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016-1047-20-020
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT sanitary Permit No: 430191 0 GENERAL INFORMATION (ATTACH TO PERMIT) tate Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)).� Z� = Ti Owls . /A Permit Holder's Name: City Village X Township Parcel Tax No: Moe, Brian I Glenwood Township 016- 1047 -20 -020 CST BM Elev: " � / Insp. BM Elev:� BM Description; t q - Section/Town /Range/Map No: 21.30.15.342A10 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 6 1,1 00 Benchmark (. 7 1 00-y qg Dosing � �-� Alt. BM ST • V'�R- � • b Aeration IN Bldg. Sewer -0 P 6 � , IS•� -(� Holding SUHt Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL LI?G, V nt to Air t ROAD Dt inlet Septic I Dt Bott m Dosing ' raf ` Z a � e Aeration / Dist. Pipe o f 4 p Zo Holding Bot. System / O PUMP /SIPHON INFORMATION Fin Grade T I Manufacturer v v Germ�and S over 13 , I � }il � y' l d Model Number tq It ( r .1 2. P f 7- S 1 TDH I rw r Friction Loss System H d TDH Ft \.• � � I .fo� •� 25.�� f t71ti (� V; 911h O orcemain Le h Dia. Dist. to Well 14 1�5 7i (a� 9 •� cgla9 `j8•�S' SOIL ABSORMOICSYSTEM BEDITRENCH Width f Length No. Of T4opskee - PIT DIMENSIONS No. Of Pi Inside Dia. ep DIMENSIONS C 1D SETBACK SYSTEM TO P/L BLDG IWELL LAKE /STREAM LEACHIN a ufacturer. INFORMATION I CHAMBER O Type System: I UNIT umber. '73 S9 1 -. (0 0 DISTRIBUTION SYSTEM �-- L Header /Manifold Distribution I I I x Hole Size f x Hole Spacing Vent to Air Intake O + �^ Length 3 Z L P ength Ilia t IZ - Spacing �" t s� 2 �( SOIL COVER x Pressure Systems Only xx 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 0 Yes N No [] Yes X No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:�/ �" Insp ion #2: / /d v*vIl'i lot Location: 1423 290th St Glenwood City WI 54013 (SW 1/4 SW 1/4 21 T30N R1 5W) NA Lot 2 U �- Pcel o: 21. 0. .3 +er 1.) Alt BM Description = 5 ' r �" N tk't. �A�Ot� - 1 I�0 --G A� " 2.) Bldg sewer length= (QI I - / _ , t - amount of cover = t i7 /f C'- 4nn_4e U Plan revlsio Required ? s o (s� Use other side for additional information. __ SBD -6710 (R.3/97) y �(tS Insepctor's Signature Cart. No. t� Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 lVi sconsin Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not state owned.) Attach complete plans (to the county copy only) for the syste on paper not less than 8 -1/2 x 11 i nches in size. County 7 - 97te3anitary Permit Number ❑ Check if revision to previous application State Plan I. D Number I. Application Information - Please ' all Information ° R -- Location: A ST Property Owner Name Property Location 3 `J- it :r '1 f 4 1/454)1/4, S;Z T ,N, R/,f(or) W Property Owner's Mailing Address > >. Lot Number Block Number 3 City, State Zip Code Phone Number Subdivision Name or C _M N ,m� bcr ���' / V!to II. Type of Building: (check one) ' // J &, �/Lya7uLa�— ❑ city 1 or 2 Family Dwelling - No. of Bedrooms: ` ❑ Village ❑Public /Commercial (describe use):_ (Town of • State -Owned 6�/ elwe eepl 5 0 ol C-ol � L 1*'1 q j Nearest Road g!? / �J � ' d 4/- # " / 7 Parcel b s III. Type of Permiti (Check only one bo on line A. Check box on line B if applicable) A) 1. Jq New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to System System Tank Only Existing System B) Permit Number Date Issued ❑ A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) I( su 6 ❑ Non - pressurized In- ground < Z� ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment Area Information: na4akl S" 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 11. Final Grade Required Proposed Rate (Gals./day/sq. ft.) I (Min. /inch) Elevation VII. Tank Capaefif in Totaf # of anufacturrer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks %6 a Con Con glass New Existing crete structed Tanks Tanks VIII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (print) Plumber's Signature (no stamps): MP/1qjkjWNo. Business Phone Number ��� C� S/►�i7'`" /6" 1 Plumber's Address (Street, City, State, Zip Code) IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Is mg A nt Signature tamps) Approved ❑ Owner Given Initial Adverse Surcharge Fee) 73 1/ a Determination X. Conditions of Appr val /Re sons for Disapprov I - '7716!0 �� G I C-�dcco;& 30 sP41r,� 7 f 3 JT L- 3 Clt-n, IX 1/k SBD -6398 (R. 07/00) 7 ■� ■� ■ate ■�s� ■■■■■■■■■■ ■r■ ■ ■ I©�'�'�� ■ ■ ■■ ■■■■■■■ ■� ■■ ■■■■■■■■■■r ,■ ■■ III ME ■ ■ ■ ■■ ■ ■ ■ ■ ■ ■ ■ ■ ■■ ■vem MUCK Mill R,,' " - /J ■I■ ■■ ■ ■ ■ ■■ ■■■■ ■■ ■ ■■■ ■■ ■■■■■■■ ■■■■■■ ■■ ■ ■ �� % ■■■ ■■■■■■■■■■■■■■IFF ■■■ ■ ■ ■■ ■ ■■■■■■■■■■c■ 1 ■■ ■■■■■■■■■ ■■■■■■■■■■■■■E ■■■■■ ■ ■ ■■■■■ ■■■■■■■■■■■■■■■ill ■■■■ ■■■■■■ ■ ■ ■■■■■■■■■■■■ ■!� III ■■■■ ■■ ■ ■■ ■ ■ ■ ■■ ■ ■■■ ■■■ ■■ ■■■ ■ ■■ ■■ ■ ON ■ 111 ■■ ■■■■■■■■■■■■■■`■ ■■ ON ■■■ ■ ■ ■ ■ ■ ■■■■■■ 1 11111111110 ■ ■ ■ ■■ ■■■■■■■ ■ ■■■■■■ ■■ ■E ■ ■ ■■■■■■■■■■■■ ■■■■■■■■■■ ■■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■■■■■■ ■R ■■■■■■■■■■ ■ ■ ■A ■■ ■ MOROSE ■MR.. ; ■ .: /gym -mo .:!� ■"mom„ , . Wes' ■:� ■■■■■ ■ ■ ■M Er . a . mm mmm z 7 a Knoll i■r■■rOrr► mou. "Now gin MEMO ■i�■. ■■■■■ ■ ■M 111111001111 ■ © ■ ■! G ii ■i ■fir r mmmm MEMO OMEN VINNIP"WRIM I EV ■ ■ ■ ■ ■■ IMEMMH �■ . �. NNE NEE �■G■ .� ■ ■■�■■■■■■■■■ 1■■■ ■■ ■ ■■ ■ ■ ■ ■ ■�+ ■ ■1 ■ ■■ ■■■ IM moll ■ ■ ■ ■■ MM IM ■0 ■ KFA .. _ Safety and Buildings 1340 E GREEN BAY ST STE 300 SHAWANO WI 54166 TDD #: (608) 264 -8777 ' \ I fisconsin www.commerc .wis ons Department of Commerce wuvw.wisconsin.gov Jim Doyle, Governor Cory L. Nettles, Secretary 0� July 16, 2003 CUST ID No.222234 ATTN POWTS Inspector ZONING OFFICE GALE W SMITH ST CROIX COUNTY SPIA 3228 HWY 170 1101 CARMICHAEL RD GLENWOOD CITY WI 54013 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 07/16/2005 Transaction ID No. 883624 SITE: Site ID No. 661230 Brian Moe Please re "fer to both (tlerifialtoi� riiml3ers 290TH St boerrtll,r�i3deri i11i fhe agency. Town of Glenwood St Croix County SW1 /4, SW1 /4, S21, T30N, R15W FOR: Object Type: Mound POWT System Regulated Object ID No.: 909866 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: ■ Adjust distance between laterals (and manifold length) from 24 in. to 30 in. so as to provide the A n q correct distance between the laterals and the edge of the cell per line 6 of Table 2 of the Jan.30, 2001 (Version 2.0) Pressure Distribution Manual. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. 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. GALE W SMITH Page 2 7/16/03 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, Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 Ross J Fugill Wastewater Specialist, Field Operations 66 6 (715)524 -3629, rfugill @commerce. state. wi. us cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544 St. Croix County Zoning MOUND SYSTEM DESIGN Residential Application INDEX AND TITLE SHEET M �2, O, Project gw M G' ,/V,:/ S Owner ',/,r¢ N A1 ,t', Address Legal Description a Townshi County j� 6 Subdivision Name Lot No. Parcel ID Number 0!�ft"' �f 'f' - G Plan Transaction Number P.Q.W.T.5. Index and title sheet Page 1 Mound calculations Page 2 Conditionally Mound drawings Page 3 APPROVED iPres. dist. calcs. and laterals Page 4 iTDH and pump tank drawing Page 5 (DEPARTMENT OF COMMERCE Pump curve Page 6 II R SI Nt4F SAEVY AND BUILDIINGS Site plan Page 7 �4� Jle�& ✓ • Soil test (a,b,& c of page 8) Page 8 SEE DENCE Designer J'1 41 License Number Signature � ) . ��..__ Phone No. Date Notice: Tampering with this file by unauthorized persons is prohibited. Deliberate modification will result in disciplinary action under s. 145.10, Wis. Stats. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. r - Straw, Morsh Noy, Or Synthetic Covering Distribution Pipe Medium Sand G Topsoil - -= = _- -- �- ��.-�_'• t, E °t° Slope Bed Of 2 2 1. (Force Main IIIur.ed Aggregate Frorn [lump aYEr . rr D Z, E'.d Cross Section Qf A Wour,d System W1 F � A Bed For f tie fit sorption Are. c � G Signed: Fr- L i cerise Number; Ft . rt Gate: F �1aS�rraf'io>} P +yam 0 1 A 1.� f � - orcc Main W ' _ �_ .�.._._ __ -__ -- _ _ __ _ _ __ __. J From Pump r Distribution E3ed Of 2� 2 Pipe !Aggregate 1 Observofion Pipe Permanent Morkcrs Plan View Of Mound Using A Bed for The lAbsorphon l+reo Fage Of Perforated Pipe Detail End View l P FoRAt2 PVC Pipe Side of cell 1 St 4 R Force Kain PVC Inspection box Holes located on bottom of force main are equally spaced Mast hole should be next to typical long sweep ell with: valve or map Distrihutation pipe layout r' P FF Ft J � Irrvert Elevation of Laterals Ft R I n c hes+ 15 111. Table � Inches.* S �"' 6 30 ' «.- �b�s -P X/I nche s (Al. 0f16 r� Signed i YInches Lice nse s Hole Diameter -f „Y lnches Date: Lateral " Inches Manifold " Inches GPM Discharge rate per lateral Force Main Inches &Pr # of holes /Pipe ;2-,3 # of laterals �2.- r Page COMBINATION SEPTIC TANK /PUMP CHAMBER 4" CI Vent Pipe with (No Scale) Approved Cap, +25' Approved Locking Manhole Cover From Buildings W th Warning Label Attached Weatherproof Approved Junction Box Vent Cap 12 Minimum Final Grade- 6 Ninimum s 4" Minimum ' Quick t Disconnect 18" Minimum - -- 1 /4" Weep Hole Baffle: F4;fe 1 A Al arm 64 B On ' C *APPROVED Of f 6` JOINTS WITH D APPROVED PIPE 3' ONTO Conc. Block Cle SOLID SOIL ' 3" of Beddi Under Tank -/ Note: Pump and Alarm Are On Separate Circuits Number of Doses: - Day Gallons Per Day /f oFDoses: —/,O' c?!6- Gallons ' w olume of Backflow:.......+ allons Tank Manufacturer: _ Total Dose Volume : ........= F,.S {2 Tank Si Septic /Pump ,�— �s Gallons 4i arm Manufacturer; .�',,�'"� -,G ��.� nodel Number: /e 1 & 40 R Capacities ; A 3t�' inches or „°Gal l ons Switch Type: M e + B 1t inches or 2 t9 Gallons + G inches or + Gallons Pump Manufacturer: C % L, d 5" _? -- Model 'Number: + D inches or LW Gal 1ons Minimum Discharge ate: -� 2 Total....._ i nches or Vertical Difference Between Pump Off and Distribution Pipe: /:2VFeet Minimum Required Supply Pressure: ....... .................+ Feet --i. h D Feet of Force Main x /, Friction Factor /100 Feet: + Feet _Inch Diameter Force Main Total Dynamic Head :... Internal Tank Dimensions: Length - Width --- Liquid Depth,3 �j f4 �`�� INC Signature License Number Date blr�.1 i >�ur�Niz Z)WI 'L.Y ING. v 12 DUSTRIF1l. RD. GOUIdS O N, W{ 54016 Submersible Effluent Pump - C�7 3871 PP05 EP05 APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron Specifically designed for the stainless steel. grade turbine ail for for efficient heat transfer, luilowing uses: • Capable of running lubrication and efficient strength, and durability. • Effluent systems dry without damage to heat transfer. r Motor Cover: Thermoplas- • Homes components. tic cover with integral handle Motor: Available for automatic and • Farms • EPO4 Sin, h h manual operation. Automatic and Moat switch attachment • Heavy duty sump q p ase: 0.4 HP. models include Mechanical points • Water Iransfer 115 or 230 V, 60 Hz,'1550 Float Switch assembled and ■ Power Cable: Severe duty • De;,aternlg RPM, built in overload with preset at the factory. rated oil and water resistant automatic reset. SPECIFICATIONS • EP05 Single phase: 0.5 HP. ■ Bearings: Upper and lower 115 V. 60 fit, 1550 RPM, FEATURES heavy duty ball bearing Pump: EPO4 built in overload with construction. • Solids handling �, ablht - automatic reset. ■ EPO4 Impeller: Thermo g 1 plastic Semi -open design 'i' maximum • Power cord: 10 toot with pump out vanes for AGENCY LISTING • Capacities up to _,; 0A standard length, 1613 SJTO riechanical seal protection. SP Canadian Standards Association • Total heads up 1^1 21 feel with three prong grounding a EP05 Impeller: Thermo • Discharge size t NP[ plug. Optional 20 foot plastic enclosed design for (CSA listed model numbers • Mechanical seal ca. bon- length, 16/3 SJTW will) improved performance, end in "F" or "AC ".) rolarykeramic -sla: oatary. three prong r,)tounding pltig BUNA -N elastomers (standard on Lf 05) ■ Casing and Base: Rugged • Temperature thermoplastic design provides 104 F (40 �C) cort'nuous s;lperior strength and 140 , F (60"C) intermillent corrosion resistance. • Fasteners 300 se ries METERS FFEr, stainless steel, to , • Capable of runnir.g L + dry without dalna;? to 9 30� --......... — +�- �—SGPM Pump: EP05 s I t -2.5Fr • Solids handling capability: 0 25 . _ . 1 w 7 f j �. maximum. -v • Capacities up to 60 GPM. = 77' ` • Total heads: up to 31 feel. 6 20 • Discharge size t Yr• NPT. = 5 ! �1 • Mechanical seal: carbon- 0 15 rotary/ceramic stationary, _j 4 1 BUNA -N elastomers o t X EPO E00s • Temperature: r 3 10 1041(40 "C) continuous 140 - F (60 "C) intermittent. 2 ' 5 - t OL 00 10 20 24 X 30 40 50 GPM L I 0 2 4 6 8 to 12 m )/h CAPACITY 0 1995 Gou1Cs Pvmps. Inc. Fn� 11VR u'� � 4��37 .�r�ror��! ■��r ■ ■ ■■ 1111 ■ ■■11 ■ ■ ■ ■ ■ ■ ■ ■■ ■� ■■ ■■■■■■■■■ ■■■■■■■■■■, ,1111■ ■►► ■■ ■ ■►��t�!" .■, : . No NM ■rli!■ ■v■ 1.�!- ■ ■�■ 1111 1111■■■■ 1111 ■r■■ ■ on _ �arr■ 1111 ■11r■■■■ ■1111■■■■ offincomm Now ME "W11111111111111 9 ■ ■ ! 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G! ■iii ■ ■f�lr 1111 ■ ■ ■ �1■ ■err■■ H ■■ ■ ■ ■■ 1111 11� �0 ■■■■E M �'''�■ ■ ■ ■ ■11 ■■11►� ■ ■ ■■ unwmwr WA M No lu mmooll ON M■■■ �■■11 ■■ ■ 1111 ■■11■■1111r�■■■ ON r■r ■11 ■ ■ ■■ 111111MINE ■1111 r■■■n■■■11r 1111 r■ x1111■ �■■■■rr Mound System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Slats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code. The operating condition of the septic tank and outlet filter, shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of a triennial assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such products are used they shall approved for septic tank use by the Department of Commerce, Safety and Buildings Division.. Pump Tank The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary. Mound and Pressure Distribution System No trees or shrubs should be planted on the mound. Plantings may be made around the mound's perimeter, and the mound shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic (other than for vegetative maintenance) on the mound is not recommended since soil conpaction may hinder aeration of he infiltrative surface within the mound and snow compaction in the winter will promote frost penetration. Cold weather installations (October - February) dictate that the mound be heavily mulched for frost protection. Influent quality into the mound system may not exceed 220 mg/L BOD5, 150 mg /LTSS, and 30 mg /L FOG. Influent flow may not exceed maximum design flow specified in the permit for this installation. The pressure distribution system is provided with a flushing point at the end of each lateral, and it is recommended that each lateral be flushed of accumulated solids at least once every 18 months. When a pressure testis peformed it should be compared to the initial test when the system was installed to determine if orifice clogging has occurred and if orifice cleaning is required to maintain equal distribution within the dispersal cell. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner, and any levels above 4 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. General This system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall maintained in accordance with its' component manual [SBD- 10572 -P (R. 6/99)] and local or state rules pertaining to system maintence and maintenance reporting. No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tanks are no longer used as POWfS components. Septic or pump tank manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. Contingency Plan If the septic tank or any of its components become defective the tdnk or component shall be repaired or replaced to keep the system in proper operating condition. If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component shall be repaired or replaced immediately with a component of the some or equal performance. If the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or replaced in its' present location by increasing basal area if toe leakage occurs or removing biologically clogged adsorption and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. Questions on the operation or maintence of this system should be directed to your county zoning or health inspector. Wisconsin Department of Commerce SOIL EVALUATION REPORT Page-/— of Division of Safety and Buildings in accordance with Comm 85. Wis. Adm. Code County Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all I R a �' Date Personal WdomraGon you Provide may be used Law. s. 5.04 (t) (m))• t "q o J PropertyOwner -/ �f c� My Location LO' a / " d UI_ 1 D 2. tat 54-) 1/45A,, 1/4 S� T 20 N R 15 OW) W Property Owner's Mailing Address Block # Subd. Name or CSM# ST 4 State Zip Code Phone ❑ City ❑ Village 0 Town Nearest Road ® New Construction Use: ® Residential / Number of bedrooms Code derived design flow rate �f.� - O GPD ❑ Replacement ❑ Public or commercial - Describe: - -_ -- Parert Flood Plain elevation if applicable � r Y IL General comments and reoanrrtendafions: M B� # O egg �/� [� pit Ground surface elev. 4 7 ft. Depth to erg factor „� ir. Sod 6p&ft Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIff° in. Munsed Q L Sz. Cont. Color Gr. Sz Sh. 'E1f//1 'Eff#2 f d 9 A2 .4- a M5:6 M v Ioy, 2 Af 46 M c S - 6 Boring # O Boring Pit round surface e!ev. ZK' _ tt • n°-F+h to HmMng factor / in. Sod Application mate Hortm Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPM in. Munsed Qu. Sz. Cont. Color Gr. Sz. Sh. 'Elf 1 I 'Eff#2 1 0-/10 o /o- o 6/_ AfA kk M FQ G S / fi:�' 7 8' FiF S C, 2AWAL t Effluent #1 = BOD > 30 < < < 220 mq& and TSS >30 150 mg1L ' Effluent #2 = BOD 30 mg& and TSS < 30 nVL C Name (Please Print) ^L _ - - CST Number Evaluation Conducted T ber Ads Date elephone Nurn Property Owner L42k , Moe Parcel ID # 7 % – 0 2 � ' mil O- P,, F Boring # o Boring 6 Pit Ground surface elev. ft. Depth to Nnw M tailor in. soir Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Lure Consistence Boundary Roots *011#1 GPDHf; in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. •1 'Eff#2 l d- /P R 3 .y s a 56K s 8'1 o 10 j9 41Ae 1 %4 a S C S v S Boring # o Borin W Pit Ground surface elev. —M* ft. Depth to GrnbV factor ! 9 in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture SULKAUre Consistence Boundary Roots GPD/fF in. Munsefl Ou. Sz. Cont. Color Gr. Sz. Sh. 'Efr#1 *M f o.. o a V N AAV S' S onng S o Boring Pit end surface elev. ft. Depth to limidng factor in. F # Sod Application Rate Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPDM in. Munsell CkL Sz. Cont. Color Gr. Sz. Sh. 'Efr#1 'Etf#2 Effluent #1 = BOD > 30 1220 mg1L and TSS >30 ISO mglL • Effluent #2 = BOD < 30 mgll- and TSS < 30 rng1L 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. sao4330pesroo► i ME ON No ME ml IN lb I I ism o w il 0 1 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code .,c Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. / percent slope, scale or dimensions, north arrow, and location and distance to nearest road. O/O - / p -�?O -&C Please print V—=Az=� ,:.. ewed Peraonai &rformaGon you provide may tie used L.aw, s. 5.04 (1) (mp. � by Date / PropeA /yO /omen /� P rtyLocation L a O' / / " O e- 61.._+. Z�l s'f� 1/45'x! 1/4 S� T�� N R �f'Or)W Property Owner's Mailing Address Lo # Block # Subd. Name or CSM# city State Zip Code I Phone "` ❑City ❑Village (2a Town Nearest Road &d 'v ad s jai 10i 0" O (l o? - r 6�1 &Nzv d o2 v - New construction Use: ® Residential / Number of bedrooms Code derived design flow rate 5 GPD ❑ Repisoement ❑ Public or 2 " Z - 2//- commercial - Describe: G - -___ -- — Parent material � A d / A L. Flood Plain elevation if applicable General comments and recommendations: Boring # t °] Borin ��� ul Pit Ground surface elev. �--'--f-�- ft. Depth to limiting factor 4 in. Soil Rate Horizon Depth Dominant Redox Description Textcre Structure Consistence Boundary Roots GPD/ff? in. Msell Qu. S7 - Cont Color Gr. Sz. Sh. •Eff#1 'Eff#2 um o^ Y o R 3 a Af-i 6 Mme• /4 S o /o j 4 2 Al 46 Mf R e- S P' e ® Ong # ❑ Boring /� 9 Pit Ground surface elev. 9y� Depth to limiting factor �- in. Soi ication Rate Horizon Depth Dominant Color Redox Description Texture I Structure Consistence Boundary Roots GPD/ff° In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Ef#2 v- a Al s6 M A 8 . AfAi e s 1 G o YR 7'-5' x M F S C, 2MAiAq F Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg& ' Effluent #2 = BOD < 30 mrg/L and TSS 130 mg/L CST Name Please Print) - - lure CST Number W 9 MZN Address Date Evaluation Conducted Telephone Number 2 a 70 Property Owner ��/l�!_ Parcel ID # � " ��% ° oZ © --? GT P IST # C] Bori El Pit Ground surface elev. 9/ 6 ft. Depth to limiting factor � © in. sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDNf in. Munsell �r Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *011#2 R 3 J o /Q .S� r s6K M S f S eJ S ❑ Boring # ° Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Sod Applkabon Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Merced Qu. Sz. Cont. Color Gr. Sz. Sh. 'Ef(#1 'Eff#2 E �ng# C Boring 11 Pit Ground surface elev. ft. Depth to timitirg factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description. Texture Structum Consistence Boundary Roots GPDM in. Munsed Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD > 30 < 220 mglL and TSS >30 < 150 mg/L ' Effluent #2 = BOO, < 30 mgrt. 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. 58041330 (R6/00) i NNE POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2 FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity �Q,Q Phi A 700 al ❑ NA Permit # Septic Tank Manufacturer (�ri ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms 3 ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units NA Pump Tank Capacity a l ❑ NA Estimated flow (average) 3 50 gal/day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.51 L —U g al/day Pump Manufacturer ❑ NA Soil Application Rate J� ! ,.4t -M 1V 0 al/day/ft 2 Pump Model ��� � ❑ NA St andard Influent /Effluent Quality Monthly average" Pretreatment Unit Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L ❑ in- Ground Igraviity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mglLNA ❑ At-Grade I Aound C 2`4 t(� Fecal Coliform (geometric mean) 510 cfu /100m1 ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other' ❑ NA Other: ❑ NA Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank eve 2-3 ❑ s) At least once eve wlsy(s) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal ee(l)s) At least once every: ❑ month(s) (Maximum 3 years) E3 NA Z� 3 year(s) Clean effluent filter At least once every: ,� month(s) ❑ NA ❑ year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA ) month(s) ❑ NA Flush laterals and pressure test At least once every: ❑ year(s) Other: ❑ month(s) ❑ NA At least once every: ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. Pa 2 of "L START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tanks) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, 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 compliant 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 infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. 1'vll� alua ' a o ing tank b e tai . ? Yoi2 A/6 40NS7R( - - A 0" Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < < WARNING > > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name n i 7 Name Phone 5 -- 3 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name S d Phone Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. - • ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/ w Rio &� - Mailing Address 2 Property Address a 3'°2 ST (Verification required from Planning Department for new construction) City /State ,����� >Doo�G� %� `t�� Parcel Identification Number D LEGAL DESCRIPTION Property Location SL- 544 K, Sec. 2 . Tlr - RAW, Town of Subdivision . Lot # Certified Survey Map Volume 6 Page # 1 Warranty Deed # 1 . Volume _ __., Page It Spec house ❑ yes no Lot lines identifiable JI yes ❑ no SYSTEM MAINTENANCE Improper use and maintenanceof 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. The property owner agrees to submit to St. C Zoning Department a certification form, signed by the owner and by a mastcrplumber, joumeymanplumber, restrictedplumber or a licensedpumper verifying that (1) the on -site wastewaterdisposal 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 Zoning Office within 30 days o die three year expiration date. 6 ,J6, G3 SIGNATURE OF APPLICANT' DATE OWNER CERTIFICATION the owners) of I (we) codify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the described above, by virtue of a warranty deed recorded in Register of Deeds Office. ' dl'Ir,(- G ' ` SIGNATURE OF APPLICANT DATE « « « « «« Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning t� De p artment. " "" «« Include with this Application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed U 2 10 9 P 3 4 3 705 ?;28 \� STATE BAR OF WISCONSIN FORM I - 1998 KATHLEEN H WALSH REGISTER OF DEEDS WARRANTY DEED ST. CROIX CO., WI Document Number RECEIVED FOR RECORD This Deed, made between Eldred O. Moe and Roberta B. Moe, 01114/2003 09:30A husband and wife, 1! EXEMPT # Grantor, and Brian Moe REC FEE: 11.00 TRANS FEE: 19.80 COPY FEE: CERT COPY FEE: PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (The 'Property"): Recordina Area Name and Return Address James H. Krave Part of the Southwest Quarter (SW 1/4) of the Southwest Quarter (SW 1/4) of Attorney at Law Section 21, Township 30 North, Range IS West, Town of Glenwood, St. Croix PO Box 304 County, Wisconsin further described as: Lot 2 of Certified Survey Map filed Glenwood City, W154013 -0304 December 4, 2002 in Vol. 16, Page 4417 as Doc. No. . 016 - 1047 -20 -000 Parcel Identification Number (PIN) This is homestead property. (is) (is not) Together with all appurtenant rights, title and interests. Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except easements and encumbrances of record. f r Dated this day of January , 2003 Ate - * * EI O. Moe * Roberta B. Moe AUTHENTICATION ACKNOWLEDGMENT ` ° STATE OF WISCONSIN ) p_ C s Signature(s) �5 ' . ` W ji•�� St. Croix County.) o l A Personally came before me this / day of authenticated this day of = * = January 2003 the above named Eldred O. Moe and Roberta B. Moe 1, -lip TITLE: MEMBER STATE BAR OF WISCO �� a�� ° ° ° - — (If not, to me known o be t e person w e t foregoing / --- .stru�nent an ackno edge the sam - 'L6 PAGE 4417 /Oc/7 -20 .-0/0 3`12q K THLEEN H. VALSH MISTER OF DEEDS T. CROIX CO., VI La f ECEIVED FOR RECORD O /Go - /Dy? -,Zp - pip 3t/z� -,20 Lod 3 2/04/2002 11:45AN CERTIFIED SURVEY MAP EC FEE: 13.00 LOCATED THE @ff 7 4 OF THE SW1 OF SECTIO ,, T3ON, R1 SW OPY FEE: 3.00 TOWN OF GLENWOOD, ST. CROD( COUNTY, WISCONSIN. AGES: 2 LEGEND N O 1'X 24" IRON PIPE SET WEIGHING 1.13 LBS. PER LINEAR FOOT Q MASONRY NAIL FOUND OWDV D RROBERTA MOE 00 2920 CTY"G" "STEEL STEEL SURVEY MARKER FOUND GLENWOOD CITY, WI 54013 o' W1 14 CORNER rlUi! ; SECTION 21 Z Z 100 ROADWAY SETBACK (COMPUTED FROM W SURVEYOR WITNESS u w A SOIL TEST EDWIN C FLANUM flc O I MONUMENTS OF m 0 NORTHLAND SURVEYING, INC. RECORD) w EXISTING FENCELINE P,0 BOX 14 N w w ROBERTS, WI 54023 Z cn Z 7 20% AND GREATER SLOPES 0 PROPOSED DRIVE N I LL ----------------------------------- ------------------------- - - - - -- _....... I _� LOT CORNER 7' +/- NORTH LINE OF THE SW1/4 OF THE SW1 /4 OF SECTION 21 LOT CORNER 13' +/- SOUTH SOUTH OF FENCELINE S 1321.1?' OF FENC N I w 33.01' :' 519.69 LOT CORNER 7' +/- SOUTH 768.42' w Qo I I 552.70' OF FENCELINE O I 1288.11' LOT 2 33 33' w '3 4.39 ACRES INC. R/W tJ 191,2 . 2J� ( LL ,3y � o cl .; 03 SO FT m w � � A A Z 4.13 ACRES EXC. R/W A n LOW F 179,699 SO. FT. AREA LOT 1 o S89 0 30'59 1 E 552.62' W 31.08 ACRES INC. R/W BERM 33.00 tO ! 519.62' 1,354,011 SO. FT. # -3 124,ge — rJ a LOT 3 �W g 29.48 ACRES EXC. RAN o�2 1,284,183 SO. FT. iD 4.39 ACRES INC. chi I M _� 191,023 SO. FT. 3 q� Q N �-- A A A W O j j 4.13 ACRES EXC. R/W W t r I SRN 179,699 SO. FT. SH on I Q SHED �i � 33.00' 519.60 r' �� 1A N S88 °57 "E 552.60' HOUSE j W N I Z C:D 0 =i p j ° LLI t0 O'• C I° 1 p O O A special exception use permit is required for the j Z N I F w disturbance of slopes 20% or greater not identified chi on the approved plat or CSM. This permit is G A UL IW) O applied for through the zoning office and is I I Z reviewed through a public hearing process by the i St. Croix County Board of Adjustment. �- 4 S I � a go I e 6 E roQ � I ............................ , y: R.: F.=.,.............,.. ........................_...... _ TIFFAi�I'(�CREEK ' j o Sri: -- ---------=------------------------ - -- - -- vi N o. " E 00 5657 E J ° I N89 °5921 548.6' ` — I — — 7 — — N89 59'21 E 741.37 12.00' — — 1 — — Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 430173 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 993 433 =Trsd At • I&* Permit Holder's Name: City Village X Township Parcel Tax No: 030 Moe, Robert I Glenwood Township 016- 1047- 20 -A9A- CST BM Elev: Insp. BM Elev: BM Description: / - Section/Town /Range/Map No: 6 7? . !�_ 6� 21.30.15.3 TANK INFORMATION ELEVATION DATA vZ TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic , 1 / /�� Benchmark _ 2 ,I (OVA 6 G{ G Dosing Alt. BM - COVE filly Aeratio ` ✓ Bldg. Sewer Holding let ' � s I St/Ht Outlet TANK SETB CK INFORMATION TANK TO P L WELL BLDG. Vent to Air Intake ROAD Dt Inlet / �r Septic LYV! Cke 0n t Dt Bottom ' B 2. -7��� Heade Ian. d �S.9o► Aeration Dist. Pipe b'b 4, 4 Sr9v Holding Bot. Sy�te� T-5-0 qS ZO / r y, . Final G PUMP /SIPHON INFORMATION w �[ 12 - — � Par Manufacturer . p re � St Cover Z, r� �, -� Crnj odel Number �,-� J r -7 q 0- cj ff Li riction L . C System Head TDH •Or, fFt I 2 / 3r� q-3 / S F rcemain Length Dia 6r Dist. to Well 2 O IOz• , - O c SOIL ABSORPTION SYSTEM Width Length No. Of Tseaehec PIT DIMENSIO . Of Pits Inside Dia. Liquid Depth MENSIONS S I C I E) 2 \ 1 -26&& SETBACK SYSTEM TO P/L LDG ` WELL LAKE /STREAM INI Manuf er: INFORMATION Type Cif System: f r C BER OR V �� ^- / OS Mo umber: DISTRIBUTION SYSTEM $� �-� Header /Manifold Distribution it x Hole Size x Hole Spacing Ven to Air Intake _ Z 11 Pipe(s) ' I' !� 3 p 5 , 3 2 w $ K C�" ll — Length Dia Length Dia Z Spacing D SOIL COVER x Pressure Systems Only xx 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 ` J Yes f 1, No Yes j No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1:_ /q / A5�3 Inspection #2: /. R 3 Q n� Locaa`#on: 1419 290th St Glenwood City, WI 54013 (SW 1/4 SW 114 21 T30N R15W) NA Lot 3 � 6"yJ Parcel No: 21.30.15. 1.) Alt BM Description 2.) Bldg sewer length amount of cover = \� I � — - — - l — Plan ' q side for additional Yes ' No Zt 1_ �- information. "f" "' Use other - �' I _ A d In epctor's Signature Cert. No. SBD -6710 (R.3/97) 2 5 Sanitary Permit Application ID Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 `Visconson Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of Commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not state owned.) Attach complete plans (to the county copy onl for the s stem, on paper not less than 8 -1/2 x 11 inches in size. County State Sanitary Permit Number ❑ 4 vious pplication St Plan I. D. Number o 1 `' ' a 3 to 33 I. Application Information - Please Print all Informatio Location: /`� �/ 1; � Q 7 4 Property Location Property Owner Name ��� & le / "/ G c--fL �% 1/4 ��y 1/4, S;Z T .N. R -90" Property Owner's Mailing Address _ - Lot Number Block Number City, State Zip Code Phone Number r CSM Numberr cpw II. Type of Building: (check one) / S ❑ Cit wb 1 or 2 Family Dwelling - No. of Bedrooms: ❑ Village 3 � � 0.0. s ` � � a i )O own of Public /Commercial (describe use):_ ❑ State- Owned a/ n q 3n uj l /� Nearest Road ye f 5 ' 0 tA&-t � / L 2.0 I ( Z`F y JSc>� I P-NT Nu a AllO III. Type of Permit: (Check only one box on line A. Check bo on line B if applicable) A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to System System Tank Only Existing System B) 11 Permit Number Date Issued A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) 4 ❑ Non - pressurized In- ground 1X Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment Area Information: ZXW A — 16D O ` 1. Design Flow (gpd) 2. Dispersal Area I Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) Elevation VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks ❑ ❑ ❑ ❑ VIII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (print) Plumber's Signature (no stamps): MPRQf No. Business Phone Number Plumber's Address (Street, City, State, Zip Code) IX: County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Iss ' g Agent Signature (No stamps) Approved ❑ Owner Given Initial Adverse Surcharge Fee) Determination �^ X. Conditions of Approval /Reasons for Disapproval: SBD -6398 (R. 07/00) r� - -�r�r ■rte- ■r ■ ■ ■r ■ ■r■ ■ ■�■ r �vo mom r ■ ■rrr■rrr■r■ ■■■ ■ ■■ MINION r■■■■■■ ■: ■zee• �� ��■■■■��■ _ ■■■■■■ ■r ■rr■rr■rrM•••.��■�� ■■■■■ ■r ■ ■ rrrr � ; _ �i.��►� ■ rr Ewa ■ ■ ■■rrrr ■■ memo / ■ r■ ■ ■ r��t;_ �I ■Wi�7 ■r ■■■rrrrrr ■ ■■■■■■r ■ r■■■■■■■rr■■■■i■irr■ rr■rr■■■ ■rr ■■rrrrr�. ■ ■■■ ■■■■■■■. ■r■■ �r��� ■ ■ ■r■■ ■ I ■ � rrr, ■■ ■■ ■ ■ ■■ ■ ■■ ■rrr■ , ■ ■r■ rr ■■rrrrr ■■� / /�/, ■r ■r ■ ■rrr ■rrrrr■ ■ ■■ ■rrr 0 Fill ■ ■ ■ rrr ■ire /er ■ rrr ■rr ■■■rrrr ■ rr■r ■� , ■■■■ ■■■■ ■ ■ail!!! ■ ■ ■ ■ /i_ rrr■ r■rr ■■ ■■■■ �■ • . �� ■rrr ■ ., r.�r ■r■r■■�r■�� �, . ■■ ■■ ■■ M a■■■ ■ ■ r■■■■■ ■r■r�c�r■■r■rr■■� ■r■■rry rrr■ ■■■■■rr■rr. . ■rr■ ■ ■■ ■■■r■ ■rrrr; ■rr■■ r■ ■■■rra�. ■■ r■■r� ■r■■rrr■■rrrr ■■rrrrr■rr■�, , ,. . s■■■ ■rrr■ : ■r■■ ■r■�■ ■ ■ ■�r ■rC ■!� ■ ■r ■l� h��i ■■■■■ ■ ■■ , ■� ■ ■ ■ rr!�r ■rr_ ■ ■rrr ■ rrrr ■■ ■■■r► ■■ ■mom ■0 ■■■ car Safety and Buildings 1340 E GREEN BAY ST STE 300 SHAWANO WI 54166 TD #: (608) 264 -8777 �seonsin www www.commerc . o ns ov .wiscnsin.gov Department of Commerce Jim Doyle, Governor Cory L. Nettles, Secretary July 14, 2003 CUST ID No.222234 ATTN: POWTS Inspector ZONING OFFICE GALE W SMITH ST CROIX COUNTY SPIA 3228 HWY 170 1101 CARMICHAEL RD GLENWOOD CITY WI 54013 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 07/14/2005 Identification Numbers Transaction ID No. 883633 SITE: Site ID No. 661232 Robert Moe Please refer to both identification numbers,- 290TH St above, in all correspondence with the agency. Town of Glenwood St Croix County SW1 /4, SWI /4, S21, T30N, R15W FOR: Object Type: Mound POWT System Regulated Object ID No.: 909868 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: ■ Adjust distance between laterals (and manifold length) from 24 in. to 30 in. so as to provide the correct distance between the laterals and the edge of the cell per line 6 of Table 2 of the Jan.30, 2001 (Version 2.0) Pressure Distribution Manual. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. 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. 4 ' GALE W SMITH Page 2 7/14/03 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, Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 Ross J Fugill Wastewater Specialist, Field Operations WiMART come: 7;6331 (715)524 -3629, rf i ill @ commerce.state.wi.us g cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544 St. Croix County Zoning I I I ti MOUND SYSTEM DESIGN Residential Application INDEX AND TITLE SHEET (kle i Ai �2' o) 1- -go --4521 Project zo!�A /V0 Owner , 1 Address Legal Description Township Township h'r�, G� c� r a� County Subdivision Name Lot No. Parcel ID Number C Plan Transaction Number Index and title sheet Page 1 ROAM calculations Page 2 Mound drawings Page 3 COnMonatly Pres, dist. calcs, and laterals Page 4 APPROVED TDH and pump tank drawing Page 5 Pump curve Page 6 11161FAMUNT OF COMMERCE Site plan Page 7 Ate am Soil test (a,b,& c of page 8) Page 8 M A �v t /1�A1 P�.oN P,,yfa`/ S C Designer - 7 - 41e Z1:.l /�`I /�l License Number Signature Z4 � � , Phone No. Date X °" f? Notice: Tampering with this file by unauthorized persons is prohibited. Deliberate modification will result in disciplinary action under s. 145.10, Wis. Stats. Personal information you provide may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)). • rc �,. �' Pak- 0 • f Straw, Marsh Noy. Or Synthetic Covering Distribution P ipe Medium Sand G Topsoil t r E d �SIop6 Bed i'Iur.td ed Of V— 2 %Z Force Main Aggregate From [lump l oycr E f Cross Sectic.n Ot k wound System Usi F < I A Bed For [tic AtGsorption lar(c G A J !' Ft• H L� ! Slgnced: liccnse Number: 1/7-11 Fr- J Ft W tc: K 1,2 3 Ft. r tJ/#, 6 Ft. v,� a rt . QBS�r�raficn Pips 1 { r � H A [ "o' cc Pump Moir, From V1l '2 Distribution 1 _ Pipe Aggfegote E3ed Of Observation F'ipe Permanent Morkcrs Pion View Of Mound Using A Bed for Die Absor i.,1 ion I +r eo Page! Of Perforated Pipe Detail End View peA FmR Atzd PVC PIP'-' �y 4� 4�t A Side of cell ,s Force Main PVC Inspection box Holes located on bottom of force \ main are equally spaced 5 Last hole should be next to typical long sweep e11 with valve or cap IA, Distributation pipe layout Y P Ft R _1nches � 1 5 ass.' erTa le � ., � r � Invert Elevation of Laterals �. Ft SPec 6 S Inches --- 0 in. 3 S X Inches Signed s Y inches Licenses Hole Diame ter .�Zljlinches Dates Lateral " Inches Manifold n .�— Inches GPM Disaharge rate per lateral Force Main " off- Inches �. G I° m # of holes/pipe 2 COMBINATION SEPTIC TANK /PUMP CHAMBER 4" C) Vent Pipe with (No Scale) Approved Cap, +25' Approved Locking Manhole Cover From Buildings W th Warning Label Attached Weatherproof Approved _ Junction Box Vent Cap i2 Minimum s Final Grade --- s,, 6" Minimum 4" Minimum Quick 18" Minimum t i -- Disconnect 1/4" Weep Hole Baffle: 1f e� A Alarm B On 61 , C *APPROVED Off JOINTS WITH D , APPROVED PIPE 3' ONTO Conc. Block i SOLID SOIL ' /' , 3" of Beddinq Under Tank , Note: Pump and Alarm Are On Separate Circuits Number of Doses: —5 Per Day Gallons Per Day / ot Doses: Y ,d Gallons ' kYolume of Backflow:.......+ R Gallons �/ Tank Manufacturer: e S� � Total Dose Volume:........ Gallons Tank Size-Septic/Pump: o ^ anR __Ga ons Alarm Manufacturer : � L ��' tko ___�� Model Number' ; i lf'L- Capacities : A �. �"i nches or&�al 1 ons Switch Type: 61-?tl u' 91 _ + B =i nches or Gallons Pump Manufacturer: tr,LdS' + G nches orGallons + D inches or Li Gallons Model Number: Off eg --;-- Minimum Discharge ate: a 4-. Total ..... , i nches or= Gallons ,Gall ons Vertical Difference Between Pump Off and Distribution Pipe: r 0 Feet Minimum Required Supply Pressure:... . .................. 3. 5?> Fe et of Force Main x 5� ro► Ta��Q 1 -s�� 5 x Lf rictionFactor /100 Feet: + eet L` Inch Diameter Farce Main Total Dynamic Head:... -7; - Feet -* 13.5��. Internal Tank Dimensions: Length Width Liquid Depth y Signature License Number Date 12 UU6 HIAL� D. uOtJIdS P, ON , WI 54016 S ubmersible Effluent Pump ,�- MODEL C(7 3871 EP05 , • ■ Motor Housin Fully submerged in high : Cast iron 9 APPLICATIONS Fasteners: 300 series Y s g , 9 stainless steel. grade turbine oil for for efficient heat transfer, Sp design for the inn efficient nt tren th and durabil g •Capable of running lubricat a nd eff c e s trength, ty . IullOwing uses: dry without damage to heat transfer. ■ Motor Cover: Thermoplas- t Ef fluent sys sys component tic cover with Integra! handle • Homes Available for automatic and Motor: and float switch attachment • Farms manual operatlon. Automatic • Heavy duty sump • EPO4 Single phase: 0.4 HP. models include Mechanical points. • water transfer 115 or 230 V. 60 Hz;'.1550 Float Switch assembled and ■ Power Cable: Severe only • Oe atenr,g RPM, built in overload with preset at the factory. rated oil and water resistant automatic reset. ■ Bearings: Upper and lower SPECIFICATIONS • EP05 Single phase: 0.5 HP FEATURES heavy duty ball bearing 115 V, 60 Hz, 1550 RPM, construction. Pump: EPO4 built in overload with ■ EPO4 Impeller: Thermo- - Solids handling ca, ab111 °/ automatic reset. plastic Semi -open design AGENCY LISTING , /,' maximum. • Power cord: 10 foot crlth pump out vanes for • Capacities up to :; GNA standard Icngth, 16/3 SJTO mechanical seal protection. 0 Canadian Standards Association • Total neads up t:, 21 feel with three prong grounding # EP05 Impeller: Thermo• • Discharge size 1 NP f plug. Optional 20 foot plastic enclosed design for (GSA listed model numbers • Mechanical seal (a. bon- length, 16/3 SJTW with improved performance. end in 1" or "AC ".) rolary/reramic -sty, 0n,�ry. three prong 9tounding plug BUNA•N elastomers (standard on W05) x Casing and Base: Rugged • Temperature Thermoplastic design provides 104 F (40'C) cortinuous superior strength and i 40 (60 intermittent. corrosion resistance. • Fasteners 300set1es METERS FEET, stainless Steel. 10 ) i • Capable of runnlrg Cry without daina,? to 9 3n� I � __6A — 5GP4.4 — cc ponar.:; ; Pump: EP05 s 2.5 FT • Solids handling capability: 0 7 1 W maximum. w • Capacities: up to 60 GPM. s ?o - _ — • Total heads: up to 31 feet. i • Discharge size 1'1a' NPT. • Mechanical seal: carbon o 15 �. °; _ _ S •....__ folary lceramic-stationary, a 4 0. I EPOS BUNA•N elastomers o Pt • Temperature: '` 3 10 - -- - - - 1041 (40 ^C) continuous ' EPO4 140 °F (60 "C) intermittent. 2 j — 1 i 0- 0 --- t 10 ~1 20 30 40 50 GPM 0 2 4 s 10 12 m�fi CAPAWY V r 0 1995 Goulds Pumps. Inc. Eneclive May, 1995 83871 No MOEN ■MESON r■■rno ■■, ■■■■■■rr■r■ . ■r MEN so o +� �� MOON ■Err ■■■E rrrr■■ ■■r■■ ■■■ ■■ ■�'::plimilffil rrrrr ■■ ■■ ■ rr ■i ■��■i■�.yy► s■ rrrr■ ■■ ■ ■■ rrrr � ■����t� ■ rrrr■■■ ■r ■ ■ rrrr ■ , ■��.��� _; E , r ■■ ■■ rrrr■ ■■■■rr�.__ ■ ■■ ■■■ ■r■■■ ■■��l.� ■�■ ■ ■ rrrr■■ ■ ■■■ ■�irr�t.�il ■f�it3 ■■■ rrrr■■■ ■ ■ ■ ro I U�l rrrr rrrrrr ■rrr■■r� : ■r��i■i ■r� rrrr ■■ ■■r r■ ■■r■r� ■�! ■•� ■■■ ■■■ ■r■ ■■■■■■■ i■■■ !■�� 0 No ON WHO ■u■ ■ ■ ■r■ r ■ ■■■. ■rrrri now ■r rrrr rrrr■■■ ■ ■■ _ ■ ■r� �r�■■ rrr ■rrrr ■ ■■rlir�lVA ■■ ■■ rrrr■r■ ■ rrrWa�c9r ■r■■ ■■■ rrrr■ ■ rrrr■ �r� rrrr ■ ■■ r■ ■■ rrrr AN ■■ ■ ■ ■■■ ■s■, r■■ ■■■►rc ■ ■ ■ ■ � ■ ■■ ■ire■ ■rr�r�i,� rr rr ■r■ ■r■r■r■■ ■av■rwF-431.• rrrr■ ■■rr ■ ■ ■■ ■r■r■■■r� ■a�rrp, ■■r■ ■ ■■■■rra�. rrrr ■rrrr ■rrrr ■■■rrrr■■rr■■ r ■■■ ■■rr■■r� ■rrs . rrrr ■ ■r rrr rrrr r■■ ■■ ■ ■�7■■Di ■.. rrrr ■ ■■■■■ _ ■■ ■■■■■■ ■ice ■■ , rrr ■ ■■rrrr ■■ ■■rr■r■r■■ WIN ■■ ■■ ■ ■ ■ ■■ rrrr■■ No 111111 Mound System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Slats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code. The o erating condition of the septic tank and outlet filter. shall be assessed at least once every 3 years by inspection. The let fil #er halt be leaned as ne to e nsure prooer o ian. The filter cartridge should not be removed unless provisions are ma e • retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of a triennial assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such products are used they shall approved for septic tank use by the Department of Commerce, Safety and Buildings Division.. Pump Tank The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary. Mound and Pressure Distribution System No trees or shrubs should be planted on the mound. Plantings may be made around the mound's perimeter, and the mound shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic (other than for vegetative maintenance) on the mound is not recommended since soil conpaction may hinder aeration of he infiltrative surface within the mound and snow compaction in the winter will promote frost penetration. Cold weather installations (October - February) dictate that the mound be heavily mulched for frost protection. Influent quality into the mound system may not exceed 220 mg/L BOD5, 150 mg/LTSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for this installation. The pressure distribution system is provided with a flushing point at the end of each lateral, and it is recommended that each lateral be flushed of accumulated solids at least once every 18 months. When a pressure testis peformed it should be compared to the initial test when the system was installed to determine if orifice clogging has occurred and if orifice cleaning is required to maintain equal distribution within the dispersal cell. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner, and any levels above 4 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. General This system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall maintained in accordance with its' component manual ISBD- 10572 -P (R. 6/99)] and local or state rules pertaining to system maintence and maintenance reporting. No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tanks are no longer used as POWTS components. Septic or pump tank manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. Contingency Plan if the septic tank or any of its components become defective the tdnk or component shall be repaired or replaced to keep the system in proper operating condition. If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component shall be repaired or replaced immediately with a component of the same or equal performance. if the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or replaced in its' present location by increasing basal area if toe leakage occurs or removing biologically clogged adsorption and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. Questions on the operation or maintence of this system should be directed to your county zoning or health inspector. Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of •� Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County , Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. O/Zj Please print all information eviewed b D ate Personal information you provide may be used fo (R�rl�w, s. 1 .04 (1) (m)). Gvv I 3 Property Owner Pro erty Location M eg G2A Lot s(,V 1 /4 54) /4 S T N R /_:5r WOW Properly Owner's Mailing Address Ad L MT lock # Subd. Name or CSM# .2 v o - al G 01 1 A2 City State Zip Code hone 1 C = ❑ Village L* Town Nearest Road New Construction Use: Residential / Number of bedrooms Code derived design flow rate 4 GPD ❑ Replacement /^ ❑ Public or commercial - Describe: Parent material /'A Flood Plain elevation if applicable ft. General comments and recommendations: F/ -] Ong # ❑ Boring !� ® pit Ground surface elev. /e ft. Depth to limiting factor /az in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. / Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. /� �j /� 'Eff#1 'EfYQ z a S Mrk' Cr S -d -3 / a M,4 FR vic 6 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/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 l o- /o S G 6 . 8' C 6 G s' / ,.6' G S - 2AlAJk M FR Effluent #1 = SOD > 30 < 220 mg/L and TSS >30 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST G /¢ / (Ple / . Pri a r� Number Address Date Evaluation Conducted Telephone Number A Property Owner o&a i°f eel MO e Parcel ID # d �o " /O ��d ° Q a O Page of J F91 Boring # ❑Boring 9 ®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/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 3/;z 2 A .Z2. 10YR I is - 71- 3 S61- AZ F -- v F � s a Boring # E) 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 GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2 F-1 Ong # ❑ Boring De ❑ Pit Ground surface elev. ft. Depth to limiting fade in. " 7 Soi1 -- Appfication Rate Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Efl#1 I 'Eff#2 Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 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.6W) r EAII ME THEARIZ • .t x i : TY (—�. �� 0 IJ 000000000 O 00000 0o0 o00og0000. 0000000 o B /R - oo �oaoa000 moo �/ D/R 10000000 00 9' - c, /'� 0000000 1 s t. F , • § N BASEMENT 4. W •, a - ACCESS ; L/R B/R � B /R -2 M -B/R, 18' -9' i0 10' -5 A 13' -4' 4 e T 'AND F E S GAS RAIV E , J ' , 4 : FROSTFREEREF IGERATOR .,r ROOF /VINYL SIDING R -19 FLOOR INSULATION t r•,.` � 6 E LL A, ; R- 19 WALL - INSULATION ; _. y }45a Mw - r p �SCULP SIRED CARPETS R-30 ROOF INSULATION ... L CATHEDRAL;OEILlNGS THROUGHOUT., AUTO IGNITION FURNACE ' DEADOLTLOCKS `. 1 /2 REBOND CARPET PAD DEEP STAINLESS STEEL `KIT. - SINK STEEL 6 PANEL DOOR - W /STORM } H2O S. OFFS-LA V,SINKS, & COMMODES LIGHTED EXHAUST FANS + 9 3i, Yi k OSB SHEATHING CORNER TUB /SHOWER STALL {' THERMOPANE WINDOWS FIBERGLASS TUB-IN HALL BATH MAIN LINE SHUT OFF PORCELAIN SINK IN BATH EXTERIOR OUTLETS (2) EXTERIOR FROST FREE FAUCET: 200 AMP SERVICE ADDITIONAL OPTIONS SHOWN IN HOME FINISHED DRYWALL IN L.R AND D.R 40 GALLON DELUXE WATER HEATER 9 LITE STEEL REAR DOOR TILE BACKSPLASH IN KITCHEN GLASS CABINETS OVER S. COUNTER LINOLEUM FLOOR IN DINING ROOM ' x V' TOWN fir GOUNTIZY HOUSING, , 2S5 SOUTH F 1 � f, VIEW RA RI ROAD, GHIV� 1A FA,LL WI 4 4i2q r S =1 _'e Sh . �`- a „k•'4; `' �aC lk: t V 5 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHM CERTIFICATION FORM Owner / X�,,!�-ew 7� /x'1 Mailing Address Property Address I � f 19 a D ' S (Verification required from Planning Department for new construction City/State 6ZL- MAO,r 6 of %1� ✓. /t/ J' _ Parcel Identification Number LEGAL DESCRIPTION Property Location 4> %, 64 %, Sec. ,�. T 3�- N -R .L W, Town of Subdivision Lot # 3 Certified Survey Map # / , Volume / . Page # f Warranty Deed # 7� .5 9 o- , Volume 9 Page # Spec house ❑ yes CA no Lot lines identifiable yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result m its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a mastarphunber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal 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 Zoning Office within 30 days of the three year expiration date. SAS E. '2n� © 7 / o l Gq SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT DATE « « « « *« « * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. «« Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed U 2 10 9 P 3 `i 2 -7 ID 5727 STATE BAR OF WISCONSIN FORM 1 - 1998 KATHLEEN H. WALSH REGISTER OF DEEDS WARRANTY DEED ST. CROIK CO., WI Document Number RECEIVED FOR RECORD This Deed, made between Eldred O. Moe and Roberta B. Moe, 01/14/2003 09:30AK husband and wife, EXEMPT # REC FEE: 11.00 Grantor, and Robert E. Moe and Sheila_ Moe, husband and wife, as TRANS FEE: 19.80 survivorship marital property COPY FEE: CERT COPY FEE: PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (The 'Property "): Recording Area Name and Return Address Part of the Southwest Quarter (SW 1/4) of the Southwest Quarter (SW 1/4) of James H. Knave Attorney at Law Section 21, Township 30 North, Range 15 West, Town of Glenwood, St. Croix PO Box 304 County, Wisconsin further described Lot 3 f Certified Survey Map filed Glenwood City, WI 54013 -0304 December 4, 2002 in Vol. 16, P age 441 as Doc. No. 700946. 016- 1047 -20 -000 Parcel Identification Number (PIN) This is homestead property. (is) (is not) Together with all appurtenant rights, title and interests. Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except easements and encumbrances of record. Dated this day of January 1 2003 I * Eldr O. Moe : Roberta B. Moe AUTHENTICATION_ +�l j(� ACKNOWLEDGMENT STATE OF WISCONSIN ) S ignature(s) ) ss. ___ •. ,* _ St. Croix County. ) �C = Personally came before me this day of authenticated this day of �� \� ' 2 January 2003 the above named Eldred O. Moe and Roberta B. Moe • Re cording Area Name and Return Address Part of the Southwest Quarter (SW 1/4) of the Southwest Quarter (SW 1/4) of James H. Knave Section 21, Township 30 North, Range 15 West, Town of Glenwood, St. Croix Attorney at Law pp Box 304 County, Wisconsin further described as: Lot 3 of Certified Survey Map filed Glenwood City, WI 54013 -0304 December 4, 2002 in Vol. 16, Page 4417 as Doc. No. 700946. 016 - 1047 -20 -000 Parcel Identification Number (PIN) This is homestead property. (is) (is not) Together with all appurtenant rights, title and interests. Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except easements and encumbrances of record. Dated this day of January 2003 * : EldT9 O. Moe * + Roberta B. Moe AUTHENTICATION ,,�1�I Kp��r�� ACKNOWLEDGMENT .' STATE OF WISCONSIN ) Signature(s) Aiq ) ss. * s St. Cro - - - - -- County. ) Personally came before me this day of of ' ' �� ' ? January 2003 the above named authenticated this day ' . , opt . `� Eldred O. Moe and Roberta B. Moe TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to m known t io e . Necuted the foregoing inst a and ge e authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY James H. Krave, Attorney at Law Glenwood City, WI 54013 -0304 Not ublic, State of Wisconsin y Commission is permanent. (If not state expiration date: (Signatures may be authenticated or acknowledged. Both are not ) necessary.) _ *Names of persons signing in any capacity should be typed or printed below their signatures STATE BAR OF WISCONSIN WARRANTY DEED FORM No, 1 - 1998 INFORMATION PROFESSIONALS COMPANY PON13 I)U LAC, WI e00- 653-2021 �2�PmlvUA� ; ._. l'�� D /!a - /Dy7 °,ZU �svc i � ra 5 4• t it eq 65AI 1G 1yS117 i" •16 PAGE 4417 " O /Co - 1047 -,Zp , 0 /O 3cl,?A K ATHLEEN H. WALSH Lod" / R EGISTER F DEEDS T. Lef ECEIVED FOR RECORD 2/04/2002 11:45AN . CERTI FI E Vi. T EC FEE: 13.00 LOCATED THE W 4 OF THE SW7 4 OF SECTIO 21. MON, R1SW OP 1 Y FEEz 3.00 AGES: 2 TOWN OF GLENWOOD, ST. CROIX COUNTY, WISCONSIN. N LEGEND 1" X 24" IRON PIPE SET WEIGHING 1.13 LBS. PER LINEAR FOOT w Q. MASONRY NAIL FOUND OWNER o 5 yj ELDRED AND ROBERTA MOE 1 ' SURVEY MARKER FOUND 2920 CTY "G" o ® GLENWOOD CITY, WI 54013 (o r W1/4 CORNER w r1UU ; SECTION 21 Z Z 1 00' ROADWAY SETBACK SURVEYOR (COMPUTED FROM w 9 • WITNESS LL MONUMENTS OF w m ♦ SOIL TEST EDWIN C FUWUM O NORTHLAND SURVEYING, INC. RECORD) w �k EXISTING FENCELINE P.0 BOX 14 N > �: � w w ROBERTS, WI 54023 Z CO 1 R, �i, C Z ? 20% AND GREATER SLOPES 0 0 i m -a-- PROPOSED DRIVE W R* m N MUyJP�4�CDD dQ�n]DD O�GvICDD OO 4Lz1CG°3� i o LOT CORNER 7' +/- NORTH LINE OF THE SW1 /4 OF THE SW1 /4 OF SECTION 21 LOT CORNER 13' +/- SOUTH I �l I F FENCELINE - 1 I o S89 c 55 � 38'W 1 21 . OF FE C IN w 519.69' LOT CORNER 7' +/- SOUTH 768.42' w ail 55 OF FENCELINE O (33LOT 2 1288.11' w ACRES INC. R/W 1 0 m 91,023 SO. FT. 3�2� O w Z 3 ACRES EXC. R/W , 7as99 SQ. FT. ARC LOT 1 G a l ; I .-- S89°3959 1 E 552.62' w - -� 31.08 ACRES INC. R/W 33.00 fO 519.62' !, BERM 1,354,011 SQ. FT. z(/ 29.48 ACRES EXC. R/W a LOT 3 1,284,183 SO. FT. N 4.39 ACRES INC. R/W �! M 191,023 SO. FT. C �� A o ` r N �' $ ♦ ♦ ♦ 3 1Y Cl) I 4.13 ACRES EXC. R/W W 179,699 SQ. FT. BARN SHED 0' � a r oo �E 33.0 ❑ SHED ❑ cG 0° 519.60 r ED: � In N S88 °57'35 "E 552.60' HOUSE ! Iall �E N cm I Z � � 0 O @i 0 r I � � I Ceti j LLJ O o o o: OfE N G A special exception use permit is required for the Z ' = disturbance of slopes 20% or greater not identified I on the approved plat or CSM. This permit is LL O IU) O applied for through the zoning office and is 2 ULU]j Z reviewed through a public hearing process by the i St. Croix County Board of Adjustment. I _ .......................•. .....•.........•.•............. y;; R= F.;;_.`............... ......................._....... --- - - - - -- N00 0 56'57 1 E ') — — — — — N89 °59'21 "E 741.37' — — 12.00' — _J — N89 °59'21 "E 548.76' — — co — — — —