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Home My WebLink About016-1036-20-000;in Department of Commsrce PRIVATE SEWAGE SYSTEM ~ and Building Division INSPECTION REPORT GENcRAL 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 Moe, John Glenwood, Town of CST BM Elev: Insp. BM Elev: BM Description: /ao ~~ Ib ~ t c,5r TANK INFORMATION TYPE MANUFACTURER i GAPACITY Septic 5~ ~k~. w Go.~,i~>> ~ Dosing G/ 47 r ~~v ~ / ~ ~{n., n ~ Z Z Aeratio Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD septic 7 ~ ' 7 70' 70 ~ 7 76 ~ -- Dosing ~ / r 7 7D J 70 ~ 7 76 r- Aeration Holding PUMP/SIPHON INFORMATION ~~`. Manufacturer ~ '~ ~ Demand dr , r GPM Model Number ~ ~ ~ 5~ , ` TDH Li 5 ~' Friction Loss System Head TDH Ft 3 , ro r. ~ 3 . zs . Forcemain Length ~ Dia. i/ Dist. to well ~ Zb z $I SOIL ABSORPTION SYSTEM county: St. Croix Sanitary Permit No: 488046 0 State Plan ID No: Parcel Tax No: 016-1036-20-000 SectionlTown/Range/Map No: 16.30.15.262 ELEVATION DATA STATION BS p.2s HI .25 FS ELEV. /4b Benchmark r.- ~ ~~ 7 /~ $d-. Go~-~- ~, 5 95, ~5 Bldg. Sewer ~ 7a + ~ 9~ ~ ~~ St/Ht Inlet ~ ~ 5 ~.~ • SUHt Outlet /D~~ g9•r35 Dt Inlet ~._ _~ Dt Bottom ~~~ 5 ~ $ . 7 5 Header/Man. t/ ~ 7 c,~ r~ Dist. Pipe ~ , 3 ~s • T Bot. System 5.~ ~~. 7 Final Grade 3 . 9~. ~ St Cover ~, 5 9~ ~5 BED/TRENCH DIMENSIONS Width / („ Length / '75 No. Of T(~enche Ike PIT DIMENSIONS ~-~ No. Of Pits --~- Inside Dia. Liquid Depth ~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR Manufacturer. ~ INFORMATION Type Of System: Oc3w i ~ ~ ~~ / / C ~ / ~ )~ /V UNIT Model Number: ~ IIISTRIgIITION SYSTEM i ~_~1.. Header/Manif9ld ~ Distribution ~~, w \ tl / x Hole Size x Hole Spacing ~ I Veneto Ai~ Inta e ~~ Length 3 Dia ~ Pipes} \ Length 3 ~ Dia Z Spacing ~ ~ Sf111 CAVFR ., o~e«....e c.,~te,,,~ n.,r.. ,.,. Mnuntl nr ot_r;rade Svctems Only Depth Over ~ Depth Over - ~ xx Depth of (~ xx Seeded/Sodded xx Mulched Bed/Trench Center / , ~ Bed/Trench Edges . ,.~,, Topsoil ' ~'v j =,,j Yes i.;'~ No ', j Yes j ~~ No J COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~ / ~~/ ,~j~ Inspection #2: / / _ Location: 2904 150th Avenue Glenwood City, WI 54013 (SW 1/4 SW 1/4 16 T30N R15 ) 40 ac s Lot ~ `: Parcel No: 16.30.15.262 r ~~~~, 1. Alt BM Descri tion = ~Ai"'," ° ~ ~`K"' Z ~ ti . \ ~ ~ e1 ~ ~ , M1t~ <~,1 ? rrL..~tJ O ~ p J ~" , pc"' ~ ~ ~ r.. L~ MAO JL.: 2.) Bldg sewer length = ~b 1 _ I~,, ` - amount of cover = ~ ~ ~ ~,. G~a; f` ~ ~ 1- O ~-U~ ~ ~a~ .1~ ~ow~ `I~Z6~o ., G T- i ~ - r-------- - - -7 - - i I I Use otheSls de for add tlonal information. No I / 2~ I ~ _.J I ~ I ~ ~~~ ` J! Date ! epct Signature Cert. No. SBD-6710 (R.3/97) Safety and Buildings Division County St. CiO1X 201 W. Washington Ave., P.O. Box 7162 isconsin ~ n, WI 53707 - 7162 8) ~~~ Mary permit Number (to be £illed;n by Co.) Department of Commerce .,~~~ ~g0 0`{~ Sanitary Perms tin {{fi~nn ~ Plan I.D. Number ~) n~S • /4 12 123 = y ) U'J " In accord with Comm 83.21, Wis. Adm. Code, personal informatio you pr~~~( s5 (') Rte' 4 T may be used for secondary purposes Privacy Law, s15.04( m) T • Proj Address (if different than mailing address) 'RCIX COUN L Application Information -Please Print All Information SOm Ave. Property Owner's Name Parcel # Lot # Block # John Moe S Q Property Owner's Mailing Address Property cation 2904150`~Ave. SW'/,, Section lfi SW '/. City, State Zip Code Phone Number , T 30 N; R 15 W Glenwood 54013 715-9243981 II. Type of Building (check all that apply) X 1 or 2 Family Dwelling -Number of Bedrooms _3 Sabdivisiotr-~Faare ~~Sh4-I'iu~er + n ^ Public/Conunercial-Describe Use ~ ~ ~ ~ /k p1J. .~6 C ~ ~y ~ J n ~X ~ ~~{~ ~ " ~ ~ ^ State Owned-Describe Use '~ / utHe..~w i SS~~ City ^ViUage X Township of G1CriWOOd bu 1( p ...- III. Type of Permit: (Check only one boz online A. Complete line B if applicable) ~~ p 3( _ Zp ^ ~ . Z( 2 ~ ^ New S stem y X Replacement S stem y ^ Treatrnent/Holding Tank Replacement Only ^ Other Modification to Existing System B• ^ Pemut Renewal Pernlit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration '"-°~`-" Plumber Owner (~GjQ ®/~!1 1+ ~ n ~~ Q~ 1 {J J l/ Ql o~ ~ t IV. T e of POWTS stem: Check all that a 1 >< S ~ 23 " ~. Q 2 ^ Non -Pressurized In-Ground X Mound > 24 in. of suitable soil Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Fiber ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Fiber ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Syrdhetia Media Fiber ^ Leaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) V. Dis rsaUTreatment Area Information: -" = a - D Design Flow (gpd) Design Soil Application Rate(gpdsfl Dispersal Area Required (sfl Dispersal Area Proposed (sf) System Elevation 450 0.6 ~/• O S /~ 450 450 94.62 VL Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units tv / ~ ~ Concrete Constructed Glass New Existing ~~ Tanks Tanks septic o< x°taing Ta"'` X 1000 1 Skaw Pre-cast X Aerobic Treatment Unit Dosing chamber X 642 1 Skaw Pre-cast X VII. Responsibility Statement- I, the undersigned, assume res~on4ibl6'ty for ulstaIIstion of the POWTS shown on the attached plans. Plumber's Name (Prins) Plumb 's S~ lure MP/MPRS Number Business Phone Number Tom Gustum 227618 715-658-1344 Plumber's Address (Street, City, State, Zip Code) N13450 937x` Street, New Auburn, WI 54757 VIIL Coun /De artment Use Onl -' ~ ^ Approved ^ Disapproved Sanitary Permit F~ (includ~es•~rrou ter ~ Surcharge Fee) `f ?S - Issued Issuing Agerrt Si (No Stamps) ^ Owrter Given Reason for Denial =~= ~ !~ p~C.• 2 ~ Ui;.. Conditions of Approval/Reasons for Disapproval 3~.~-~`.S ~,,~~ ~ ~_ ~ S S ~ ~ ~at~,e~ ev. C~-S SYSTEM OWNER: ~~( -, ~-~ Sai.I S'~ ~o-Q S~~Q 1 Se tic tank efflu nt filt p , e er and ~U,_S ,~ ~~ ~,~,~r may-" S'4--C(b2"~G dispersal cell must all be serviced /maintained T`'`'`om as per management plan provided by plumber. ~~;~~,~,,L,F~ ~,,,~~ ~Z __ 2. All setback requirements must be maintained ~ „ ^ ,, . r~ }`~ ` ~~ ~~ ~ b ,, as per applicable code/ordinances. ~ ~ ~a+-~S ~ t6 ~„r Attach plete plans (to the County only) for the yslem on paper less than 81 z 11 inches in size ~L.saiR ~.-~('v ~ C~9-~1 E ~~ ~ess . ~_. U'2,t; ^ (,~+~,.. ~ ~S w~( (oe_ ..~.~,. / -_ /I I 1`A m V N to + ~ ~~ '~ ~ '~ ,. t i '~ ', ~-,';~ ~ rn A ~ '~ ~ ~ , '. s ~ a n a ~. o o~ N~ 3 ~ v ,~ g w ~~, b -o o m n ~ , ~ ~ o ~, ~ ~ ~ W 4t , ,1 , ,1 0 tJ~ ~ ~ ~ ~1 ~, i , ,, 1~~~ ~` /oL ~'01S 1 ,`, o ,~ ,. ~ ~~ ~ 1 ~ ~ ~ i t 1 ,\ ~ , ,,` ~ ,, ~, ~\ 1 '~ ',, ~, ~~ , ,, ~, ;, - \ N `~ ~~ Q ~ ~ ~~ ~~ G~ K n ~n~8 < s -~~~' ~.~~m~ w w I ~ ~_ ~~ ~" .~ ~~ a'o O ~~ r O (~ m ~. ~ DAN m z mgt ° ~g~ o it 3 0 o m .p ~: YET V fD O1 2 -o ---------------~ ---------------~----------------Q°------~.s!~osZ I 1 1 1 1 i 1 I 1 1 I I 1 1 i i i i i i i i 1 i I i i i i i i J I 1 D~ ~' 4 1 I i 1 1 1 1 1 i i Q ei• C C C t commerce.wi.gov isconsin Department of Commerce Safety and Buildings 4003 N KINNEY COULEE RD LA CROSSE WI 54601-1831 TDD #: (608) 264-8777 www. co m m e rce . wi. g ov/s b/ www.Yuisconsin.gov Jim Doyle, Governor Mary P. Burke, Secretary December 21, 2005 CUST ID No. 227618 THOMAS GUSTUM GUSTUM SEPTIC SERVICE N13450 937TH ST NEW AUBURN WI 54757 ATTN: POWTS Inspector ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 12/21/2007 Identification Numbers Transaction ID No. 1227123 SITE: Site ID No. 708371 John Moe Please refer to both identification numbers, 2904 150th Ave above, in all corres ondence with the a enc . Town of Glenwood St Croix County SW1/4, SW1/4, S16, T30N, R15W FOR: Description: Three Bedroom Replacement Mound System Object Type: POWTS Component Manual Regulated Object ID No.: 1056049 Maintenance required; Replacement system; 450 GPD Flow rate; 13 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual -Version 2.0, SBD-10691-P (N.O1/O1), Pressure Distribution Component Manual -Version 2.0, SBD-10706-P (N.O1/O1); Biofilter 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 approved plans and with the component manuals listed above. • 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 POWTS 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. • The area within 15 feet horizontally below the system shall remain undisturbed. Vehicular traffic or soil compaction in this area is prohibited. • 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 Comm 84 product approval conditions. • The existing POWTS shall be properly abandoned per Comm 83.33, Wis. Adm. Code. • Comm 83.22(7) - 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. P O.~"J.T.~. Co~ditiona~'ly ~~~R~v~t THOMAS GUSTUM Owner Responsibilities: Page 2 12/21!2005 • 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. • Comm 83.52(1)(a) -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 iti accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. 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 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, --~ Gerard M. Swim POWTS Plan Reviewer -Integrated Services (608)-789-7892, Mon. -Fri. 7:30 am to 4:15 pm j swim@commerce.state.wi.us Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 WiSMART coder 7633 cc: Leroy G Jansky, Wastewater Specialist, (715) 726-2544 pg 1 of 6 Cover Page Project Name Owner's Name Owners Address John Moe 450 GPD Mound John Moe F ~~ syF ~ C I g F< ~,~e coos ~~ ~/y 2904 150th Ave. Glenwood City, WI. 54013 715-924-3981 Legal Description ~~, sw ~ '/,, sw I • /, Sec 16 T 30 N, R 15 ~~ N/ ! ~ Township Glenwood County Saint Croix Subdivision Lot# Parcel I D# ~ Table of Contents (~"~~ ~ ~~O 1 Cover page C/j ~~1i4~~ D ~~~~ atn ~ 2 3 Mound Sizing Calculations Pressure Di trib ti L d D i t ': ~~ 4 s u on an ynam ayou cs D T k /P C : ~~~ , ose an ump urve o 5 Management and Contingency Plan ~ ~ `' • r` 6 Plot Map ~`~~G N gyp` . _, ..~.~ total # of pages: 6 Uk?AR7tJ1EN~f OF COMMERCE pIVISIpN SAFETY AND BUILDINGS Designer Name: Tom Gustum ENCE License #: D1201 Date: 12/14/2005 Ph. #: 715-658-1344 Signature: Mound System Design Methods Used per "Mound Component Manual For Private Onsite Wastewater Treatment Systems" (Version 2.0) SBD-10691-P (N.01/01) per" Pressure Distribution Component manual for Private Onsite Wastewater Treatment Systems" (Version 2.0) SBD-10706-P (N 01/01) 3bAdvisement N12486 220th St, Boyceville, WI 54725 Ph: 715-643-6068 email: Mound System Page 2 of 6 Mound Sizing Calculations Project Name: John Moe 450 GPD Mound Site Conditions PrOJect Type: i 1 or 2 Famil y Dwelling ~ ~ Slope: 7 1 # of Bedrooms: 3 Depth to limiting factor: 13 in. Absorbtion rate of fill material: 1 gal/ftZ/day Absorbtion rate of in-situ soil: 0.6 gal/ftZ/day Effluent quality Eff#i 'i ~ Max BOD effluent value: _ _ _ 220 mg/I Max TSS effluent value: 150 mg/I Design of Entire Fill Cell depth at upslope edge (D): Cell depth at downslope edge (E): Distribution cell depth (F): Cover thickness over edge (G): Cover thickness over center (H): End slope width (K): Fill length (L): Upslope width (J): Downslope width (Toe) (I): Fill Width (W): 23.0 in. 28.1 in. 9.5 in. 6 in. 12 in. 11.8 ft. 98.6 ft. 8.0 ft. 13.8 ft. 27.8 ft. Design of the Distribution Cell Basal Area System Design Flow: 450.0 gal/day Basal area required: 750 ftZ Distribution cell width (A): 6.00 ft Basal area available: 1485 ftZ Distribution cell length (B): 75.0 ft Area of Distribution Cell: 450.0 ftZ Observation Pipes Contour Elevation of Mound: 92.70 ft Location from end of cell (Z): 12.5 ft System Elevation of Mound: 94.62 ft Final Grade of Mound: 96.41 ft Mound Plan View /Observation Pipes z~ --- ___ W K Distribution Cell ~'~', ~~ _ __ - r B k I Tilled Area/Fill Material L Mound Cross Section Fine.l Grade- ~` Synthetic Faoric-~--~-~-,, Distritautian Dell-~ ~- System Elev~ition ~ - ~~ ~ ~, q d Caner Materii~l ~.~ E La#~ral Fill h~laterial I Inert Slcipe Notes: Fill material to consist of ASTM C33 Sand Distribution cell aggregate to comply with Comm 84.30(6)(1) Synthetic Fabric covering on cell per Comm 84.30(6)(8) Distribution Cell to have minimum 6" aggregate below lateral and 2" above. ~• Mound System Page 3 of 6 Pressure Distribution Calculations Project Name: John Moe 450 GPD Mound Lateral Layout Lateral/Manifold Design Lateral elevation: 95.1 ft Lateral diameter: ! l~iz I ~ In. Rows of Laterals z_ ~ Lateral spacing (S): ~ ft Manifold type: '~ Center ~ i Lateral to cell edge: 1.5 ft - _ -__ Orifice diameter: o.is8 ~ In. Lateral discharge rate: 12.52 gpm # of Laterals: 4 System discharge rate: 50.07 gpm Distal Pressure: 2.5 ft Manifold diameter: z ~ In. Lateral Length: 37 ft Manifold length: 3 ft Orifice Spacing/Distribution Forcemain Friction Loss Orifice spacing (X): 24.00 Inches Forcemain length: 55 ft Orifices per lateral: 1g Forcemain diameter: I z ~ In. Avg. ft2/Orifice: 5.92 ft2 Friction loss in forcemain: 2.751 ft Lateral Side View ngth `I' Lateral Length Lateral Plan View Turn-up w/ball valve or claa nouf PVG Manifold °~l Lei ~~ by sPa ed PVC laterals, forcemain and manifold to comply with specifications per Comm 84.30[2] Forcemain connection via tee or cross to manifold at any point Clean Out Detail Glean-gut plug final Grade ror ball valve Sprinkler Box Lang Sweep 9~ artwa 45's~.,_ Observation Pipes 6" fvlinimum 1.~ SS Water tight cap or plug Nake: Closet Collar may be used in plaee of 3I8" bar `318" Bar Mound System Septic, Pump and Dose Tank Project: John Moe 450 GPD Mound Tank Information Pump tank manufacturer: Pump tank size/model: Pump tank gal/inch: Tank bottom elevation (inside): Septic tank manufacturer: Septic tank size/model: Skaw Precast 642 16.47 88 Skaw Precast 1000 Page 4 of 6 Dosage Volume Does forcemain drain back to tank? U Lateral void volume: 15.6 gal ft Dosage to absorbtion Cell: 78.2 gal Forcemain volume: 9.6 gal Total dosage: 87.8 gal Pump and Filter Total Dynamic Head Pump Manufacturer: Little Giant Are laterals highest point? Pump Model: 9EH if not, enter highest elevation: 0 ft Effluent Filter: biotube ft50854-36 System head (distal x 1.3) 3.25 ft Vertical Lift ("D" to lateral) 6.62 ft Note: Access opening of sufficient size to be provided to allow removal of filter. Opening to terminate at or above grade. FfICtIOn IOSS In fofcemaln: 2.75 ft Pressure loss from filter: L-Jft Total dynamic head (TDH): 12.62 ft Pump Tank Diagram WatertightLodcing ~ Cover Dose Tank Levels 4 inch IMth blaming Label Finished MnimUDli Grade In. Gal A Reserve 25.6 422.4 Alternate B Pump off to Alarm 2.0 32 9 Outlet . Location C Total Dosage 5.3 87.8 E 1 lect. per Comm 6.28 and D Effluentde thfor um 6.0 98.8 p p p cemain N EC 300 Total Capacity: 39.0 642.0 A Weep Fble orMti- B Siphon °eV1ce c Pump Curve 9EH rLOW- LITERS/HOUR D Pump must be capable of: and head pressure of: 50.1 GPM 12.7 Feet 3 10 1- N W 7.s w ~2 W i ~ a 5 a 1 z,s 0 0 20 40 60 80 Little Giant FLOW- GALLONS/MINUTE 9EH PUMP PERFORMANCE CURVE 11sV 60HZ 12/21/2005 12:13 17156581344 TOM GUSTUM PAGE 01 ~~#ITiI~ S~~n ~Yh~~a011'1@11~ Plait pursuantto comet 88.r5~ vlr. A.C. t~wttAr"a Ftesponslb#tlty; The component owner is reeponsiblo far the operation and rrralnte~nance of the component. The Courtly, deparCnent or . PbVUT'3 Service cnritraCtor may make periodic inspeGions of the cnrrrpCnents, checking for surlbce discharge, trBBted el9tlueftt levels, eta Ttter~rrer~-rnwrter's agent iclti~nsd~exetbmit n~ssary maint~ance reports tb the appropilats jyrisdiCtlon and/or tl~e department. 8aptlc 7'al~k: Septic tank{sa are t4 be inspeCte~d routinely end maintained lhy dapartmer~t approved individuals wM~en necesaa~y In accordance with their.approv&ds. The use of ahemical/bioto~icai "Erea'tments" is not raqufn~d or reComrtiended. if such addaivea ors used, tnt~la~~une they area~roved'!ti!-'C~eeu~t vf~ommerce, Sacfety and Buildings Div.; Effluent fitters are to be removpd & deaned as necessary, with provisions to keep solids from passing the septic durir~ remavaf. No more than 1/3 of thb usable tank volume may be occupied by sludgelscum. 3'year inspeotlen: !f tank has granter then 113 rroiume sludge, tank oontenta must be emptied and disp08ed of in accard9~nce with NR 113 W~nsin Administra~tir+e Cade b5+ an approved individual. if the inspector does riot recommend punrtping of the septic t2lnk, then the owner rtXUb't be notified of when puafpirrg .ild be clone as #o not exceed t!3 siudga votttme. Sep~ie tank shauid ~ ~ trtspeded tq f~ Wgtarrtlght and of good repair, PumplDosa Task If art ef!lueat filter has bean installed in the.pumpldose tank, it mus# be removed 8 cleaned as nece~ry, with provi,slons to keep solids fman prig to .tbexoarnd componen! during removal. The pump. goat ~swiGches stud adalrms must be inepxt®d 8t l~at ,every three hears for ~ faroper operation. i~umplddse tank should be routinely inspept~ tb be rnreterCigAt and, a# good ~ppir. llllound and l.»Iteraf 3ys~sr The mound system component moat remain free of panded sunF2~ce water prbr to pump operation. ff 4 inches or more water level i$ detectecl..Jq the pbservaeara pipes, the owner must fie natifiad crf passible, problemaRaiture. The designed da11Y t1CS,er caspabilit' of .the component should near be exceeded, "frees and any attrer deep rooted aegete~tbn should neiwver ~ ptanteal, or a+"i"~ to grow anywhere cn the component. {4ctlvities r.~TWER than mowing/tnaintgnence {i.e. excossfve tNaticcirr¢, pate, vehtalas, etc...) could compress the component and rritduce it's absarbtlon CapabNlges arrdlar possibly Muse it trs fraeve in whiter conditions. Lateral distribution pipes sN-ould t~ flushed out/t~te~i eveN 18 months U9ing ttte ci~pout poirsxs at each end of the vomponent to remove scum th2rt m y slog ertfrc~. P~erformanca tlAonitaring: Pgrfarmancx~ mnnltraring must be done at least once every years fnlrowinq the installation or at the tinge of a problem, cxfr-tplairtnt, br faitur+9. Owner vufTl #e rntldifled bJ- the county itx regained Inspections. Conttttgency E'lartc If the septic tank. pump tank or any of their campanerota therein (including floats. afarn'rs, pumps, etc) become dafecdhr+e, the defective tank or~amponeat must be replaced irnmediateiy to ensure that the system can operete as desigricd. If the malwrtd Component ~annat accept wasia+aeter or ponds wastewat+er~to she ~surfbCe, the ~cortrponent moat ba r~irgd or Nsplplaad ~ln it's 5lurrent tocskfor- tsy either: extending bassi toe to pno+ride added ,abaorgtion area; or by removing the dogged br181 mat,aggreg~ +seli, and distr}tyution piping within the mound >:tnd replaaing said coarrponents in order to nstum system to ptbper Working order as required. Gotttect ~nfb~rrrt~on: tt,liieir Gourr4y Agenlrs: Custarrr Seppttc Services Barron Ciaurity Zoning ph: '718-837-8'375 N13454 837th St Chlpp~etiva Cow'riy ~dl'tirtg ph: 71'~'T28-7944 ~7New Aerbum, WN 54757 Dunn Colunty Zgrtirt~ pit: 715-2~.14fl1 r r~ ~~~_ 1~ ~, f EaU Ctat~e CpJ~rrty H+eallth [~vt ph: 71~-8'J82 'l ~F+atk ~:cui~ty ~anl>ag ~h: 7Y51~'i''g F~t~9c Copntty ,Zoning ph 1-7'15~»53~ ~-i 56 ~~St Croix iCounty 2csning ph 1-71;~3t36-4680 '. D ~ W ~ I • - I I I 1 I 1 i ~I ~ N 1 1 - I I i i i ? O /~ (A , i i i p p ~ N 1 Na ~ 11°, i .n g ~~ ~ V~, 1 O ~ ~ ~ p ~~ `~ 1 ~ 11 ~ m ~ i ~~ ~ " p ~ 1 T y ~1.~ I 1 1 ' ~. 7 ~ ~ ~~'~~ - ~ ~ ~ m ~ 1 I ~ ' ' 1 , jam ~ ao +, w I o '~ '\.` I 1 I 11~ ' ~,t ~~ °~u1~0IS I I I I O 1 ~ ~ 1 ' I r.. f , `1 \ ~~ ~J 1 1 J I ~ 1 1 ~ 1 ` ' I ^ {D 1 I ~. O ~ ~~ ~ '^ ~ 1 1 0 " - ~ ~ m n r ~ r ~ ~ D`~ z rg~ 0 1 ~~^ m 0 _~ 1 a ~ . . g (~ I I I = ~ n o I ~ I I ~ ~,. ~~ W ~ ~~ o a -~ ~ ~ . _ ~ A s 1 : ~ ~ I ~ 1 1 N y ' (((5~~~ q~ ~ ~ o j A 7 --7~~ --7~ __i4 ~{7~ .__\~A ( v ~ I i I - ~ O OHO ~~ .__`~~ __.1 ( r( ~~ ___`LA T N ~U I 1 (Q~Q~ m ~ (( --~ I 1 - ~ ~ ~ ~ p I ~° ~ O ~ ~ ~ I I n~ sY ~ d 3 I 1 (D j m o --i W W ~ / ~ 1 1 1 1 I ~ 0 Z I .~_ I 1 U1 i I L 1 i S --- ---- -----~ -------------------------~- -- ~lS 4~ ----~----- --- 1 ~~%~IC~I]1s%/'~ SOIL EVALUATION REPORT Depar6nent of Commerce in accordance with Comm 85, Wis. Adm. Code n~~~~,,...,f e~f~.. ~..a a. ai,~~..,,~ #2129 Page 1 of 3 Gustum Septic Service Courtly Attach complete site plan on paper not less than 8%: x 11 inches in size. Plan must ' St. Croix t (BM}, direction and include, but not limited to: vertical and horizontal reference Parcel I D percent slope, scale or dimensions, north arrow, and t n distance to nearest road. . . Please print aU in n. Reviewed By Date Personal inforynation you provide may be u ary purposes " acy Law, s. 15.04 (1) (m)). Property Owner ~ ~~ ~ Property Location Moe. John ~ Govt. Lot n/a SW1/4, SW1/4, S16, T30N, R15W Property Owner's Mailing Address ~ GCS; Lot # Block # Subd. Name or CSM# 2904 150th Ave. ~~ n/a n/a N/A City State ip Co~. Pho umber City Village / Town Nearest Road Glenwood City WI 013 715-265-4110 Glenwood 150Th Ave. New Construction Use: / Resi ential /Number of bedrooms 3 Code derived design flow rate 450 GPD Replacement Public or commercial -Describe: Parent material loess Flood plain elevation, if applicable n/a ft. General comments Part of 140 acres. Recommond mound system along 92.7' contour. and recommendations: ~ ~~_ ~~ ~.^,- S~ d u ...----n--_ /"C` t r----_ rp'_._~- 1 - r-° -~-- J ._ Boring # Boring / Pit Ground surface elev. 91.5 ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft2 in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Et(#2 1 0-8 10yr3/2 none sil 2mgr mvfr as 2f,im 0.6 0.$ 2 8-13 10y5/4 none sil 2msbk mvfr cw im,lco 0.6 0.8 3 13-20 10y4/4 c2-3p 10yr7/2 7.5yr5/8 sil 2msbk mvfr cw - 0.6 0.8 4 20-35 7.5yr4/6 C2-3p SOyr7/2 7.5yr5/8 sl 2msbk mfr - - 0.6 1.0 Boring 2 Boring # / Pit Ground surface elev. 91.5 ft. Depth to limiting factor 14 .--irt:- Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 }Eff#2 1 0-9 10yr3J2 none sil 2mgr mvfr as 2f,im 0.6 0.8 2 9-14 10y5/4 none sil 2msbk mvfr cw im,ico 0.6 0.8 3 14-21 10y4/4 c2-3p ioyr7/2 7.Syr5/8 sil 2msbk mvfr cw - 0.6 0.8 4 21-35 7.5yr4/6 c2-3p 10yr7/2 7.5yr5/8 sl 2msbk mfr - - 0.6 1.0 * Effluent #1 = BOD ~ 30 < 220 mg/L and TSS >30 < 150 mg/L 'Effluent #2 = BODS< 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature: CST Number Tom Gustum 227618 Address Gustum Septic Service Date Evaluation Conducted Telephone Number N13450 937th St. New Auburn. W 154757 11/21 /2005 715-658-1344 ~~ ~- _~ ~ ~ ~- 3 Boring Boring # / Pit Ground surface elev. ~•0 ft. Depth to limiting factor 13 ~~ ~ 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#t *EtT#2 1 0-8 10yr3/2 none sil 2mgr mvfr as 2f,im 0.6 0.8 2 8-13 10y5/4 none sil 2msbk mvfr cw im,ico 0.6 0.8 3 13-24 10y4/4 c2-3p SOyr7/2 7.5yr5/8 sil 2msbk mvfr cw - 0.6 0.8 4 24-40 7.5yr4/6 c2-3p 10yr7/2 7.5yr5/8 ~ 2msbk mfr - - 0.6 1.0 Boring Boring # Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horzon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft~ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *EtT#t *EtT#2 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/ft~ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Efr#1 *Eff#2 * Effluent #1 = BOD 5> 30 <220 mg/Land TSS >30 <~ 50 mg/L * Effluent #2 = BODS430 mg/Land TSS <~0 mg/L The Department of Commerce is an equal opportunity service provider and employer. )f 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. ~,,.. o~,~~ m ~~....,. r_...w.... ce..w.. ce...:..e U 290th St. ~ ~ : ~ ~ ; 3 'o : (h - ~ ~ Z ~ O r •- ~ ~ M = ; I ,° ~ ~° N N - 1 ~ ~ i i C _ W a m3 0 ~ Q r ~ ,~ ''C v aLU~~j ; \t~\R ~~I~ F~l~~~l-- ~%%%p1 .._ ~ 3 ~ E x ' _ ; $$ C ~. L ~ m b S V ; ~~ N ; ~ `~lq \ z i i i ~ i = L O v U y d ~ i ~ O 7 ~ ~V ; r- ~ O ~ v i O N ~ (6 $ r IB i _ r Y 0 ~ ~ m I I I W ~ ~ ~ / ~ C`1 JV C G ~ w mW~ ~, ; ~o ~~ ~~ °° ~ r ; > ~~ ~ .Q Q ~ ~L '~ ~~ ~~ ; O ~ ~ ; mope ~°~ ~n o m~ ~~ ^ ~ o ~ th T ; ~ i i a ~ i ~ i d "` ~ ~ i ; ; ; ~ i i ; ; i ; ^ i ~ ~ i ; ; N r m ~ ~ ; ; ; ; i ; i ~ ~ ; i i ; ~ ~ ; U m ~ Q ~ ~~~ S'7:3, ~~`7 : srnre 9AA orF wrsCf.7nlstra ixcYr~l~a 1 ~ > qea L~N1~ CON'1'R+1CT w+dWai Rwd e CTt3 Ei UiP.la Ft]R +CI.L TYtAN5d1[:tN14 ti>~Eit+A:: LWCN f?OGLYhAtr tVT' ta0. its 'xxY es :>trYwrte-.t=n ~+rrts trY +iTma rrt~s,t~Ct~rxst,ut;a ACS T1tANARC.T/C31VSY i..l)l7 tTt~C.1 > by uttd l7et:w'ECn ~~ r O t~MO@ ,-- .._._.37~~.~?.L h v~.,t_~1.L1.~1~.....12.f:tBt4~i#_..--•--- -------_-. .... w•ttr:ht~r anr. nr mOtc:) aYtd ~Q~n. R'.._. MO@ ._._.__..-._.__- .--._.... -.---..._---....._-._._....,..................-...__...__.__..-------...--- ,-,,.., t:'Ptcrcltaaar', whether s»te ar mar+e')• 4endta sells and agrees to [:txt,•ry t[r C'urchatser. ulacxt ttre pn~rn}art and full prrfaerrt'tunee ;sf ihts ccmtT'ttct la)` PurrhasC'r, ttta f'nl'lawing, pr[sperty, t.~t'ther wtth tha reins, fSasfliY:, fiatumsrnd Yxttrr appurtenant tntr.TY:sts tall callyd the `f naprrty"l, m .,_ _._..._-,._ .............aRt.~.._.......~xQ3$...-.......--.~_._-__.._......_..--,..........._........_ C+atattty, State of Wise[+nsitY: t ~a~V~A ~rQ«y E~'[ Q9:30 I-.- ~~.. TliiB S['+s~ aea~vaa Y'OA wrxaoPtflarct tawrw ~~~~~~~ ~~ ~~~~~ 7i0 MaMr 3~sst ' ~aldw~,. Wi 5 West Half of Southwest Quarter (W~ of Sits) and Atolrtheataet Quarter of soutt-west Quarter { 1iT3~'~ of 3it~ y of section ~cixtes>e>t (16) . ToTrnship Thirty (30) North. Range Fifteatn (15) West. Tf~ ~~~~~ -[i,iti .._,,,__...._., i ~__.....,_.w..-_.--__..-- Fxintestrad Ixopeay tia) (itA61[ t utrhasrt • rera to . uTSfTSSe tlx Praprrty astd to pay rc'+ 1ri:.ndvr at _.~.~,~.a~~ B~.B~, ~1 '~'.@d _l9~- . V~lldOr -----._-. tlsr suin c>f 5..._.S~ C._~Q~! Qo _.. in thr FFil^~wiai massttct: (.a} 5..._ 7! _7V~~-~-.----••- aY rltr rxrc:uti[sn +~f'thia C:ctnt.racs, arYd t1a) tltr lxsiunce tsf 5 gO • Q~Q • ~_ _--~~~ .._ _ [age'cltrr vczth i:threat from date hi~t>y[-i ors thr ltalani:r twsytanding fsYSm titstr to tir:e at the ra[C of ..'....~~~~~ _S„± A~~.prrrrna ,~x~r artstvYn urttdJ paid is ful$. as. F:~tbvvs' semi-annual paymentY~ of $50Qq.gt?, co~sencing July 1 r 1998, and each I3~ac®ttn3~r~r 31st and Juiy 1st thereafts~r. Pnavtded, httwcver, t.tsr. entirr outatandiatK IwtattcY- shall Ix' paid to full +stt +~r hafYarr tl~___,~~YS ~ ~~ ~~_ ~ __,. (tltr. inaturiry tlatr.). i=:atk~wdng aa:y 3rfatrlt in payment, tntetett shat! arrtroe at t.kx: race of ~~'9s per aizrtutSi oat ctta antiTr am[sunt to deFauli (suhie•!t att:tt ittClude, M'ttliOtit ii:nuatiaNY, deliitq~urnt intt!rC3) and, uptstt ac~•'tirrati+m ur ttwt:trtiy, the retire pritt(:i~¢eal balaTYee.) Pun-ltaser, untrue rt[ruxrd ey Lirnd[sr, u8~* to pay rtuxttltty t<~ ~°rnckir amc~urrts sutlir.ient tct pay reasw'rscFitytutticipated attntial tasuys, spacial assraY:rttrnts, flrt and rtrquirtd insurant>r ptemiurns when dtye To the extenr tr.:•eiwrd ~ ~e't'idor, lkttdcsr agues t'o apply paytttrstts to tltrsr itl]iti '}~tt+1it91Vllrti CItAr. SGCIt agt~nlnt~ tY'CR.IVCd Ity [ftC ~Cttdt7r Fi?r payYtterii Ot 18ttC.5, ,ASi,C:ShctYlfltt9 Attd lttlii7tt'at1Ca N'tll hp drp<)61trd ittl0 at1 aSCYPw fund nr tntstrxr a+x:trttnt, but slta-{t n[:n hear :nrerex unkas ~•x{•nsYV'ts,e mtluu'Nd by taw• i'ayraanu: slt~all lee appltcd ftrsi t:Y irtrrrrst on the unpaid Isalantt at tttr rtttr spr+:ilird and then to principal Any tutusutu trtay be prepaid wtthaxat. prrn:itttxt or fee. upait pnnrtpal at am• time. after ___.l~anlial~. ~.........._........._....._-.. 1.9 ~ -- In the evt nt +~ arty prefwyntrnt, this txYnerart stYali not tx: treated as in default wtth respect to pap'trtent sea lent; as the unpaid batantr of pnncipat, and irttrreax {and in attch r:aaa• au-.crutnK inrerrst fa>m mxnttx :v nY[srirh shah hr. traatrd as unpaid pttinetpal) itr Ie.Yta than the asntaunt that uta# ittdehtrdnrra. would ltn.•r hrrti had the nYa:trhty paytncttts Ixs-.n made as fires apectfKd abasve, pas+tidrd that raYxuhly paytnrrtta soul! Ise. rontYnttrd to the event of credit [af any pnkec.ds of utsssrstn[:e <>s [~xtdcmnatinat, rla; ccxY[trtnrrd premia~es lxing tltcrrufcer rxrlttdrd herr.frtam. Ptir[!tas,rr states tltai Pier[ ha~rr is aaltSlird NRIlY lhr. lttl£ aYr Sltasv.Rl by tltr. t.itfr rvtdrncr submiued tiY P+irchasrr for rxaminattam exnept: t'ttret,a;rr agrees ic) pay Yltr [xKt of fut+Yrr Yittr +:Y'idrnce If title. rvYden,.e tS in the flares of an ak>stiact, n altatl tae n:tai[trd by Ven.~~tr wail tht- Euii lautt.tatctr price is ptvi[t. 1'urc.lYaac•r sltutl ts.r rnrirird us ia1[C Ixssrexsmir [Y,l the E'roperry an ._. ~~ OP C10~Et~[1~_,_,___-..-..., ~..__......._. STATFi. 6AR oF' WiSCCHiSiPt w:yt~v~xr, t~pat ttttv:- Co kc t .nhiY a [I t~TR.I[:1 - anatS.idewt xud [°.u:yr.~rwiz LYorw Ns. tt - iWR2 t'~•~''~~ N'~a W;scongih Department of Commerce '"'safety and Building Division GENERALINFOR Personal information you p Permit Holder's Name: i '` h ~ ~a J~ Q ' h Moe, John CST BM Elev: soy 4 ~"~ 5 -~- ~c ~~ TANK IN FORMAT ~ ~ TYPE ~ " ~ ;APACITY Septic Q Dosing /~ Aeration ,/)/,1 ~~ l (/ 2 J Holding TAIWC SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic- 7Q ~ .~~ Dosing / ~d ~ Aeration Holding PUMP/SIPHON INFORMATION /~lG7- ~/~T' Manufacturer ~ Demand tuber TDH Forcemain Dist. to Well PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) rivacy Law, s.15.04 (1)(m)J. City Village X Township Glenwood, Town o~/f~ 1 `(/ ~ .SIGWYI ELEV TION DA A Ft SOIL ABSORPTION SYSTEM ~ w-,/ ~S a~ILG~~Fin,_a-h~- County: .St. CrDIX Sanitary Permit No: 4$8002 0 State Plan ID No: Parcel Tax No: 016-1036-20-000 Sedion(fown/Range/Map No: 16.30.15.262 STATION BS HI FS ELEV. Benchmark ~i gas ,oa. ~ ~~ Alt. BM Bldg. Sewer 76 i SLy p ~.~ , SUHt Inlet /~ o~ o•S ~ -7S St/Ht Outlet in~ha a-9 8 ~3~ Dt Inlet Dt Bottom ~.~ ~S' 7S ea er an. Dist. Pipe Bot. System Final Grade St Cover~i ~ ~ ~ y(S ~ S 7S BEDITRENCH Width Length No. Of renches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM L C G Manufacturer. INFORMATION CH ER OR Type Of System: UN Model Number. DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER Y Pressure Systems manly YY Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes ~ No Q Yes [] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~/ Z ~ / t~ Inspection #2: / / Location: 2904 150th Ave. Glenwood C/ity^, W,,I.54013 (SW 1/4 SW 1/4 16 T30N R15W) 40 acres Lot I u( Parcel No: 16^.3~0,,1A5.262 1.) Alt BM Description = ~~~ ~ 1~/t-~ Z '~'~,~,' I~~~~~ ~ ~N~¢'~~' "° "' 2.) Bldg sewer length = 7~ ~ /lam ~~~'~-Cr l~Jv Z~rY~~ - amount of cover = ~ ~, .~ ~jJ ~ho Plan revision Required? Yes No _ , , Q Use other side for additional information. Date insepctor's Signature Cert. No. SBD-6710 (R.3/97) Loss ISvstem Head ~I fit; . y I I n p~j ? 01 ai O ~ d ~ 3 ~ p N N C 3 C O -' N D. = 7 7 ~ ~ I 3 I o v V) v ~ C ~ ~ ~ Q p W j I 3 o~. o ~ .0 C' y I °~ I ~ ~ I o ~ ~ '-'~ y C O ~ ~ o ' 3 ~ _ I o N I n z 0 I ~i O I o m C W d fD ~ Z 0 f D ~ ~ I ~_ I o I I I c°~~ aim a n I ~ w •3 - m 5 o~»~~~ j f ~9 my a m I ~ ~° ~'~ 3 ° z a , • ~ 'p o O ~ 7 ' p N ~ f C, /1 ( _ 01 m I ~ O ~ _ .~m ~ y r `G ' ~an3om ~ ~ I n c~ ~c C ~ N d .~.. 7 ~ -~ ~ N 7c I ~.~.-aa ~ g ~ ~ ~ O 0 ~p X O f/1 o N Q N ~(~ 7 _ I I ~ ~ gay N y' N~. Z N . o=y a I '~ m O N ~ ~ o : o c~cn0!. 3~n d c ~ A 1 ~ ~ N A .. I ~ O , o ~ ~ YJ ~ ~ t~ • ~ w ' ~. N O ~ ~ ~ ~ ~ O ? i N n ~ N O O A i O ~ o C a o i i a D ~ I . ~ ~ ~ ~ J i I G1 ~ (n w Q G1 ' n ; ~ o ~ ~~~ ' N N N ~ ~ ~ , ~vvo' w'~ o ~ ~ i ~ A - ~ m w N N ~ ' li N m o o y m ~ ~i co ~ ~ • ~ y l~1 -~ C ~. N ~. 7 i ~ N C ...- ~ ~ ~- I A ~ .. w rn c ~ ego ' ~ z a ~ p ~ ~ A ~ O '•' !A ~ N C ~ j C ~ A to 01 3 m ~ ~ i - o c ~ j ~ m d ~ O i ~ I O a !0 N ti I O wA~ 1a ~ ~'0 ; 1 ~ GW ', ti t+,~ `°, b , ety and Buildings Division County St. Crolx ~ ~ Ol ashington Ave., P.O. Box 7162 ~~~O~S, adison, WI 53707 - 7162 Sanitary Pe rmit Number (to be filled in by Co.) Department of Commerce ( // // "7~~~ ?/ Sanitary Permit Applic tion State Plan LD. Number In accord with Comm 83.21, Wis. Adm. Code, personal info anon ~gplprpvide ~ 2005 ~' G may be used for secondary purposes Privacy Law, sl .04(1) Project Address (if different than mailing address) I. Application Information -Please Print All Information ~~/J'~ ZONING OFFICE - Property Owner's Name Parcel # Lot # Block # John Moe ~/ - ~`03(/-a~ ~a Property Owner's Mailing Address Property Location 2904 150'" Ave. City, State Zip Code Phone Number SW '/,, SW '/<, Section 16 . Z (a''L Glenwoon Ciry WI 54013 715-265-4110 T 30 N; RAW 11. Type of Building (check all that apply) ~ II X I or 2 Family Dwelling -Number of Bedroo s _3 ,(~-t Subdivision Name CSM Number ~~ ^ Public/Commercial -Describe Use G~ ^ State Owned -Describe Use ^City ^Village X Township of Glenwood III. Type of Permit: (Check only one box on line A. Co line B if applicable) `~' ^ New System ^ Replacement System Treatme eplacement Only ^ Other Modification t Existing System B• ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Pr vious Permit Number and Dat Issued ~ ~ ~ ~ f~ N/~' Before Expiration Plumber Owner V ~ ~ h " : ~` h f k' ~'6- Qh,c.~t~tccQo IV. T e of POWTS S stem: Check all that a 1 X Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. 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 al/Treatment Area Information: esign Flo (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation 450 Unknown VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank X 1000 1 Skaw Pre-cast X Aerobic Treatment Unit r Dosing Chamber X 642 1 Skaw Pre-Cast X VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number Tom Gustum 227618 715-658-1344 Plumber's Address (Street, City, State, Zip Code) N13450 937`" Street, New Auburn, WI 54757 VIII. ount /De artment Use Onl Approved ^ Disapproved Sanitary Permit a (includ G undwater S h F ~ Date Issued suing Agent ignature (1`1 ps) ^ Owner Given Reason for Denial urc arge e 1~ -7, GL ~S tJ ~ ~ 2 1 D IX. Conditions of Approval/Reasons for Disapproval --~2~VzC.- ~ ~~~ii~~Q~ j~~ ~W t0 ~~~f-YJ ~~ (i~/ v ~ L~1'r`-~l (i¢~ ~ ~~~ (l _ ~ ~G~~'L;~~u~ J' /~~~ n ttacn copiptete pla~ ounty only) for the system on paler not les/s than 1/2 x 11 in~chyes in size ®~/~'~~ 1Yll ,i(1C/~°y„C,/[ `J ~{,L~.U„`ZiY'/J ~ ~ l~ -T " 4~~i(/~C..2~ SBD-6398 .01/03) a~ b 0 v C 00 m O m 0 v O Z z -~ m r 0 -~ C Z n O Z T~ N (C O Z O z r D Z m rn -.~ I~ c rn m m v 00 rn rn c 0 m v Z m I rn c _v O Z ~~ a c~ zrn vn o~ 7v r O ,. ~~ z OD O~ C~ m -~ '~ C Z~ W TI T 0 r C~ N N 0 z m y la ~, ~~Vp N~ ~ ~ ~ 7 ~ M M~1 ~ 6~ 0~ V 7~~~ ~. ~~ 7 ~ b 9 C s~ ~ ~.~~»~~~~~°~ m x3 gg~ ° ~ ~~.i '° ag ~ ~+~$~ ~ nm~~Z 8~ ~ ~~ 3$ ~o ~ ~~~~. ~ ~ ~$~ Qs}M ~ ag a +~ ~'~S' ;G O A d ~ Y ~ ~ ~ s S ~ ; `C ; ~ ~~ r ~' ~~~ v ° r ~~~ o ° a ~ ~ 3 ~, rn Z rn r -~ rn C O C n rn D z D ~~ - n a O rn ~ ~ ~_ C z ~' -1 m y 11/18/2005 10:44 AM PAGE 1 OF 1 Alt. Parcel #: 16.30.15.262 016 -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 CaOwner JOHN R MOE O - MOE, JOHN R 2904 150TH AVE GLENWOOD CITY WI 54013 Districts: SC =School SP =Special Type Dist # Description Property Address(es): * 2904 150TH AVE * =Primary SC 2198 GLENWOOD CITY SP 1700 WITC Legal Description: Acres: 40.000 Plat: N/A-NOT AILABLE SEC 16 T30 R15W SW SW Block/Condo Bldg: ,5 Tract(s): (Sec-Twn-Rng 401/4 1601/4) ~ ~ 16-30N-15W ~ Notes: ~ ,/'~ ~ ~ ~ ~ ` /~ Parcel History: Date Doc # Voi/Page Type 1 1 e.~, p ll _~1 _l~U- n.~un~~nno e~nnn~ enn~inon ~r 2005 SUMMARY Bill #: Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 10/06/2003 Description Class Acres .Land Improve Total State Reason AGRICULTURAL G4 36.000 3,600 0 3,600 NO UNDEVELOPED G5 2.000 200 0 200 NO OTHER G7 2.000 9,000 109,100 118,100 NO Totals for 2005: General Property 40.000 12,800 109,100 121,900 Woodland 0.000 0 0 Totals for 2004: General Property 40.000 12,800 109,100 121,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 112 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 - ~ (~ ~~ ~ ~(;~ ~ ~ ~(~ ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer ) p /! ~ 1 Mailing Address r - ~s'~o ~'}~ Q o L- RFCEIVE~ JAN 2 6 2006 n fl ST. CROI OUI~ITY `~-~ ~C/F-e n- w 6 o d e f ti Lv~ S `~D j Property Address ~ ! d y ' l s~ ~ h. C(, 1/ ~e. ,,~/,e --,,, w Q o ~ C (~' (.v z S-- ya / 3 (Verification required from Planning & Zoning Department for new cons ction.) City/State ~ %e tiv W c o ~ ~- f i/ ~' P rcel Identification Number ?~ `Z X 13 ~ / (~ ~ ~ .~ ~~ -~ c1~ ~c r -e S LEGAL DESCRIPTION Property Location S iN '/a , S w '/4 ,Sec. ~ ~ , T 3 U N R J.~ W, Town of ~ `~ ~ ry ° ~ Subdivision ~~ Certified Survey Map # "~~ Warranty Deed # Spec house yes Lot # Volume ,Page # Volume ,Page # 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(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms _,~_ SIGNATURE OF APPLICANT(S) ~/ 3 `~/ O ~ 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. osios) ~ ~ a. 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