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HomeMy WebLinkAbout028-1048-10-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 563876 0 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Velaski, Phillip & Diane Rush River, Town of 028-1048-10-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: a t CS !T 35.28.17.301 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER t CAPACITY STATION BS HI FS ELEV. -'l 0 7, } 0 P Septic Benchmark 3• SZ /Q3'S Dosing Alt. BSI .7 I k~_ Wb Pv 1 A+tion Bldg. Sewer h SLS It J4 92 . z Holding SUHt Inlet \ TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom 30 36, 'q' 14.7 g Dosing 30 t d 1 l y Header/Man. P p t 2 7 Aeration Dist. Pipe S S.rS rP z.Y Holding Bot. System lot r-1 Final Grade PUMP/SIPHON INFORMATION ft I ~r-r 09 10 3,li 7 Manufacture Demand St Cover Z era f0 GPM' 1 QO. rS Mod umber 15 3 1.0 /6" yr z • f~ DH Lift Friction Loss System Head TDH Ft 6'V 1,i2 ,rj 23.1 7 Forcemain Length + Dia. r r Dist. to Well .3 11.1 Ll6 2 a SOIL ABSORPTION SYSTEM 1. Ss BED/TRENCH Width ength No. Tren s PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth I ;0 + Q( DIMENSIONS Q L SETBACK SYSTEM TO P/L / BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION a CHAMBER OR Type Of t~ J i Z 31 5 , I I UNIT Model Number: DISTRIBUTION SYSTEM AI+BV3f HeaderMlanifold Distribution Tole Siz x Hole Spacing Ve Air I take t u Pipe(s) 24 t/ 3 / Length-6- Dia Length Dia Spacing ;4 r SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only ^'W Depth Over i Depth Over XX Depth of xx Seeded/So ecyd d xx Mulc ed Bedlrrench Center Bed/Trench Edges Topsoil ' F~- Ie. No es Fm No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / r 1 7 / ~-3 Inspection #2: / / Location: 38 191st. Street Baldwin, WI 54002 (NW 1~L SW 1/4 35 T28N R1 7W) Village of New n;ervill~Lot 1 b Parcel No: 35. 17.301 1.) Alt BM Description = Gtr 2.) Bldg sewer length aAn- - amount of cover T 6^- Plan revision Required? 0 Yes J No Use other side for additional information. SBD-6710 (R.3/97) Date Insepctor's ignature Cert. No. ~ST Ckoi k C&4Alr %1 - 0~0 Seg. 33-728AR0u) S~~Le. C /~''f avl ~a l vJ a2 po % l ~PV3 PCc_rv,~rtOQ tlec I F~Tlav~ ort t ~~Ka~l~ i ~ -0 oa r eDck,•... County C Industry Services Division 1400 E Washington Ave Sanitary Permit Number (to be filled in by Co.) • P.O. Box 7162 Madison, WI 53707-7162 S~ 3'3'7 Co ary Permit Application ~/1 State Transaction Number In accordance 1Adm. Code, submission of this form to the appropriate govemmenta e, 7 S8~ is requirei *or inin ttary permit Note: Application forms for state-owned POW~ / je submitted to ject Address (if different than mailing address) the Depa of Sa nd Professional Servies. Personal information you provide may b8 !(e~forrs~ondary purp oses or nce with the Privacy Law, s. 15.04 1 m , Slats. / Q / C / c7 1. Application Information - Please Print All IyfoWation T ; V ! G Property Owner's Name )1 k Parcel # Property Owner's Mai/ ing Address Property Location ~p i 38 91 S1t ~ of Govt. Lot / -6/ac/ City, State Zip Code Phone Number a I f, \ y4 S i v\ 7/ Section ~ O A / .._3 gab (circle one IL Type of Building (check all that apply) Lot # T N; R E o1 V1 or 2 Family Dwelling - Number of Bedrooms / Subdivision Name Block # ❑Public/Commercial-Describe Use 'C. ,3 ❑C1 of / ❑ State Owned - Describe U~p CSM Number N-Village of deli/ /4.j yj/ j /tJ 6 ✓,ti e~ell r ~ 1 own of ? A,g h R I CJ t it Ill. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B• ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. Type of POWTS System/Component/Device: Check all that apply) ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ® Mound > 24 in. of suitable soil ❑ Mound < 24 in. o suits le soil ❑ Holding Tank ❑ Other Dispersal Component (explain) Pretreatment Device (explain) V. Dis ersal/Trea ent Area Information: DesignFlow (gpd) Design Soil Application Rate(gpds Dispersal Area Required (sf) Dispersal Area Proposed sf) System Elevation VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units a v y New Tanks Existing Tanks A U ° yC a g p ~a SZ cC iw a Septic or Holding Tank /~O DD r7 Dosing Chamber CSO 1J S~ a/ VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Number Plumber's Name (Print) F Plumber's 'gnature M c~P/MPRS Nuumber Business Phone JGY► I.- 1 eS E SD va 22..x- / / Plumber's Address (Street City, State, Zip Code) J [ 7(~ Y /~{w /-P h/n L~a~ l -r ~y 71° VIII. Coun /De artment Use Onl pproved prove Permit Fee Date 71;ued Issuing A Signature 1 4Z5 T 4 P//- 3 en Reason for Denial IX. Conditk8t(~asons for Disapproval 3~ /6~df a s l s~-~ p('aJ t 1.' geptiC tank, effluent filter and ~i M I ~ r /I M dispersal cell must all be services / montained ^ as per management plan provided by plumber. g, iA>l sack requirements must be maintafn€d a t oa, f ofd ott, 4 ! V a nc ~ lOt K~✓ AA Attach to complete plans for the system and submit to the County only on pliper not less than 81/2 z 11 inches in size SBD-6398 (R0313) VART. IV" DIVISION OF INDUSTRY SERVICES >5~ 3824 N CREEKSIDE LA ' D S HOLMEN WI 54636 Contact Through Relay P S www.dsps.wi.gov/sb/ 2Q `cw www.wisconsin.gov A~Ossror:Scott Walker, Governor Dave Ross, Secretary July 31, 2013 CUST ID No. 220292 ATTIC- POWTS Inspector BENNIE W HELGESON ZONING OFFICE HELGESON ENTERPRISES ST CROIX COUNTY SPIA N7649 STATE ROAD 128 1101 CARMICHAEL RD SPRING VALLEY WI 54767 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 07/31/2015 SITE: Identification Numbers Philip Velaski Transaction ID No. 2275887 38 191ST Street Site ID No. 793405 Town of Rush River Please refer to both identification numbers, St Croix County above, in all correspondence with the agency. NW1/4, SWI/4, S35, T28N, R17W FOR: Description: Two Bedroom Mound System / 6% slope Object Type: POWTS Component Manual Regulated Object ID No.: 1439935 Maintenance required; Replacement system; 300 GPD Flow rate; 26 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01/01, R. 10/12), Pressure Distribution Component Manual - Ver. 2.0, SBD-10706-P (N.01101, R. 10/12); Effluent Filter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. APP No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06 I)EPTOF R stats. PROFESSI©N The following conditions shall be met during construction or installation and prior to occupancy or use: OMSION OF WO Reminders: • A sanitary permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. 4 SEE • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. • A state approved effluent filter is required. Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. Access to the filter for cleaning must be provided per SPS 384 product approval conditions. • The existing POWTS shall be properly abandoned per SPS 383.33, Wis. Adm. Code. • The area within 15' downslope of the dispersal cell shall remain undisturbed. Vehicular traffic, excavation or soil compaction is prohibited in this area. • A copy of the ap rp oved 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 ins ecp tors BENNIE W HELGESON Page 2 7/31/2013 Owner Responsibilities: • The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and maintenance manual and/or owner's manual for the POWTS described in this approval. • The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. SPS 383.54(1). • In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. • The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 250.00 This Amount Will Be Invoiced. Gerard M Swim When You Receive That Invoice, POWTS Plan Reviewer, Integrated Services Please Include a Copy With Your (608)789-7892, Mon - Fri, 7:15 am - 4:00 pm Payment Submittal. jerry.swim@wisconsin.gov WiSMART code: 7633 cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Industry Services (formerly + Safety & Buildings) will be modified. Code references with prefixes starting with "Comm" have been replaced with "SPS" to recognize the relocation of the Division of Industry Services from the former Department of Commerce to A Department of Safety & Professional Services. Additionally, all IS (formerly S&B) codes have been renumbered arty 4dQessed in a "300" series. For future reference, the Wisconsin Commercial Building Code will be addressed by SPS Chapters 360-366. BENNIE W HELGESON Page 2 7/31/2013 Owner Responsibilities: • The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and maintenance manual and/or owner's manual for the POWTS described in this approval. • The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. SPS 383.54(1). • In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. • The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 250.00 . This Amount Will Be Invoiced. Gerard M Swim When You Receive That Invoice, POWTS Plan Reviewer, Integrated Services Please Include a Copy With Your (608)789-7892, Mon - Fri, 7:15 am - 4:00 pm Payment Submittal. jeny.swim@wisconsin.gov WiSMART code' 7633 cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm PIV03 Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Industry Services (formerly q-A Safety & Buildings) will be modified. Code references with prefixes starting with "Comm" have been replaced with 14 "SPS" to recognize the relocation of the Division of Industry Services from the former Department of Commerce to OIZ 32 Department of Safety & Professional Services. Additionally, all IS (formerly S&B) codes have been renumbered i 0 VjCp 41essed in a "300" series. For future reference, the Wisconsin Commercial Building Code will be addressed by SPS Chapters 360-366. 3:ttL .~»ir RECEIVED JUL 1 5 2013 INDEX SHEET PROPERTY OWNER: PHILIP VELASKI 38 191ST STREET BALDWIN WI 54002 PROJECT NAME: PHILIP VELASKI PROJECT LOCATION: NW '/4 , SW '/4 , S 35, T 28 N, R 17W MUNICIPALITY: TOWN OF RUSH RIVER COUNTY: ST. CROIX DESIGN: PRESSURE DISTRIBUTION MANUAL VEgU" SBD-106706-(N.01 /01) NED MOUND COMPONENT MANUAL VERSIOlFE",QAft 10691-P (N.01/01) 1 SERVICEq CONTENTS: 3TRY SERVICU Page 1: Plot Plan Page 2: Cross Section and Plan View of M c Page 3: Distribution Pipe Layout Page 4: Septic Tank and Pump Chamber Cross Section and Specification Page 5: W1000/500 - MR Tank Specifications Page 6: Pump Specifications Page 7: POWTS Owner's Manual & Management Plan- Pg 1 Page 8: POWTS Owner's Manual & Management Plan- Pg 2 Page 9: Payment Voucher Name: Bennie Helgeson Signed `l Address: N7649 Hwy 128 Spring Valley, WI 54767 Credential Number: 9220292 Date: 07-11-2013 T r x a~x'a. YAW, O~ ~iA.s ~ Rr s~~ To~.ti:~s ~ ~ 1- Sc~~e 'q h, 10 VN 1, Ian" U ~o ly !m lC 5~ 5 F ~fr,- s~ ~AD3 tie Se fi~ T~k V A 2,M_ qg W- o,~S+om5, Ae fEyorS t d se'sL~ ~~'f l p (a ~ `t (,t?aL $e~Q cx~ o Ga~dg ~r r VCL~-~r~ 1 l~i to Y ~Q. ~L! C c7 1 Page Synthetic Covering AST M C 33 Distribution Pipe Medium Sand G.,, Topsoil 3 E 11 D b Cah{rj kRe~, jp0. °/d Slope- CELLOf 2~- 2'" Force Main Plowed Aggregate From Pump Layer D Ft. Cross Section Of A Mound E y.3 Ft. F Ft. G . S" Ft. A Id Ft. H Ft. Signed: B 3D Ft. License Number: K Ft. Date: L 176 Ft. j :5' Ft. T 10 Ft. W .2S.SFt. L_ _ Observation Pipe A I T - - - - --.-rw g -T_. _ J 40 u n' Distribution Cr GL- Of 2 - 2 2 Pipe Aggregate Observation Pipe (OO /Scc'r'{`L Plan View Of Mound aw ~ PtA ~ r, PC C3 V - Perforated Pipe Detail Cleanout Access 0 Threaded Cleanout End Vi 4 w )Pot 10101C G PVC Pip( \0 ` c• End Manifold Jot c~ f . K A; X. Holes Located on Bottom Are Equally Spaced Force Main From Pump X~ S First Hole Next to Manifold e Cleanouts Distribution Pipe Layout P R S x Y r( Hole Diameter 6 Inch Lateral " Inch (es) Signed: Manifold " r Inches License Number: Force Main " Inches Date: Invert Elevation Holes Per Lateral f 7 Number of Laterals Total HolesI y ~U~-n"'► 1 i ~r`I~ ~e.~ ea'sLr Page -4-ord- SEPTIC TANK E PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS 4 fikVENT PIPE 12" MIN. ABOVE GRADE E WEATHERPROOF ? 25' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE WITH CONDUIT MANHOLE COVER W1 PADLOCK E Grouq~~ WARNING LABEL Zy a 18" IN. S. D.~ INLET WATER TIGHT SEALS GAS. SEALT APPROVED FILTER , JOINTS WITH APPROVED 6 fO ALM ARPROVEQ PIPS PIPE 3' B ' ON 3' ONTO 101 ONTO SOLID T SOLID SOIL SOIL PUMP OFF ELEV . O.O,FT. --v"t OFF D 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE , ) to ( (-Tc..l s L_ rri ~ TANK MANUFACTURER : (5c* ~ ' , TANK SIZES: SEPTIC 000 GAL. DOSE VOLUME INCLUDING DOSE S'<Dd GAL. ---~FLOWBACK: GAL. ALARM MANUFACTURER: 5,TIE khO4 b 4.S CAPACITIES: A = INCHES = D6.6~f GAL. MODEL. NUMBER: 164 2 INCHES fQ6 GAL. SWITCH TYPE: A4kl , + Jac, ~f 8 PUMP MANUFACTURER -2- Oe- I/f!~ C = INCHES = 57,0~rGAL. MODEL NUMBER: SWITCH TYPE: Flo, - D = INCHES = /GAL. REQUIRED DISCHARGE RATE q7, GPM PUMP E ALARM WIRING AS PER ILHR 16.23- WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE l- FEET + MINIMUM NETWORK SUPPLY PRESSURE FEET +35 .,M FEET FORCEMAIN X FT/100 FT. FRICTION FACTOR FEET TOTAL DYNAMIC HEAD = C) FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH WIDTH DIAMETER LIQUID DEPTH X57 /~/Pa s' Sr e c . SLt ~r~` /4r 7-,qc-k SIGNED: LICENSE NUMBER: DATE: 1/88 aw-oo6/00o1M:311J 99tl8-9Z2-008 tOOZ 'Ndf 'n321 IOoz k8vnNvr :31VO 0909 IM 'N00d N301VM 'OIdMH sn 9ILCM lyflNbW OIld3S z\ p 1MS'.18 NMV80 31380!100 N 0 ~ 31VO 'ON A38 .~=..b/1 :31VOs B3531M W-OOS/000 LM ~A W N 4 ~ W Z LLJ U w z ~ vO W D w U O w O LLJ N 0' L W n J F > N J V) W o V^ Q U- U U I Z 0 W w2 ° o Z 0- Z o w mop ~ ~a x w a U V)i ° ° aa zz > w \ ° a c; O Q JU J J U O> N ° O U O O ° co W F- W Q Q z Z O W Z W DON O. m J O V) U_ ? > 3 V) p 0 X . D W O J N\ r,- W Q W N c.00 O W W a (j a:c Lf) V \ I L N M UWI FW- (n (3) 0 Q ° In 4z 00 LLJ CL O dF J I H Q = N W U W O W M: O) - W W I -i J Z I- y: N M O I U'I lij pMj Z W ~ F F- (n N ~ C~ Q J O \ a Y w LL) O /A V) tV~..~~5 -JF O:3 V) z ckf L) Q OOW Q N x3 m V) Qa O Y ZJF-LJ 05(_) OU OUP Q ° Z W tr ~U ° QO>z zQ -i z ' zN0 U U ZQ U N O OY Z N S~ m u m= J m J ~i a Q . Z Q U N LLJ Z co LLI Q W W W O O ~ Z X 0 0 Z Z la- O U a u v ~ z a W 0_ Q V) Y z Q r LLJ „bS 0 w I I a'a \ \ > Ii 3 II W II Li (N I ~~~~111;, I 5 n . ES I O ( \ I I W -J UJ 0- w ZON ~~W tJi I O J o J~Q N „L 9 = W V1 N 11 l \aao Eom S \o m a -KN W N J z i „L5 + „£6 469 it i EFFLUENT' KIW GORES. FOR=ZOELLER PUMPS ~ . BN = w/ Float In Box M Auto Float Attached (vertical) N = Non-Auto (manual) 'PUMPS E = 230V Non-Auto (manual)U ~Q! O "FLOW-MATE" 98 :Q&WrYL/MP9 SHWf 19,7 ZBN98 BN98 1/2 `HP 115/1 Automatic Cast Iron 1/2" Solids, 1-1/2" Disc.Tethered Float (15) 358.95 ZN98 N98 1/2 HP 115/1 Manual Cast Iron 1/2" Solids, 1-1/2" Disc. 319.45 FEATURES: - Th&'Flow-Mate" is constructed HEAD CAPACITY CURVE MODEL' 98" 1/2 NP BN98 of durable cast iron, carbon 30 ceramic seals and a non- 2s clogging vortex impeller. 15' Cord 20 APPLICATIONS: 15 The "Flow-Mate" is ideal for septic tanks, dosing, low 70 pressure pipes, large mounds 5 and step systems 0 0 10 20 30 40 50 60 70 80 "-DOSE-MATE"'F51, 1529 153 ZBN151 BN151 1/3 HP 115/1 Automatic Cast Iron 1/2" Solids, 1-1/2" Disc. Tethered Float (20) 322.08 ZN151 N151 1/3 HP 115/1 Manual Cast Iron 1/2" Solids, 1-1/2" Disc. 281.16 ZBN152 BN152 4/10 HP . 115/1 Automatic Cast Iron 3/4" Solids, 1-1/2" Disc. Tethered Float (20') 355.08 ZN152 N152 4/10 HP 115/1 Manual Cast Iron 3/4" Solids, 1-1/2" Disc. 314.16 ZBN153 BN153 1/2 HP 115/1 Automatic Cast Iron 314" Solids, 1-1/2" Disc. Tethered Float (20) 498.95 ZN153 N153 1/2 HP 115/1 Manual Cast iron 3/4" Solids, 1-1/2" Disc. 462.00 ZE153 E153 1/2 HP 230/1 Manual Cast Iron 3/4" Solids, 1-1/2" Disc. 462.00 Y FEATURES: PUMP PERFORMANCE CURVE The "Dose-Mate" is constructed of r MODEL 1511152/153 BN152 durable cast iron, ;carbon ceramic 14. 163 seals and a non-clogging vortex 11 40 impeller. 20' Cord ,o u s: 30 s a s, APPLICATIONS: ~ The "Dose-Mate" is ideal for septic , tanks, dosing, low pressure pipes, mounds and step systems 1 „ 10 1) X 4 SO p ,0 4 p 100 a~uara a a Im , : G:+ TX uhns FLOW PER NRWM 3-2 Revised 2-15-07 • PAS OWNER'S.Iy►ANUAL & a(LwErtieNr FOFP tMAT•. ON MANAGEMENT PLAN Page 7 Of a ~.t {D S.YS'r,SM~ IFl Permit # f A f .CANONS. Tank Manufat tWen I~~r 41 SIGN RA Sept{c D -PC NA ER5 Qosa,.:0 Holding VOlurne: Ntimberof.BedFOOms 'rink-Mant ! her /dG0 (gal) Number of pub,,. 0 NA.{~ NA Feolilty Units: o'Septio' poee.. C7 Ho(ding Volume:- (gal) Estimated (aversga Flow: NA Vertical Distance Tank Bottom(s) to Serv►ceSe~ ) Design (peak Flow = (estimated .76 d (9allday). Horizontal Distance Tank(s) to.Seto (n) x 1.5): ce•pad: In Situ Soil A 36 C (9aVday) If horiz tserVicing megbenica must tae prcvtdtld ib' (h) ppllcation Rate: 150 feet. Specific inatructiona to I ticel is -Is: feet or Standard (Domestic) InfluenVEffluent (gaVday/f(~) Efi)uent Filter Mandfargr ( providerlon back. thiy average a - . Fats, 0118 Grease (FOG) j . fs3o e Biobhemicel O en Demand' (BOD6) 9220 wnt FlItBhModel; . u i ` ] •NA 5 ipcol {tap&aitds . ❑ NA Pump Manufacturer: High Strength Influerit/Effiuent st5q t ►I~,Meesty p [ l ~e. v Monthly average NA (FOG) >somg/e' . Pretceatntent:Unit (RODS) >220 mg7L ®NA Manufacture S r. Pretreated Effluent: s >150 m /L • ❑ Mechanical Aeration. ~ Monthly average 0 Disinfection C1 Peat•Filto NA (Bops) s30 mg/L ❑ Sand/Gravel Filter Ej Welland 11 Other. Fecal Coliform (TSS s30 mgfL Soil Absorption y eomatric mean) s10' ' IN NA $ stem . Maximum Effluent Particle Size ❑ In-Ground (gravity) Offter; )6 in dia 0, ❑ At-Grade O ",round (preasur¢). D. Drip-Line Mound G7 NA . . ~ Other. ' 0 NA Other: MAIN'FEN~I►NtC9 SCMEDULE Service Event 0 NA Pump out contents of tank(s) in Wh Service Frequent y an. combined sludge and scum equals one-third Inspect O When the high water alarm is activated of tank volume condition of tank(p) At least once every: ii" months . Inspect dispersal`ce11(s) years ) At least Once every; dmaximum iwairs) C1 NA Clean effluent filter month(s) At least once every; year(s). (Maximwm 9.y®r ) L'1 NA i 3 month(s) Inspect:pump, puntp controls & alarrrt year(s) At least-Odce*v0 NA ear nth(a)! Flushlaterals atd.pressure test,. Dry.. M. Otirah = At least once every- y (s) m0 NA onth(s) aria Other: At least once every: orith s 13 N~..k C).yee 8) MAINTENANCE INST'RUMONS . Inspections of tanks and soil ebso D NA Master Plumber, Master Plumber Restric td SewshaMad Tank Inspections Yvan Individual ca pectrber must include a -visual inspection a pOW the tank(s)nsto Identify an nYing one . of or the following icing OOs r mper measure the volume of p'Maintainer or and jcurn ; and ' hardware, lde6f e' ~~flc any missing any missing or broken ide ti a check absorption system shall be Visually in pected to check the effluent(evels in p fpumpQr) the ground surface. Y back up or pondin of KI any cracks -or leaks on . notiffcatcon of the local r ulat the o I The ponding of effluent on the,;py6Und surface may . bser aii a Pipes effluent and to ort the ground surface, The soil bservation pipes end to check for eg aY authority. ponding of elfiuent When the combined accumulation of-sludge and.scum in any treatment contents of the tank d°n and respires the immediate tank shall be removed b y a Septage Servrt In Adntrnisfrative Code equals one=third (J) or more WIs6Ohsin of the tank the 0 Operator .(PUMP er) and dispo volume sed of In ac ehtirs All. other services, including=abut not: llfiltgd`;tiaiie seN{cifi of: fianc e.. wt h, any servicing at intervals of 512 months, shall be erformapterNR 1 l3, g effluent t fie ntecha 8 M ©r~eesurized ctamponaais . A service report shall be Provided-to: the local regulatop by a certi fied PO WTS a►ntatner. ~ treatment units,. ry authority within 30 days of completion of any<setv)ce.event. ' GMW-065 (02705) Page O of . . A START UP AND OPERATION For new construction, prior to.use. of the POWTS check treatment tank(s) for the presence of painting produc;t$, s&6111i=:or other chemicals or sediment that may impede the treatment process '.and/or damage- the soil absorption system. if high concentrations, are detected have the contents-of the tank(s) removed by a Septage Servicing Operator (pumper) prlor to use. Pump tanks may.fill above normal highwater levels prior to startup or due to. pump. failures „Startup or restoration of..power underthese conditions is not recommended, as the excess wastewater-will b6discharged to the abli absorption system in qne large; dose ca~in9 an overload that may result in the backup or surface discharge of effluent..and-damarge16 the system.- To aV0&:thl~°4w~olo i, P umber contents of the pump tank removed by a Septege Servicing Operator (pumper) -prior to restoring power-top p umptank. pump • ' _ or POWTS Malntainer..to.assist in manually operating the pump controls until normal effluent levels are restored within the System start up shall not occur when soil .conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soll'absorption system. Do not drive or park. over, or btherWI6 disturb or compact, the area within 45 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewaterebtam may improve the performance and prolong the life of the treatment tanks and soil absorption system: adds, antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drain (sump, pump). discharge, .fruit and vegetable peelings, gasollne, graases, herbidides, meat scraps, medications, oils, painting producX pestlddes, asnitary napkins, solvents, tampons, *and water; softener..brine.discharge: -ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following a" shall be taken to1nsure 'that *system its properly and safely abandoned in compliance withos. Comm.83.33, Wisconsin Adrhi iistrative,COdt~'' e All piping to tanks, pits and other soil absorption systems shall, be disconnected and, the abandoned pipe openings sealed. e The contents of all tanks and pits shall be 'removed and properly disposed of by a Septage Servicing Operator. (pumper). . e After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soli, gravel or another Inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures .have been, or must be taken,, to provide `a code tompliant replacement systems E3 A suitable replacement area has,been evaluated and may be`utilized for th elooatibn of a replacement soil absorption system: The replacement area should be protected from disturbance- and compaction and should not bs lrifringed :upon by -required setbacks from existing and proposed structure,.lot lines and wells. Failure to protect the replacement:areA will resuft in the need for a new soil and'sita evaluation .to eatabllsh a suitable- replacement area. -Replacement systems must comply' with the rules in effect at the time of their permit issuance. .p A suitable replacement area is not available due -to setback and/or soil' limitations. If the soil absorption system cannot be rehabilitated and barring.advances in POWTS technology, a holding tank. may: beInstalled as a last. resorts ❑ The site has not been evaluated to Identify a suitable replacement area. Upon failure of the POWTS a soli and site evaluotion must be performed to locate a suitable replacement area. If no eeplacement area is available a holding. tank maybe installed as a last resort to replace the failed POWTS. Mound and at-grade soil absorption systems may be reconstructed in. place following removal of -the `biomat at•the infi(tradve surface: Reconstructions of such systems must comply with the rules -in effect at that time. WARNING TREATMENT TANKS, PUMP TANKS; AND HOLDING TANKS' MAY `CONTAIN POISONOUS 0 . SES- OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. ;NEVER ENTER ANY TANK. UNDER ANY., CIRCL*iSTANCE. DEAT,Ii MAY 099ULT: ESCAPr"Oh FESCUE RROM 1 HEiNTERiOR OF A-TANK MAY NOT BE POSSIBLE. - ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS-MAINTAFNER.; Name _b n; 1 Name T6114 o K t 40 Phone Phone SEPTAGE SERVICING OPERATOR PUMPER L CAL.REGULATORY AUTHORITY , Name JoG~►, 5 Nome Gi+► ; °~-ti.t- to 1J vvI It Q Phone C 'Phone '715 i~rb This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agendas In compliance with sections Comm 83:22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Page g Of START UP AND OPERATION For new construe ion, prior to:use.of the,'ROWTS..check treatment tank(s) for the .presence of painting produds;:s614,6 11rm other chemicals or sediment that may, impede tho treatment process'.and/or damage'the soil .absorption system.. if high cpncentratio>as:are detected have the contents- of-the tank(s) removed by a Septage Servicing Operator (pumper) prior to use. Pump tanks may.fill-above .normal highwaberlevels priorto startup or due. to. pump..fatluros :,Start up.or restoration.of power-under these conditions'ts trot recommended, as the excess wastewater~wlll b6discharged to the soil absorption system in Qne large; dose3cpusing. an overload that may result in the backup or surface discharge of of luent..and.darnage to the system.-...To avotii~ti~IS:sititatiorr'F~a exhe contents of the pump tank removed by a Septage Servicing Operator (pumper')prior to restoring power•tm4he pump oroontac a Plumber or POWTS Maintainerto.assist in manually operating the pump controls untilnormal effluentlevels are restored within the pump tank. System start up shall not occur when soil :conditions are frozen st.the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption systern. 'Do not drive or park otter, or otherwise dlsturb or :c ompact, the area within.15 feet.down.slope of any.mound or at-grade soil absorption.area. Reduction or elimination of the following from the wastewateratream may improve the performance and,prc1ghg the.life of the treatment tanks and soil absorption system:' acids, antibiotics; baby wipes,' cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation dron (sump..pump), discharge, .fruit and vegetable peelings, gasoline, greases; -herbidides, rneat scraps, rriedicetions, oils., painting products, pesticides, oenitary napkins, solvents, tampons,'and:uratsr.softener.brtnadisd~arge: -AIPANWNMENT When the POWTS fails and/or Is permanently taken out of service the following steps shall be taws tcrtnsure thatthe.ffiystegr ls:.propetly and safely abandoned in compliance with:s. Cornm.83.33, Wisconsin Admiritstrative:Codt#i'' All piping to tanks, pits and other soil absorption systems shall, be disconnected and :tare abandoned pipe openings sealed. a The contents of all tanks and pits shalibe removed and properly disposed of by a Septage Servicing Operator(punVer-).: • After pumping, all tanks and :pits shall be excavated and removed or thetr•covers removed and the void space filled with :soil, gravel or another Inert solid material. CON71NGENCYPLAN Y If the POWTS falls and cannot be repaired the following measures have been, -or must be taken,. to provide a .code pliant • .replacement system A suitable replacement area. has , been . evaluated and may be. utilized for the. 'location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not. be tl9filn@ed`gpnn: by •required setbacks from existing and proposed structure, -lot lines and wells. Failure to protect the replacement-area aAIVresult in the need for a. new soil and'slte evaluation :to establish a suitable- replacement area. Replacement systems must comply wlth'the rules in -effect atthe time of their permit Issuance, .0 A suitable replacement area Is not avallabte due to setback andlor :soil' limitations. If the soil absorption' system cannot be rehabilitated and barring.advances in POWTS technology, a holding tank, maybe;instalied as a lastresort ❑ The. site has not been. evaluated to Identify a suitable replacement area. Upon failure of the POWTS a aoll .and slts evaluption must be perforated toaoc ate a suitable replacement area. If no,^eplacement area is available a holding. tank maybe installed. as a last resortto., replace the failed POWTS. Mound and at-grade soil absorption systems may be reconstructed in place following removal of -the blomat stAhe infiltrative surface. Reconstructions of such systems must comply with the rules -in effect at that time. . WARNING TREATMENT .TANKS, PUMP TANKS- AND HOLDING TANKS IMW'-CONTAIN POISONOI?3`.GASS>_s O.R:.LACK SUFFICIENT OXYGEN TO SUSTAIN LIPE.::NEAR ENTER ANY TANK:UNDER ANY.. CIRCLVWSTANCE. DEATHj4AY 1€ESt1LT: F_9dAFiE_6A**AESC1JE RROM THe-WEreaR QF A-.TMK'-MAY NOT BE-POSSIBLE.- -ADDITIONAL INSTRUCTIONS: P0!1RVJ S,INSTALLER POWTS :MAINTAINER Name Name Toth O A+10 Phone -71 -777 -7,. IPhone 7 I .Z ~j -cd L: SEPTAGE SERVICING OPERATOR PUMPER L CAL.REGULATORY AUTHORITY ;game .,_SoVih 5 CJ,Ah Name. , ri~n Phone 115 - a -7 1 1, - ' Phone '715 This document was drafted by the staffs of the Green Lake, Marquette and Waushera County POWTS regulatory agencies in compliance with sections Comm 83:22(2)(b)(1Hd)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. STATE OF WISCONSIN Department of Safety and Professional Services sPS Fiscal Plans PO Box 8602 'o`ff Madison WI ? kf 83708-8802 '•-'•Y Governor Scott Walker Secretary Dave Ross Payment Voucher If you are requesting to be invoiced for your plan review, DO NOT use this voucher form. Transaction ID: (Leave blank if this review has not been pre-scheduled) Check # Dollar Amount: o0 Payer Name[ ~l (Individual or Companpame as printed on first line of check) Payer Address ` A -74,49 l.( w A !ES (As printed on check) Payer City 50~^► VA. U a L l.e State Zip Code S cE 7 Phone -7 1 5 - 777 R- a `7 9 Plan Submitter Names h c se-,,, (if different from:Payer) - 1. Mail your check (payable to Industry Services Division) and this completed form to: DSPS Fiscal-Plans PO Box 8602 Madison WI -53708-8602 2. Send a copy of this completed payment voucher form along with your plan submittal documents to the office that you select belgw. Plans submitted to:lcircle or check one of the offices) Madison ❑ Hayward ❑ LaCrosse/Holmen g] Green Bay ❑ Waukesha ❑ Madison Hayward LaCrosse/Holmen Green Bay Waukesha 1400 E Washington Ave 10541 N Ranch Rd 3824 N Creekside La 2331 San Luis PI 141 NW Barstow St 53703 Hayward Wl Holman WI 54636 Green Bity, WI 4°i Floor PO Box 7162 54843 54304 Waukesha WI Madison W1 53707-7162 53188-3789 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer ; Mailing Address Property Address (Verification required from Planning & Zoning Department for new construction.) City/State 1 c u LL Parcel Identification Number 0.;Zg>C~ V A0 - oe 0 LEGAL DESCRIPTION ' Property Location Il! U1 V4, ~ r/ ,Sec. , T ,,4_N RAW, Town of io e Y Subdivision T~ Z ~IQ Z:K~ Lot # Certified Survey Map # Volume , Page # Warranty Deed # ~n 2 01 U ---7 , Volume Page # g Spec house D yes,1 no Lot lines identifiable ❑ yes ❑ no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(l) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed. by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, ws set by the 1",coartment o commerce and tae Department ot'Natural Resources, State of Wisconsin.- Cettification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of 'the three year expiration date. i I/we certify that all statements on this fo 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 warran deed recorded in Register of Deeds Office. Number of bedrooms / / SIGNATURE OF APPLICANT(S) DATE ***Any information, that is.misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) - t-,1,M i s> ~r $ PI a i it t r, IM n ,"r rv'- , ii'-11 r DOCUMENT NO. X fy WARRANTY DEED 01- THIS SPACE RESERVED FOR RECORDING DATA - REGISTERS OFFICE THIS DEED, made between John J. Miller - , ST. CROIX CO. WIS. - Rec'd. for Record this 7th_ - - day of~ept• A. D. 19 77 Grantor anaPhilip P. Velaski and Diane L. Velaski at R, husband and wife, as joint tenants r I Grantee, W i to e s s e t h , That the said Grantor for a valuable consideration Twenty Keo Deeds Thousand and No/100 Dollars conveys to Grantee the following described real estate in_-_St C r o ix County, RETURN TO State of Wisconsin: Lots One (11) and Two (2), Block "B Tax Fey It in the Village of New Centerville. This is homestead property. TRANSFER s_.~? O, UD FEE Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; And John J. Miller - - warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except - easements and rights of way of record, if any. - _ and will warrant and defend the same. Executed at River Falls, Wisconsin this-~ day of September 19 77. SIGNED AND SEALED IN PRESENCE OF ~~"r`L'%~~' `~'~I`• 6ki " t (SEAL) John J.,' Miller (SEAL) ` (SEAL) - (SEAL) Signatures of - - authenticated this day of 19 . Title: Member State Bar of Wisconsin or Other Party Authorized under Sec. 706.06 viz. i STATE OF WISCONSIN --Pierc-e } sS. -------County. Personally came before me, this ~N y Se teTRber 19 77 the above named John J Miller to me known to be the person-, _ _ who executed the foregoing instrument and ackn wledged t same. This instrument was drafted by h ~ Al Ne !h C. L. Gaylord, Attorney Pierce li liilillliilllllillllllliiili 7 ? n 7 N.cJ[.•//` P Tx;4141a14 Document Number Document Title 983068 BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 07/26/2013 10:03 AM EXEMPT REC FEE: 30.00 PAGES: 6 Recording Area Name and Return Add ess 3g 1°fl 64-- Parcel cvrnllJ~ 5~vo~ tea g -/0~l1-95- ~o dab- ra~FB-rv-ova Identification Number (PIN) THIS PAGE IS PART OF THIS LEGAL DOCUMENT - DO NOT REMOVE. This information must be completed by submitter: document title, name & return address and PIN (if required). Other information such as the granting clause, legal description, etc., may be placed on this first page of the document or may be placed on additional pages of the document. WRDA Rev. 12/22/2010 Doc. No. SEWER EASEMENT WHEREAS, Kerry C. LaFavor and Keri LaFavor, hereinafter known as Grantors, are the fee owners of the real property described in Exhibit "A". WHEREAS, Philip P. Velaski and Diane L. Velaski, hereinafter known as Grantees, are fee owners of the Parcel No: real property described as set forth in Exhibit "B". 028-1041-95-100 WHEREAS, the above parties wish to enter into an easement agreement for the purpose of giving Grantees the right to construct, install and maintain a sewer system and all necessary laterals as needed on the Grantors' real property. THEREFORE, Grantors, of 1910 4th Ave., Baldwin, Rush River Township, St. Croix County, Wisconsin, in consideration of good and valuable consideration, the receipt of which is hereby acknowledged, have granted and conveyed and by these present do grant and convey to Philip P. Velaski and Diane L. Velaski, 38 191St St., Baldwin, Rush River Township, St. Croix County, Wisconsin the right to construct, install and maintain a sewer/mound system and all necessary laterals on the property described as follows: a parcel of land located in Section Thirty Five (35), Township Twenty Eight (28) North, Range Seventeen (17) West, Town of Rush River, St. Croix County, Wisconsin and more specifically described as follows: Point of beginning being the Northerly point of the East line of Lot Two (2) Block B, in the Village of Centerville; thence North Thirty (30) feet; thence West to a line which represents the Northerly extension of the West line of Lot 2, Block B, in the Village of Centerville; thence South Thirty (30) feet; thence East to the point of beginning, together with the free right to enter and depart over and across the property insofar as necessary to the proper use of any other right granted in this document upon the conditions that the Grantees keep area mowed and free of noxious weeds. Dated• ~oz 2013 Kerry LaFavor, Grantor K ri LaFavor, Grantor STATE OF WISCONSIN ) )ss. COUNTY OF ST. CROIX ) Personally came before me on ~VLI za 2013,,~~tk~~ NlS above-named Kerry C. La Favor and Keri La avor to me known to •e`. ~•,'•~J persons who executed the foregoing instrument and acknowledgecvt,b.. t2 c~ same. ~j • • Diane L. Velaski bf~ 5Z Notary Public, State of Wisconsin My Commission expires: 09/15/2013 Dated: 2013 Philip P. Velaski, Grantee STATE OF WISCONSIN ) )ss. COUNTY OF ST. CROIX ) Personally came before me on Vr V~t aZ~ 2013, the above-named Philip P. Velaski to me kno n to be the person who executed the foregoing instrument and acknowledged the same. Diane L. Velaski 4 Notary Public, State of Wisconsin My Commission expires: 09/15/2013 fem. F< 2 ~ is ; , 'f Dated: 2013 C)Q, zzx_.~ Diane L. Velaski, Grantee STATE OF WISCONSIN ) )ss. COUNTY OF PIERCE ) Personally came before me on 2 2 2013, the above-named Diane L. Velaski, to me known to be the n who executed the fo egoing instrument and acknowledged t e s soame. Donald J. Sc wab Notary Public, State of Wisconsin My Commission is permanent ~ka 40 SOMAS THIS INSTRUMENT DRAFTED BY: I Donald J. Schwab Schwab Law Office, LLC i 2295'x' L1161 PART OF SW 1/40F NW 1/4 AND PART OF NW 1/40F SW 1/4 OF SECTION 35, TOWNSHIP 28 NORTH, RANGE 17 WEST, ST. CROIX COUNTY, WISCONSIN DESCRIBED AS FOLLOWS: COMMENCING AT THE NORTH 1/4 CORNER OF SECTION 35, THENCE S46°10'53"W 1886.94 FEET; THENCE S00000'00"W TO A POINT 1000.00 FEET NORTH OF THE SOUTH LINE OF THE NORTH 9 CHAINS AND 60 LINKS OF THE NORTH % OF THE SW 1/4 OF SAID SECTION 35, BEING THE POINT OF BEGINNING OF THE PARCEL TO BE HEREIN DESCRIBED; THENCE S00°00'00"W 1000.00 FEET; THENCE WESTERLY 937.00 FEET ON THE SOUTH LINE OF THE NORTH 9 CHAINS AND 60 LINKS OF THE NORTH ih OF THE SW 1/40F SECTION 35; THENCE N00°00'00"E 1000.00 FEET; THENCE EASTERLY PARALLEL TO THE SOUTH LINE OF THE NORTH 9 CHAINS AND 60 LINKS OF THE SW 1/4 OF SAID SECTION 35, A DISTANCE OF 937.00 FEET TO THE POINT OF BEGINNING. r+ F ti~ JUN ~~~0 Wisconsin Department of Commerce SOIL EVALLIAT~QN Page-of 3 Division of Safety and Buildings CR in accordance with Comm 85, Wis. Adm. CQ.4.00 un - / Attach complea r not less than 8 1/2 x 11 inc hes in size. Plan must ' includebut d horizontal reference point (BM), direction and Parcel I.D. o percet l s, north arrow, and location and distance to nearest road. ®.3 81 D IMP print all information. Re ewed by ! Date Y Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). I ' i,1,4,-- I ~ -3 Property Owner Property Location f Ue- f ask Govt. Lot NW 1/4,501/4 S35 T.) 9 N R I? E (o w Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# fqjs S~r«fi L 2-N4B 1*38 City State Zip Code Phone Number ❑ City 29illaYe . Town Nearest Road f WT- S N00-1 (IS748 71 &t5k (o,--t- /9/ s Sfit ❑ New Construction Use: WResidential / Number of bedrooms Code derived design flow rate .30O GPD Replacement ❑ Public or commercial - Describe: Parent material L.OeSS Oyet- T, (1 Flood Plain elevation if applicable A IA General comments and recommendations: (~S / SQL ct' Gt ~tr L~/D/0 e e d f e O C Nl O 6h O~ S s Eta 1 e~ . /0 73 / Boring # Boring I!Q Pit Ground surface elev. l , a ft. Depth to limiting factor Xb in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fe in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 0-7 © 3 L ~s6 CLJ aM ~o 6 g / .2 !o SQL cw '7--Ml 11 C- 8 -3 0 - S L vn ' t uJ t o 6 75-cL of , 3 ®Boring # El Boring 0 / a pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fl? *Eff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 a- v►~ b i.4r Uj u 0 3a W -1k yj~ f 7 s L V 71 02 N3 V c -7, s C L J -5 1 2 -3 * Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L CST Name (Please Print Signature ? CST Number Address f I (Date valu Conducted Telephone Number Y s r 1.17 U& 11 A 7~S--77~ 3a'78, f y, Property Owner 1 I V e (QS k j Parcel ID # Page' of Boring # ❑ Boring p Q p Ground surface elev. ft. Depth to limiting factor- in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDO in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ire) I k% ('n I owe y, , , C U 1 to 7-41 o 2 f-F 5-A ScL u) a /-R, :Zs-iR y' m3 t) -7 YR L l V-(- ❑ Boring # E] Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil A plication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cord. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Boring # ❑ Boring F-1 ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 I * Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.07/00) Property Owner Parcel ID # Page _ of Boring # ❑ Boring - Q p Ground surface elev. ft. Depth to limiting factor ' ° ,SoiiApplication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cord. Color Gr. Sz. Sh. *Eff#1 *Eff#2 -1 O Cc L 1- M .5 c? 47 a t Lj 1 7-14 l =IR - f 7 5VY 5CL cj 15 - -7, VIZ ew 56L J-C k 1 v-. ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz- Sh. *Eff#1 *Eff#2 Boring # Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil :Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fg in. Munsell Qu. Sz. Cord. Color Gr. Sz. Sh. *Eff#1 *Eff#2 II * Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.07/00) . ~ . ~~of plate hh 2l esov~ ~~o~ N ofs~ SeL,3~TA81J vi ui 14 51 Is~ l _ FIto, Elco, Etc ~ foss y ~ X00.9 fro fora NeLo . 48,9 A)prfi& kot y-14 ff 1- off" I-~^•e _ uses ~ r ~ 0 p63 s CAP ~~o(to.n o S cru~~Sh<c~ 5hcA / o 8.~. ~Do.~o ~ M IQI ~f IWL BCA Rom d Parcel 028-1048-10-000 07/01/2013 E 1 OF A 1 PAGE Alt. Parcel 35.28.17.301 028 - TOWN OF RUSH RIVER Current ❑X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - VELASKI, PHILIP P & DIANE PHILIP P & DIANE VELASKI 38 191ST ST BALDWIN WI 54002 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description SC 0231 SCH D BALDWIN-WDVILLE SP 1700 WITC Legal Description: Acres: 0.000 Plat: 01-047-NEW CENTERVILLE 024-1856 SEC 35 T28N R17W LOT 1 BLK B & INC N 1/2 Block/Condo Bldg: B LOT 1 VACATED ALLEY S OF LOT 1 BLK B VIL CENTERVILLE ASSM'T INC 028-1048-20 (302) Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 35-28N-17W Notes: Parcel History: Date Doc # Vol/Page Type 08/05/2002 686003 1941/070 RD VA 07/23/1997 560/353 2013 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 08/30/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.476 12,700 126,100 138,800 NO Totals for 2013: General Property 0.476 12,700 126,100 138,800 Woodland 0.000 0 0 Totals for 2012: General Property 0.476 12,700 126,100 138,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 567 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00