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HomeMy WebLinkAbout453155Wisconsin Department of Commerce :Cafety and Building Division PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Telli~ohn, Mark Forest Townshi CST BM Elev: p 0 • 6 Insp. BM Elev: / Ud o BM Descri ti n: ~ --~-~~ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~ , ~ ~ Dosing /',~,~ /, ~ Jz ~ -~7 ~~, v (/ v Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic , ~ ~ ~~ r ~ ~ ~ ~ ~ I • Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer / /~ ~ ,.( Demand ~.._.(~!_.[- Gf 61.ti/- GPM Model Number ~ ~%7,' I ~ ~~ TDH Lift Fricfion Loss Syste~m7Head TDH Ft ~•y ~ ~.h Forcemain Length Di Z ~ Dist. to V`I ~ t 3 SOIL ABSORPTION SYSTEM ~ / r~ ELEVATION DATA county: St. Croix Sanitary Permit No: 453155 0 State Plan ID No: ~~~~ Parcel Tax No: 014-1043-50-000 Section/Town/RangelMap No: 20.31.15.317 STATION BS HI FS ELEV. Benchmark /. p 5 0 1. a BTU-o Alt. BM ~ ~--~ Bls~-r~/ r~3 ~ 8-~ ~Z. 3 SUHt Inlet . ~ ~~ t, ~ . -7 Z St/Ht Outlet .~~ .~-, Dtlnlet l/ ~ Dt Bottom / /_, (~ ~ s~ eader/ an. .0 3,os Dist. Pipe --~ +---~ T~ ~i . ~I / 3. / y Bot. Sy tem - ~ L~ 9Z-zi Final Grade (~.~„' ~-d r~ ~,~ ~'~ St Cover !rte Y llt,. BED/TRENCH Width Length ~ No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. liquid Depth DIMENSIONS f 1 ~ t l ~ f" SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM EACHING CHAMBER O Man urea Ty Of System: ~~ ~ ~~ /~~ ~ ~~ ~ ~~ UN Model Number: DISTRIBUTION SYSTEM Header/Manifold r Length Dia Distribution ~ Pipe(s) c ~ Length `- 3 Dia ~ '~ Spacing ~ x Hole Size x Hole Spacing VentVent t~ ke ~ I - .~~ ~( SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Onlv Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil s'` Yes No Yes No COMMENTS: (Include code discre~ ncies, ers ns present, etc.) Location: 2034 280thgwn~NfE,l(1/4 SE 1/4 20 T31N R15W) NA Lo 1.) Alt BM Description = s~ ~ I'~~' 2.) Bldg sewer length = -~ Z i -amount of cover = „~ K _ 1-- Q ~ .fir„ ~ ~I Plan revision Required? Yes (j/No ~ /'~ (,~ Use other side for additional information. ____ I !_!r__ ~ r SBD-6710 (R.3/97) Date Inspection #1: 5 / ~ ~/~~ Inspection #2: / / t Parcel No: 20.31.15.317 e~~2~ ~- s~." ~~/~ 2 ..-''' Insepctor's Signatur Cert. No. o1N.~ I Safety and Buildings Division Counb' _,. n S 201 W. Washington Ave., P.O. Box 7162 / ( / ` onsin i Madison, WI 53707 - 7162 t Number (to be tilled in by Co ) mi Sanitary Pe r se ~l ~ - s T~ JOSS Department of Commerce Sanitary Permit A ~•~--~ ;plication State Plan LD. Number _ Z ~ ~ "' ~ Q~s' ) Code per 21 Wis Adm In accord with Comm 83 i nal infgppglipn MOt}.prgyj{I 6 b , , . . . may be used for secondary purposes Priva ~ n y Law, I~:''11~~ d~(1 ~+n)( t(J `t ject Address (if different than mailing address) 1. Application Informatio Pleas rintAll Informat n Fs . vK(Jfr:vVUo'J''-~ ~p,~.y~Q,~ 'ONING OFFICE Property Owner's Name Parcel Lot # N Block # Property Owner's Mailing Address Pro erty Location ©.3 ~ ~ ~ L '/, ~'/., Section Z~ City, State Zip Code Phone Number f~'~,,/~ f'~~~ i / ~`~72~T/ ~ Z- 7 circle T J ~ N; R~ ~ E W h ll h l k at app ec a t y) II. Type of Building (c CSM Number Subdivision Name / ^ I or 2 Famil Dwelling - Number of Bedrooms ,/1 ~ /Y! / `'~ 2 ~I¢-' 1 "Z ~' ~ ~ ~ /,(,// ~ / /4~ 1 /I r/r---/ ? 7 ~Pubtc/Commercia Describe Use t ^Village ~iTowttship of ^City ^ State Owned -Describe Use _ III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A' ~ New System ^ Replacement System ^ TreatmendHolding Tank Replacement Only ^ Other Modification to Existing System B. ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. T e of PO~VTS S stem: Check all that a 1 -Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 itt. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) V. Dis ersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (st) Dispersal Area Proposed (st) System Elevation ~ ~ ~ ~/a~, ~ ~{z~, ~ ~ ~~ v ~' VI. Tanl: Info Capacity in Gallons Total Gallons Number of Units ' M-^anufacturer t~~.~aWat! A, - (C~ refab ncrete Site Constructed Steel Fiber Glass Plastic New Existing / -lti l~ Tanks Ta~ilcs Septic or Holding Tank ~ ~ ~- ~ G Aerobic Treahnent Unit /'- _ ~ 1,.A7 ~' `~Z- Dosing Chmnber ~w r-- VII. Responsibility Statement- I, the undersigned, assume responsibility for in Ilation of the POWTS shown on the attached plans. PI ber'p Name (Print) Plumb 's Sign ure MPRS Number Business Phone Number //~ ~ t° Z Z l °- ~ S~ Plw tier's Address (Street, it , State, Z ode) I Vlll. Count ~/Dc artment Use Onl Approved ^ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued / / Is it Agent Signat a (No Stamps) ^ O Given Reason for Denial Surcharge Fee) ~ ~~ ~ ~~ 2,~ O ( ~1!/ • p IX. Condition • 'Approv' ~ 3~ ~5 ~~ i5 ~ \ t~--T-S S SYSTEM OWNER: cry; -~, tM.i~~~~ •~~.,~~;~,,~ ~ ~~~ 1 Se effluent filter and ~ g tic tank ~ , p dispersal cell must all b~servi d /maintained ~a;~-,~ ~ ~~Q , as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code/ordinances. wttacn comprete plans tto the eounry omyl ror me system un pnpcr nvr ~~~3 r..,......~.. . SBD-6398 (R. 01/03) e 3 p N ~ ~, ~ ~ w 3`' ~ ~ 1 ^ V 1 t" "\,J ~ ~ ~ ~ o r ~ ~ o~ ~ ~~ a p. o M ' o ~ ~'~ ' I 3 - ~~. ~~ ~a ~~ 0 1~ J~ ~~ ~~ ~ ~~ ~ ~ 1 ~- r ~~ F ~'~ ~xs J ~~ J 3 c~ ~~ Q ,~ ~~ •~ F 1 ± ~1 `~ `~, 11 '1 ~~ W i ~~ ~` x~ ~~ J ~~ 3 ~~ > ~° ~ "' I ~ AI G~P~ ~1 Q 7 ~' N .o 0 n (J1 L S ~ --~ K ~ ~- .~-- d` '1 ti f~ J o~ v { (~~7 W - `1 ~- ~ ~ 7 J ' r I ~ 1 ~ M ~ 0 •~ V° o-. I` ~\~~ >-.~ ~ ~~' S ,~~ ~~ 1 1'~ o- 01 o- M,` a..11 commerce.wi.gov isconsin Department of Commerce Safety and Buildings 141 NW BARSTOW ST FL 4TH WAUKESHA WI 53188-3789 TDD #: (608) 264-8777 www.commerce.state.wi. us/sb www.wisconsin.gov Jim Doyle, Governor Cory L. Nettles, Secretary April 19, 2004 CUST ID No.224617 LYLE J MYERS ATTN: POWTS Inspector ZONING OFFICE NORTHLAND PLUMBING INC ST CROIX COUNTY SPIA E1556 STATE ROAD 64 1101 CARMICHAEL RD BOYCEVILLE WI 54725 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 04/19/2006 Identificat~~n Numbers Transaction ID No. 986267 SITE• Site ID No. 681951 Mark Tellijohn Please refer to both identification numbers, 2034 280TH St above, in all corres ondence with the a enc. . Town of Forest, 54012 St Croix County NE1/4, SE1/4, S20, T31N, R15W FOR: Description: Commercial Conventional w/ Leaching Chambers, 51 GPD Estimated DWF Object Type: POWTS Component Manual Regulated Object ID No.: 950934 Maintenance required; 300 GPD Flow rate; 58 in Soil minimum depth to limiting factor from original grade; System(s): Conventional POWTS Component Manual, SBD-10567-P (R.6/99) The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: This system is to be constructed and located in accordance with the enclosed approved plans and with publication SBD-10567-P(R.6/99) "Conventional Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems". If a pressure distribution network is proposed/needed, it shall be constructed and located in accordance with the requirements of publication SBD-10573-P(R.6/99) "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems"and/or the sizing methods of publication "SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST-SAS (01/81)". In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. In addition, the ow ust~ ~' insure that the operation, maintenance and monitoring duties as described in section VIII oft e con~iti$ ~ ;. r~~ component manual are complied with. A copy of this information must be given to the owner on cdx>~s~io the project. ~~\ ~~~~ ~ ~ NOTE: The correct soil application rate for this site is .6 gal/sq.ft./day. Although the plans indicaf~ t the system has been sized fora 2 bedroom home, this is a commercial type facility and the actual estimated dailyi~~ stewater flow is 51 gallons per day. A state approved effluent filter is required. Maintenance information must be given to the owne:• 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. LYLE J MYERS Page 2 4/19/04 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. Sincerely, Julia ALewis-Osborne POWTS Reviewer 2 ,Integrated Services (262) 548-8638, Fax: (262) 548-8614 j lewis @commerce. state.wi.us Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 WiSMART code: 7633 cc: Leroy G Jansky, Wastewater Specialist, (715) 726-2544 RECEIVED Nortliland Plumbing Inc. E 1556 State Road 64 Boyceville, WI 54725 715-643-2520 To whom it may concern: APR - 9 2004 SAFETY & BLDGS. D1V. This particular site is privately owned dairy. Contents consist of a bathroom, breakroom with a sink, and mechanical room floor drain. The owner and one employee have been used to size this sight. This attachment is for the Mark Tellijohn conventional system design. ~~ s~Sr~ ~ ,-~ ~~ G y ~ ~~~ ~~~ Y ~Y~2 ~~~~ ~2`~~0/7 ~: a Chambers Cover Page Page 1 of 5 RECEIVED APR - 9 2004 Project Name: Tellijohn-Chambers SAFETY & BLDGS. DIV. Owner's Name Mark Tellijohn Owners Address 2034 280th St. Emerald, WI 54012 715-265-7168 Legal Description NE • /4, sE • /. Sec 20 T 31 N, R 15 w _ • Township Forest County sarrrt Crobc • Subdivision Lot# Parcel I D# Table of Contents P9~ 1 Cover page 2 Calculations and Drawings 3 Management and Contingency Ptan 4 Plot Map 5 Lift Station total # of pages: 5 Designer Name: Lyle J. Myers License #: 224617 Date: 1 /13/04 Ph. #: 71543=2520 Signature: Design Methods Used 7N-GROUND SOIL ABSORPTION COMPONENT MANUAL FOR PRNATE ONSITE WASTEWATER TREATMENT SYSTEMS' (Version 1.0) SBD-10705-P (8.699) <•~. .~ r'y ''~~ ~~~. `o'c~ ~~. <; yC~, WI 54725 Ph: 715-G43~60G8 email: CPiar>if5ai`~ Page 2 of Calculations and Drawings Site Conditions Infiltration Elevations Site Type: Prhrate ~ 9~6SIope~ # of Bedrooms; Depth to limiting factor] 58 in Soil Application Rate: ~ 0.7 gaUR^2/ Effluent Quality Elf ~i ~ Design Flow: 300 gaUday Max BOD 220 mg/1 Max TSS 150 mgA Distribution Cell Choose chamber type PSA Bio-Diffuser li" Standard U Laying Length: 6.21 Ft EISA Determined Area: 31.1 Ft2 Open Bottom Area: 15.20 Ft2 Chamber Height: 11 Inches Required Infiltrative Area: 428.6 Ft2 Total # of Chambers: 14 Total Cell Length: 86.9 Ft Trench #1 Trench #2 Trench #3 o ' ~ _ _._._-. - __ _ _ _ on Elev: Infiltrati g5. 9 _ 0.00' Ft '~ Limiting Factor Elev: 91.26 N/A N/A Treatment and Dispersal Zone: 3.83 N/A N/A Cover Material Required: 12 N/A N/A In Finished Grade Over Cell: 97.09 N/A N/A r r Cross Section of Cell Cover Material Observation Pipe (if required} -Final Grade Ground ~ Contour Leaching System Chamber Elevation AStM 303~f a 5ch X10 ~t ~, pVC plc Plan View of Typical Cell ~~ L 6 1. 6 ,O ~4 Ob~erMat~crr pipe Obecrra ba, pipe w~a,~, Page 3 of 5 In-Ground System Management Plan pursuant to Comm 83.54 w. A. C. 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 owners 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 appoeved 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 Dep~ttP~iertt bfi CBniPYiBi`~, Sfifety aita BUildirtg~ Div.. EffliiB/it flltefs ire to t5e faitibVBd 8 clefin~8 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. Absorbtion Cell The absorbtion 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, vehiGes, etc...) could compress the component and reduce it's absorbtion capabilities and/or possibly cause it to freeze in winter conditions. Performance Monitoring: Periormance 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 or other components therein (inGuding floats, alarms, etc) become defective, the defective tank or component must be replaced immediately to ensure that the system can operate as designed. If the absorbtion component cannot accept wastewater or ponds wastewater to the surface, the component must be repaired or replaced in it's current location by removing the clogged bacterial mat, aggregate/leaching chamber cell, and distrlbutlon piping within the cell and replacing failing components in order to return system to proper working order as required. If repair is not feasible, a new system is to be constructed in a designated replacement area 3 ~ - a~.. ~ ~~ ~c ~ ~a ~~ ~ ~ ~J ~J ~ ~ ~ _ ~ ~ ~ ~ N ~ ~ o ~ ~ J ~ ~ ~ it ~ M ~ M ~9_ - ,t ~ V ~ ~ I ~ ~~~ ~ ~~b ~~ ~~ ;~ ~~ w ~~s ~~ ~~ .~ J" aJ, ~1 LL ~~ ~ J~~ J 3 c~ R^ ~ Q ~~ ~~ x~ ~~ J ~~ 3 ~~ > ~° A~ M ~~ 0 O~ 0 '• ~ w ~_ J r 1 I • (L 1 0 ~ 'G~'_', ~l ~ \ ~ ~. ~ ~ 1 O 11 ~. 2~` 1 1'~ ,01 ~ ~ ~ o- M , ~1 (`/~ Y S -~ ~ ~ ~K s- ~ ~- }, 'rEU..tJo Nrf Project: I Tank Information Pump tank manufacturer: Wieser Concrete - ---------- -- Pumptank size/model: wiooo/5oo-MR __ ' ~ Pump tank gal/inch: 9.84 Actual Pump Tank Volume: 502 gal Tank bottom elevation (inside): 87.12 ft Septic tank size/model: ! wiooo/5oo-MR_ Page~ofg Septic, Pump and Dose Tank Pump and Filter Pump Manufacturer: Little Giant Pump Model: 9EH Effluent Filter: Zabel A100 Note: Access opening of sufficient size to be provided to allow removal of filter Opening to terminate at or above grade. Dosage Volume Forcemain drains back to tank? OQ Yes O No Lateral void volume: 9.1 gal Dosage to absorbtion Cell: 45.4 gal Forcemain volume: 3.5 gal Total dosage: 48.9 gal Total Dynamic Head Are laterals highest point? y if not, enter highest elevation: 0 ft System head (distal x 1.3) 6.50 ft Vertical Lift ("D" to lateral) 9.30 ft Friction loss in forcemain: 0.12 ft Pressure loss from filter: ~ft Total dynamic head (TDH): 15.92 ft Dose Tank Levels In. Gal A Reserve 36.0 354.7 B Pump off to Alarm 2.0 19.7 C Total Dosage 5.0 48.9 D Effluent depth for pump 8.0 78.7 Total Capacity: 51.0 502.0 Pump Tank Diagram Watertight Locking Cover 4 Inch With Warning Label Finn Minimum f~._ outlet Location `~ Elect. per Comm 16.28 and NEC 300 Weep Hole p` or Anti- Siphon 8 Device C D FLAW- LITERS/HOUR 3 w ~2 W 15.7 GPM =1 16.0 Feet to H 7,5 r i s a S z.s 0 Pump must be capable of: and head pressure of: Little Giant FLAW- GALLONS/MINUTE 9EH PUMP PERFORMANCE CURVE IISV 60HZ ST CROIX COU2V'Y'Y SEPTIC TANK IviAINTENANt:"E AGREEMENT AND OWNERSHIP CERTIFICA'T'I~~N FORM OwnerBuyer ~~'~ -2.~-/ ~-~uJo- Mailing Address Z o 3.4 2 8 O tl• S"'7` ~ ~n~CC-~-~-~5 , w I S~ / 2 Property Address _ ~ .•..-- erificationrequired from Planning Department for n<;w constntctioa) City/State ~i~-e-rLne.~ ~ w l Parcel Identification Number ~~:.~ -- i~ %~-3 ~ ~~ '" ~v~ ~ 3~~"~ LEGAL DESCRIPTION Property Location N~ '/<, S~ %,, Sec. Zo , T 3/ N-I~,--.15 W, Town of f ~~5? Subdivision V(J~~.1 .Lot # _7~. _~~ Certified Survey Map # ~~~ ,Volume .Page # Warranty Deed # ~.7~d ~~ ,Volume _~~, Page # ~v Spec house D yes (~ no Lot lines identifiable yes O no ~, ~~ SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result iYi it; promature failure to handle wastes. Proper maintenance consists of pumping out the soptic 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 (I) the on•site wastewater disposal system is in proper operating condition andlor {2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read rho 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 Deparmticat of Natural Resourcos, State of Wisconsin. Certification stating that your septic system has been maintained must be completed acid returned to rho 5t. Croix County Zoning Office within 30 of the thr~ea ti date. SIGNATURE OF APPLIC DATE OWNER CERTIFIC_ ATION 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 d~ 'tied ~ye, by virtue of a warranty deed recorded in ltegistcr of Deeds Office. ~~~a SIGNATURE O APPL ANT DATE «***•« Any information that is mis-represented may result in the saniGsry permit besng revoked by the Zoning Depamnent. "*"*'`` •« Include with this application: a stamped warranty deed from the Register of Deeds ofI`icc a copy of the certified survey map if tcfercnco Ls made in the warranty deed , ;t.;9- .. -~ . Wisconsin Department of Commerce Division of Safety and Buildings SOiL EVALUATION REPORT Page ~ of r~ .n axareanca wltn :;cmm cc, vv~s. ttiem. ~.we Plan must than 8 1/2 x 11 inches in size t l it l h l t A -- ~~ ~~ ~i~0 . an on paper no ess comp e e s e p ttac include, but net limited to: vertical and horzontal reference point (BM), direction and p~~ ;.p, percent slope, scale or dimensions, north arrow, and location and distance to nearest road. ~., -~ PleBSe print ~ I mf4i~3~i~ ~~~~°` ` 0 Re iewed by Dat/e ~ _ 04 (t) (m)) f ur oses (Privac Law s d f econda f i id b f Orf~2a,,,/ . . p y , . ry p e use o s ormat on you prov e may Personal in . Owner Propert y ~ ~ ~ ~ ~ 2 ~ l) 4 Property Location ~ A ~7~- ~/' ~~° l EL..L/C~OffA/ Go Lot /vE 1/4SF 114 S Z U T ,3 I N R ($ f'(o( V~ Proper~r Owna; s Mailing Addrass Y! r %;- ' ' ~~,v r ~„llU+'~ Lc # Block # Subd. Name or CSM# Z 03 ~ ~Q h. ?ONING OFFICE City State Zip Code Phone Number ^ city ^ Village .Town Nearest Road ~/1~ERtl w/ Sg~s/ (~/5) 2105- ~/G ~a/L~ST Z 8U N. 5 New Construction USe:~Residential /Number of bedrooms Z Code derived design flow rate ~O U _ GPD ^ Replacement Public or commercial -Describe: Parent material -t C.JQC//! L ~ GAL Flood Plain elevation rf applicable _ ft. General comments and recommendations' ~~ ~~~ . ~~/~'I ~ Boring i J i Fw-~iini~ # ~~ n~ ~,, t~~~ C2 ~S~ gS n .. I I ~ pit Ground surtace elev. _ ~J , ~ tt. uepm [o umiung raaor Tv _ m. Soil A ication Rate Horzon th Ce Ccrrinant Ccio Redcx Description I Texture Structure Consistence Boundary Roots GP C/fF p in. Mansell Qu. Sz. Cont. Color Gr . Sh. 'Eff#1 'Eff#2 2 ~- 6y/z4/ si / '6k /Ytv{~r cS /~ . 5 3 l -3 /e yie ~'/ Zs6 k rn / ~- es /~ . S , ~- ~•5'/ S/G ' s c / Z s,:s k m t~~ cs - ,-y~ 5 -~~ ~rsye4~ sc/ 3s6k rnv~'Y cs - .4 I 7 1I l~±rina # ~ Boring is ~ ._ r3 ro U ,~, pit Ground surtaceelev. / cF+. v lrt. uepm ro nmmng raaor .~ rn. Soil A ication Rate Horizon Depth Dominant C;oior Redox. Description T9xbJfe Structure Consistence Boundary Rootr, GPD/ff` in. M ~nsell Qu. Sz. Cont. Cokx Gr. Sz. Sh. 1 'Eti# 'E1f#2 {, ~f e Z 2 -22 b ,c~/3 mss'/` ~ ~sd /~c A'r t/ r S ~' . S r8 ~ 22-2,$ l6`lti~~ S'~ ~S1k rntr~'r CS - . S - .5 J~-~!o ~,51~eS/8 ~•5 ~/ d s sc ~ 2 s.b k „-.v~'r S - • `~ • I I I 'Effluent #1 = BOD > 30 < 220 mg/L and TSS > < 150 rrig/L `Effluent #2 = BOD < 30 mg/L and 15,5 < 3U mg/L I CST "lama Please Prot) f~,~ Sg afore ~ i ~ Nuprt?ber `~ //` S l0 O I Address Gat Evaluation Conducted Telephone Number 2~g~ ~34~. /y-V~ (~/~CILClJD,sC~' ~/iS 6/ ~/G -O~ (~/S~ZIoS'~1o2- ~.~ i ,~ .~ . `-~ . ~( .~ .~ . ~, .~ Property Owner ~ARk /E~LG/.~DHit/ Parc~ei iD # Page Z of 3 Boring # ~ ~~ pit Ground surface elbv. 9~• 3"i ft. Depth to iimiting factor ~ in. Soil A icatbn Rate Horizon Depth Dominant Cobr Redox Description Texture Structure Consistence Boundary Roots GPD/fF ~ in. Munseii Qu. Sz Cont Color Gr. Sz Sh. 'Eff#1 'Eff#2 p-9 ~eye3/i si~/ ~3~bk /~iv~r eS 3~ ,s ~ z -~~ /eyR ~3 S,~ 3s.~k ~~~ ~s ~ s ,~ 3 ~-2~ /a Y,e 4/ s/ ~3s6 fs ~ ~,- c s -- S , S ~2-~8 5 K 4~~ OS ~~ ~ S - , I^' ^ Boring ~nrin~ # L I U NII v~~unuaunawa~cv. ~~ vaNui w nnnw~y ~auU .. Soil A lication Rate Horizon Depth Dominant Cobr Redox Descriptioh Texture Structure Consistence Boundary Roots GPD/fF in. Munseii Qu. Sz Coal Color Gr. Sz. Sh. `Eff#1 'Eff#2 i (~ ^ Ong I f Boring # r, ..__.._~ _...y-- -~_.. a .,__.~ ~ ~:_:.:__ ~...,.,._ i Soii A ication Rate Horizon Depth Dominant Cobr Redox Description Texture Stru~ure Consistence Boundary Roots GP D!fF in. Munsell Qu. Sz. ConL Color Gr. Sz. Sh. 'Eff#1 'Eff#2 'Effluent #1 = BODS > 30 < 220 mg(L and TSS >30 < 150 mglL `Effluent #2 = BODS < 30 rrxyrL aril TSS < 30 mg/L The Department of Commerce is an eyual opportunity service provider and ecnpioyer. 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. .~ .~ .~ . q- ~gn o,~~;r,.c~~x; ._~' ~: ~ ~_ M A;- ~ N ~ 7 ~ ~ 3v ~ ` ~ ~ w ~ ~~ ~ ~ ~~ ~ ~ ~~ F ~~ ~~~ ~J /- ~~ c~ M~ 3 z ~ o ~ • .~ O M om ~ ~ Q .. ~~~ a , o ~- ~- ~- ~ ~ p4 ~° '~ d' n J v ~1~ 3 ~a ~~ 4 ~J ~ ~ ~` 5 J ~~ O ~ ~- p- ~~ J `~ a a n~ -~-- 1 I 1 ~, 1 '~ ~ j ci 1 ~ ~ ~= `+ ` ° 8 ~~ 9 1 ~ ~^ ~~ ~S..x J ~/ J cl~ Y 3 ~~ "~ ~ ~ M ~~ A ~~ 1 MQ ~~ ~y C O O 0 ~: ~~ ~. ~ i .,,o N ~-. , 1 ' ~\ ~' 1` ~l ~`~ ~ ~` ~ o- Q... ~l `, F ~ ~ ~~ :f °~ ~ • ~' DOCUMENT NQ. TATIQ BA8 OF WISC 8IN HORN[ 1 ~• 18f1f ~t ~ TMs sees assswrse row aecoeeiNa owre . ' f WARRA DEED 4'~5Q86 ~ y ~~ce2~ von ,, RECISTER~S OFFICE _ _w _ . . __ _. -, r . _-: __ ST. CRO~x 00., VW This Deed maa. be'cween Go rdon D_. Te I 1 i ohn ............... .............. j..... ---...$........ '~ b - Ret'd for R~tOrd C~.~~~,.otte-, E.•„ ane ~.-wife,.•.and,.,--..,,,. ellijohnx..hus. ;~ ~ OCT281991 Ma.rk...G~...Te.~Y.3,john..a~~...Kr.stir...#~.•...:~:el.~john,.....----•• hus.b 70. , wi.... ................ •--.._........... ................ car for Dair Tnc a duY- or' anize~' ~e~1•~i• ofin~ at 8:30 A. M (~ ~~t ~ ti and ......................... ~.......... ..... ~L...... .s t . .. .. .. y ~ , ... . ....... ..... ... ..._...... .. .. . --- and existr<n Wisconsin cor oration •_ ~pkw-ofDwrb .............................. ....................... ................................. Grantee, Witne~rTath, That the said Grantor, for s valuable consideration.... St - rvroix conveys to Grantee the foI[owing described real estate in .....• ................... ..... Raru~w Ta County, State of Wisconsin: See attached Schedule "A". -` --~- -~ Ta: Parcel No : ................................... Exempt No. 15. This -...1S--,I1.0~•.--.-. .homestead property. (ie) (is not) Together d+ith all and singular the hereditaments and appurtenances thereunto belonging; And.....-• ..................... ........................-- - ....................-..-•-•---....-•---........-...-_.-...-..-..--•--•--..... warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except and will warrant and defend the same. Dated this ~ fT!~ ...............•---..... Say of ........... ...~'taY....................-.. ..........--..........-.., 18.89... ~~!%~"r' :!. :`1 ~ 4 ! t ~~~ (SEAL) ^=G ~~ ~':" "` ~ ~:: '(`~\ ` ~ (SEAL) ' 't' '~" s~` J .. ....... . , ,._-_--Gordon,+-D.._. ..,, . . .. .. ......--.. i Tellijohn _ . . ....... -... . . . . . . . . . Mark L. Tellijohn nn: ......~1sL.l.t~,,.. _ ,_ .~ ~... " E.Q~.G~.. l4tL.. (SEAL) ...~1 -~-.- i R ~~,C„~ 4.!~.~,,~•--.... (SEAL) h T lli~ Charolotte E. Tell john . e ~ Krist o n e AIITHBNTICATION slgnatnre(a) o£...Gflr_ds~.n..~....1;...Chaxlax.te... Tellijohn $ tdark L. $ Kristie R. Tel I i j ofin-""-- autheaticated this ~~ day of._..~`~~a! ................ 19..89 _~~ __7 .------G . E . Norman TITLE: MEMBER STATE BAR OF WISCONSIN )i~)(9~f~X?~XOQQ(48X~76X~CtX9i.X ACSNOW LSDOMBNT STATE OF WISCONSIN sa. ....................•--•--... _.....---County. P~raonally came before me this ................day of • ..........................•----.........., IB....._.. the above named to me known to be the person ......._._.. who executed the fnreonino instrument and arknnmledne the same- t ~. • ~. _ ., von g~~r~c.~~ _ . SCHEDC7.E 'A' 1. The Southeast 1/4 of Section 20, Township 31 North, Range 15 West. 2. The South 1/2 of the Southwest 1/4 of Section 21, Township 31 North. Range 1S West, EXCEPT the South 738 feet of the West !40 feet of the South est !/4 oC the Southwest 1 /4 thereof. 3. The West 1/Z of the Southwest I/4 and the Southeast 1/4 of the Southwest. 1/4 oC Scction 22, Township 31 North, Range 15 West, EXCEPT the East 1 1/2 rods of the said Scuthe~st 1/4 of the Southwest t/4 and EXCEPT the Certified Survey iViap recorded in Volume 4 of Certified Survey Maps on Paga IOS3 as Document Igo. 370536. . _ __ _ _ ~~ ~ T-31-N • R-15 -W FOREST DIRECTORY '!'sc HNM~~ Ltt E1 'fir. CROLK Covrvri•, WtSCON~'i See Pases 135-140 For Addition al Names. (Residents -Owner or Renter) POLK CO. _ _. POLW ST Shane Pruitt M O ^ ^ ^ • Ga ^ ~ Phillip n g ^ Paulson Darin a R x u G Rogers re dahl Anderson I ~ a a ~ ~ ~ ~ 9C4 `s N REEK ^ $ ^ Norman J RG~ I BEEN ~ ^ CO[mican ~ ^ Chard 5 ~unbert ^ 4 3 .a 2 0 1 ~ Warne St ~ n ^ ^Todd Ray ^ e ~m' ~ I 6 ~ l~uyd Loi_an ^ 'Darren 9 1 Pietx Patrick at ~ A W La sen ~ w Scepurl~ ~ sand I : ~ ~ : II ^ ^ ^ y _ _ ~ x~ 230th AVE ^ rustin ^ T i{oeff e SB ^ q ^ ^ ~ Gary $ u ~ Nekon ^ I ~ ^ ^ Jamie Alan Glue e ^ Robert ^ R Fuller Alver- mann LYon Phi • ^ Spal- p va ~,o ~ $ ~ Mil ~ ~ ^ Nelson Nestrud g I ison Inger Mde U ~ Helge ac ~ Robert Neil ^ Harold Lawrence ~ 7 P t i k 8 ~ 9 ~~er Ulrich 10 ^ I ^Bradly Cress 11 ~"dr K Brooks Rosin ^ 12 r c a ^ amu Steinbe er ~ e Sne s > ^ k'O [ c K A n F oemg ^ c y B B ~ , en ^Eaa~ ra Micheal ~ ^Thomas $I M l m c ~ g m ^ Dennis ynn ^ LN hng ~ d ~u ~u o w ~ l ~ ~AFEK ~i ver= e vin ieibe] ~ W.~~ ^ Hall EBBert 220th AVE ueben Glu e ^He eson ^ ~ '~'- "' _ D ^ 1 ^ obemkk u ~ ^~ ~ ~a~~ ^ t I ~ SKe> ~eth ^ Fol~ Alice ^ Iverson ^ [T•ii Hey d ^ CWrrss y n7 W N {L ~1 LOS ~ j tr ^ ^ DdVM 8 17 16 $Clm]1 15 I c a n ~ 13 ,a N ~ lavid Fink ^ ~ Lt] Thomas ~ Johnss •n atc _ r \ i;, ae Denise \ I 3NOWMOBIL ^ ~ ~ o ^ derson ~ 09 N V '~~ ~~ ~ eld ^ / ~ E TRL Hahn ^ ert Todd ix ~' ~ iW a~ I yI Jacques Randall ggaa DeBoer Roger Robert Mazk I cgFF Monty ` ,.tit ~ ^ j ^ ^ ^ ^ ^ ^ Anderso ~ Edwards ^Hard ^ Goodrich N t ^ • z , O i Ronald ^ 0th AV ^J ^ avid ^ ^ ^ David ~ R _ _ Joel ~ - - I h ff n h,? Riniker ~i,onl ~j R~en Jurisch 3I Graese Tumm obert poEl ~~ Swan Salseg Scott ^Buhr Bp~EN L Sc a au ^ I 0 ^ Darre6 ` y ~ ~ A H S ^ C rmican I Berg m ! I r~ ^ David Ros 21 m r~ / 22 David 23 ~ qu ~ j ^Enc 19 Tim LO - -- Janss 7 U I Moll Wienke ^ azk ~ellijohn I ~- S m ^ rd Blom rg a 205th AVE ^ I S$u ~ (.e ^ Belli ohn^I 1 N C I ~ uh M ~° ~~ ^ ansY r~ C Y k ^Richard c3 Tiber a4 ~ I -ames o ^ D Robert Q ^ Edwin ^ ^ 1 Dennis ton ^ ess m O U 3 ^ ~n N ~ g ~n ^ uane ~ buval ^ Wom Hall Duval ^Rose ^ ^ 200th AVE -~ _ _ ~ ^Roger ~~ ~'~' 1~-'-~ ^ ^ A V M of ^) lN~son I Robert Fitzer Beestma ^ ~ R D ce / a n Vceltz DeBoer ~73 Joe ^ S l ^Larson r ^ Keith ~ ^ Alfred ~> wanepoe Lawrence ^ McNamara ert Ot Kra Rick - 34 RIVER ; 0 29 28 u u 27 ~~ $teln- be<ger 26 25 I ~ w <~o ~ Bart . ^ I w ~O ~ ~ Sco ~/ F i ^Todd ^ R •n ^ Derrick .d $ Doyle ,~ I ~}(celtx ~ ~~ _ \• ~~ ~ ranc s ^ 1 Winbe/g Lawrence MM Ca istrant P ~ ^ Otto Barmet Ro t I e p ~ Ted u u Milton BetheB 'a~~'-°~ Riba Laverne ^ Die Hoitomt Hill I e ~ i iU ^ K h oe tz M~ i ^ Cr eu ^ ^ Mill er ^ ^ ^ ^ u n ^ ^ ^Allen Marvin Wi ^ ^ ~ ltJ ^Scott • ^ a ^ Gary o James ^ ^Roger Miller 64 ~ Anderson .~^, '~~ O~tEST J i Hurst et ~ane- Helnbuch N3 Hanson ~~ ^ Do Hill~as A OV v~ Dale , ~ 31 P D 32 ~ I 33 S : ` ~'~' 34 35 ~~a 36 ,~ N Webster I I _ t , ^ ^ B d Clarence H ' '~ ''tis a, ~ e All I ^ mt 728 Iackel ~ John c a Simon ~ ~~~~ ~ en Warner ~x t•v3i ^ ,:.. iesse Schmidt Crawford ^ ^RYan L d 9FF ^Caerard ^ "t Carufel ^ ^ ^ ^ ^ ^ o s S _ u emann EMERALD PAGE SS GLENWOOD PAGE 57 ;i ~ i! www.edinarealtycom "If you are buying or selling with Doris, you'd better start packing!" Doris Schmidt RealtorT"' ABR New Richmond Office (715)263-2365 24' PVC Outlet Plpe / ~~ ~10'~ 23'-~. ~~• i i slope -2sz s• per lo' ~ ~~ ~ ~ i ~ Reception Gutter ' ~D ra a '~a1oSa°'"w i ~ .~ 0 ®ICE ~ nn bath GILE EQUIP ROIL level 4 ~ ~,'`I e ti` list` ~L A : 1500 Gn6 v ~ ~ torng ,~, U , ~ 7' Dln. ~Q ~.p j V ` 10' 0 C ~ BREAK ROOM I ® I -i ~ 8' ~D I ~ i• sat+d svh • • ER UNI. X2. 9'-6' LEGEND A Antenna ,~„y,..,~,. ERU Energy Recov~,~nit, ,,, y} F Flush Valve OVD Werhend Door HVH High Volume Hose ~v ` 4 PC Ptate Cooler ~ ~ ~ ;y R Receiver ~ ~ v ~ ~`\/l, VDT Vertical Distrlbutbn Tnnk ' \, W/H Water Heater WP Water Pressure~Tnnk ® Water C hot and cold ) Hose outlet 7'- Foot. Bath ~o M X w L N d R1 u both +' MIL level ~ FOOL Bath 2000 Gal. 85'x120" ~~~~ ~ :i ~~ 24''• owner. 4, .~.,~. Pen 1 I I I ('7 .~ O Pen 2 ""' ~ Pen 3 M .--~ 10' OVD ~" 1 .sz i 3 U ,~ 5~ ao Gutter Cross Section nlOTr=s> exaggerated for clarity 1. The oQerntor pit floor Is to be crowned 1-1/2 through the center and sloped toward each pit wall to n 2' x 2' or larger gutter. 2. If ID Is to be used, follow ID Lnne Placement Information for the specific gate used 3. Follow Blue Diamond Installntbn instructions. 4. Consider Llft out gates M Nofalhg Area 5. Consider denrance under crowd gate -f using skid-stet 6. Idlking Parlor to hove self closing doors 7. Breezeway doors to contnh windows in doors 8. See drawing M-3021 for flush valve instnffat/ons L=- DeLaval 2 x 10 PARALLEL PARLOR Dn AOr uu for caxiwctibn a~ ~ ~ ~~m cc~ ~S~j ~ E c w E 4 t v -' ~~n~ ~~~$ m~ a s~Wq =AE_i0a «v.~ o m r ~ $mv ~;~ ~ 8 aS ~~s•a ~~B~ ~~~~ B~~g 8 $ ~~ g~9~ ~;m~ W ~~ ~ E ~~~ a 's ma'. $~ 5 ~~~ $~s 8 ~$s I'B~ 8~€ E~~ iom~g ~~6m :~ W~ ~~~ .~ ~ s. i? ~ m E r~°. ~~a ^os€g o ~ ~~~E ~~r~ B a~E`'' o E s$~~ a ' io=~~ ~w ~~g$ .~°~° ~~~~ ~~W~ ~~ ~ m m£E` n°~p c ~ tl1 m ~~s~ ~B~ ~m~~ m$ ~oo~ PRELIMINARY