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016-1016-80-000
Document St. Croix County Title Affidavit of Reconnection to Existing POWYS Name - (Owner) Typed or printed being duly sworn ,states, under oath, that: 1. He/she is the owner/part owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume 21 S Page '35<8 Document N~unberr7111$1 St. Cra:x C~,urt~ i cgster of Deeds Office: p~ A parcel of land located in theS~ %< of the W'/< of Section 0 T~~ N - R (S W, Town of e h fvoa~ , St. Croix County, Wisconsin, being duly described as follows (include lot no. and subdivision/CSM or detailed legal description): ~D~r~.s Na a and Return Address ~h1AI y.} wl4'lellll3`~2~ 167 5 2 c~`f'`'' <ST. Wt~D Cf?y, Vtl`t o-~ 3 Did-~o/lo-~o-=c~c~ Parcel As owner of th ove described property, 1 acknowledge that the existing Private On-site Wastewater Treatment System (POWYS} serving this residence (fs s not undersized by current code standards for a,~ bedroom 1-2 family dwelling. The system components have been inspected and certified by a icensed master plumber to be in good condition and appear to be functioning properly. There was no indication of failure i.e. ponding or surfacing of wastewater in the distribution portion of the system at the time of inspection. I understand that the issuance of a county sanitary permit to allow the reconnection of the septic system fines not iT.~ly +~at the system meets curent wi.ie sizing requirements, nor does it imply that the system will continue to function after it is placed back in service. I also acknowledge that I will disclose this information to any future parties interested in purchasing this property. Dated this day of ~~ °-~g7~f t~ LL~CY r~ E.~r- A~JTHE"JTlCA'3'ION Signature(s) authenitcated this day of , (PIN) TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY (Signatures may be authenticated or acknowledged. Both are not necessary. ) ACKNOWLEDGMENT ~~ STATE OF WISCONSIN ) )ss. St. Croix County. ) 2 ~P~sonally came before me this 2 5th day of Feb . uZ5 the above named bona J. Warner tome known to be the person(s) who executed the foregoing instrument and acknowledge the same. Kathleen. `~tan~~j Notary Public, State.~Wi§consin '. "°' `- My Commissionis erm %` If not,~state expiration date: Date: Feb-. 1 ~, ~21 ,~ t.:; "THIS PAGE iS PART OF THIS LEGAL DOCUMENT- DO NYO~''REMOVE" '•~.`~ Lh ~ ~ ...... • • ~~~,. This infom-afion must be completed by submiftec document title. name & return address. and PhV- f~i`,rel~tirrecF~ ~ Other information such as the granting clauses, leagal description, etc. maybe placed on this first page of the document or may be placed tih' additional pages of the document. Note: Use of this cover page adds one page to your document and 52.00 to the recording fee. 1MsconsJn Statutes, 59.517. ~~ ~~~~~ ~~y:~~ ~ ar,~ s~ z~~~~ January 31, 2008 Ms. Donna Warner 1675 280m Street Glenwood City, Wl 54013 RE: Reconnection of new house to existing POWYS Code Administration Town of Glenwood Parcel # 016-1016-80-000 (8.30.15.131 } 715-386-4680 Dear Ms. Warner: Land Information ~ Planning 715-386-4674 On December 3, 2007 an application was submitted to the Zoning Office for reconnection of your existing mound to a new structure. When remodeling or making Real Property other changes to a dwelling you are required to examine whether or not the planned 715-386-4677 modifications involve an increase in design wastewater flows to the existing Private On-site Wastewater Treatment System (POWYS). Recycling 715-386-4675 According to your stated description, the project involves removing a mobile home and building a new three bedroom house. The original septic system was designed and installed based on wastewater flow for three (3) bedrooms (450 gallons/day) with a maximum occupancy of six (6) persons. This project will not result in an increase of the design wastewater flow. Your plumber, Rand Bates, was requested to provide house plans and certification for use of the existing septic tank and pump chamber. Owners are also required to record an affidavit of reconnection on their deed to disclose the actual age and size of the POWYS. Enclosed is an affidavit form to be completed in the presence of a notary public and then submitted to the Register of Deeds office here at the Government Center (see above address). Your plumber never picked up the county sanitary permit issued for the reconnection and, even though the work has been done, I've enclosed your copies of the signed permit paperwork. The original system was installed in 1983 by Gate Smith and was inspected by zoning staff at installation and was found to be code compliant at that time. Inspection report, as-built, and sanitary permit documents are on file in the zoning department archives. To prolong the life of the POWYS, remember to have the septic tank pumped at least once every three years or when the tank becomes 1/3 full of sludge and scum. Other efforts to extend the lifespan of the system include water conservation measures such as repair or replace leaking plumbing fixtures, reducing shower time, running the dish washer only when it's full, avoid using a garbage disposal, using a wash machine with a suds saver feature, etc. The projected lifespan of your POWYS is dependent upon proper maintenance of the system. ST. CRO/X COUNTY GOVERNMENT CENTER 1 1 O 1 CARMICHAEL ROAD, HUDSON, Wl 54016 71 X3$6-46$6 FAX If this POWTS should fail at any time in the future, the system will be need to be inspected by a licensed plumber or POWTS maintainer to determine if it must be replaced according to state code requirements in effect at that time. The proposed reconnection and house construction project must comply with ail applicable building codes. Please contact the Building Inspector for the town of Glenwood to obtain a building permit. Should you have any questions, please contact this office. Sinc ly, Pamela Quinn Zoning Specialist Cc: Joe Draxler, Town of Glenwood Chair Ron Hastings, Building Inspector, Town of Glenwood Rand Bates, MP#230766 Sanitary permit file ST. CROIX COUNTY GOVERNMENT CENTER 1 101 CARMICHAEL ROAD, HUDSON, Wi 54016 71 X386-4686 FAX „gyn.-., .-~,,,,-r.-.,.,,., ~.., „~ ~.~„"„-r. ~~~~~T,-~,-.~.. ~.,~ ~ ~~ I~ n s rn @ O. 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S. 15.04(1)(m)] 1101 Carmichael Road CROIX COU ~ TY Hudson, WI 54016-7710 ~ ZONING OFFI E (715)386-4680 Fax (715)386-4686 Attach complete plans for the system on paper not less than 8-1/2 x 11 inches in size. County Sanitary Permit # ^ Check if revision to previous application ~J 7Z- Z I. Application Information -Please Print all Information Location: Property Owner Name ~ c~ S L'J 1/4 /1'~tJ1/4, Sec a F~C2-!1 k Ct r~ ~~'+ r ~.t~ 0. v r'L t Y' T 3 J N, R j~ E (or) Property Owner's Mailing Address Lot Number Block Number jt~~ ~ a~o`~" s+. ity, State Zip Code Phone Numer Subdivision ame or CSM Number Crl~.n~~t4 C<; WL ~Ya r 3 ~iS-~~5 - ~~7~3 ~~ Q~c/t~ II Type of Building: (check one) .v¢-, ~'S ~~ $ amity ^ Village Town of GY 1 or 2 Family Dwelling - No. of Bedrooms: 3 U ~ ^ Public/Commercial (describe use): ~y-f Q/1 Wt'1~ ^ State-owned Nearest Road II. Type of Permit: (Check only one box on line A. Check box on line B if applicable) a ~~ S~• Parcel Tax Number s) ;( ',,,,,1 A) 1.^ Repair 2. (~ Reconnection 3.^Non-plumbing 4. ^ Rejuvenation ~/~ - ~~ ~ "~ri -'C.~.~ Sanitation , ~ ~ f~ - - B) ~•~,~ ~j yyu~-°~ Permit Number ~ ~ ~ ~ Date Issued ~ Q ~~ ' ~ State Sanitary Permit was previously issued t IV. Type of POWT System: (Check all that apply) ~ ~ ~f ~ ,~ , -,,, „j ^ Non-pressurized In-ground ^ Mound ? 24 in. suitable soil ?"E~~L1 Mound A+0 ^ Sand Filter ^ Constructed Wetland ^ Peat Filter ^ Drip Line ^ Pressurized In-ground ^ Holding Tank ^ Single Pass ^ Other ^ At-grade ^ Aerobic Treatment Unit ^ Recirculating V. Dis rsal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade ~S~ Required Proposed (Gals./day/sq.ft.) (Min./inch) Elevation VI. Tank Information Capaicty in Gall Total # of Manufacturer Prefab Site Con- Steel Fiber- P{astic New xisting Gallons Tanks Concrete strutted glass Tanks Tanks ~ r~ ^ ^ ^ ^ ^ VII. Responsibility Statement 1, the undersigned, assume responsibility for repair/reconnenction/rejuvenationlinstalfation of non-plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installztion of non-plumbing sa ' n system. Plumber's Name (print) Plumber's Signature (no stamps): ~ MPlMPRS No. Business Phone Number ~.~ a 3~•~~ ~ 7~ 3~ - s~ Plumber's Address (Street, Gity, fate, Zip Code) Vitt. County Use Onty ~, Disapproved '" Sanitary Permit Fee Date Issued Issuing Ag t Signatu ( stamps) !~r Approved Owner Given Initial Adverse ~j ZZS ~ J~ /r „ Determination /~ 1 !/ G _w -' w/'vJ~. IX. Conditions of Approval/Reasons for Disapproval: ~~a SYSTEM OWNER: ~~., ~t~i1 lif/L '2G7it/,LC. G'e'l.. l7~ ~~ 1 Septic tank, effluent filter and %~ ,,t_ ~.~( dispersal cell must all be serviced I maintained YC~f' ~~ecr~ ..S~G'~-a-~ ~YYu~t~..cj.r~- ~ `~ (.) as per management plan provided by plumber. ~ ~~ ~ S:~r- 2. All setback requirements must be maintained /~ ,, ~ ~ ~~~~~ ~~~`'~u-~T ~' f ~t ~ de/ordinances bl i ~2 f T ' , . , i ~, e co ca . (.i J as era l l. ~ <_ _~ r v~ c~ z~ ~m C~ ~ 0 ~ zy ~~ 70 -~-i Z zz -~ m r O 0 -~ m D 0 ~ ~ z 0 T z m r D z m 0 C _~ O z s ~" 0 _~ ~7 y. fD K ~ n ~ O X O (D C W O .. ~ O a ~ ~ y N ~ ~ ~ m ~ ~ ~ :"' N S 'O 0 N m z r O s -~ z O ~~ to ~' ^m Q l '~© I_ z ~) r O c~ ~ Q r ~ C Z ~ m m ~ r n 'dam v ~. ~; ~°-• < o~ p ~ C ~ O m ~c. m ~• p1 O ... O ~ 7 y O j 7 pj 7 `z ti ~ a' ~. ~~ ~ O 7 ~ y W ~ N ~ 7. Q. 7 W ~ n~ o W v as Wm ~~ m ~~~ a ~~ o~ >> (Q o~ ~ a~~ c ~ y om N ~ ~ m c o W~ .° ~ N (O ~a~ m N ~.O y~ O n 0~ 0 O O D N ^l O C U1 O ~ ~ ~ o "" ( ~ > > `7 ~ r. m X Ui ~ y N O N n~ ~ ' ~_ O. N N ~ "' c ~ 3 N d ~ fD ~ =O V1 ~. - ~ D. Q = N~ ~ m O 'O ~. 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V, Q a~ ~ Mart nson i%Bever/y 0 ` ~ /24 r Fl /3373 •R 6 t awn ~ cGn- „fit • • Bo R2hwa/dt ~~~ ~ • s ~m Cra by 4o ehz/" .c _ lY ~'J /%B .PocE d Ma fi/.s,7 OD r 40 a ¢o >° P r'S ~w•/97 S££ PAG£ 3Tr cSf Croix Count l~t/i~s. GLENWOOD GLENWOOD CITY GLENHAVEN, CITY AUTO CO. CO-OP SERVICES INC. GLENWOOD CITY, WISCONSIN 54013 hour Home - Away From Home • ' ~ Phone: 4bs-a44a Intermediate Care MiN: 4bS-4827 -Fertilizer Plant: 265-7412 Facility GAS * FUEL OILS * LURE OILS PHONE: 265-4877 ' • Phone. 265-4555 TIRES * LP GAS ACCESSORIES GLENWOOD CITY ~ 612 East Oak ®. UNIVERSAL MILKERS * FERTILIZER Glenwood City, Wisconsin wiscoNSiN GRASS SEEDS * FEED, BAG & BULK 54013 Parcel #: 016-1016-80-000 1z/osizoo7 10:27 AM PAGE 1 OF 1 Alt. Parcel #: 8.30.15.131 016 -TOWN OF GLENWOOD Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O =Current Owner, C =Current Co-Owner O -WARNER, FRANK H & DONNA J FRANK & DON ARNER H - _ ._- 2841 170TH OD CITY WI 54013 ..............~ v.W.................,...._.....,.~....~..~~..~....-.- Districts: SC =School SP =Special Property Address(es): ` =Primary Type Dist # Description ~~~~! S,~-; SC 2198 GLENWOOD CITY ~ /~, "~ SP 1700 WITC / / /~,, ".. ~ i~0~/ Lv/~U ~~~Z'G~..~ j Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE ~ ~ ~ SEC 8 T30N R15W SW NW 40ACRE G LK ~ Block/Condo Bldg: J ~- Tract(s): (Sec-Twn-Rng 401/4 1601/4) 08-30N-15W Notes: Parcel History: Date Doc # of/Page Type 02/26/2003 711181 2154/348 OC 2007 SUMMARY Bill #: Fair Market Value: Assessed with: Use Value Assessment Valuations: ,~~ _ Last Changed: r 10/18/2007 Description Class Acres L nd > (` Improve Total State Reason RESIDENTIAL G1 2.000 25,000 't,, 5,000 30,000 NO 00 AGRICULTURAL G4 37.000 6,500 `'~~_ 6,500 NO 00 UNDEVELOPED G5 1.000 100 0 100 NO Totals for 2007: General Property 40.000 31,600 5,000 36,600 Woodland 0.000 0 0 Totals for 2006: General Property 40.000 5,000 0 5,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 l Parcel #: 016-1016-50-000 i2iosi2oo7 10:27 AM PAGE 1 OF 1 Alt. Parcel #: 8.30.15.129 016 -TOWN OF GLENWOOD Current X ST, CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O =Current Owner, C =Current Co-Owner %FRANK & DONNA WARNER O -WARNER, DONALD H DONALD H WARNER 2841 170TH AVE GLENWOOD CITY WI 54013 Districts: SC =School SP =Special Property Address(es): * =Primary Type Dist # Description ' 2841 170TH AVE SC 2198 GLENWOOD CITY SP 1700 WITC Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE SEC 8 T30N R15W NE NW 40ACRE Block/Condo Bldg: Tract(s): (Sec-Twn-Rng 401/4 1601/4) 08-30N-15W Notes: Parcel History: Date Doc # Vol/Page Type 02/14/2006 818569 OC 02/26/2003 711181 2154/348 OC 2007 SUMMARY Bill #: Fair Market Value: Assessed with: Use Value Assessme nt ValUatIO11S: Last Changed: 10/18/2007 Description Class Acres Land Improve. Total State Reason AGRICULTURAL G4 36.000 3,500 •="" ~ ~ "'"°E) 3,500 NO 00 UNDEVELOPED OTHER G5 G7 1.000 3.000 100 f 15,700 ~ 0 ~ 90,500 100 NO 106,200 NO 00 w Totals for 2007: General Property 40.000 19,300 90,500 109,800 Woodland 0.000 0 0 Totals for 2006: General Property 40.000 11,900 57,600 69,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 „', , AS BUILT SANITARY SYSTEM REPORT O W N E R ~~~~, .y~ ~' ~I.J T 0 W N S H T P ~,~,.¢y~~ S E C. ~T30 N- R~~W ADDRESS ~~ ST. CROIX COUNTY, WISCONSIN. ~' ~ ~~y SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 SHO~YERYTHING WITHIN 100 FEET OF SYSTEM ~1- 5'~' i Q~~ 1 1 1 I I I I i I I I I I I I I I I I I I Inldidat~ Npr~h Arrow 1 BENCHMARK: (Permanent reference Point) Describe: r"p/~ oFwe~~ C,4S//V~ /O O ~ Elevation of vertical reference point: ~p O ~ Slope at site: SEPTIC TANK: Manufacturer: ~j~s~/~7S Liquid Capacity: /GOO Number of rings on cover ~ Tank manhole cover elevation: Tank inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer : ~v /~ s"e/~S Number of gallons ~.SO Number of gal.. pump set for a cycle /,;2/,. 2 gallons; Total capacity of distribution lines gallon: size of pump ~~?~ ~~~ head; gallon per minute horsepower ~~ ;brand name of pump and model number ,' Type of warning dev ce ~, jq~f- g~ ~L~/~.f HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover ; Type of warning device SEEPAGE PIT SIZE; Number of pits feet diameter feet liquid depth seepage pit inlet pipe-elevation bottom of seepage pit elevation feet. SF.F.PAGF. RF.iI ST7.R~ nnmhar of lima width length the debt DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS Dlvlslor P,O. BOX 7969 BUREAU OF PLUMBINt MADISON, WI 53707 ^CONVENTIONAL C~ALTERNATIVE State Plan l.D. Number: ^ Holding Tank ^ In-Ground Pressure ^ Mound (If as igned) ~ 30 2 7 6 4 NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Frank Warner R. R. 1, Emerald, WI (p~a~3°03 ~j ~~ BENCH MARK (Permanem reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELE V.. SW NW, Sec. 8, T30N-R15W, Town of Glenwood Name of Plumber MP/MPRSW No.-. County: Sanitary Permit Number: Gale Smith 5690 St. Croix 38489 SEPTIC TANKIHOLDING TANK: • 0 ~ • ~~~ MANUFACTURER: ~ LIQUID CAPACITY: TANK INLET LEY.: TANK OUTLET ELEV.: WARNING LABEL LO IN ~'~°~ ~` ~ ` ~ ~ ~ ~' c~ ~ ~ ~ ~ OVI ED'. ^ PR VID Lf ~ . ~ 1 YES NO S NO BEDDING: VENT DIA.: VENT MAT L.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT T FRESF t I ALARM: FEET FROM ~ Mf~ O LIN ., ~ F/ 1 AIR N E ^YES O ( ^YES ^NO NEAREST tlJ ~~.. t V DOSING CHAMBER : __ MANUFACTURER: BEDDING: LIOUID CAPACITY PUMP MODEL. PUMP7SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER ^YES ^NO ^YES ^NO ^YES ^NO GALLONS PER CY CLE: PUMP ANO CONTROLS OPERATION AL: NUMBER OF PROPERTY WELL. BU ILDING: VENT TO FRE51 (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: PUMP ON AND OFF) ^YES ^NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing _ ~ r ~.:,,., DIAMETER: MATERIAL AND MARKwG or excavation. I if soil can be rolled into a wire construction shall cease until FORCE , the soil is dry enough to continue.) MAIN CONVENTIONAL S YSTEM: BED/TRENCH WIDTH, LENGTH: NO OF E DISTR. PIPE SPACING. COVER INSIDE OI A.: tt PITS: LIOUID PT TRENCH S: MATERIAL: PIT H: DE DIMENSIONS GRAVEL OEPTFS FILL DEPTH DISTR. PIPE DIST R. PIPE DIST R. PIPE MATERIAL: NO. DISTR, NUM BER OF PROPERTY WELL: BUILDING: V ENT TO FRESI BELOW PIPES. ABOVE COVER. ELEV. INLET ELEV. END: PIPES. FEET FROM LINE: AIR INLET NEAREST- -----s~ Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ^YES ^NO OIL COVER TEXTURE. PERMANENT MARKERS: OBSERVATION WELLS ^YES ^NO ^YES ^NO DEPTH OVER 7RENCH;BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED. SEEDED: MULCHFO. CENTER. EDGES. ^YES ^NO ^YES ^NO ^YES ^NO PRFSCI1Rl7Fr) nISTRIR11T1A1U CYCTFM: 7i BED/TRENCH WIDT - LENGTH: N OF S: TRENCH LATERAL SPACING: GRAVEL DEPTH BEL PIPE: FILL DEPTH ABOVE COVER: DIMENSIONS ~ MANIFOLD E E PUM E MANIFOLD OI A DISTR. PIPE MANIFOLD MATER AL' NO. DISTR. PIPE DISTR. PIP DIA : y DISTRIBUTION PIPE ATERIAL & MARKING: ELEVATION AND L V.: V ~~ ~~ .~ ~~V.: S . J (~ D{STRIBUTION ~ ~ ~~ ~ ` INFORMATION HOLES 2 } HOLE SPA 1 N~ DRILLED CORRECTLY COVE ~ VERTICAL LI T CORRESPONDS TO APPROVED PLANS, L YES ^NO ~ YES ^NO COMMENTS: ~ PER A NT MARKERS: ` OBSERVATION WELLS: NUMBER OF ROP TY WE BU ING' ~ OM LI 7 4 ~C YES ^NO YES NO NEARES ~~ 'etch System on ~erse Side. SBD 6710 (R. 01182) ~ Qom, 10 . t~ G, `~ 3 ,tom 3 n U r~~~ ~~z I ~ -3 ~ C~,-v ~1 ~ ~a.~ Retain in county file for audit. State of Wisconsin ~r~t ~'Q. 193 Mr. Frank for Flouts aTd~ Yfscvets#rt 54Q1Z Department of Industry, Labor and Human Relations SAFETY & BUILDINGS DIVISFON $ut'eau of f'ttwabi~lg ~P~~,,~ ~ 281 East ~tasnin~tcm ,~,-~~ JG~y~ //i,. ~.. P.ti. 8~t 799 j~~ ~'C~lf ° Ma~d~fsoal, Yiscor~sl>~ 53~~7 "~ Petit 11Nt ~3-fl27`~~-P ~e z l~tr~t", Crank • its i die Alter~atiwt sys- ~~~;~~~ ~ ~ ~ite€twpUd~ $t. Croix Ctuanty, iiI The su~,~®ct Petition far l4~fifisatian et` sactian sK 6,23 ~~~ {d) ~ the Yis~sin Al~inistratlre Cede was consialered ~ June 17, i~3. IL wes ~Prt-v~~ the rul~t ,re~rires that t~erw sA~tll be at least 24 itnct~es of unsatarate~ astural se4i aibwta~ tst#rated him ~raw~lrat~r €au- the installatit~n +of a wound systeo. Tktt rar'iC~ regttustec# was to i~Stdi1 a w~-ans# 5ystew a sfte wee ttte d>~Itb to astlwart~ bi+~s graun~lrater is i6 fps. 1413 df tb+t delta a~ sta;~earts su#waitted in Matt tr~t t]he ~#1tt+an vrere ccas doe~at. Tl}ig apP~ntsl is sPec~fie t+o t#~e sect petltlan ana# ca~anot ~ used fair: any +~fditio>I~al ±eaa!#f#catta~s. Sincerely, ~ ~r Kam, C~ # ei' Settia~ of t'rivatte Sewage and Platting VR.dP:~h GC. L+~ Jansk~, t~iS - €~iStsrict fi, C!~#Pptw3 falls , lel C. 8arb~er. T~ ~- S-t. Cro#ac County a~lg Swittx lluaibin~ ~ ~eatia~g DI LHR-SBD-6423 (N. 04/81) Department of Industry, Labor & Human Relations Division of Safety & Bldgs. Sttate of Y~ isCOri3iri Bureau of Plumbing Platting & Fire Protection _~ P.O. 60x7969 Madison WI. 53707 Tel. 608-266-3815 IQI~u.~Z /~.~;l~im Gentlemen: /NALL CORRESPONDENCE REFER TO PLAN /DENT/F/CAT/ON NO. l ~~ ~ tv i Examination of plumbing plans and specifications for the above-mentioned project has been completed. In accord with Chapter 145, Wisconsin Statutes and Wisconsin Administrative Code, the plumbing plans and specifications are approved contingent upon com- pliance with the stipulations indicated on the plans. Please review your code for the requirements of each code section noted. The architect, professional engineer, registered designer, owner or plumbing contractor shall keep at the construction site one set of plans bearing the stamp of approval of the department. In granting this approval, the Division of Safety and Buildings does not hold itself liable for any defects in plans or specifications, plan omissions, examination and reserves the right to order changes or additions should conditions arise making this necessary. This approval is based on Wisconsin Administrative Code. requirements. It shall be necessary to obtain and fulfill the permit require- . merits of the city, village, township or county in which this installation is to be constructed Failure to obtain local permits will auto- . matically void this acceptance. Sincerely, cT/JSrs~ James Sargent-Bureau Director For Prig%t,te ~~~N:~gB S~3stems Onty; This apr:;'o~~~ s i:, v.~'i~; for t'.^;o years cr it `,°~ii~ ~e valid t;r:tii the exs„r~,'.i;;~ rafo of ti-~s initial sanir~;ry }~%;"fTlit. cc: DP Owner DI LHR Lo Plumber H ~ R (2) unt Mfp. Rep. Bur. of Health Fac. & Services DI L -6099 (N. 06/80) Rec. & Env. Services .. . ,., /~ State of Wisconsin 2fl Zg~3 Department of Industry, Labor and Human Relations SAFETY & BUILDINGS DiViSION t31trB~u 01' P1);aat~ing 2~1 E~St 6iashingtal~ Ase~!we P.11. t3o~c 79b9 Maclisoe~.611scoaain 537'i?y pr. Frame Marner R+auta 1 F.leerald, Misc~-sin S~12 Petition ttri. $3-027~~-P tsar Mr, iiar~easr: tte: 6larnex, frank -Residence Alternative S,l-ste~ St~t,li61$, 3a,~ 561 Tewn +a# &lenw+~vd, St. Croix County, III The sui~~ssct Petition for t4odificatitull of section N 63.23 {1) {d) of the 6sconsin Aginistrative Code was considered an June j7, 19113.. It was a~roved. Th+l± rule requires that there shall be at feast 2~ inches of ~saturalted natural sail above estiAated him graunct~rater for tt~e iastallatioa of a a~tnd systems. 't'he vari~Ce regwested was to install a ceau~ad systew r~ a site where the depth to eat mated hi +,~ greu+ndwater # s l6 i archers. All t~f the data atrsf sta is sut~#tted in behalf t3f the petition were considered. This a~rrprtr-al is specific to the sutr~ect petstion enc,# canntrt be used for any additional naOdificatic~ns. Si t~erelgr, Jwroare Knepp, Chief Section ta<f Private Sewage acrd P1 atti ng ~C~JP:~h ccc Levay Jansky, t~S - pistrict 5, Chippe~ra Falls Ha ld C. Barber, ZA - St. Craix County le Swith Plrin3 b gating DILHR-SBD-6423 (N, 04/81) '~ ION1~~L WORKSHEET ' ~ru " ~` (~a rn ~ r MOUND SYSTEM • /~ I1 I<\-GROUND PRESSURE SYS 1. Wastewater Load, Total Dally Flow = ~ ~ . TEM{ontinucd- Use section H 63.15 (3) (c) Wis gal, 10. Force Maln: ~/ , . Adm. Code and PROVIDE ADETA ILED Minimum Dosing Rate = - "T..s~ gpm' LIST OF SIZING ON PLANS Dlamtter = rte. in . 2. Depth to Limiting Factor = > -__L~~ ft 11, Total Dynamic Head: 3. Landstope = 4. Distance from Dose Chamber to . ~_ ~ System Head = 2.5 ft. Vertical Lift = ---~-z~.~ ft Distribution System = Frictlun Loss / 3~ ft. 5. Elevation Difference Between Pump and Distribution System = 6 Ab ,~' ~ _...Sz • J_ ft. 12. Pump Selection: Pump will discharge at least ~r~ . . sorption Area Siting: " _ >~ ~G 8pm at . ft total d nami h d Area Required = Bed or Trench Length (8) _ 3 ~s sq. ft. ~ ft . y c ea . Pump model and ma~yfacjurer. :S p j t ~~ m q rc Bed or Trench Width (A) = L''~. ft. 13. Dose Volumt: Trench Spacing (C) = 7. Mound Height: ft. 10 Times Void Volume of Fill Depth (D) = j,rl J f Distribution Lines = gaL FIII Depth Downslope (E) _ t -"z'" ,_ (,~L ft Dally Wastewater Volume+ Bed or Trench Depth (F} = , . ~ `~ ft 4 Doses In 24 hrs. _ //3 gal. Cap and Topsoil Depth (G) _ Cap and Topsoil Depth (H) _ . . / (3 ft, /. S~ Backflow = Q -Z.-Z gal. Minimum Dose = Jul -----sZ. Bal. 8. Mound Length:. ft• _ 14. Dose Chamber: Volumt = ~ 7~ End Slope (K) _ ~j, ~~ -~ ft "'~al. Total Mound length (L) _ _ . ~~, ~ ft 9. Mound Width: • II I. CONVENTIONAL PRIVATE SEWAGE SYSTEM ' Upslope Correction Factor = ~9, 1. Wastewater Load, Total Daily Flow = .__~ gal. j„q Upslope Width (I) _ • C' 4•~'~ ft ~ Use section H 63.15 3 ( ) (c), Wis. ' Downslope Correction Factor = . ~- -~- ~. /~ Adm. Code and PROVIDE DETAILED Downslope Width (1) = ft LIST OF SIZING ON PLANS. Total Mound Width (W) _ . ~ ft 2. Required Septic Tank Capacity = gal 10. Basal Area: . 3. Percolation Rate = --,. min./in. Infiltrative Capacity of 4. Absorption Area Sizing: Natural Soil = ~`~ Refer to Table 2 in chapter H 63 Basal Area Required = gal,/sq.ft./day de1.~r n sq ft and PROVIDE A DETAILED LIST OF Basal Area Available = . . fL)G~_4Slsq ft SIZING ON PLANS. 11. If Standard Tables from Chapter . . Required Area = ---__.. sq. ft. H 63 and Used, Indicate Table No Length = ft. . 12. For the Distribution Network, Use Numb ers 5-14 In Section li Width = ft. . Number of Trenches I1. INGROUND PRESSURE SYSTEM Trench Spacing = ft 1. Depth to Limiting factor = ft 5. Distribution System: 2. Landslope = . ~ Lateral Length = ft 3. Percolation Rate = Number of Laterals = 4. Proposed System Elevation = min./ln. ft Lateral Spacing = in. 5. Wastewater load, Total Daily Flow: . gal Distance from Sldewall to Pipe = in Use section H 63.15 (3) (c), Wis. System Elevation = ft. Adm. Code and PROVIDE A DETAIL ED IV. LIST OF SIZING ON PLANS SYSTEM•1N-FILL . Required Septic Tank Capacity = Fill !n All Items from Section III ~ ~, ~ 2 6. Absorption Area Siaing: gal. Percolation Rate = V. SEPTIC TANK Area Required = min./in. sq ft 1. Capacity = ~„_, gal, System Length = . . 2. Manufacturer: System Width = ft. 3. Show Site Constructed Tank Details on Plan 7. Distribution Pipe Sizing: ft. Holt Siie = VI. DOSING TANK Hole Spacinµ = -LT _ in. 3 ~. 7 fl 1. Capacity = gal. Lateral Ltnµlh ` . ~ 2. Manufaclurcr. L.ucl.ll Sliu ..L:_. It --- /'+ in !. Pump M.tnuldclurer. 1..111.1'.11 til,.kllllk . ~~ Il 4. Pump Model: Ui.lauu• Irnnl Siklcwdll •In I'il,c ~ . ~ S. Opcratinµ Hcad= ft g. UlstrRnltlnn Plpe Ditich.uµu kale: •~ 1i1' . 6. Flow Rate= gpm Nunthur ul Iluk+. I'cl 1'ipr 7. Show Slte Constructed Tank Details on Plans , I Iuw !'ul Pll,r• 1~ `-. M.utlinld SiNnµ: -- .~._ ui„n. VII. HOLDING TANK _._ I YPe (cuntcl ul und) I. Capacity = [1 IA4 gal. Ltnµlh = -~ ~? It 2. Manufataurcr:'--'~~f ,~~~ Dlamtter = - . . 3. Show Slte Constructed Tank Dttalls on Plans --~_ In. ' _..... A,=~ -SHOW ALL INFORMATION ON PLANS- - -.__ .)ILHR SBD•6761 (8.03/82) _,~..-~~,,.~...._...a -- - Smith Plumbing & Heating PHONE (715) 265-4838 GLENWOOD CITY, WISCONSIN 54013 S~ y ~ !~ y se ~. S ~' ~d N, R /~ ~ ~o~Pe 1.7 t~eA K ~ m e 0 v ~lGa~d 9 1983 N r-_. ~: ~ ~ iii c _., ' ~ ~ .~~3~ ~~ p SAL p,yM P C'~M~tR /dao 6~A! StP~`~e t.~NK sy ~ 1ri/° ofi ~"k~etL CAsiw~ BeMay/ti, ~...;1 ~v,. _ . 1 ,; ~~. c~, h,; ~~,,,, , ,~: _, ~ ~_lai~~~~~s ~ ~ .~ r +. Page ~ Of _~ Straw, Marsh Hay, Or Synthetic Covering Medium Sand - - ,.._. Topsoil ===--- `J ~ E 3 Slope Bed Of 2~- 2 %Z Aggregate Distribution Pipe -`1 ~F D Force Main From Pump G Plowed Layer D X67. E 1~~~~.. G _ ~ C? b ~,t ~'~4 ~ H _~~_ Cross Section Of A Mound System Using A Bed For The Absorption Area r A ~ Ft. Signed: :~ G..J~~---~"- g ~.L~ Ft. License Number: /t~j/~`~ X10 _ I /,j__~Ft. Date. ~ -~°,.~r_~ J _9.5~ Ft. K /~, 7_~ F t . Alternate Position L ~~.~/~Ft. of - Force Main ~ W.~U,~7 Ft . 1--- L. (~ 2 ~` ~ 4 Observation Pipe-~ r ---------------------- Ir-------------------- _ --------------------- A I«--------------------- ~ t, ' Bed Of 21 2 % Distribution "~'~ " ' Pipe ~` ;, ,~ Aggregate - ~_ .. .<., Observ~tlonw,P~pe Perm~nE~nt M,orkers G~'~~..,. ~~ _; ~ _ ~::.; ~~L~~;1 QQ :.. ~. ~ ~ 1 ~ ~ ~~ 1 / 6 ~ ~ r Y' ~ yin / ~ ~~.J~~ K Force Main From Pump <` ~: ~ ~ ~- Plan View Of Mound Using A Bed For The Absorption Ared"`p"' '1 ` ~' ~ ~i ~~ Perforated Pipe Detoil t.ai -••- -°~ u~smounon ripe ~oyout Signed . ~ .~~ ~../~r,..,i~` License Number : ~j ~ ~ ~ ~~~ Date : ,~ ~- ~ r'-~ ~,~~ ~~ ~' ~.~T ~ ~,_~ ~ ~ Page ~ Of t Located On Bottom, 'e Equally Spaced ~~ Q note Poeltlon Of Main From Pump P ~' ~~®~ R ~, ~ ~ S X ,6 ~ ~.- t~~ // ~ sc ~~f.i Hole Diameter 1~ Inch i Lateral %~ Inch(es) Manifold ,~2 Inches Force Main ~, Inches ~ 3 ~~-u-~ ........:..... !' L'E n~tifi T:lf~\i ~. i' 4 t1~f ~ ~ ~ 5 ~li• i t ,r~ ~ {~~ar,i~~V.S ~~+~.J ~~ ~ /,~ 'SEA: L:~1-~ t~~f~t~rvD~;~;~~ 'i°~C.Z. 'DENT PIPE -' 25° FRCM OLOR, WWDUW UR F-RkSH Atl7 IA.ITAKE 18'°MIN. IA1LE: T^` APPKO`JEG JGINT Wf C. t. PIPE. E7CT'ENpIRJ[~ :5' o~-TO sc,L ID ;~,~1. PAGE ~ OF~ PUMP CHAMBER CROSS SECTION AA1D SPECIFICATIOtiS A B ~~. D - VEtJT CAP WEAL-aER PKOOF_ JUIJCTIUIJ BOX 12"Mlll. I I GRADE - I COIJDUIT ~-- APPROVED LOCKIAIG MAtJHOI.E COVER 'i°° MIA1. I ~ ~ IB"MI-J. III V III III APPROVED JG'~ III W/C.I. PIPE II At_ARM EXTEAl0i1JC, ;: II O-JTo soon Sr 1, ~ - `~' -~ RISER EX11~ P V \~~~~~ 1- PROVIDE ~ AIRTIGHT' `SEA1_~ ~ 4 I I s'is° C! I I ,- _ " . ,~ ... ~.~ _, I f M ,~ I L~ tft~=c~i / ,~ ^ I ~.. i.. . .... , J V M~ '1-_- -._.~ ~„ ~ ~~ ,~ L~ ~. ._ -- ~ r1, w~ ~ .+~_ u -r----- ' . .. f a _- E~I~. M I Tf" E D G AJ L 4b •~-116 ~Y1~. kj~Ci ~f~!'ti 1~1'F'k'~-`'T't}'Ct`E. R ~PEGIFIGATIOI~JS OI~ OFF FIAS SUCH APPROVAL ~~02'704 OPTIC AND )SE TAtJKS MAWUFACTLJRER ~ ~ ' i~zr^ ---5~- -JUMBER OF DOSES: ~_--PER DAy 1-Ah1K .,IZE : __ / l _~~~~`..._~__ ___ GALLO-.IS ~~/ .~_ GALLC) DOSE VOLUME: ALAKM MAAlUFACT'UREk: 1 _~_~_~~cTru-_ L, L'APACITIES: A= ~T IIJCHES OR •_ AI~C>1. M<~(~E=L -.IUMkSER: ____ ~U 1 v 4-J LJ ~ B=__r?Z~IAICHES UR ~LLO~~ .TWITCH i ~F'E: _------- - ~1~5 1V" , , ~IIJCHES OR'L~~ ~ GA~LG-.i ~~~~~~~~~- __-... __ ~_.-_.__.._--_-- _- I~IIMI' MA~lIIIAC I UKE K: _. ___~~.~~' ~`.' 0= IJLNES OR GAL'.uf.. Mi.~I~EI A1UMtiEK'. __--U~__~.__~~___--__-__._--~- NOTE. PUMP ANU ARM ARE TG _ :~wrlr_fi TYPE: ___ _1'her~,u.~.____I~_t~ ~ `- _ iLISi-A L.L_ED OIJ SEPARATE CIRCUITS F'UME' UISLHAF~hE KA f E _ 1'f'' GPM ~: `i!z , ERTICAL DIF ( ' ' - ' F ~ - " V . Fcf Eil(E 0F. I LIMI R1t3UT WE.EAJ F f)F F AND DIS1 I EE OiJ PIPE:.. _SP~ _ 1 ~//p -1- MIAJIMUM. AlE1~nlORK SUPPI-'~ PKE~~!~K~ ~ G1 9 ~,.',~ _~'.~ ~ FEET,. -- t `JU_° TEE i GF FUItCE. ,, ~"~ ~. MAIF1 ?C :x_7~?._._.,~~,~~.FKICfIOFI FACTnI{_.._I._~.~_ FEE t `~ ., L 1 O I A L. U J t~1 N NI I ~.. HEAD =_- l~cb ~ FEET (~ (i !I ..~rr,1ISr~Rwa~m~~ ~F -~nNx! LEN6-TiF~- C,~ w~nT-#..~>...-f~f~+xa ~~-Yri~ 3 ~ - ~~ ` • MDR-0=rT1~TIC secTloN z,,. PUMPS DIMENSIONAL DRAWINGS & PERFORMANCE DATA MODEL: OSP33 SUBMERSIBLE SUMP PUMP -MAX. SOLIDS 5/a" SPHERE -1750 RPM TOTAL Lit. No. 113.5 348 HEFT. 3/,o HP MOTOR 24 22 I ~' 20 F,9OCgA 1a gC~TY 16 14 12 10 8 6 FULL LOAD 4 f AMPS AT 115 V. 6.5 2 - . ` 'l ,i 0 10 20 30 40 50 60 ~ ~i ~j U.S. GALLONS PER MINUTE ~ 1983 MODEL: OSP33 9'/a is NOTE: CASTING DIM. MAY VARY ± ~/e V µ ,.. _. 4 SBD 6878 (9181) iPlb 100a) Detach .And Return Upper Portion Of This Form .With 7 ~ Any Return Corresponde ~yF ~ :„~ n ~G~ ~i~. DATE: (}6f 09/83 ~ '2j~O Gale Sflzith Piling & Hating RQUte 2 Giernaood fifty, WI 5013 ~~ ~[~ V STATE OF WISCONSINkflILHR` f DIVISION OF SAFETY & BUILDING: .BUREAU OF PLUMBING 201 f. WASHINGTON AVE. RM 178 P.O. BOX 7969 MADISONR W1 ~37Q7 608-266-3815 ~~ PROJECT:. `_ lv8rt'fer, .Frank - Resfdenee ~4~~9) SW, NN, 8,30,i5W Tn &lenwood 5t. Cro1x ~Ii PLAN ID. # 1~3_a27~4 P DETACH HERE A_ r ~ PROJECT NAME 1itaCnt~l", Ft"~tCtl4-- R~51f~~11C! ~ PLAN ID. # 8~-OL~~64 P: - ._;_ '~- This is to acknowledge. receipt of your plans and cifi tions for the aoove-indicated project. s p e c a Preliminary review indicates the required fee is $ ~ / ~ / ~ ~ j ~ 1 y ~L"~' Fee Received is $ ~ 70•~ ^ Underpayment -Please submit the additional fee. ^ Plan accepted for review. ^ ``~~ Overpayment -Refund forthcoming. ~ ~V• ~ ` Plans being returned. ~ ~(~ ~~ ^ No fee has been remitted. Plans submitted with no fees will be ~ r Additional information required. SEE BELOV'i~ heldln abeyance. I. Ian Submission ^ Complete data relative to anticipated use of bldg. Additional information shall be submitted in duplicate un- ^ 2 copies of PLB 60 enclosed. less specificatfy'noted. ^ Deed restriction required (1 copy-. Plans not clear, legible or permanent. ^ Condominium declaration. (1 copy) ^ All information submitted shall be signed, dated and sealed or stamped in accord wi Section H 63.08(2)(a) Wisconsin Administrative Code.. Affidavit enclosed. IV. Holding Tanks Profile. of holding tank showing vent, manhole alarm anc manufacturer if precast. Complete construction details if II. Pressurize Distribution Systems (Mound or 1n Ground Pressure) site constructed.. ^ Application for use of an alternative system signed by owner. ^ Holding tank agreement signed by owner and Ic,l unit-o' and notarized. (1 copy) government (sample enclosed). ^ County onsite required (1 copy). ^ Design calculations ^ Reason for installing holding tank. Soil test or~statemem for pressurize distribute n. ^ Soil borm & ereolat+on _ __ -. -~ ~_ ~ .•°- ~;;~ ~ ~-w: ~~ _ .a: -~ ._~. 9 . .P - ~ _ ~- ~ = - Plot plan shove ~l~c ~ . ~ °` test data. -"'~ ^ ing o tion of holding- ank with lateral dist ^ Cross section of system. ^ Pipe lateral layout. ances to any building, wells, water. service piping, wate+ ^ Plan view of system. ^ Plot plan. course,. lot lines, swimming pools, all weather service road ^ Verification of Exception. Status Form by County. (1 copy) Etc. Provide benchmark with elevation reference point. III. Private Sewage Disposal Systems ^ Ground slope with 2' contours in entire area of soil absorp- tion system extending 25' on all sides. ^ Elevation of permanent reference point (benchmark). ^ Location of area suitable for replacement system -provide soil data. ^ Plot plan showing lot size and .all lateral distances fre3m sewage disposal system to .buildings, lot lines, well, water course, swimming pools, water service piping, Etc. ^ Construction detail of septic, holding or lift pump tank if site constructed or tank manufacturer if precast. Construction detail and cross-section of soil absorption system. ^ Soil boring and percolation test on 115 completed by cer- tified soil tester (1 Copy). V. Lift Pump ^ Calculations for total lift- pump discharge, head and gallon; pumped per cycle. ^ Size, length & depth of force main. ^ Detail & model of pump or acttomatic siphons ncludinc size, pump curves, drawdown and average flow rate Gf'M.- ^ Cross section of lift pump tank showing pump(s) or siphon(s). VI. Systems In Fill (Fill must be placed prior to plan submission) ^ Total area filled (fill to extend 20' beyond edge of trend before side slope begin). ^ Depth and type of fill ^ Copy of onsite report by county or district staff. ~ I . ~ ''^ ~: +C i , t ~'y.. '~i'. . June 7, 1983 ST. CR01 X COUNTY WiSCONSI N ZONING OFFICE 796-2239 1HAMMOND) 425-8363 (RIVER FALLS) HAMMOND, WI 54015 Division of Safety and Building Bureau of Plumbing P. 0. Box 7969 Madison, WI 53707 Dear sir: An on site investigation for the Frank Warner property ,, located at the SW~ of NWT, Section 8, T30N-R15W, Town of Glenwood in St. Croix. County revealed suitable soils at a depth of 1.33 feet, below which seasonable high ground water was noted. This site should be suitable for a mound system. Should you have any questions, please feel free to contact this office. .- Yours y, Thomas C. Nelson Assistant Zoning Admigistrator TCN:mj Enclosure ti- WISCONSIN DEPARTMENT OF INDUSTRY, LAQOR ANU HUMAN RELATIONS • DIVISION OF SAFETY & BUILDINGS, BUREAU OF PLUMBING ' P.O. BOX 7gG9, MADISON, WISL'ONS1N 53707 Verification of Exception Status for an Alternative Private Sewage System In the County of st. Croix Location sW 114, Nw 1/4, Sec. 8 T 3o N, R 15 FX~l4~~ W Town o r (!C-yr-~>~ lfpcaP~1~4 >~~ G l e n w o o d Street Address Lot No. Block Subdivision Landowner's Narne: Frank Warner The application far this site is for: ^ new construction use. ' Q replacement system use. If this is NEW CONSTRUCTiUN USE, the alternative private sewage system is: ( ~to have one of the first five approvals guaranteed for this year. This is number - - of those applications. (Use one of the first five quota nurn ers i sue to you.) ( one of the applications needing a quota number. The quota number assigned to this application is - - [._~for one additional homesite on a farm to he occupied by a parent, child, grandchild,'sibling, niece, nephew, or first cousin. ((for an individual lot for which a sanitary perrrrit was issued but was later ruled unsui-table due to new or changed soil criteria established by the department:. (_.~for an application nn file prior to February 1, 1980. ~_..~for a lot that meets the criteria for a conventional private sewage system. If this is a REPLACEMENT SYSTEM USE, the alternative private sewage syste-n is replacing: [.~ a failing conventional sail absorption system. ^ a holding tank that was installed and in use prior to February 1, 1980. ^ a privy that was installed and in use prior to February 1, 1980. if this is a REPLACEMENT SYSTEM USE and the lot meets the criteria far a conventional private sewage system, check here. I certify that the above infor~nation is true and accurate to the hest of Try knowledge. -. _ _--_-_ /~~.-1 Name 'Thomas C. Nelson _..--~l9ndture _ _ ~. _ i County Official Title Assistant `Coning Administrator Date June 7, ,1983 UILHR-SBO-6158 (R 12/82) ' w STATE OF WISCONSIN-DEPARTMENT OF.INDUSTRY, LABOR & HUMAN RELATIONS DIVISION OF SAFETY & BUILDINGS - BUREAU OF PLUMBING ` P.U. BOX 7969 - MADISON, WI, 53707 APPLICATIOfd FOR THE USE OF AN ALTERNATIVE SYSTEM Location : Township /7fQ.~fi~R K~f 5W ~ NWT S 8 `t' 30 N/R 15 R(~3fr$W Glenwood Street Address: Subdivision: County: Landowners Name: Mailing Address: Frank Warner RR~1, Emerald, WI 54012 I (We), the undersigned, hereby make application for an alternative system on the above-described premises. I recognize that the above premises are~'not suited for a conventional private sewage system. If approval is granted, I .. a ree to have the system installed in conformance with the Bureau's approval of plans and specifications. I further understand that an alternative system is more complex in nature than a conventional private sewage system and as such will require detailed inspection during construction and monitoring after the system is put into use. I agree to permit both county officials charged with administering county sanitary ordinances and Bureau employes or other authorized persons to have access to the above described premises at any reasonable time for the purpose of inspection the construction of or monitoring of the system. I further agree to either personally or by my agent contact the proper county official to arrange the time and date to begin construction of the system. I understand that, this application does not permit me (the applicant) or my agent (the contractor) to begin installation. If the system is approved, the Bureau will send the applicant a letter of approval which authorizes construction of the alternative system after all necessary permits have been obtained. I agree to give notice to any subsequent buyer that an application for an alternative system has been made and if installed, that the 'premises are served by an alternative system and further agree to give the buyer a copy of this application. ' The Bureau accepts this application subject to this understaneling and sub3ect to all the conditions and obligations set out in this application. STATE OF WISCONSIN SS. COUNTY OF DILHR-SBD-6413 (N. 05/81) Signature of Applicant Date Subscribed and sworn to before me This day of 19 Notary Public, State of Wisconsin My Commission Expires: