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HomeMy WebLinkAbout018-1096-17-000Wisconsin Departrnentofrommerce PRIVATE SEWAGE SYSTEM Safety and Building Division ~~ INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Grebowski, Bruce Hammond, Town of CST BM r*v: Insp. BM Elev BM Description: mt` r q=j ,~ Y1(~ M 1 ? TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~ ~ ~ ~~ Dosing ~~ Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. vent to Air Intake ROAD Septic ~I / {o ~~ t Dosing - /~_ /~ Z~-` ~/ .. Aeration Holding PUMP/SIPHON INFORMATION /~~/ Manufacturer ~ / ~e, f, v GP and Model Number ~ ~ G TDH Lift ~ Friction Lo~ ` System Hea TD~~ ~Ft J r Forcemain Lengt~~ / Dia. ,~ +% Dist. to well SOIL ABSORPTION SYSTEM county: St. Croix Sanitary Permit No: 463388 0 State Plan ID No: Parcel Tax No: 018-1096-17-000 Sectionlrown/Range/Map No: ' -" 0.9.1 .792 ELEVATION DATA STATION BS HI FS ELEV. Benchmark ~.~ RQ ~7 Alt. BM ~~~ 3 ~ ~ / ~ .~ Bldg. Sewer 7~ 5 q~ ~ ~' St/Ht Inlet ~ L J ~5 q. St/Ht Outlet `\ ~ Dt Inlet ` ~` Dt Bottom 1 z ~z 1 HeaderlMan. Z , 3 4 ~Z Dist. Pipe ~.3 /~z-1 Bot. System , n . `~ Final Grade r + .~ / /~ 3 l-~-, St Cover ~.o, 1 ~' l _ J ` /~ y Cod-o~~- ~, ~ /da~ 3 BEDlTRENCH Width ~ Length /1 No. Of Trench PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS D ~~ ~ ~~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: ~ INFORMATION CHAMBER OR ~ Typ Of Syste /~/ ~~ / , I ~ fv UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold / Distribution /~ / Pipe(s) ` x Hole Size ~ ~ ~ x Hole Spacing i Ve to Air Intake Di L XZ Di ~ S i L th ~ ~ ~ ~ ength a a pac ng eng SOIL COVER Y Pracenra Svctamc rlnly YY Mnund nr At-Grade SVStemS Only Depth Over ~ BedlTrench Center Depth Over Bed/Trench Edges xx Depth of Topsoil xx Seeded/Sodded xx Mulched i N ' ~ ~ ~ ~ es No o Yes /~I COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~/ Z ~ // as Inspection #2: / / Location: .1092 173rd Stre~e-t H mmond, 154015 (NW 1/4 NW 1/4 9 T29N R17W) Pheasant Rid~DLoT 17 O~ Parcel No: 09.29.17.792 1.) Alt BM Description = F,°~~--- ~GO~r ~4'.~ e, p ~~~ 2.) Bldg sewer length = Z 4 - amount of cover = ~ y _ Plan revision Required? !Yes ~ ~ ~ I~` ~ - r~~~/ ; - Use other side for additional information. I ___ ~ _ V Date Cert. No. SBD-6710 (R.3/97) Safety and Buildings Division Couny' 1' - ~ ` 201 W. Washington Ave., P.O. Box 7162 I ,~ ~ ` ,~~O~~I ~ Madison, WI 53707 - 7l 62 itary Permit Number (to be filled in by Co.) > (608)266-3151 Department of Commerce Sanitary Permit Applic~t' n R umber stet Plan LD.~N ,. J personal infonnati y provide 21 Wis. Adm. Code In accord with Comm 83 , , . may be used for secondary purposes Privacy Law, s4 .04 ) R 0 ~ 2QQ Proje Address (if different than mailing address) Y I. Application Information -Please Print All Information ~ GROG ~ p ~ ~~~ / OF S Property Owner's Name ` ~ ~.~ P 1 # # 1 '7 Bock # ~ • t It91. t7 • r ~~ ~ ~1 _ ~ Mailing Address s Property Own r erty do ~ ~ Q e ~' \~ ~/ ~ . City~,IState 4-~' v f 1 Zip Code ,~*~ Phone Number TV'" N; or (check all that a l ) e of Buildin II ~ ~ ~~ g pp y b ~ . p ..~ ov ~ Subdivision Name CSM Number or 2 Family Dwelling - Number of Bedrooms - i l D ib U bli /C ^ a - escr e se Pu ommerc c ^ State Owned -Describe Use City ^Village ship of lY` III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A' System ^ Replacement System ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System B. ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Lssued Before Expiration Plumber Owner t IV. T e of POWTS S stem: Cbeck all that a 1 ) ^ Non -Pressurized In-Ground ^ Mound ? 24 in. of suitable soil nand < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sank Filte~ ^ r Recirculating Synthetic Media Filter ^ Leaching Chamber ^ Drip Line ^ Gr el-less P' e ^ Other (e plain) /~ ~ 1 V. Dis ersal/I'reatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) r t Disp rsal Area R fired (s r ~ Dispers 1 Area Pr sed (~s/f) ~ System Ele~io r,~, ~v~~ ~' ~ ~ Q '~ (Y J t?7 ~ i `'~ ~ ~~' 0 ~ ~C VI. Tank Info Capacity in Gallons Total Gallons Number of Units Manufacturer efab Concrete Site Constructed Steel Fiber Glass Plastic New Existing Tanks Tanks Septic or Holding Tank AerobicTreatment Unit Dosing Chamber '~ VII. Responsibility Statement- I, the undersigned, a e responsibility for installafion of the POWTS shown on the attached plans. Plumb s ame (Print) Plumber's Si a MP/MP7RS Number Business Phone Nu(m~ber l Plumber', A~ s (Street, City, State, Zip t ~ n ~ ~ ~ cy ~ 1 VIII. Coun /De artment Use Onl ^ Approved ^ Disapproved Sanitary Permit Fee ('ncludes Groundwater Surchazge Fce) ~ ~ Date sued Issuing nt Signature Stamp ^ Owner Given Reason for Denial ~ /Z ~ p ~j ' ' ~ ~~gyaUReasons for Disapproval 3, ei,, ~, ~, S ~Oi-~-- u 4 ~ e- ~ . ~. I ~~~~ptic tank, effluent filter and (7~ • d ~ , n.. ro~ ecJ dispersal cell must all be serviced /maintaine as per management plan provided by plumber. ~. All setback requirements must be maintained as per applicable codelordinances. Attach complete plans (to the County only) For the system on paper not Tess man aria x i r mcnes m size 5BD-6398 (R. O 1 /03) • PLOT PLAN PROJECT" Bruce'and Doris Grebowksi ADDRESS 2156 Burke Ave E. #2 W. St. Paui Mn 55109 NW " 1/4 NW 1/4S 9 /T ~ 29 N/R 17 W TOWN Hammond COUNTY ST.CROIX SYSTEM ELEVATION 101.8 1.1' sand lift! BEDROOM 3 CONVENTIONAL AT-GRADE CONVENTIONAL LIFT HOLDING TANK MOUND XXX SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 630 HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 454 # of chambers none BENCHMARK V.R.P. Top of 1" pipe ASSUME ELEVATION 100' Filter Zabel A-100 ^ BOREHOLE O WELL *H.R.P. Same as Benchmark Property Line Tank is to be properly bedded and provided with lockdown covers with approved warning labels Well is to meet all setbacks found in Comm. 83 101' 100.7' B-1~ 00' B.M. #1 B.M. #2 Top of 1 " pvc pipe 9.7 3% Slope Area 15' below system is to remain undisturbed Property Line Huffcutt "B-3 Pro 3 Bedroom House to is to be done 't run-off _ ^ B-2 379' Property Line (not to scale) Property Line To 173rd St. r commerce.wi.gov ^ ^ ~scons~n Department of Commerce Safety and Buildings 4003 N KINNEY COULEE RD LACROSSE WI 54601-1831 TDD #: (608) 264-8777 www. com merce.wi. g ovlsb! www.wisconsin.gov Jim Doyle, Governor Mary P. Burke, Secretary Apri105, 2005 CUST ID No.226900 SHAUN R BIRD BIRD PLUMBING, INC 1008 192 ND AVE NEW RICHMOND WI ATTN: POWTS Inspector ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD 54017 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 04/05/2007 Identification Numbers, Transaction ID No. 1123949 SITE: Site ID No. 696557 Bruce & Doris Grebowski Please refer toboth identification numbers, 1092 173rd Street above, in all comes ondence with the a enc . Town of Hammond St Croix County NW1/4, NW1/4, S9, T29N, R17W FOR: Description: Proposed Three Bedroom Mound System Object Type: POWTS Component Manual Regulated Object ID No.: 1011618 Maintenance required; 450 GPD Flow rate; 23 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 the "Mound Component Manual for Private Onsite Wastewater Systems Version 2.0" SBD-10691-P(N.O1/O1). • The pressure network is to be constructed in accordance with publications SBD-10706-P(NO1/O1) "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems -Version 2.0" and/or the sizing methods of publication "SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST-SAS (01/81)". • A sanitary permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(Z)(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. CoF~i ~! T S SHAUN R BIRD Page 2 4/5/2005 • Comm 83 22(7) - A copy of the approved plans specifications and this letter shall be on-site during construction and omen to inspection by authorized representatives of the Department which may include local inspectors. Owner Responsibilities: • The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and maintenance manual and/or owner's manual for the POWTS described in this approval. • 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 in 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 jswim@commerce.state.wi.us Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 T cc: Leroy G Jansky, Wastewater Specialist, (715) 726-2544 Cover Page Shaun Bird Bird Plumbing Inc. 1008 192nd Ave New Richmond Wi 54017 715-246-4516 Date: 3/29/05 Owner: Bruce and Doris Grebowski Location:NW1/4NW1/4S9T29N,R17W Lotl7Pheasant Ridge 1092 173rd St. Hammond System type: Mound System Manuals Used: Mound Component Manual Version 2.0 (01 /31) Pressure Distribution Manual Version 2.0 (01/31) Page# 1. Cover Page 2. Mound Plot Plan 3. Mound Cross Section 4. Pipe Cross Section/Pipe Layout 5. Pump Chamber Cross Section 6. Pump Curve 7-8. Maintance and Co tigency plan 9-11. Soil test Shaun Bird Signature License number ~ r `~ p~PAR7 SAFETY AND BUILDINGS IViS10N SEE GORRE ONDENGE RECEIVED APR - 1 2005 SAFETY & BUILDING PLOT PLAN PROJECT' Bruce'and Doris Grebowksi ADDRESS 2156 Burke Ave E #2 W St Paul Mn 55109 NW ~ 1/4 NW 1/4S 9 SYSTEM ELEVATION /T ~ 29 N/R 17 W TOWN Hammond COUNTY ST. CROIX 101.8 1.1' sand lift! BEDROOM 3 CONVENTIONAL AT-GRADE CONVENTIONAL LIFT HOLDING TANK MOUND XXX SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 630 HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 454 # of chambers none BENCHMARK V.R.P. Top of 1" pipe ASSUME ELEVATION 100' Filter ZabelA-100 ^ BOREHOLE O WELL *H.R.P. Same as Benchmark Property Line Tank is to be properly bedded and provided with lockdown covers with approved warning labels Property Line Well is to meet all Pro 3 setbacks found in Comm. Bedroom $ 3 House 101' 100.7' B-1~ 100' ~ B.M. #1 B:~I: #2 Top of 1 " pvc pipe @ 9.7 3% Slope Area 15' below system is to remain undisturbed Huffcutt Combo Tank B-3 ^ Grading is to be done to divert run-off away from system ^ B-2 379' Property Line (not to scale) Property Line To 173rd St. 1_.-- . ~~-' • No Desi~gner_ , Date 4" Observation Pipe Perforated Below Filter Fabric ASTM G-33 5 o n d ~' Topzo;; y~ Slope Forst Noire From Furrtip Cress Section Ot A Mound S S1em Usin A Bed For 7t-e Absorption Area .__--- p Ft. p~lowe d t~aYer ~ {p ~~ E. ~ F G N ~' ~ g ~ F t . C ~~ a~.~C ~L'`t2~" Ft /~ l' F n. 0 W ~ 0 O %Jt r Non-Woven Filter Fabric ~pistribulion Pipt i _} H -_. F G Bed Ot~j~-2't Orain Rock I ~ • ~ ~~jFt. _ ln, '~ Ft. I- ~_ 4~Observot;on Piet_~~r tC ,_ .__....- ..--- 1 A ~1 _ ----------- l Force Moan __ From Pump l ~r '• Distribution Bed Of /Z ~ 2 Pipt ~ Drain RocK 1 4~~Observotion Pipe '~:-~G~~ Permonent Morktr / pipe or Rods Plon Vitw 0f Mound Uiln A Bed For The Absorpt;on Areo PAGE,_ ~F_- C/~ci 1.oLOled oa $0114m. E4~altp Saoceo tR9T 4401.E Tltx'i' t'e CertY4tG}re Ft. Ff. ~, , ~ Signed: i.icense Number: C}8 to Vim- X ~ inch@s ~ ' ~` Inches / 'Hole Diameter-3~<-~ Inch Lateral ~" ~ ~ Inch(es) ~:an i fol d a Inches F4rCe NId7 n " °~ Inches ~ of holesipipe~~ Invert Elevatiorf oP Laterals 0~~3Ft. PerfarateG o~C! Oetaif S~PTZC TANK E F~3MP C~,aM ~~ TCN hNB SP£CtiFCpTIONS Cr~OSS S£CT• .. 3AZ3~i _ ABOVE GRADE ~ ~~~ Oy VENT PIPE I~tIN~O~ 4R ` FROH D4f}R, ~ FRE~ ~.ZR IMTA3CE ~ ' ~Et!~~"`r~ ~.' E t ~ ~~ ~.._... _ ~ _ ~~ _ INLET _ i,,;AT£R TIGHT g~I.S ...~~-^- 7 ~~~~~ ¢p~ 35QLI~ 1 p~Mp OPF gLE~ - [ ~--== T D SOIL 1 S ~t£a'~H£RPR~F Ji3HCTCCh~UOT {~;TK _, a. =, :a = s i ~ '_ GAS- ~ TIGHT' SEAL : w 3 ~ i ~ S APFROV ~D ~~aLE cov £~ W/ pppLtlCK ~ wARKZxG ~-$~~ ~g",N~~- ,~.. - --- ~~-~IP FE ~~,yQ SOIt SEpfl~i+tG VRD~. TA~~ Cp~}CRETE PAD 5 ~ APPRO~ ~ ~ ri ~ J ~ q,) SPiCIFICp,TZONS p211t+i9E~ DflS£S P£.R i3AY - ~ SEPTIC ~ j3pSE ~~£ ~t{3~ME IT1CLUflC~ ~ J GAL- / £ACT~1R£R = ~ / T AAiK M~ bZ7~ GpL . F i,t~~~ - b~~JGAL - SZ2$S' gEPTZC ~~~~~ ~L_ = eZ-7' ~i~CKES TA11iC ._--•-•-- npSE ~ CRFACITZ'ES' A __--- .~ j~ C~AL- ALAS I„~-R~iFAC1~IRER;' s l ~~ J/~F" -----" MODEL ~~~ / -~~G C = /',~IHCKES _.._.----- ---•-- D g IKCI;ES puKP MA~FAC~R£R ~ ~~ 1----- I LHR i6. Z3 wAC -- Kpti EL ~i#SER = ~ n ~x f R ~ MG As PER SWZ~n ~•+tPE= ~un~ £ p'~ FEET c'~ ~ GFM PIPE - 7~ FEET DI 5CF}AR{,E RATE _,[.~-- f3 Z STR I BOT I ~ 3 i RE~t13TRF~ PUMP fli F ANB - - FEET CB $EEK ~ ~ ggiCTIaM FACTOR • _ ~.5, FEET vERTICAi• D~~~O~ SUPPLY F'RES 3 ~T/~DO.£T_ OYI+fAI'fIC BEAD / MIN;Mari F£~T FORCE~AI~ X ~~ ~flTAL _ . DIAMET'FR _.-.---- '' ~_ J SCI Z D ~~..~.~-.^ IOi~~ {?F P~HP T~K: L~Q~3 D ~ ;~~ FpT£Ri~t-L DZM~NS 5 IG Pt E1~ - _~------"''" ;I88 TOTAL DYNAMIC NEAD/CAPACITY PER MINUTE EFFLUENT AND DEWATERING W 12 °a w x U a 8 0 J Q F- 4 0 ~ 20 40 60 80 100 GALLONS LITERS D 80 16D 240 320 FLOW PER MINUTE CONSULT FACTORY FOR SPECIAL APPLICATIONS • Tmed dosing panels available. '`' • Electrical alternators, for duplex systems, are available and supplied with an alarm. • Variable level control switches are available for conVolling single phase systems. • Double piggyback variable level float switches are available for variable level long and short cycle controls. • Sealed Qwik-Box available for outdoor installations. See FM1420. • Over 130°F. {54°C.) special,quotation required. 1521153 Series MODEL 152 153 Feet Meters Gol. Liters Gol. Lit-:rs 5 1.5 69 261 77 291 10 3.1 61 231 70 2E~5 15 4.6 53 201 61 231 20 - 6.t 44 ~ 167 52 197 25 7.6 34 129 42 159 30 9.t 23 i 67 33 125 35 10.7 -- -- 22 55 40 12.2 -- -- 1 t 42 Lock Valve: 35.0 Ft. (11.fim) 44.0 Ft. (13 4m) 3 27 '2 :2 i 72 1/8 r~ I 5 t/ 1 --~- 3 s~ SELECTION GUIDE 1. Single piggyback variable level float switch or double piggyback variable level float switch. Refer to FM0477. o cAUrlolu 2. See FM0712 for correct model of Electrical Alternator E-Pak. All installation of wntrols, protection devices and wiring should be done by a qualified 3, Variable level control Switch 10-0225 used as a control activator, specify duplex (3) licensed electrician. All electrical and safety codes should 6e followed Including the most Or (4) float System. recent National Electric Code (NEC) and the OccupationaLSafery and Health Act fOSHA). RESERVE POWERED DESIGN For unusual conditions a reserve safety. factor is engineered into the design of every Zoeller pump. MAIL T0: R.D. BOX 16347 Louisville, KY 40256-0347 Manutact~ersof. SH1P T0: 3699 Cane Run Road qp Louisville, KY 40211-1961 QVgL/TY~UMP9 SNCE ~9di7 ~ ' ~~ o w r (502) 77B-2731.1(800) 928-PUMP http;//wwvrzoelle~.com ~'/ /~~~Y~~ `O FAX (502)774-3624 ©Copyright 2000 Zoeller Co. All rights reserved. Wiscor-yn Department of Commerce SOIL EVALUATION REPORT Div(sicrtof Safety and Buildings Page y of - n. auwn uanw mu. van~u.. w. •~u. rwni. vwc County Plan must Attach complete site plan on paper not less than 8 1/2 x 11 inches in size . is ce ne w n i o ^ ~~_ ~~ Parcel I.D. Ol ~ _ D q~ arest road. tan and locatxxt sand d north arro ops, sca a or d mensions, peroent st / v Please print all information. - vie y Date Personal information you provide may be used fa . 04 (1) (m)). l,(',~yy~` J/6 Q , j Property Owner -. _ Location ~~ G .Lot N 1/4 (v(~,}1/4 S q T Z~ N R ~~ E (or W Property Owners Mailing Address - ~ s - Lot Block # Su -Name or CSM# ~ t ~ . ~ , ~ City State Zip Code hone ` , r~~ ~1 ~~OI ~ ( ) G OFFICE }l-fit(-~1l 1~'f,~`i~J~t,1''i~ City ~Ilage_ {..Town Nearest R ~ ~ ,.( C~Xl' ~~' ~V New Construction Use: ® Residential / Number of bedrooms ~~ Code derived design flow rate ~/ ~ ~L 00 GPD ^ Replacement ^ Public or conunercial -Describe: , Parent material ~~~f' _ Flood Plain elevation if applicable ~ ff. General comments $~s~ t w\ e I f'_ \! , ~ U~~ CD ~ _ _ ~, Q~ ~ ~~, l~~ ~ ~! ~ ~i and recommendations: ~~ ~ ~ ~ If U ` ~QO. S O Boring # ^ Boring Pit Ground surface elev. ~GY~, ZO ft. Depth to limiting factor 3 n. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. MunseO Du. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 •Eff#2 ~ o-~o l0 12 -- 3< < Z k r c s c ~ L' . 5 . ~' Z I y ~ 5~ ~-~ ~m I~ m r ~S - 3 Z3- I 4 ~ C ZP ~. ~ r ~t ~ 5; ~(~ Zm~bk m~'r -- -- ~ , ~ L~ ~~ # O Bonng .®, pit Ground surface elev. /Od ~ fL Depth to limiting factor ~ in. Soil Appliption Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft~ in. Munsell 11u. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 I (~-I ( 3 Z ~ 5i ( 2 'r ~~ l ~~ ~ 5 I - g I~ y `~ Si C~ r ~ ~ -' . ~a 'Effluent #1 = BODS > 30 < 220 mglL and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mglL and TSS < 30 mglL CST Name (PI se Print) Signa CST Number ~__~ Z5.33o Address Date Evaluation Conducted Telephone Number ~_3 gQ!~_~. ~_ ,~oz~ ~ - -s- ° 2 (~i3)zy ~-yap ~' Property Owner ~~ Paro21 ID # !D ~ / Page ~ ~ of •{ Boring # ~ ~~ . ~, pit Ground surface elev. ~~~. Zd ft Depth to limiting factor in. Soil Appliption Rate Horizon Depth Dominant Color Redox Description Texture Strudiue Consistence Boundary Roots GPDIftZ in. Mansell Qu. Sz. Copt Color Gr. Sz Sh. 'Eff#1 'Eff#2 ~ ~p X312 S'i 2 c Iv . 5 , 8 Z 10- u ~ t' yl ~ -- S~ ~1 k ~` c s - - `~ , ~ Boring # ^ Boring [,~ pit Ground surface elev. ft. Depth to limiting factor ~ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Mansell Ou. Sz_ Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ^ Boring # ^ Boring ^ Pit Ground surface elev. ft Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture . Struchue Consistence Boundary Roots GPD/ft2 in. MunseG Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 - 'Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L 'Effluent #2 = BODS < 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. sso-saw (Rmroo~ r' N TAT A l~~f~ ~p,~ ~e T OT# ~~ T AL DESCRIPTION Nw ~NW t4 ,S ~ T Z ~' .N.R. > ~ E(or~ SCALE: I"= ~O ~ BM 1 ELEVATION lQ'~-O BM 1 DESCRIPTION ~ p O~ ~ ~ D ~1 ~ Q, "4T BM 2 ELEVATION 9 ~. ~ BM 2 DESCRIPTION {gyp ~3-~ ~ ~ OyG ~,"DP SYSTEM ELEVATION /U / (~ d SYSTEM TYPE j4'~ 0 y ,~~ ` s XS,~ e t~ CONTOUR ELEVATION /Q'> ~ S~ ~ti (~mZ PAGE ~ OF~ - -fi' ~ Sec, rG \ c.~ ,~ gm ~_-2 \~ao SIGNATURE 6'3 /~ as row , C~ ~ - ~~ -sac\~ DATE (~ ` ~ ~ z $ y ~~ ~ ~S MANUAL 8~ MANAGEMENT PLAN ' ppWTS OWNER SYSTEM SPEC1FICATEONS LE 1NFORINIA'nON , ~ re,b th.J.y r . Septic tank CaPa~ F[ .~ 17 optic Tank Manufacturer p,rrner Permit ~. Effluent Filter Manufacturer Effluent Filter' Model l7 tdA DESIGN PA~~S Number of Beds - Pump Tank CapacflY Number of Commend Units pump Tank Manufacturer . ~ ~2.~,nailda Estimated ltow (a~y`~ n flow (pea~~ (~t,rrtafled x 1: 5} si sjj atld~ ..•.: . A d De g . a (7 al/ Soa qon Rate Nlonthty average' lnfluent/Effluentguality FOG) Oil 8, Grease ( t S30 mg/l- s,. Fa Biochemical Oxygen Demand (BOOS) ded Solids {TSS) ~~ mg1L 5150 2 Total Suspen Monthh average" Pr+etrea~ Effluent Qua1'dY ~. d (BODs) 530 mg/L en Deman B'iocherrircal Oxyg Total Suspended Solids (TSS) 530 mgn- 510' cfu/100m1 Fecal Col'iform (geometric mean) Y inchdiameter Maximum Effluent Partide S¢e .Pump Manufacturer Page Pump Model pcetr'eatment Unit ^ Peat F1lter [] Sand/Grdvel Filter ~ Nlecttanical Aeration ^ Wetland ^ Other. ^ Disinfection a ^~NA- f] NA ^ NA D NA NA ?~^ N~°- Disp ~ Celt(s) L7 -ground (pressur¢ed) ^ In~round (gravity) and ^ At-grade ^ Other ^ Dri ine n~a ~~.na • Values typlcar for domestic (non-o~T~~ n ~p<jc tardc effluent ~~ ,,,~stewater. •~ values types ~ ~ Service Frequency Service Event ins nCOn~ ion of tank(s) Pump out contents of tank(s) Inspect dispefS~ Cell(s) Clean effluent filter Inspect pumP• Pump Controls 8 alan'r- Flush laterals and pressure test t feast once every A uals When combined sludge and scum eq ` At least once every At least once every At least once every At least once every At feast once every At least Once every ^ '^ ^ (Maximum 3 yrs.) (Y~} of tank volume ;) {Maximum 3 yrs.) ^ NA ^ NA ^ m no the ^ year(s) ^ NA ^ months ^ year(s) ^ NA __--_- n one of the following licenses or ~~NANt~ 1NSTRUCTiONS an ind'Nidual canyi g ctor POWTS Maintainer, Septage of tanks and dispersal cells shall be made by Sevver; Povv.is inspe a m~ng or trroKen Inspetxions Master Plumber Restricted s to identify ny moons:. Master Plumber. a and scum and to check for any back up floc. Tank inspections must indude a visual inspection of the tank( to Chi the effluent levels han~ro. kientifY ~,y packs or leaks, measure the volume of combined sludg of went on the round surface- The dispersal cell(s) shall be vlsuatty Inspe~ ponding or ponding of effluent on the g nding of effluent on the ground surface. ulatory authority. i and to check for any Fo uires the Immediate notification of the local reg in the observation P PeS or more Of the tank volume. the ground surface may indicate a failing condition and req tank equals one-third (~ ch. NR e and scorn in any sect of in accortitance v+iRh When the combined aceumulation of studg b a Septage Servicing Operator and dispo entire contents of tl-e tank shall be removed y retreatf ment components, and any 113, Wisconsin Administrative Code- - onents. P mechanical or pressurized pOWTS comp ~~ by a certified POyYTS Maintainer. The servicing of effluent filters. service event other maintenance or morirtoring at intervals of 12 months or less shall be ~ of completion of any . shatrbe provided to the focal regulatory authority within 10 days A services report nti roduds or other POµrfs check treatment tank(s) for the presence of pat n9 p STARTUP AND OPERATION ersal cell(s). If high concentrations are For new construction. prior to use of the s and/or damage the lisp rm a the treatment proroces by a septage servicing operator prior to use. cherrtlcals that may ~ ped detected have the contents of the tank(sl Page of /~` conditions are frozen at the infiltrative surface- is restored the excess System stars up shalt not occur wttt=n sort above nomu~ titghwater levels. Vtifhen ~~ cetl(s} and may result in the r outages Pump ~n~ try ~ cell(s) inane large dose. overloading ucn tank removed by a During tie ed to the dtsPetsal `~~~ su~~ d~scha ge of effl~t To avow! Otis s~tion have me p n~n~d a Pi n~ or' POWTS Maintainer to UadwP ~ r~Lofirtg power to the effluent pu P ~ the pump tank- ge Servrdrt9 pperatoc P~ um -~tnp(s to restore normal levels with' assist in manually operating rite p p .. ~. Do not drive or park over, ar otherwise disturb or compact, over tanks and dispersal po not drive or park vehid~ mound or at-grade soil absorption area. the area within 15 feet down slope of arty ter stream may improve the performance and prolong the e Reduction or-elimination of the following firom the wastewa degneasem: dental floss; diapers: rte butts: condoms: cotton swabs: herbicides; meat of the POWTS: antibiotics;baby wiP~+: ~~ water fn~it and vegetable peelings; gasotrne; grease; disatfectants: fat; founda~n drain {sump Pump •des; sanitary napkins; tampons:'and water soiterter brine. saw: ~-moons; op; ~ain8ng Q~ucts: P~ -- gBANOON~MENT taken out of service the foitowin9 steps strati be taken tO insure that the When the pOWTS falls andlor is petmanentlY trance rtith ~. Comm 83.33, ~scansin Administrative Code: sys~ is properly artd safey abandoned in comp • i nl s seated. A[t piping to tanks and prLs sha(1 be disoonneded and the aband sect p ~ o~yn ~pthge ~~cing Operator. The contents of air tanks and pits shall be removed and properly Pce • ~ Sha{{ ~ excavated and removed or their covers removed and the void space After pumping. al[ tanks and p ~~ yy{~ spit, gravel or another inert solid material- CONTINGENCY PLAN the following measures have been, or must be taken, to Provrde a code If the POWTS fails and cannot be repaired compliant feptacerrtent system: evaluated and may be utilized for the location of a replacement soil p A suitable replacement-area has been coon and should not absorP~n system. The r~eptacement arerom existin~andtproposed strucxure. tot lines and wel(s_ Failure to wired setbacks 9 be infringed upon by req rated the replacement area v+n"U result i s must comply with the'rule~ n effect at that time~blish a sulfa eYVTS P replacement area- Replacement system O A suitable replacement area is notice !!11~ as a last. resort to replace'the failed POWTSng advances in ~ technology a holding tankk may be of n eval to ide - a suitable replace ent are Pon t re of The s' has to a su" ere ment re ff site, ua n ~ lied -last re a e it O - ° f k s ma be reconstructed rn place fo[(ornnng removal of the biomat at ound and at-grade soil atrsorPfion s of such systems must comply with the rules in effect at that time. e infitb'ative surface. Reconstruc~O <cVl(ARNINC~> 'r/4NKS MAY CONTAIN Lt=THAL GASSES ANDIOR INSUFFICIENT OXYGEN. SEPTIC, PUMP AND OTHER TREATMENT CIRCUMSTANCES. DEATH MAY DO NOT ENTER A SEPTiC, PUMP OR OTHER TREATMEhIT TANK UNDER ANY RESULT. ,RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAYBE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMiNTS POWtS JNSTALLER Name ~ r~ / Phone ~ f v = ~ Jam` POVYTS MA{NTAINF~ 2 Name Phone ~/~ % ~ li J LOCAL REGULATORY A{JTHOR(7Y ~ , SEPTAGE SERV{C(NG OPERATOR PUMPER Agency S ~ ~ Name ~ _ Phone 7/~ ~ Phone / J = ~ ~ -{his doarment meets rnis document was dialled bl! the staffs of the Goren Lake. Marquette and Waushara County Zoning and San ~ ~ deurmen[ does not me minimum requiremants of cat Comm s3.22C2)(bH7iH~~(fl and 83.54(1), f2l ~ (3}, Wcsconsin Adminis>•ratTMe ~~ (2l01) guarantee the performance of the PL71M1rrS. ~~N t ~ ~ ST CROIX COUN`T'Y ~ SEPTIC TANK MAINTENANCE tt-GREEMENT AND OWNERSHIP ~~~ICATION FORM '~~ 1 .._: ~ ~L ~ ('?wnerBuYer ' ~' r t> _, < ~ - ~ r > : f 5 ,~ y ~.~ ~ c '.~a Mailing Address ~o~a ~ ~ ;~ ~?, L~.~ , ~,~ ~ ~ ~~ ~~ 5-t ~-1c~,M,M o Property Address (Verification required fr°-o~m Planning Department for new coast City/State ~ U-~"n ~ ~ ~ `L P~1 Identification Number i Erg DESCRIPTION 1 Propetty LOCahon ~ `~4,~_= SLibdlYlSlon~~~~ ,.~-- ~~ N-RI ~ w~ ~. `z Sys ~ ~~/C `1 i:. .. aI~S- /D9h - 1 ~' ~- 6~. Ha~~r~;. Town of Lot#~ Volume ,Page # ~~ Certified Survey Map # `~ / ,Volume ~ Page # J WArranty Deed # _ ~ ~ ~~ `~ / Spec house ^ yes ~ no Lot lines identifiable ~ yes ^ no SyS'T'~M MAINTENANCE om could result in its premature failure to handle wastes. Proper maintenance Improper use and mamtenanceof Your septic syst b a licensed pumper• What you put into the system consists of ptiinping out the septic tank every throe years or sooner, if needed y ~ can affect the function of the septic tank as a treatment stage in the waste disposal ~ owner a to submit to St. Croix Zoning DePartmesrt a ceitification form, signed by the owner ens b em The property verifying that (1) the on-site wastewater dispose yst masttrplumber, joumey~Plumber, restrictodplumberor a licensedpumper ~ tic tank is less than 1/3 full of sludge. condition and/or (2) after inspection and ptitiiping (if necessary), ~P is in proper operating to maintain the p I em with the standards is and agree rivate sewage dispose cyst ~~ the andusignod have read the above requiremen ~ of Natural Resources. State of Wisconsin- Certification set forth, herein, as set by the Department of Commerce and the Departm Office within 30 Ming that your septic system has beta maintained must be completed and returned to the St. Croix County Zoning days of the three Year' expiration date. t c ., ~'~~ ~,1 i.rtt_:~,...--z....~~ DATE SIGNATURE' OF APPLICAN'T' OWNER CERTIFICATIOI~I our knowledge. I (wc) am (are) the owncr{s) of I (we) certify that all statements on this form i~~~ ~ R~°g~~r of Dads Office. the property dcsGn'bed above, by virtue of a warranty ~ ~ ~, ~_ ~ ~~ ` ~. ~ _ v . ~.. ~~--<-"n. ~'ti DATE SIGNATURE OF APPLICANT ««.••, s•as«« Any information that i5 IItis-representedmay result in the sanitary peiniit being revoked by the ZoI11IIg Department. '/4, Sec. _____._ U~ ~ •~ Include rv{th this application: a stamped warranty deed from the Register of Deeds office s copy of the certified survey map if reference is made in the warranty deed Parcel #: 098-1096-17-000 04/12/2005 09:33 AM PAGE 1 OF 1 Alt. Parcel #: 09.29.17.792 018 -TOWN OF HAMMOND Current I X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): " =Current Owner *ULFERTS FAMILY TRUST, KARL M & KATHARINA G KARL M & KATHARINA G ULFERTS FAMILY TRUST 1011 170TH ST HAMMOND WI 54015 Districts: SC =School SP =Special Property Address(es): ` =Primary Type Dist # Description ' 1092 173RD ST SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 1.860 Plat: 2299-PHEASANT RIDGE 1/32 018/02 SEC 09 T29N R17W PT NW NW PHEASANT RIDGE LOT 17 1 860AC Block/Condo Bldg: LOT 17 . Tract(s): (Sec-Twn-Rng 401/4 1601/4) 09-29N-17W NW NW Notes: Parcel History: Date Doc # Vol/Page Type 08/06/2002 686239 9/26 PLAT 2004 SUMMARY Bill #: Fair Market Value: Assessed with: 56903 45,000 Valuations: Last Changed: 06/30/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.860 37,700 0 37,700 NO Totals for 2004: General Property 1.860 37,700 0 37,700 Woodland 0.000 0 0 Totals for 2003: General Property 1.860 37,700 0 37,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 t•1 U; 2 7 3 fi P 0 3 6 ~85`~'~~ KATHLEEN H. MALSH State Bar of Wisconsin Form 7-2003 REGISTER OF' DEEDS ST• CROIX ;CO. , -ri TRUSTEE'S DEED . RECEIVED FOR RECORD I)oeumentTtumber DoeumexttName 81 /24 /200 10 : 00A11 TRUSTEES DEED EXEIIp't ~, 'THLS PEED, made between ~c M. Boete as Trustee of REC FEE: ~ 11.00 I{arl M Ulferts and I~th,~jna G Ulferts amity Trust TRANS FEE: 134.70 ("Grantor," whether one or more), GOPY FEE: and ~uegM. Grebownkt and Doris IV[. GreboYrski. husband and wile CC FEE: ' PAGES: 1 ("Grantee," whether one or more). Graatot conveys to Grantee, without warranty, the following described tear estate, ; together with the terns, profits, fixtures and Other appurtenant interests, IT1 St Croix RaO^~'"a'°'^°a County, State of Wisconsin ("Property") (if more space is needed, please attach ; addendum): Name and Aetucn nddrcss , Lot 17, Pheasant Ridge. 5t. Croix County, Wisconsin. ~(• ~ ~'''"~' 30 ~' ~ cd t s~far~ X8-1 ~ arcel IdenUficatior; Number (PIN) Dated f ~~~ ~ *Dine M. $onte, Trustee (SEAL} {SF-AL) * AUTHENTICATION Si$nattu~e(a) authenticated on s TITLE: MEMBER S~'ATE BAR OF WiSCONSIIV (Tf not, authorized by Wis. Stat. § 706.06) THIS INSTRUMENT DRAFTED BY. Attor{~v Kristine Ogland Hudson. W 1940¢ ACKNOWLEDGTNENT STATE OF ) )~ St Croix COUNTY ) , Personalty came before me on fie above-named pine M. Bonte. Trnstce ;~_ to me known m be the person(s) who executed the foregoing instcumcnt and adrnowTedgcd the same. * Naacv J Nichob Notary Public, Stau of Wisconsin My Commission (is peamanent) (expires: 09-10-06 ~~ (Si/natarea may be aud-eadexWd or ~elmorvledaed. Hot6 etc not .ce~.ryJ NOTE: TH(S i$ A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY >DED17'IFIiED. TRUSTEE'S DEED Q 2003 SPATE BAR OP WISCONSIN FORM N0. 7-x003 • Type name below li~awres. 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