasonal soil saturation based on an interpretive determination process. Approval of the interpretive determination negates the requirement in s. Comm 85.30(2)(b), Wis. Adm. Code to designate the ground surface as the highest level of soil saturation when redoximorphic features are less than 4 inches below the bottom of the A horizon. 2. The estimated highest level of prolonged soil saturation approved under this determination is six inches below grade: At least 30 inches of sand lift on top of six inches of unsaturated, in-situ soil is required for adequate treatment and dispersal. 3. The basal soil application rate for the mound shall be 0.20 gpd/sf, and the linear loading rate 4.50 gpd/ft. 4. Chisel plowing to a depth of 12 plus inches immediately prior to sand placement is required to improve vertical water movement into the soil solum. 5. Landscaping up slope of the mound shall be incorporated into the POWTS design to prevent surface water from concentrating along the up slope edge of the mound and to divert surface water drainage away from the system. 6. This approval shall remain valid unless the site is altered in such a way that the depth to soil saturation would change or if saturated conditions are observed for seven consecutive days at depths less than 3 feet below the infiltrative surface of the POWTS distribution component. 7. This approval in no way relinquishes the use of color patterns to estimate the depth to high groundwater on any other parcels or portions of parcels. 8. A copy of this approval letter and attachments must accompany the mound system design for this site for purposes of plan approval and sanitary permit issuance. If the Interpretive Determination Report was accompanied with a plan and an expiration date is shown on this letter, the expiration date only applies to the plans for the design, not to the decision on the Interpretive Determination Report. MARK W NERSON Page 2 9/19/2005 r • ' 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. If plan index sheets were submitted in lieu of additional full plansets, a copy of this approval letter and index sheet shall be attached to plans that correspond with the copy on file with the Department. 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. Sincerely, ~' Leroy G. J4lisky, PSS, astewat pecialist Integrated Services Bureau (715) 726-2544 Voice (715) 726-2549 FAx ljansky@commerce.state.wi.us Fee Required $ 100.00 Fee Received $ 100.00 Balance Due $ 0.00 WiSMART code: 7633 e. 3 INTERPRETIVE DETERMINATION REPORT Property Owner: 3ulie Lorenz 2691 Hwy 12 Woodville, WI 54028 P.O.W.T.S. Cc~ttditiotzally ~ R i~OV E D DEPARTMENT OF COMMERCE DlVI ' ON OF SAFETY AND BUILDINGS SEE RRES NDEN Site Location: NE '/4 of the NE '/4, Sec. 36, Town 29N, Range 16W Town of Baldwin St. Croix County 1X93p~y , Prepared by: ~... Mark erson, PSS #197, CST #46672 August 31, 2005 Date Evergreen Irrigation Inc. Mark Iverson, Professional Soil Scientist P.O. BOX 1SS Hammond, WI 5401 S Phone: 715-796-5664 Fax: 715-796-5246 TABLE OF CONTENTS I. Introduction .............................................................................................................1 II. Project Information ..................................................................................................1 III. Method ..................................................................................................................... l IV. Discussion of Results ...............................................................................................2 A. Local Hydrology .......................................................................................... 2 B. Geomorphology ........................................................................................... 2 C. Soil Disturbance and Hydraulic Modifications ............................................ 3 D. Landscape Position and Local Topography ................................................. 3 E. Soil Series and Mapping Units ...................................... . 3 F. .. ........................... Additional Data ............................................................................................ 5 G. Comparative Analysis .................................................................:................ 5 H. Government Reports and Comments ........................................................... 5 V. Conc lusions and Recommendations ........................................................................ 6 VI. References ................................................................................................................7 Table 1 Table 2 FIGURES Figure 1 Figure 2 TABLES - Soil Series Characteristics - Hydric Soil Classification Appendix A - Appendix B - USGS Topographic Map Soil Map APPENDICES Soil Evaluation Report Correspondence I. INTRODUCTION On July 21, 2005 Mark Iverson, Professional Soil Scientist #197 and Certified Soil Tester #46672, completed an Interpretive Onsite Soils Evaluation. An interpretive evaluation is required because the site does not meet the requirements to install a new private on-site waste treatment system (POWYS) through completion of a conventional onsite soils evaluation (<A+4 inches of acceptable soil is present). The onsite evaluation was completed through the observation of the soil profiles at five hand dug test pit locations. This report has been prepared to present the results of an interpretive determination completed to determine site suitability for installation of a POWYS. The evaluation was completed at the request of the homeowner, Julie Lorenz. The evaluation was completed to identify a location to site a replacement POWYS for the Lorenz residence. The current system includes a septic tank with surface discharge. The current discharge location is identified on the figure included in Attachment A. The property is located east of Woodville on the south side of Hwy 12. Mark Iverson completed a preliminary soil evaluation. The preliminary evaluation included the entire property (18 acres) and concluded that A+4 soils were not present on the site. The location the interpretive determination was identified as the most suitable location on the site for installation of a POWYS. No data from the preliminary assessment has been included. II. PROJECT INFORMATION The following is site-specific background information, which has been collected: Property Owner: Julie Lorenz 2691 Hwy. 12 Woodville, WI 54028 715-698-2217 Site Location: NE '/4 of the NE '/4, Sec. 36, Town 29N, Range 16W Parcel ID # 002-1090-10-000 Town of Baldwin St. Croix County Historic Land Use: Agriculture Crop Production /Fallow Current Land Use: Fallow Vegetation: The site is currently vegetated with miscellaneous grasses and thistle. III. METHOD This interpretive evaluation and report was completed following the guidelines set forth in Comm 85.60(2) of the Wisconsin Administrative Code and in the summary provided by Leroy Jansky titled, "Preparing the Interpretive Determination Report" (March 13, 2002) IU. DISCUSSION OF RESULTS A. Local Hydrology 1. Surface Water Drainage Patterns -Surface water drainage is uniform over the majority of the proposed system azea. No azeas of concentrated flow were identified. 2. Subsurface Water Drainage -The majority of the soils exhibited moderate structural grade with subangulaz blocky structure within the surface horizon providing good infiltration potential. The slope within the proposed system azea is approximately 3-4% this in combination with the moderate structure observed in the surface horizon will provide good lateral movement within the surface horizon. During frozen conditions and following heavy precipitation events, runoff will be much greater and temporary saturated conditions are likely on the site. Water drainage has been impeded in the subsurface soils by a number of factors. Platy structure is present below the topsoil at most of the boring locations. In addition, the bulk density was higher in the subsoil versus the topsoil at many boring locations. This is apparent through the firm or very firm structure that is present in Borings #1, #3, and #5. 3. Artificial Drainage Devices - No artificial drainage devices were observed during the completion of the evaluation. 4. Contributing Drainage Area -There is area upslope between the proposed system location and the house that contributes surface water to the system area. See the figure in Attachment A. 5. Soil Saturation -Saturated soil was not encountered during completion of the test pits identified on the figure included as Attachment A. The depth of the test pits within the system azea was 16 to 19 inches. 6. Surface Water Elevations- Surface water within 1 /4 mile of the site has been identified on Figure 1. The neazest surface water feature is an intermittent steam located approximately 200 feet Southwest of the site. B. Geomorphology 1. Parent Material -The pazent material is loess over dense glacial till. 2. Landform Type -The proposed system azea is positioned on the backslope of a till plain just above an intermittent drainage way. The till plain extends up to the east for approximately '/4 mile. The general slope shape in the vicinity of the proposed system area is convex perpendicular to the contour and convex along the horizontal contour. 3. Slope Aspect -The slope aspect with in the proposed system area ranges from W at 270 degrees to WNW at 300 degrees. 4. Surface Elevation -The surface elevation is between 1160 and 1180 feet msl as observed on the USGS topographic map. C. Soil Disturbance and Hydraulic Modifications The proposed system location is in a fallow field. The proposed system location has not been disturbed by cutting or filling. No hydraulic modifications, such as drain the or ditches, were observed at the time of the assessment. No additional surface water is received from impervious surfaces. D. Landscape Position and Local Topography The regional topography is shown on figure l . The direction of slope in the vicinity of the proposed system area is northwest to southwest as shown on Figure 1 and the figure included in Attachment A. The ground surface elevation is between 1160 to 1180 feet mean sea level (msl) within the vicinity of the proposed system. FIGURE 1- USGS TOPOGRAPHIC MAP ~~,.~. _ - ~ 2;x`:1 1 " ~~ _ ~~ ~ fir.. ~~ -1180.. 4 ~~~~~ f t I ! 78 ~ -- --- s-~ i, :.. ~} ' - ~ ~e La~atfon{ '• • 1160 ~--~-, 270th St. f a ~" E. Soil Series and Mapping Units The Soil Survey of St. Croix County maps the soils on the Lorenz property as Santiago (SaB), Skyberg (SrA), and Vlasaty (VaB). The location of each soil type is identified on Figure 2. The primary soil characteristics asdescribed in the series description are identified on the Table 1. Table 2 identifies the wetland indicator status of all soil identified on the property as identified in the USDA - NRCS Technical Guide - Hydric Soil Interpretations and in US Army Corp of Engineers (USACOE) hydric soils list. TABLE 1-SOIL SERIES CHARACTERISTICS Texture I Pazent Material I Permeability Soil Series A Horizon E or B Horizon Surface Subsurf. Surface Subsurf. Drainage Class Sa SIL SIL/SL Loess Till M S to MS W Sr SIL SIL/SICL Loess Till MS or S MS or S SP Va SIL SIL/CL Loess Till MS MS MW Abbreviations Permeability IM =Impermeable VS =Very Slow S =Slow Drainage Class VP =Very Poorly P =Poorly MS =Moderately Slow RA =Rapid M =Moderate VR =Very Rapid MR =Moderately Rapid W=Well SE =Somewhat Excessively SP =Somewhat Poorly E =Excessively MW =Moderately Well Table 2 - Hydric Soil Classifications NRCS -USDA Soil Series Com vent Inclusions USACOE Sa No None No Sr No Auburndale No Va No None No Component soils aze soils that are most likely hydric. If inclusions aze identified, small pockets of hydric soils listed may be present within the soil series. 4 FIGURE 2 -SOIL MAP F. Field Observations The soil within the proposed system area is mapped as Skyberg (SrA). The soil identified during the completion of the test pits has textural qualities similar to either Santiago or Vlasaty. Because the site has been out of crop production and seen little or no disturbance, the soil exhibits good structural properties within the surface horizon (upper 8 to 9 inches). The slope within the proposed system area is 3-4%. The slope in combination with the moderate structure observed in the surface horizon will provide good lateral movement within the surface horizon. Redoximorphic features were observed primarily as Fe concentrations in the bottom of the A and in the E and B horizons and occasionally as iron depletions in the E and B horizons. Redoximorphic features were observed in the A horizon as spots with occasional oxidized root channels at depths greater than 7 to 9 inches below surface. The redox features observed in or just below the A horizon can most likely be attributed to short term seasonal saturation. The redox features are also likely a result of increased bulk density observed in the subsoil of Boring 1 (horizon 4), Boring 3 (horizons 2 & 3), and Boring 5 (horizon 3). The soil on site does not meet the hydric soil criteria. The lack of hydric soils indicates that the soil is likely not saturated for greater than 5% of the growing season (approximately 7 consecutive days). The lack of these features does not precluded the possibility that the soil is saturated to or near the surface prior to the growing season or for shorter periods of time during the growing season. G. Comparative Analysis Soil boring (B-5) was completed down slope to determine if the soil conditions were uniform throughout the site and if additional surface water received down slope had any impact on the soil characteristics. The results of the soil evaluation indicate that the soil down slope had coarser texture within the subsoil, however the redoximorphic features were similar to those observed within the proposed system area. H. Government Reports and Comments On August 24, 2005, Leroy Jansky of the Wisconsin Department of Commerce assessed the conditions on site. Mr. Jansky verified that the soil profile in B-1 is generally in agreement with the conditions presented on the soil evaluation report included in Attachment A. A copy of Mt. Jansky's inspection report is included as Attachment $. V. Conclusions and Recommendations The site is suitable for installation of a POWTS (mound system) for the following reasons: 1.) Redoximorphic features were not observed in the upper 8 inches of the soil profile within the proposed system area. 2.) Hydric soils are not present within the proposed system area. 3.) There are no features that concentrate surface water flow toward the proposed location of the system. 4.) The slope at the proposed system location is 3 to 4%. The slope is uniform with no dips or valleys. The following recommendations should be considered during installation of the proposed system: l .) The system should be installed on the 100' contour to stay within the tested area. The approximate length of the contour is 128 feet. 2.) Sand fill shall consist of 2.5' of material meeting ASTM C-33 specifications. 3.) Four inches of sand should be placed on the system area immediately prior to chisel plowing. 4.) The basal loading rate shall not exceed 0.2 GPD/ftz for EFF#1. 5.) The system shall be designed to have a linear loading rate of 4.5 GPD/ft or less. 6.) The system will follow the 100 foot contour and have a concave shape on the upslope side. 7.) Due to the concave shape of the system and the potential to receive surface water from upslope, the topography upslope must be modified to limit surface flow toward the system area. This can be achieved through the creation of a drainage ditch. The final approval of this site must be made by the Wisconsin Department of Commerce and the St. Croix County Zoning Department. This report represents the observations and professional opinion of Mark Iverson, Professional Soil Scientist (#197) and Certified Soil Tester (#46672). VI. REFERENCES 1.) United States. United States Department of Agriculture Soil Conservation Service, in cooperation with Research division of the College of Agriculture and Life Sciences University of Wisconsin. Soil Survey of St. Croix County, Wisconsin. 1978. 2.) State of Wisconsin. Department of Commerce Code, Chapters 83 and 85. 3.) US Department of Agriculture, Natural Resources Conservation Service. 1996. Field Indicators of Hydric Soils in the United States. G.W Hurt, Whited, P.M., and Pringle, R.F. (eds,). USDA, NRCS, Fort Worth, TX. 4.) Schoeneberger, P.J., Wysocki, D.A., Benham, E.C., and Broderson, W.D. (editors), 2002. Field book for describing and sampling soils, Version 2.0. Natural Resources Conservation Service, National Soil Survey Center, Lincoln, NE. 5.) United States. Us Geological Survey. Topographical downloaded from http://terraserver. microsoft. com/ 6.) St. Croix County. St. Croix County Land Information System. http://72.21.23 0.178/website/pasystem/gisportaLhtm 7.) United States. United States Department of Agriculture -Natural Resources Conservation Service. Hydric Soil List for St. Croix County, Wisconsin. ftp.//ftp-fc.sc.e~ov.usda.gov/WI/Soil/hyd/hyd109.htm 8.) United States. Us Army Corps of Engineers. 1987. Corp of Engineers Wetland Delineation Manual, Technical Report Y-87-1. USAEWES Environmental Laboratory, Vicksburg, MS. 7 APPENDIX A SOIL EVALUATION REPORT APPENDIX B CORRESPONDENCE canmerce.wi.gov ~sconsin Department of Commerce Date of Inspection: August 24, 2005 Project Name: Lorenz Use: Residential Legal Description: NE, NE, 36, 29, 16W Site Number: NA Subdivision: Municipality: Town of Baldwin County: St. Croix Plan Transaction Number: Sanitary Permit Number: NA Wastewater Flow: 450 gpd Persons Present: M. Iverson INSPECTION REPORT SAFETY AND BUILDINGS DIVISION Integrated Services Bureau 13 East Spruce Street Chippewa Falls, WI 54729 www.commerce.wi.gov/sb (715)728-2544 Plumber Name and Address: NA Certified Soil Tester Name and Address: Mark W. Iverson, CST 46672 PO Box 155 Hammond, WI 54015 Owner Name and Address: Julie Lorenz 2691 US Hwy 12 Woodville, WI 54028 (715) 698-2717 An onsite soils verification was conducted at the above referenced site as per district policy for all sites with less than four inches of unsaturated soil below the bottom of the A horizon. The intent of this investigation is to confirm initial observations by the certified soil tester (CST) relating to the presence or absence of redoximorphic features in the A horizon and/or subsoil. In-situ soil texture, structure, and consis#ence factors were also reviewed as they -relate to wastewater application rates. Other site conditions such as percent and direction of slope, landscape position, land surtace contour length, and surtace water hydrology may also be noted and their effects are factors considered in the recommendations and conclusions portion of this report. Atypical soil profile at B-1 could be described as follows: 00-10" 10YR 3/2 sil 2cgr, dsh, cw. 10=14" 10YR 3/2 sil, 1f-mpl, dsh, as, with c1f 10YR 4/4 rmfs. 14-17" 10YR 5/4 sil, 1mpl, dsh, cad 10YR 5/6 rmfs The soils verification conducted on this date is generally in agreement with the report filed by CST Iverson dated August 16, 2005. No redox features were observed in the upper 10 inches of the A horizon. If a mound system. is designed to overcome limitations of a high level of seasonal soil saturation and slow permeability, the linear loading rate should not exceed 4.5 gpd/ft and the basal wastewater application rated should not exceed 0.2 gpd/ftz. The additional basal area will partially compensate for the gentle land slope and prevent wastewater leakage at the mound toe. At least 30 inches of sand lift is recommended when applying septic tank effluent to the distribution cell of the mound to ensure proper treatment. The longest portion of the mound must be orientated along the contour. The mound shall be constructed to divert surface water around the mound stricture as much as possible. In addition, an up slope drainage ditch should be considered if it is determined that surface or subsurface hydrology is improved by intercepting water and diverting it away from the mound site. If there are any questions regarding this report, please contact me. eroy G. nsky, stewat pecialist cc: ®County ^ Plumber Ljansky@ mmerce.state. .us E-mail ©CST 715/726-2544 Voice 715826-2549 fax ^ Owner ^ Other ., A . commerce.wi.gov isconsin Department of Commerce Date of Inspection: August 24,2005 Project Name: Lorenz Use: Residential Legal Description: NE, NE, 36, 29, 16W Site Number: NA Subdivision: Municipality: Town of Baldwin County: St. Croix Plan Transaction Number: Sanitary Permit Number: NA Wastewater Flow: 450 gpd Persons Present: M. Iverson INSPECTION REPORT SAFETY AND BUILDINGS DIVISION Integrated Services Bureau 13 East Spruce Street Chippewa Falls, WI 54729 www,commerce.wi.gov/sb (715)726-2544 Plumber Name and Address: NA Certified Soil Tester Name and Address: Mark W. Iverson, CST 46672 PO Box 155 Hammond, WI 54015 Owner Name and Address: Julie Lorenz 2691 US Hwy 12 Woodville, WI 54028 (715) 698-2717 An onsite soils verification was conducted at the above referenced site as per district policy for all sites with less than four inches of unsaturated soil below the bottom of the A horizon. The intent of this investigation is to confirm initial observations by the certified soil tester (CST) relating to the presence or absence of redoximorphic features in the A horizon and/or subsoil. In-situ soil texture, structure, and consistence factors were also reviewed as they relate to wastewater application rates. Other site conditions such as percent and direction of slope, landscape position, land surface contour length, and surface water hydrology may also be noted and their effects are factors considered in the recommendations and conclusions portion of this report. A typical soil profile at B-1 could be described as follows: 00-10" 10YR 3/2 sil 2cgr, dsh, cw. 10=14" 10YR 3/2 sil, 1f-mpl, dsh, as, with c1f 10YR 4/4 rmfs. 14-17" 10YR 5/4 sil, 1 mpl, dsh, cad 10YR 5/6 rmfs The soils verification conducted on this date is generally in agreement with the report filed by CST Iverson dated August 16, 2005. No redox features were observed in the upper 10 inches of the A horizon. If a mound system. is designed to overcome limitations of a high level of seasonal soil saturation and slow permeability, the linear loading rate should not exceed 4.5 gpd/ft and the basal wastewater application rated should not exceed 0.2 gpd/ft2. The additional basal area will partially compensate for the gentle land slope and prevent wastewater leakage at the mound toe. At least 30 inches of sand lift is recommended when applying septic tank effluent to the distribution cell of the mound to ensure proper treatment. The longest portion of the mound must be orientated along the contour. The mound shall be constructed to divert surface water around the mound structure as much as possible. In addition, an up slope drainage ditch should be considered if it is determined that surface or subsurtace hydrology is improved by intercepting water and diverting it away from the mound site. If there are any questions regarding this report, please contact me. Leroy G. nsky, . stewat pecialist ®Count L'ansk cc: Y ^ Plumber 1 y@ ommerce.state. .us E-mail ©CST ^ Owner 715/726-2544 Voice 715/726-2549 Fax ^ Other ,~ Wisconsin Deparhnent of Commerce SOIL EVALUAT Division of Safety and Buildings In accordance with Comm ` Attach complete site plan on paper not less than 8'/z x 11 inches in size Include but not limited to: vertical and horizontal referen po' M), Percent slope, scale or dimensions, north arrow, B fer to Please prin ion Personal information you provide may be used for ndary p vary Property Owner Julie Lorenz Property Owner's Mailing Address 2691 Hwy. 12 City State Zip Code Phone Woodville WI 54028 715-698-2217 '~~~~~® Vi . Page 1 of 3 ~~. .r St. CTOiX lan mu~ ~ ~' '~. ~ j O d~ rection'ar-~ Parc 1 LD. 002-1090-10-000 . s"/Z ) ne t road. ST. CROIX CUUNTY Revi d by Date ~.g ZONING OFFICE `~ (_ fi `, lr/ La ~'d~ Property Location +' cJOVt. Lot NE v< NE '~, s 36 T 29 N R 16 w ~ Lot # Block # Subd. Name or CSM# ~ ~I~tvrc~r ^ City ^ Village 0 Town Nearest Road Baldwin 270' Ave. 0 New Construction Use: 0Residential /Number of Bedrooms~_ Code derived design flow rate 450 GPD ^ Replacement ^ Public or Commercial -Describe: ~, Pare enal Loess over Glacial till Flood Plain elevation if applicable NA ft. I General comments and recommendations: a Boring # Boring 0 Pit Ground Surface Elevation 100.00 ft. Depth to Limiting factor 9 in. Soil A liceti n Rate i H th D Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ftz or zon ep in. Munsell u. Sz. Cont. Color Gr. Sz. Sh. *Etf#1 *EfT#2 1 0-8 10YR3/2 NONE SIL 2 f sbk mft as 2f 0.6 0.8 2 8-13 10YR3/3 f-1-f 7.5YR4/3* SIL 1 f pl mfr gs 1f 0.4 0.6 3 13-15 10YR4/3 f-1-f 7.5YR4/4 spots SIL 1 f pl mfr as 1f 0.4 0.6 ** 13-15 10YR6/4 c-1-f 10YR5/6 4 15-19+ 10YR5/4 m-2-p 10YR5/6 8~ 5/2 CL 3-f-sbk mfi - None 0.4 0.6 * Spots and Ox. rt chan. ** Makes up 30% Boring # ~ Boring OPit Ground Surface Elevation 100.00 ft. Depth to Limiting factor 8 in. Soil A lication Rate on H ri De th Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft~ z o p in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-8 10YR3/2 None SIL 1-f-sbk mfr as 2f 0.4 0.6 2 8-12 10YR3/2 f-1-f 7.5YR3/3 SIL 1-m-sbk mfr as 1f 0.4 0.6 3 12-16+ 10YR5/3 f-1-d 10YR4/6 LFS 1-m-pl mfr - None 0.4 0.6 . Fm.,P~r a i = unn. > ~tn < ~~n ry,on . pna 'rcc > an < 1 sn mon . * Effluent #2 = BOD, < 30 ma/L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number ~_ Mark Iverson z,.../' ..~'- 46672 Address Date Evaluation Conducted Telephone Number P.O. Box 155 Hammond, WI 54015 July 21, 2005 715-796-5664 • ~ . . .. Property Owner Julie Lorentz Parcel ID# 002-1090-10-000 Page 2 of 3 a Boring # ~ Boring aPit Ground Surface Elevation 100.0 ft. Depth to Limiting factor 9 in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ftZ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *EtT#t1 *EfI#2 1 0-9 10YR3/2 None SIL 2-f-sbk mfr gs 2f 0.6 0.8 2 9-12 10YR3/2 f-1-d 7.5YR4/6 spots SIL 2-m-sbk mfi as 1f 0.6 0.8 3 12-17+ 10YR4/6 f-2-d 10YR5/6+4/2 GRLS 1-co-sbk mvfi - None 0.7 1.6 Boring # ~ Boring aPit Ground Surface Elevation 98.7 ft. Depth to Limiting factor 8 in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ftZ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-8 10YR3/2 None SIL 2-f-sbk mfr gs 2f 0.6 0.8 2 8-11 10YR3/2 f-1-d 10YR4/6 spots SIL 2-f-sbk mfr as 1f 0.6 0.8 3 11-17+ 10YR5/3 o-1-d 10YR5/6 SL 2-m-pl mfr - - 0.0 0.2 Boring # ^ Boring EIPit Ground Surface Elevation 97.2 ft. Depth to Limiting factor 7 in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ftZ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-7 10yr3/2 None SIL 2-f--sbk mfr gs 2f 0.6 0.8 2 7-10 10yr3/2 f-1-d 10YR4/6 spots SIL 2-f-sbk mfr as 1f 0.6 0.8 3" 10-15 10yr5/3 f-1-f 10YR4/6 GRLS 1-c-sbk mfi gs 1f 0.7 1.6 4* 15-19+ 10yr4/4 f-1-d 7.5YR4/6 S O-sg ml - - 0.7 1.6 *Horizons 3 & 4 are very compact ' E8luent # 1 = BODS > 30 <_ 220 mg/L and TSS > 30 5150 mg/L • Etlluent #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. -r Page 3 of 3 , . ~~ B-4 98.T ~ ~~ ~~ ,~ /~4 ,OO~~A. i~ OO The proposed system area is located in a vacant field. BM# & Description =Bench Mark Elevation 0 ft. 24 ft. 40 ft. 80 ft. - Fence (83 feet North of B- place system on the 100.0' contour Curry effluent Surface Discharge Location f0 N .` 0 ,~ ;; Trees =_ Trees _-Trees - \\\ I //~ ~\1 I //i Trees _- ~ Trees _= /'/ / I \ \`\ ~/ / I ~ \`\ `~\\Il/ i ~\\Il,i -_ Trees - ,Trees '',/ I ~\\` ~,/ \~~ House /I~ ~\~I//, \\~I/,` O c~i Try ~ -Trees - c = ~ ;; Site Location r~s , -_ Trees = Trees _- ~,,,y ~ z Sect on N 60111 Ave. B-1 is 125' from B-3 at All property boundaries are greater than 100' feet 17 degrees from the proposed system with the exception of the north property boundary which has been identified. ~, =Boring Location & Elevation O =Well Location Owner: Julie Lorenz Site Information: Completed By: Mark Iverson 2691 Hwy. 12 NE 1/4, NE 1/4, S36, T29N, R16W 680 Larcom Street Woodville, WI 54028 Town of Baldwin Hammond, WI 54015 St. Croix County 715-796-5664 Phone: 715-698-2217 PSS #197 / CST# 46672 _ M ua~ ~ ~'~~~ Pnc~C~9? ,s ~ \~C)ti~~F ST:~TE FAIL Or WISCONSIN f=ORM 3 - 15)32 nltll' ('T"AIM DL•L•D bOCUMENI NO. __ ___John M. Lorenzo a_si_~le person~__._____ quit-claims t.+ _.~tt.~~~_.~21;~T17 s-~-i~g~ 5.-n?rS.Q.LL,._ - the lullowing described real estate in State of Wtscunsin _ St. Croix ca7unq-, r/. _ Y ;az 12:15 P . ~~ THIS SPACE nESERVED FOR RECORDING DADA NAMt AND RcTVP.1d AIiDRCJS 002-1090-70 _ PAR ;EI_ IDENTIFICATION NUMBER That part of the NE1/4 of NE]./4 of Section 36, Township 29 North, Range 16 West, St. Croix County, Wisconsin, described as follows: Commencing at the NE corner of said NE1/4 of NEl/4; thence South on the East line thereof, 482 feet; thence West 431 feet; thence South 148 Feet; thence West to the West line of said NE1/4 of NE1/4; thence North on the West line of said Quarter to the Nn~J corner thereof; thence East or. the Ncrtr line of said quarter to the point of commencement. This deed is given to release any and all right, title and interest pursuant to judgment of divorce granted June 22, 1994. ~ ~rn ~.~ -----I~~E~,P-i 'I'bis 1S nOt _.____ homestead ;iv~ol) i ~ 1 Dated this --(- -. da;• of AUTHENTI:.'ATIOIv Signature(s) authenticated this _ day of _ 1"ITLE: MEMBER 5'iATE BAR OF tVISGONSIN tlf not, awhuriaed by §746.06• Wis. 5tats.) THI$ INSTRUMENT WAS DRAFTED BY (5F aL) 19 -----T- i J ~, « ~r Jo Ytn M. Lorenz j _ (SEAL) ACKNOWLEDGMENT ~Z i rtn r5~~ S t a to o f l~tee~o•trsizr; - C~~ S5. ftC illlr-t~lr /1 County. Pe'rsonally -c~{a;me p~fore me this ~ day of _L (L/ 19~~• the above named John M. Lore~n~le ;e_rso:a, ~ - ----- -- - - ~ ~ u• 'TIC known to be the person who executed !hc farega~ing ~LL, instrument and acknrnvledgcl 7c same. - _ -- ^ - - ~ - ~_ ~ _-_ ~iud~s~.n., WT __5_4S21,f~--- -. _ _~-_ ~ Notan -____1t.~ L4 ,L~ - _ Ci,unt): 'M5. (ti+g;nanlns ma hr authenn::ar•d .,r arkna wlydgcd Both are ~ M1iy e.: ,:r r' f+crmatt. nt. llf/ na[, state rsl,tr~atai(~,-n~na[e viii .S.l R'~ _. `•` Y.. _.__~_.~/-__....-.. _...___.-l `/.,-L~~ 4. - _ ti 1,,TF R:\R ()F \V{1C.Cl\11\ \'. ~ace:~s~n i.e.7~ ~•an4 C :• (fit ~ll (!.\i\: nl~!_n 1-nrnt tit, 1- {oF2 nn:M.au~P- ••(~s v" +,' y ~~ ~ ~° ~J-~c.tE [,e2E-~1Z 2(v9/ /-~wY /Z t~JaoD tt ~~~ w t ~~~--t ~w s l~ rs~~l~ l~~'/~ .~34 '~29 ~ Z f l~ ~, ~~ ~~~ ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer Juc.l ~ ~oJ2~En/z Mailing Address .2Co9~ s'1~rTE ~w `! /2 Property Address ~~Z.. (Verification required from Planning Department for new construction) City/State Gy~ /It.GE! u~/ Parcel Identification Number ' ~ 2-~D - LEGAL DESCRIPTION , SZ ~~ Property Location /~~ `/., ~~ `/., Sec..5'CP , T 2`~ N-R,1~W, Town of ~~+ibw~~ Lot # ,'/,~ Subdivision -~=,1~-. Certified Survey Map # ,Volume ,Page # / Warranty Deed # s(p 2' ,~ ~ Y Spec house ^ yes ~ no Volume ~as~ ,Page # ~ ,2 Lot lines identifiable ~ yes ^ no SYSTEM MAINTENANCE Improper use and maintenance ofyour 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. The property owner agrees to submit to St. Croix 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. Uwe, 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 Zoai.ng Office within 30 days of the three year expiration date. .~' SIGNA' APPLIC ~ ,+~~ O ~ DATE OWNER CERTIFICATION 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. SIGNA OF APPLICA,A DATE •••••• Any information that is mis-representedma'y result in the sanitary permit being revoked by the Zoning Department. •'*•«« •• Include with this application: a stamped warranty deu+d from the Register of Deeds office a copy of the certified sttrvcy map if reference is made in the warranty deed ~~w~ ~ zor~a~~ May 19, 2008 Julie Lorenz 2691 Hwy 12 Woodville, WI 54028 RE: Failing sanitary system at 2691 Hwy. 12 residence Further described as the NE/NE'/4 of Section 36, T29N R 16W, Town of Baldwin -Parcel # 002-1090-10-000 -Computer #36.29.16.512A Code Administration 715-386-4680 Dear Ms. Lorenz: Land Information Fr Planning The St. Croix Count Plannin and Zonin De artment is the " overnmental unit for the 715-386-4674 y 9 g p 9 regulation of private sewage systems" in St. Croix County pursuant to Section 145.20(1) Real Property (a) Wis. Status. Section 145.20(2) (f), Wis. Stats. States that the governmental unit shall 715-386-4677 investigate violations of the private sewage system ordinance and shall issue orders to abate the violations. Recycling 715-386-4675 This office has a Soil Evaluation Report on file concerning the Private On-site Wastewater Treatment System (POWYS) that services your residence at the above- mentioned property. This report, furnished by Mark Iverson, Certified Soil Tester # 46672 on September 25, 2005, indicated that the existing POWYS is discharging to the Hwy 12 road ditch. This has been identified as a Category 1 failing system pursuant to Wisconsin Administrative Code Comm. 81.01 (92) and Section 145.24(4) Wis. Stats., which includes discharges to surface water and/or zones of saturation. The existing system is also considered a human health hazard as defined in Wisconsin Administrative Code COMM 81.01(128) and Section 254.01(2) Wisconsin Statutes. Pursuant to the St. Croix County Code of Ordinances, Chapter 12 Sanitary Ordinance, subchapter 12.1 (F)(4)(d) when a failing POWYS is identified it shall be brought into compliance with Wisconsin Statutes and Wisconsin Administrative Code and 12.1(F)(4)(e) the discharge of domestic wastewater or effluent to the waters of the State or to the ground surface is prohibited. This letter constitutes an order to abate the above-referenced violation. Any plumbing work required for compliance by replacing or repairing the failing system shall be performed by a plumber who is licensed in the State of Wisconsin. A list of plumbers can be provided at your request. You will need to have a plumber complete your sanitary permit application for a replacement POWYS within 30 days of receipt of this letter. St. Croix County participates in the Wisconsin Fund Grant Program, which is a financial assistance program that may provide funds to property owners by reimbursing a portion of the cost of replacing or rehabilitating failing private sewage systems. All work, however, must be completed before applications can be submitted to the Department of Commerce. If you are successful in receiving a grant through this program, a $125.00 administrative fee is due and payable to this office at the time you receive your grant award check. A brochure outlining the general program is enclosed. ST. CROIX COUNTY GOVERNMENT CENTER 1 1 O 1 CARM/CHAFE ROAD, HUDSON, WI 54016 715-386,4686 FAx .,~~,,-., ~,,,,,,r,~,,,,,,, ,.,, , ,~ Failure to comply with this order and with the provisions of the St. Croix County Code of Ordinances, Chapter 12, St. Croix County Private Onsite Wastewater Treatment Systems Ordinance, or any order issued in accordance with this ordinance shall be subject to a penalty as provided in Section 12.8 (B) (2) (a). Penalties include forfeitures of not less than $10 per violation or more than $1000 per violation as/or be subject to injunctive relief. Each day a violation exists is a separate violation. Pursuant to Section 12.8(B)(3)(b) of the Sanitary Ordinance, "Any person, company, partnership, corporation or government unit aggrieved by a written administrative decision made by the Zoning Administrator, or his/her designee, or the Committee may appeal the decision to the Board of Adjustment. An appeal of a decision shall be in writing and shall be made on a form provided by the Planning and Zoning Department and shall be filed with the Planning and Zoning Department within 30 days of the date of that administrative action. Other substantiating evidence will be accepted." pe lY, amela Quinn Zoning Specialist Cc: Town of Baldwin Dan Sitz, Code Enforcement Enclosures: Wisconsin Fund Grant Program Brochure ST. CRO/X COUNTY GOVERNMENT CENTER 1 7O 1 CARM/CHAFE ROAD, HUDSON, W/ 54016 715-386-4686 FAx FROM NORTHLAND PLUMBING, INC. FAX N0. 715-643-2520 Jan. 21 2009 09:41PM P2 L rri }1 v .y` ~~ v ~~ Q ~~ ~ N W G a Or n a m ti Q W a c m tai 0 c 6i C 0 v ;,E _ i' ' (~ ~ . x .~ ~ ~ I ._ I r __ ~ ._ _. - - -- O - -- -- ., m ~ I s -- - ~ ~ D ~ ~ ~ ~ r O ! ~ n ; ^ r ~ 0 ~ r^ a ~~ ~ ~ ~ ~ ~~ ~- i m N Lbw' Fmj~ D n ,/, 1.~ ~ ~ (Y 1 ~ l~ m n ~ m° a m 1 ~ ~ ~ b N _ m G Oq ~ ~ . _ a z N C ~ 1 , a a ! ~ ~ ~ Z c ~ _ j~ ~ o !~ L3 o ~ ., C. ~ i -- o 3 a Q ~ ~ ~ •+ q r q W '~ m } 77 _ ~ r as-. ~ ~ ~ r m 3 e „ ; I ~ D ~G ~ I a A ~ = ~ _ ~ ar r I X; i~ I I t^ ~ I ~ Q ~ e >n ~, x ? Z{ offI D I 7 0 m v\ ~~ $ I ' ~ ~ d ~ ~ Z y x n 9 < ~I to O f i ~ i a ~ x I ~.1 n ~ i n a G ~ ~ Ig ~ ~ ~ o ~ } ~ T ~ ~ i '. o I n ~ 1 m v ~ o r ~ ~~ ~~ ~ m i ;w l a ~, c - C o ~ ~ o ~ ~ ~ ~ , o ~ , x 9 ~ ~ f r ~~`~~ ~ : ~ ~ 1 k S~ ~ ~ ~ ~ - v~ Q ~ i w D s O c D .~ ~ z { a ~ v a A Z Y 0 °~ s~ ~ ~ ~ ~ ° ,~ ~ ~ C ~ ~ O ti ~j ~ ~ ~ ° z N v~ N a r~ a ppC n Y 0 y z Z s a Y M ~ h C.i 1 Q+ C~ Ca C;i». ~ ~ ~ ~ ~ wo ~~ ~~~w [v ~ w D N C.7[ .~ 4- ~; m ~~~ ~ ~ ~ ~ '~. ~~ *J ~'~ ~ °n N~~ O .`C (~ W O1t08/09 THU 13:21 FAX 715 386 4686 ST CRX CO ZONING State of Wisconsin DepaRment of Commerce PRIVATE SEWAGE SYSTEM REPLACEMENT OR REHABILITATION GRANT PROGRAM OWNER'S APPLICATION ~ 004 Safety and Buildings Division lnstructlORS rvr rru cn VRIIVI V• use ROIrC1YO~1 You may apply after you have received a determination of failure and obtained APPiI~^ Number a sanitary perrr-it. Complete Part A of this form, attach evidence of your annual income, and send these items to the governmental unit listed below: PART A. TO BE COMPLETED BY THE PROPERTY OWNER Social ~„~y No. •• Owner Name' Socbt Security No'• Additional Ov~msrs b Their Spouse(s) ~ ul; e. ~ r e~z-- N~ loll } r4 owner's Spouse Name , Sb'ed or RouEa ` a~R I ~`'1 l _ Talephor-e Number (included ~~ ci`'r~ 0 O~ V i 11 ~ W 1 ~ (~ a-~S ~-l,s~ l~`~l ~S .~~..,. ^..ard. ,~ e. Issued ks the name of this owner. ••No6e: Your .,Debt Security Number may be used to verity your incase -- .~.,.. ~.....~ ..~ www~ ./InnnA srd maNttenence palfltlarltS. resldsnos or srrwll corrrnerebl eshblbfvrreM oonsbucted prkx b and oocupbd by July 1.1978? ^ Yee I,2f.No 1. Wasthsprlncipal ^ No if your prindpal residence b a mobile home, was the current una placed ffi this location by July 1119789 ^ Yes ~. This application b for (complete bath K aPP~~): +~r pd Re,~ po y~ ~cupy qds rr~da~ at last 51 % of the year. ^ Yes ^ No l~^, Sn-fR Commardsl E,r~abliahrtwnt iao Y~'~pir tMs small commeraal eatablistxrieM al bast 51 % M the year: ^ Yes ^ No SmaN Commsrcbt EstabtishrMnt Name: 9. Was the prNata sewage sYst~ ~ I~ of a real estate transaction or change of owrrership9 ^ Yes ~lo 4. As the owr-er, are you a licensed f~lumber or conVaator erx in the twsinee --- ~.rdrlns9 ^ Yes ~ No xxana tax return forth ~~~- , ~, <-~ if 5. 1~Videllce Of krcorrra. Attach a copy Of Your ~'~' r ~ '~~" n9 y~ are applying as a principal roaidancs. It you an applying as a small ~ '~ #a}'~ ~~x Y~ ail aehedulq for the year of or prior to the order ar daterrrdrotion of hilure. It ~ ~ ~ ~;~ fiL `.~ted You must include I ~` `~_ spouse's Wboorrein irrcorrre tax rehrrn tar the same Y~• merdal and and b' s{,~ y ~ , vi by above. Evidence of income wiY be kept on flb at the gowrm ~~ .Cis Daparlrnent o(Conuneree. zr, If you or any awrror listed above dkl not the a Wbcor+atn incorr-e tax rdum a ~' "~ r, _ _~ _~~...r ...ll lr nnvemmAnral Unit tOr further instrur~c Owrrsrs SCipnarure ~~C~~ p iniarrraUon you SBD-9163 l(R. 1/9~} 01/08/09 TAU 13:22 FAX 715 386 4686 ST CRX CO ZONING f~005 PART B. TO BE COMPLETED BY THE GOVERNMENTAL UNIT ~ Z - ~0 9~- ilJ-o~~ Tax Parcel Number t , Legal Description of Property: ~',f[~l ~ ~q-L ~ ~ l ~ va s 3(~ , T 2~ N, R ~~ °!~' ^ City ^ Village l~ Town of: ~ Gf Block No. ~- Subdivision ame OR Lot No. _ 2, Wh verifying ownership, does the owner(s) name agree with the name(s) of the applicant on Part A of this application? Yes ^ No I~cation, did the applicant own th prcP®rtY when the orded If the applicant answered yes to question 3 on Part A of this app ' ^ No verification of failure was issued or the system installed and incur the cost of replacement? Yes Documen ~ ~ ~7 What document was used ~~~ ~~~~ a e umber to verity ownership? ,,--,,` is outlined in COMM 87.04(4) been met? tfd~Ires ^ No 3, li this application is for a rep{acerrient structure, have the req ' 4. Is a public sewer available to this pro sRy? ^ Yes NO No 5. Has a previous rant be~- awarded fot this property under this program? ^ Yes Q~ evidence evidence of income. Please indicate applicable annual income: S ~ ~ ~ ~° 6. Principal R Year Line ~ ~ _. Year 2D6 Affidavit of yy'~onsin income tax form _~ Year Line~,~ Otter form used Snail Commercial Establishment evidence of income. Piease indicate applicable annual gross income: S Line_ ~ Year Profit & loss form used: sewage Category Category 2 Category 3 sewage to (check aN 18111 IP.. ~.~ ~~~~-- -~ ..................... r. roUndWatef ............................. ......................... Surface water or g ................................... A zone of saturation .......................................................................................... ^ ................................. ......................................... A drain file or zone of bedrock ................... .................................... . ............................. round ...................................................... ^ The surface of the g ............. ...................... e into the structure served .......................... Back-up of sewa9 ~ ~/2 ~/~ (~~, ' _ 5//~_ pate of O er or Determination of Failure (moldaylyr): system Type: ^ At-grade ~ ound ^ Holding Tank ^ Conventiona4 ^ In-ground Pressure n_ ~D F~ ^ Other, explain /7 -? .~ '~ ?j Oate Issued -- Uniform Sanitary Permit Number ~S ' ~ Date Approved 7 Plan Approval Number f3. Eligible Il[1 Ineligible ^ Reason: 10. Govemmentai Unit Representative's Certificatwn. 1 certify that I have reviewed and verified all information provided on this ... _ .~ _.. ___ ....e a.,.r rr,rreet to the best of ma knowled a and belief. n~re Ginned Signature O1f08/09 THU 13:21 FAX 715 386 4686 ST CRX CO ZONING OWNER'S APPLICATION cont. 4. If yes, remember to deduct the correct amount on PART II, Section B, of the grant worksheet. 5. Explains the forms used to verify income. 6. Certifying that, to the best of their knowledge and belief, the information is correct. Owner's Signature One of the owner's listed above must sign and date the application. The signature of the co-owner's is optional. PART B - TO BE COMPLETED BY THE GOVERNMENTAL UNiT Eligibility Checklist; ~ , Legal description of the property. 2. When verifying ownership, /if property has changed hands recently, please check that the applicant was either the owner when the order was issued or the system installed and that they incurred the cost of replacement. 3, If this is a replacement str~ttne;~Yerify if the applicant fias met the requirement of Cam 87.04(4). i/~ 4, If a public system is available to the property, the applicant is not eligible. _~ 5. Each property is only eligible for one grant award. v if there is a new owner on the property and the system again fails, the new owner is not eligible. Each property is only eligible for one grant award. f~ 002 if an applicant receives a grant award and then moves to another property where there is a failing system, they can receive another ' award as long as the second property has not already received a grant award. 01!08/09 THU 13:21 FAX 715 386 4686 ST CRX CO ZONING 0 003 QWNER'S APPLICATION cont. g, Lists the annual income of the owner or small commercial establishment, how this amount was verified, and for which year. A copy of the forms .used for income verification should be kept on file at the county. / If tax forms are not available, an affidavit should always be completed. 7. U List the category of failure and the date that the failure was verified or the order issued. $, The type of replaceme .system that the applicant is applying for is listed here. List the uniform sanitary permit number and date issued. List the plan approval number, county or state, and the date approved. g, o y u, the governmental unit, determine that this applicant is igibl or ineligible. If you feel that an applicant is ineligible but would like the department to issue the denial, please explain why you feel the applicant is ineligible. ~ p, Authorized represen#a#ive only signs the form, fists their title, and the date the application was signed. 01608/09 THU 13:20 FAX 715 386 4686 ST CRX CO ZONING OWNER'S APPLICATION The owner's application must be completed for each applicant, another form will not be accepted. This is the first page of the packet of information submitted to Commerce for each applicant. PART A - TO BE COMPLETED BY THE PROPERTY OWNER Owner's Name Name of the applicant must also be the owner of the principal residence or small commercial establishment. Social Security Now required. The social security number is used to verify that Number: the applicant is not delinquent in child support or maintenance payments. Additional All owners of the property must be listed on the application. Owners: Add. Owners Now required to also verify that they are not delinquent in their Social Security child support or maintenance payments. Numbers: Street, City, Current address of the applicant. State, Zip & Telephone: ~ , Verify that the current structure was located at the property and occupied _prior _to~_,hhc~_ 1, 1978 1f a mobile home has been replaced since that time, it is not the original structure and not eligible. 2. Distinguishes if the application is for a principal residence or small commercial establishment. It also verifies that the structure is occupied by the owner the majority of the year. The small commercial establishment name is listed here, the name of the owner is listed under owner's name at the top of this form. Description of the small commercial establishment: bar, restaurant, farm, etc. 3. If this system was replaced as a part of a real estate transaction, verify that the applicant was either the owner when the order was issued or the system installed and that they incurred the cost of replacement. X001 Page 1 of 1 Pam Quinn From: Pam Quinn Sent: Friday, January 23, 2009 1:28 PM To: 'Joyce, Jean -COMMERCE' Subject: RE: WI fund application OK that will work and expedite the submittal -thanks! Pamela Quinn, Zoning Specialist (POWYS) St. Croix County Planning & Zoning Dept. 1101 Carmichael Road Hudson, WI punzq(cuco.sai~zt-Croix. x~i. us From: Joyce, Jean -COMMERCE [mailto:Jean.Joyce@Wisconsin.gov] Sent: Friday, January 23, 2009 1:10 PM To: Pam Quinn Subject: RE: WI fund application Hi Pam, It's really just a technicality thing, the rules require that we use federal income tax forms to verify the income. So even though the amount listed on the Wisconsin form is the amount carried forward from the federal form, she will still need to provide you with the federal form. But, why don't you use this as her income on the owners application so that you can send that one in and just have her send it to you later. I'd hate to have her miss the deadline because of this. Jean From: Pam Quinn [mailto:PamQ@CO.Saint-Croix.WI.US] ' Sent: Friday, January 23, 2009 12:45 PM To: Joyce, Jean -COMMERCE Subject: WI fund application Hi Jean, I had a very nice applicant come in today to submit her WI fund paperwork (Julie Lorenz). For some reason, she had been faxed (it may be my error) the old forms that required WI tax forms, not federal. If she has 2007 Wisconsin tax form that indicates her AGI from Federal form, will that be adequate or shall I ask her to get me a copy of last year's 1040? Thanks - I felt bad not catching it while she was here in the office! Pamela Quinn, Zoning Specialist (POWYS) St. Croix County Planning & Zoning Dept. 1101 Carmichael Road Hudson, WI ~amg~co. saint-Croix. wi. us 1/23/2009