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HomeMy WebLinkAbout018-1036-80-000 (2)Wiscon;~n Depar.`.ment of Commerce 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)]. 'ermit Holder's Name: City Village X Township Revoir, James Hammond Townshi :ST BM Elev: Insp. BM Elev: BM Description: o I fi' ~I- C~ IAIVK IIVt•UKMAI IVIV TYPE MANUFACTURER CAPACITY Septic Dosing ~ ~l / C„re~r~,~li. / t Aeration •~_ Holding TANK SETBACK INFORMATION TANK' 0 P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ ~ 1 ~s I Dosing L/ ~. `I Aeration Holding PUMP/SIPHON INFORMATION Manufacturer ~~ _ p ~ Demand ~,,,Q,pIL GPM Model Number ~` d ~ ~ t ~~~ TDH Lif~ ~3 Frictio ~s System Head TD` 3•~ Ft ~---.. Forcemain Length I Dia. 2 u Dist. to well t ';~j } SOIL ABSORPTION SYSTEM i~ ~ RENC' uvidtn ~ / en DIM S SETBACK SYSTEM TO INFORMATION Type Of System: DISTRIB .~ / 3z ` >~ ~ o/~. GLCVHIIVIY LI/11/1 county: St. Croix Sanitary Permit No: 405178 0 State Plan ID No: Parcel Tax No: 018-1036-80-000 '~ ' STATION BS HI FS ELEV. Benchmark ~^ ~ '' 1 ~ l5 ,0 ~, qq • ~ 1 Alt. BM Bldg. Sewer C~ 9~ • ~ ~D J I or• ~} r 1 SUHt Inlet ~p ~~•~}` J ~ . ~D ~ ~• 3 } / SUHt Outlet Dt Inlet Dt Bottom 103, IS ~` ~~^~~ i Header/M n. S Bot. Syste Final Grade [7yn. St Cover p~ ~~ // • PIT DIMENSIONS INo. Of Pits LEACHING M~pufac]liyq: 4 ~.I /~ ~ " CHAMBER OR .•-)••~a1'I IITT ~'~^~' UNIT Mnrlel N her:. _ n ~ Header/Manifold ~ /1 Length Dia Distributioq , . ~ ~ - ` Leng h - " Dia Spacing x Hole Size x Hole Spacing • Vent to Air Intake 7 3'S $OIL COVER ' ~ x Pressure Systems Only xx Mound Or. At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched BedlTrench Center Bed/Trench Ed es g To soil p [i Yes ~ ~ No ',I Yes i,l No .Q) O MEN S: (I cl dQ,code discrepencies, persons present, etc.) Inspection #1: ~KiL l~/~ Inspection #2: ""'~~'"~"-" ~ ~ ~, IQn: 983'1,66th,St~et Hammond, WI 54015 (NW 1/4 NE 1/4 17 T29N R17W) Prairie Ru~ t 5~ Pagel No: 17. 9.'~/. 9 rj.tx ~,.K' ( r t~ J c~~~, o.,. l°s.~.`~~ = S~ndf ewe I~as ~ i ~• y`" 1.) Alt BM Description - .I 2.) Bldg sewer length = _ ~ n ..A - amount of cover = ~`/ -~~' ~' ~, iW~ lea ~4' ~ ~ 1 w...r, of ~~ 4.l •. ~ ~ T iDr n r ision Required? ~° N ^'~K1'`~ / 3 /'7~tJ0 3 --&,~,Q C ~ ! ' Use other side for additio r i - ~ ~. ~ ~ ~T SBD-6710 (R.3/97) ~ ~/~ (~..~'~~ Date , ` I se or's Signature 1 (~ Cert. No. o ' 1~ l . ", Y s ,;: . , . ,.. BSI, . ~g ~ °°'~t ~ l~+ •.SL ~ ~o~ $ ~~, ~~ ~ o~ • ~ ,~-sb = ~i=t ss' t 6 ~ ab ~ -~,--~~ ~~ ~' 9 • - ~ fig ~~ I`:;~ 'r / r I T'iA~ - ` t - ~... - ,.. .. , j 1. ~ 1 ., c~ f___ -..___,___.~_ Safety and Builtlittgs Uivisicm--- I ~ ~ i 2,)! W. 1~Vashint;wn Ave., P.O. Box 71F2 ~~ourty--- I~,,,~ ~ F''~1 ~L X ,~''~~~'~j~ ~ Madison, Wl 5370', - 7162 . . Sarusary Permit N[tmber (to be filled in by Co.i ~ Department of Ccrnmerce {6Q8) 2bb-3151 `-{D5 ~ "7~ ' ~anitar~ Permit Applieativm State Plan 1.17. Numbe v l+ In accord with Comm 83,21, Wis. Adm. Coda, personal information you provide / L may be used for secondary purposzs Privacy Law, si5.()4(I}(m) Prajecz Address (if differens than mailing address) l I Pl p f ~~~ LL ~~13 `~~ ~ Sr ~ licat an ti orrtta~tion - ease Print A11 Lttfar atio i n~ ~~ -~ ~ I ~~ - Property Owner's Na me ~- _ ~~~ 2 1 2003 _ ~~ .~ _ i acne! ~l Lot ~ Bloc k # ~ ~' / ~. ~' { - Prepert<; Owner's M ailing Addres~~ ~~ _ ST C1tQIX CCUNTY - ~ QroPerty Location ,~~.~ ~ Q~3 ZONWGOFFIGE ~ ~ ~ ,fir Section ~ ~ ~'~ ~ ~ City. State yip Code Phone Number , ~ ' '~ ~~- `Y! rf~L.~fitld /~1~-_ I ~1{d 1..~ _ ______ ~ (circle o ) E or L T ~~ '~ R II. 71'ypc of Bui'ld%ng (check all that apply) ___._ _ _ /' / or 2 Family Dwelling -Number of Hedreu~ms ~Q~t~B'~~(. ~ ~Z~~ ~ Suf- c7divisian Nama CSM Number i ___.-_. ____ ^\\ PubliciCommercial -Describe Use _!_T ____/- ____ -- ___ 4 r~Y ~q~.fc~ State Owned - Descritx: Llsa _ ~_ ~ I .. i_.C'ity_^V i!lage ,township of ~ {lZf~/d _ __ III. Type of Permit: (Check aniy one bax en lzne A. Camplete line B if applicable) r ~~ ~'' ~ ;c~, New System ~ J Repla ement System 1 !.~ Traa:merititiclding Tank: Keplacement Grily ~ ^ Other !Ltodification to Existing System - !!!~• ~ { - _ f List Previous Permit Number and Date lssued ~ B. ^ Permit Renewal arrnit Revision ^ Change of i~ Permit Trnnsfer to New i Aefore Expiration Plumber Owner 7 /~~~ '7 ~' ~p/2 ~ d Z , / VV 1 ~ ~N. Type of PO~~'TS Systems {Check all that app1Y) M _~ ....-_.~-~ Non -Pressurized In-Graund ^ Maund ~ 24 in. of suitable soil ^ lvfound < 24 in. of suitable soil ^ A2-Grade ^ Single Pass Sand Filter ^ Constructed ~Jetlarad ^ Pressurized In•Ground ^ Holdir.; Taril[ ^ Peat Filter ^~ Rarobic'1'reatment Unit ^ cXzcirculating Sand Fit[ar ~^ Rrcirculating SynQtatic :Media Filter ~Leaclting Charnber ~~ Drip Line ! Gravel!^Ie.ss Pipe ^ Other (explain) ~. ~V. Dis rsaUTreatment Area Informatiatt: _~ _~ ~s ___ 1.~.-' Dasign Flow (gpd) Design Sail Application Rate(gpds , Dispersal Area Raquired (sf) Dispersal Area Proposed {'s.) Syste oval ~© I cl~ ~ ~~ ~ _ ~ ls~ ~~150~ ~ `VT '1'a11tc Info Capacity in Total ' Number R4anufacturer ~ Prefab Site TPlas[iC _ Gallcns Gallons ~ of Units ~ ®- Q /~ ~ Concrete Constructed Glass New Existing ~ a~Q-G-~/~ /7 ~6~ f Tanks ~ Tan;cs I ~ U ~ Septic or Iialding Tank I ~~~ ~ ~ ~ T Crg-~r -~~ Ae;obie'ircatment Unit I _ ___ _ (Dosing chamber i ~ -_._~.~._.,~. ~~ 1 i r~.5"r __- ~____~ ,~ ~ I ~ VII. Responsibility 6tatement- I, the undtrsigttt:d, assume i•esponsibidity for Nation of the POWTS shown on the attached plans. i Plum'xr's Na me (Print) +' Plumber~'fS~i ~gnature~s' I P PRS Number ,,~,~~' ~i yap 5~~~~,~~. (!.~ ~<~2~ ~ ' ~2 ?~9~1" ~ Business Phone Number 7 t:5'--~~'~ ~- ~~'~ l Plumber's .4ddre ss (8ireet, St ale, ?ip Code} i ry. C . ~ - , ~ 1 ~i ,+ VII ~outtt /De artment Use Only _ _ _ d Sanitary Permit Fee (i dudes Graundwater D't lssued 2 suing ent Signatur o tamps} I A roved ^ Disa v pp ppro e ~ S h 1" ~ urc arge ee) Z/ ~ 3 G2~~ ~C!~/Li.l~ __ ; CJ Owner Given Reason for Dehial ~, ~~ LY. C:antiitions of Appt'aval/Reasatts for Disapproval ~ ~- sue s~ - ~:~ ~~ - -~ s ` ~~ -1~~ ~ `- ~ e ~ ~C.~ ..CiCX/L/ [~" w ^4 Vim[- ~`^ W ~--' ~ /r~~/~/Y4 Q/,,Q~ Lh j " A tech ptete plans (to h, C:ornt nl ) f r the systey~ar~~p~ of s tl~ 8 (, s ches Iu sire L~J- 9'7• S~ U%t~E~ G(/~c..~ QG~ ~i,P/tL CC.~~ ,~j ~tG~' s i d~ S~e~~ ~~ ~~ ~~ ,.~~~' ~ ~o ~ ~ b v ~ ~~~ .~ ~I' ~~d~ ~GY ~~ ~~ ~~- $~~7/D Z sy~ , ~ bvr~`n~'.~ v 1 ~~- ya'sC,e~~ ~.~ '~s~a~~ ~,,~ ~ s f 5ys~~ ~° s~ ~~ ,,,~.°.~~d Qh.:2.a~. y 2~6 3 f~c,~2 S-~~~-`~-'~ ~~,~,~' ~ ~~ -e S ~ ,e v D~ ~ tea" ~~~Y.t- <</~,' -~ ~Ca ~ ~< ~ ' S~' g ~ ~~ ~,1 ~q U~U ~-~b~ ~~ ~ ~~~ r • Fasteners: 300 series stainless steel. • Capable of running dry without damage to components. Motor: • EP04 Single phase: 0.4 HP, 115 or 230 V, 60 Hz,1550 RPM, built in overload with automatic reset. • EP05 Single phase: 0.5 HP, 115 V, 60 Hz,1550 RPM, built in overload w'lth automatic reset. • Power cord: l0 foot standard length,16/3 SdT0 with three prong grounding plug. Optional 20 foot length,16/3 SJTW with three prong grounding plug (standard on EP05). APPLICATIONS r~ 1 Spec~cally designed for the following uses: • Effluent systems . • Homes • Farms Heavy duty sump • Water transfer • Oewatering SPECIFICATIONS Pump: EP04 • Solids handling capability: ale" maximum. • Capacities: up to 55 GPM. • Total heads: up to 24 feet. • Discharge size:l'!a" NPT. • Mechanical seal: carbon- rotarylceramic-stationary, BONA-N elastomers. • Temperature: 104°F (40°G} continuous 140°F (60°C) intermittent. • Fasteners: 300 series stainless steel. • Capable of running dry without damage to components. Pump: EP05 • Solids handling capability: ~~' maximum. • Gapacities: up to 60 GPM. • Total heads: up to 31 feet. • Discharge size: l'r~"NPT • Mechanical seal: carbon- rotary/ceramic-stationary, BUNA-N eiastomers. • Temperature: i04°F (4Q°Gj continuous 140°F (60°C} intermittent. c~ O 1995 Goulds Pumps" Irsr. METERSIIFEET 10F '' ~' ,~ Goulds p~~ G °~ ~ ~~~ <<~~`~ ~~~ Submersible Effluent Pump ~~ C~7 3871 EP05 91- 3 2 4 ~ x ~ s 2 5 p 1 a a °r Q 10 2Q 30 • Fully submerged in high grade turbine od for lubrication and efficient heat transfer. Available tar automatic and manna! operation. Automatic models inclade Mechanical Flaat Swlich assembled and preset at the factory. FEATURES ^ EP04 Impeller: Thermo- plastic Semi-open design with pump out vanes #or mechanical seal protection. ^ EP05 Impeller: Thermo- plas#ic enclosed design for improved performance. ^ Casing and Base: Rugged thermoplastic design provides superior strength and corrosion- resistance. ^ Motor. Housing: Cast iron for efficient heat transfer, strength, ahd durability. ^ Motolr~Gover. Thermoplas- ticcover with integral handle and float switch attachment points. ^ Power Cable: Severe duty rated oil and water resistant. ^ Bearings: Upper and lower heavy duty ball bearing construction. AGENCY LlSTIN6 ~• canedtan ~„~rds pssosiation {CSA listed model numbers end in "F' or "AC".) - I: _~ i `}'i ,.~ 1 1 ~y I ~.} ~ i -T---- 5 o s o e r- 5 o I 50 GP! 0 2 4 6 8. 10 12 m~1h CAPAGrTY ~,fc~` "• ` ' ., ~ . E May, 1995 sasrl • ~ PUMP CHAMBP.R CROSS SEC;TIUN ANA iPECiFICATiCNS SEPTIC TANK -~- - =--------- ~'t ~CI V~NM DOOR,1WINDOW~ ORBOVE GRADE ~ > 2 5 ! FRO FRESH AIR INTAKE FINISHED GRADE 4" CI RISER -" 1g„ YN. 6" MAX. NLET ~ ~~ `WATER TIGHT SEALS PPROYED ~ B APE 3' "f"" NTO SALID C OIf. PUMP OFF ELEV . ____ FT. -~'r D AFPROV ED MANHOLE COVER W / PADLOCK E WARNING LABEL ~~ ~/APPROYED 30I~tTS WITH ALM APPROVED PIPE ON 3' ON70 50LI0 50IL OFF ~`~` RISER EXIT PERMITTED ONLY IF TANK MANUFACTURER HAS APPROVAL 3" APPROV ED BEDDING UNDER TANK SPECIFICATIONS SEPTIC / DOSE TANK MANUFACTURER: ~°~~-S'~ ~" TANK SAS ~ DOSEIC ALARM MANUFACTURER: ""'"'"'"~ MODEL AIUMSER : SWITCH TYPE: J_a_,~_,~.. GAL . g- Qo' _ GAL. evil ~~ d PUMF MANUFACTURER : ~~~%~~ ___.__ MODEL NUMBER s _,,,,~`~_. ~.__ SWITCH TYPE: ~rG REQUIRED DISCHARGE RATE 3~ GPM CpNCRETE PAD NLJMgER DOSES PER DAY : ~--- DOSE VOLUME ~L~WBACKu,,,~,?~ GAL' CAPACITIES : A = ~ ~ INCHES = .- 2f1 ._GAL' WEATFiERPR00F tN NOTION SOX WITH CONDUIT .- • ~~ ~~ i { `~ GAS-}~ ~,~ TIGHTS ~ SEAL ~ ~ r ~ r I B 2 INCHES = ~ 2 GAL . C ~ ~ INCHES = X74 ~AL' D ~ INCHES = /~~ SAL PUMP E ALARM WTRI NG AS PER S LHR ~I6.23' WAC VERTICAL DIFFERENCE BETWEEN PSUREOFF .AND .DISTRIBUTION PIPE. + MINIMUM NETWORK SUPPLY PRES FT/140 FT. FRICTION FA~T~ •_ +~ FEET FORCEMAIN X ~ T.OTAL D+NAMIC 2 FEET °Y~~= "~'"'" FEET FEET ~ .!~-~-F EET~?= ~- I D' ~ ~, ~3-~ ~ LENGTH ; ' _,,,~__.__ D~I,/AME y ER INTERNAL DIMENSIONS OF PUMP TANK: LIQUID ~~- k_....~- -~ ~ f~~'l ~'~~ ~ • ~ LICENSE NUMBER ~ ~~ ?~ `I l --- DATE SIGNED : .--~- 1/88 ~~ - ~ ~ O S~~ ~ti l • / ,,C~i! ! yr/G c X00 ° /~ ---~ ,(din ~- ~ y ,dam ~ ~~ 3~ t / ~- '!' ~ 3 ~- H~ ^ ~` d ~v ~~,~ y c ~'~ '~~ Sys ~ ~ ~ / ~ D 3~16a~,~L,h . ~ ~~ ~~a~r ~ S ~•~w ~~~' , ~~ , sc~ =T° ' ~i ,~ ;;. s:,, <, '~ ..:. ~ ~~ `° .~r , v t Wisconsin Department of Commerce SOIL EVALUATION REPORT Page ~ of Division of Safety and Buildings m accordance wnm Comm rsa, wis. Ham. t.ode ~ County - Plan must Attach com l er not less than 8 1/2 x 11 inches in size sit l n n a t ' . p p p e e e p a o include, but not limited to: vertical and horizontal reference point (BM), direction and p~ I,p, percent slope, scale or dimensions, north an'ow, and loption and istance to nearest road. Please print all information. t~.Z 3 ~ j~ Reviewed by Date Pe~sonai information you provide may be used for secondary pur<wses acy law, s. 15.04 (1) (m)). Property Owner Properly Location / ~~ C ' Govt. lot„~'~ 1/4 ' , /4 S T ~t N R E (or)ap- Property Owner's Mailing ddre ~ ~ < Lot # ~ Block # ame or CSM# ~ ~I . j < Q':i r t C u r~ Zip Code Phone Number City State ~ City ^ ~Ilage ®Town Nearest Road / New Construction Use: (~ Residential /Number of bedrooms ~ " Code derived design flow rate ~.5~ ^ Replacement ~~ ^~~ Public or commerclal -Describe: ~_- _ Parent material q -7 Flood Plain elevation'rfappliceble ~ General rxxtvneMs G' ~/~,~/a1 ~~~1/• ~,~ / t. S~ Cc~rr.-rrC~~: p p' and recommendations: ~ T ~U i~ ` S( /~ ~` ~ GPD __. %~/'~-~ ft. l ~°+ ~'~ ~=: ~ ~a ~ ~ 1 2 2002 Boni # ^ Boring - ~~ n9 Pit Ground surface ele .1~ ~ ~~ Depth to limiting factor .~ in. ST. is-f:OIX CO!J~.~TY ~-~-, " " Horizon Depth Dominant Col Redox Des Texture Stnx~ure Consistence Boundary Roots GP D/ft= i n. Mansell Qu. Sz. CoM. Color Gr. Sz Sh. 'Eff#1 •Eff#2 .~ / yy~ / Z lJ/ `6 ~~ ~ - ~ ~n o~ ~~~- ~ ~ - • ~ , /~f ' r, ~-- Borit~ # ^ Boring ® pit Ground surface el ft. Depth to limiting factor .~ in. Soil lication Rate Hor¢on Depth Dominant Cdor Redox ' ti Texture Structure Consistence Boundary Roots GPD/fF in. Mansell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Etf#1 'Eff#2 G- ~ f~. ~' Z `_ ~,'~ ~ r ~ d-~- ' ~ ' ~ - ~ ~ ~, wF ~~-~I / Z . ~'?~ Effluent #1 = BOD > 30 < 220 mglL and T5S >30 < 150 mglL ~ tmuent rrZ =taw < su mg/r_ and i ~ < str rrxyt_ CST (Please Print ature CST Number c ~ 1 Cj address Date Evaluation Conducted Telephone Number ~! .s~ ~ ' - -1 ,~- ~ zs' ~ - ~ r6 ~ -pis-~ ~~ ~~ Property Owner ~,t /~,i°n. S ~---~~arcellD# (~T Page ~ of .> Baring # ^ Boring `~ ~ Pit Ground surface v.,~~ ft. Depth to limiting factor ~~ in. Soil ~~ Rate Horizon Depth Dominant Cabr Redox Desch Texture Structure Consistence Boundary Roots GP DIPF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 "Eff#2 l G-Y ~~ ~.~~ S,~/ ~~m ~ GS ~~ ~y -~ ~ o / ~ ~G Zm~ - C S ~ ~` `Z /G ~ - ~~ c ~ ~ .~v ~~ # ^ Bonng ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Etf#2 a Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil ication Rate Horizon Depth Dominant Cdor Redox Description. Texture Stnx~ure Consistence Boundary Roots GP D/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Effii•2 ' Eflluent #1 = BODS > 30 < 220 mg/l_ and TSS >30 < 150 mglL • Effluent #2 = BODS < 30 mg/L and TSS < 30 mglL 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. seo-e3w (n.~ao) Property Owner P-1K,c L ~ i ~n S Paroel ID # C ~ T ~ Page ~ of _~ 3 Bonng # ^ Bonng ~ ~ sC~ Pit Ground surface elev., ft. Depth to limiting factor ,~_ in. SoN ication Rate Harimn Depth Dominant Color Redox Description Texture Stnrchre Consistence Boundary Roots GP D/fF MunseN Qu. Sz. Cont. Cdor Gr. Sz Sh. 'Eff#1 'Etf#2 -,~ Z o/ .~ G 7m~ C S .,$- /G 7 5^ c L ~, , ) = 7 2- a ^ Pit Ground surface elev. ft. Depth to limiting factor in. Sad ication Rate # ° ~~ Horizon Depth Dominant Redox Description Texture Strtxture Consistence Boundary Roots GP D/ff!' in. Munsefl Qu. Sz Cont. Cdor Gr. Sz. Sh. 'Etf#1 'Eff#2 a ~~ # ^ ring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Sofl ication Rate Horizon Depth Dominant Redox Description. Texture Strtxture Consistence Boundary Roots GP D/ff in. Munsep Qu. Sz. Corn. Color Gr. Sz Sh. 'Eff#1 'Etf#2 • Effluent #1 =GODS > 30 < 220 mglL and TSS >30 < 150 mglL ' Effluent #2 = BOD, < 30 mglL and TSS < 30 mglL 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 depargnent at 608-266-3151 or TTY 608-264-8777. seo-e~w cR-~,ao- f ;~ ~~ '. ~~ ~ oi~-'-' -U ~6' ~ /~~~,~ ,~C' ./ ~~~~ v ~~ G, ~ /'~ f. `~ ~ ~- ~V / r -~ - s ~~, i~ Safety and Buildings Division P.O. Box 7162 Washington Ave. 7A1 W County S ~ CY/ t~ Gti , ~ ~ . Madison, WI 53707 - 7162 Site Address ~' ~~~~~~~~ De artmeni of Commerce G 'Z-S~-aL S~~ n° -`- . °~83 ~6~ S • Sanitary Permit Application 5aaitary I'es~t Number /l/`^' S'I ~$' In accord with Cotrma 83.21, Wis. Adm. Coda personal information you provide ^ Cbeck ~ Revision be used foc es Fri law, a1S. f m I. Applieatton tntotRnation - Plwse Print Al! Information State PWt I.D. Number c-- Property Owner's Name Parcel Number ~ ~ ~ Id jL - 0 , ayr,,eS ~` ~ ' s Mailing Address Property Owner ~°,~ "~ ST. CROIX COUNTY ~ ~ ~ ~ 5i' S T.2g N R l~ City. State Zqt C e Lot Numbers I31ock Number Sabdivssion Name CSM Number II. Type o! Builtiiag (check all that apPIY} ups p~ s•..b ~ S. OCi<yy ',~' 1 or 2 Gamily Dwo11ia8 -Number of Hedrootns ~~ _ ^Viilago ^ Public/Commercial - Deacrt'be ~Uae ovvrlsbi U ^ state Owned ~~ 3' x j o h.zs ~ ~ ~ t Nearest Red _ l ~ 7~~ ti III. 't'ype of Permit: (Check only ne ox on litu A (atuaberIng scheme for ternal use). Complete line B if applicable) A. For Conan' ttse 1 ~Nea 2 ^ Replacement System 3 ^ Replacement of 6 ^ Addition to sttm Tank ON S stem Permit Number ~~ ~~ B. ^ Cluck if Sanitary Formic Previottsly lanced 1V. Type of Permit: (Check all that apply)(tttunberhrg scheme is for intertral ass) .~E,'.br,Qse~ .A-~(av - 44 ypNon -Proaa<triud in-Ground zi^ Mound a7 ^ sand Filter 50 ^ eot~sC~ttctai wedu~d 22 ^ Pressurised in-Ground 41 ^ Holdin,8 Tank 48 ^ Slagle Pass Sl ^ Drip Line 45 ^ At-Grade 46 ^ Aerobic Unit 49 ^ Recircula ' ~ ^ Other V. ersaV't'reatment Arse Information: ~.r a r ~ ~ e ~~ gam, 4S1?~ Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade Elevation Proposed I~ ~ Rate(Gais./Days/Sq.Pt.) (Mia./Inch) G^ O d . z x'40 ~~-ad `~3~- ~ ~ ~~ ~ ' ~d 8 . VI. Tank Info Capacity is ToW Number Manufacturer Concrete Co Snstructed Steel Glass Plastic Gallons Gallons of Tanlca New 1 Tasks Tacks sepde o: ttoldiaa Task - l a ~Q ! GJ `r° S ~ >~~ c~,« Vfi. i1itJ' Statement- I, the undend8tted, assume r^ea nslbijity for lion of the POW'T3 shown an the attached liusineas Phone Number r's Name (Print) Plumber's Signature /MFRS Number Pbtutbe / i~ ! •Q~YYI. {ICY r ~a(1~ n~o~~~~ ~~S ~~6'~l~ Plumber's Address (Street, City, State. Zip Code) - ~ 70 ~ ~ o ~ Scv.,~ ~ T 't' ~ ~ VIII. Count t Use OaI Permit Fee (includes Groundwater Date laaued Issuing Agent Signature (No Stamps) Approved ^ Disapproved ^ Owner Given Initial Adverse ~~ J 2~ ~ " ~ DetelIIlinatiOR ~~ g~ editions oP ApprovaURsasons [or Disapproval ~~ ~ ~w ~ r` ~ i .i!- Co IX. 1-~ ~t+,ot~v,,o ,-> k,-~ w~.. C.1. t ' ~ " ln -~ I "~- ~' c~. vv~~,t.- ~ ~ Z. ~e ` l cm? ~° ~- ~ ~ S~. ~' ~a.e~- ts~~ ~ ` ~ Q ie_ .tR vv~t~.~ ~-i ee.w so~ - e~ - ~Q~,~ K y ~~° ~v ~~,~ ~ c M ys ~~ ~ ~~~~r ~u,~~~ ~~'~~~~ y ~Q ~ir~ ZD~.J ~?"e~`Yi~C /7 G~.Oy IYGG brs 1^~6.1~~ ! 1 %/G c ADO- ° /~ ~~ 1 l y.~r ~ ~I~I 3D ~\ • ~~ 5i ~~~/~ i ~ _..~ ~~. ~, t. Wisconsin Deparfinent of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT .._a____ .:.~ `.___ ~ ~~~ Page / of J 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. Please print all information. Re iewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location `l QLL)K1 Govt. Lot /l/Gv 1/4/f/~ 1/4 S / ~T z~(N R t ~ E (orb Property Owner's Mailing//Address ~ Lot # Block # S d. Name or CS ~~~ l~ City State Zip Code Phone Number ^ City ^ Village ~ Town Nearest Road h'lMprtc.~ w1 S ~/S (7/S) ~9G-Z ~9j -/urn rno•t of /6G'`~ New Construction Use: ~ Residential / Number of bedrooms 3- `7/ Code derived design flow rate~< '.~ GPD ^ Replacement ^ Public or commercial -Describe: 'r ` ~- Parent material ~ Flood Plain elevation if applic a ,-` ' /l/ . ~' ft. General comments ~!~ c~Cy~ e%V, fop ~J'G•~fo Gawti- 9~•G d • '`'' ••• _ and recommendations: "$ ' ~G.~. G~~tV• ~~' QG•3d G~w-~`'" qG' ° ° I ,l~~r ,~ ,~ fry , -~ ~r' ~0.~2' -:a: ;?prvitVG ~: I ^ Boring ~ ~~ : ~" ` `•• " Boring # ~A ~ r ,. ..,,. ;~ ,~ ~~ 4~. Pit Ground surface elev. /~ ft. Depth to limiting factor ~ i / ~ ~ 't Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 I -I ~ r s~J 2 ~- cs Ivy .8' 2 1 3 - S L c5 - 3 I I - .x~ k ; --- Boring # ^ Boring ~~ d ®, Pit Ground surface elev. • 7 ~ ft. Depth to limiting factor ~ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 I f~ 3 1 ~Z --~ ~/ m ~ . 5 .~ 2 ~ i I - ~ °t,f. Z J~ ~ y~4 * Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L CS Name (Pleas rin Signature CST Number a e>'- ~3 Address Date Evaluation Conducted Telephone Number 211 ~ $0 ~' . ~dmer~ e--~ , I l ~'Zg O/ ~7/ 2 - ~11~ ~Z SBD-8330 (R07/00) `' .- •y Property Owner ~(~~y~n~ ParcellD # Page ~ of Boring Boring # h Pit Ground surface elev. 9 ~' Z ~ ft. Depth to limiting factor ~ p U in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 2~ Z ~ r ~ v 2 - L r ~ ~-- 5 - 3 rr~i ~ -- 46-zu ~~ ~ ~~ 'Z $ ~ ,~ Boring Boring # ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 ^ Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ^ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 * 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. SBD-8330 (R.07/00) t PAGE .3 OF ~ T ~~ w5 ~' ~ r~ S LOT# ~ LEGAL DESCRIPTION ~(/~ ~ rU 14 ,S l ~- T Z~,N,R~ 1 ~ E(or~ SCALE: 1"= ~ 0 BM 1 ELEVATION /DG • U BM 1 DESCRIPTION -b (~ Q-~ l ~ PJ c- (J; P e BM 2 ELEVATION q~, 3 ~ BM 2 DESCRIPTION ~ P o-t- ~~~ p ~~ P ~' p e SYSTEM ELEVATION -(a~ q(v.~C~ Luw<+- `IG• ~ ~ ALTERNATE ELEVATION aop 9G.3U Lew-' ~" `~'(,o•a 0 CONTOUR ELEVATION q ~. ou d- 9 ~ . d d N ?~ I - ~` SPG. (~ I U~ A.~/ ~\ ~2 oy ~~~ ~ ~ ~' SIGNATURE ~~ DATE / Z - /Z - o ~. ~ a ...' Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In-Ground Soli Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code eaci~ Prfvate Onslte Wastewater Treatment System (POWYS}shall include Infom~atlon and procedures for maintaining the system within the parameters of Conan 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In-(around Solt Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- ~_~~_ ~. a...r~... na~~hr, Qe~cif{estiens s awia ~ . w, vw......•.o. Sanlta Permit Number - - - - r ~ Number of Bedrooms Deal n Flow • Peak d Estimated Flow • Ave e d 8e tic Tank Ca aci f Soil Absor Ilan Com Went lze T of Wastewater Domestic Table 3: Malntanance it S8NIC8 Once every s years a. year and clean at least ance once The septic tank shall be maintained by an individual certified to service septic tanks under s. X81.48, State. The contents of the septic tank snail be disposed of in accordance with 1VR 113, Wis. Alm. Code (Servicing Septic ar Holding Tanks, Pumping Chambers, C3roase - Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restroams}. The operating condition of the septi and outlet niter shall bs assessed at least once every 3 years by inspection. T outie filter sea to ensure pro er operation. The filter cartridge removed unless provfslans are made to retain solids in the tank that may slough off the filter when removed from its enclosure. if the ;.~ - , Management Plan for a Septic 7ahk s^~ Say AQSOrptlon Componer-t flier le equipped with an alarm, the fiitsr ehail be tervlct-d ;f the alarm ig activated +~tltir+uaus€y. Ir140rrnlttent filter alanrn may indlaate surge flown or an impandlrty continuous alarm, Tne septic tbtftk lihBN t~lltve its contentll reniOVed when the Voluble of eCUrn and siudpe 111 the tank •xn+r~ls t!3 tx» iiquld volunts of the tank !t the cantarrt>~ of the tank aro net rernovsd at the lime of en aeeesentent, meln~nance peraortnel shall advise the owner of when the next sere+ca medal to be petfarmed t0 m~llntaln is=e than maxirnur» scum end +rlud~e accumuiatlorl ii1 the tank, Manhala risers, ar~ase risers and covers should be inspected for water li~htneas and soundness. Acoas openings oared for service and assasertlent shad b~e seaied watartipht span the com~l,~on at Oervi00. Any Openit~ deemed unso~snd, d~Ctive, or subject to failure must bar repiaced, ,Exposed access openinQa greater than 8-Inahes to dlarneter allele be secured by an e!'lec-tive lacking device ~ prev#nt so~dsntai or unauthorized entry into the tank. No ens ah+oestd enbr a sfpNc or other tr+iratnaen# or b+pi'dfrtQ tank far any trwgan wfthoat ~n t4Wi car»pJkcaoe w1~h Ei~IA s~tatralsr~ii l~or anMrtny at ,coned #ipaoe. the ~tmoiph~ t~rJtirlR tin aeptia or atlaer p"Elth!laat of holdln~ tank naay oonalsln !! ~AtiR, tttd raarcw of aR pewltort ~» !~ ln~l4r of the tank may ba dll~out>~ or Il~poarefbts. Tank abandonment ahail !» In ar-aordance with Qamnt 83.33, Wle. Adtn, Cods when the tank l: z1o loner used ae a P~1lV'i'3 component, Tt-e:oli absorption component servins this structure is designed tc eQCept domestic wastewat.r from a rerildential f#cirsty. Ths limit: of operation of >n~ camporsent are shown ;r~ Table ~, The iort~evlty at * soli absorption component depends ~rltatiy an proper and timely mein#enanoe, and system ua within or tselaw tine iitttits of rollable aparatlon, C3ood water coneervalion pnotit~ by tlrl! laooupants snd the instaiiatian of water conservlnp plumbinp flxturea are key fac~ora In extendlnp thlr uastu! life of this oampanent. The soli absorption component's operation must be aseeased by lnapecttar at least anae every three yeere. The lnspaCtion shaif inotuds t~rc;ordirlg the ~evaltt of pesndirtq, H' airy, fn the obearvat~n plpea, end a vle~el inspeotlon for any evidence of surfeca seepage or dsaharge fr~am the component. On st+a1-ply slaplnp seise, eroaa ~ eraion should be Identified and reparced to the owner far repair. The surhra diicharQ$ of dementia wastewater or sewagr~ from the system ie prohibited and conslde»d a human 1leslth hazarrd, Tral~ic around or ;aver the soil absorption component should be avoided particular€y during winter months, The compaction or nmovai Qf snow carer aver the cgmpon~rnt rttay lied to hydreutia failure by freezing. This type of faliure is usuarily temporary, bu# ie dffticult ar impassible to repair until weather aonditlans improve, in general, Boll compaction aver this cQmportertt wHi r+Kiuce dlttus~n of oxyain tr:to the sot; end dlsperaFbl oeti, i~rhich rr~ty l tc more inter, and earlier, onpanio clo~ln~ of the Boll. Z ' ,~,... Man~esnent Plan for a Septic Tank and Bail Abeorpt;on Component PiantN~a s~ daap~rootad turf #nd allrubt dirrctly tWer of w{thin ten fart of the r.+~mpanenx ehauld be avaidrd ainoa root Intnaaian rota thr component may obatrctct wa:tewater llaw. Cantingsncy Plan In the awnt. of ayatarn faiiun, a nrw eyatrm Could be inatalfrd in an alternate atw, 1lYith ter inatallatwn aC a divertsr valve, the rxiatinQ iyatrm could ciao br Huard aRrr a period of three to row ye.re. k is the Ixoparty ownera rrtrponeibltlty to rnairttain the aitrmatr area fnr from arnr planting of trees, ahnaba, rtc, in oaN~ of failure of the ariQ(nal eyatao+, thr alternatr aria will be neadrid. if any urea, ah~,. etc, have barn piarrted on thr aEtamate area, ~Y Wiii haw 1o be ewnoved at !+ oMn~rrt ~~'. It altrrrtate area le dratroyad, there are othrr aiterrauw 1-yatems that care be used, in which, could rea+~+lt In adried expense to the properRy owner, Any tank abandonment ahali iir done in aaccrdance with 1Niac. Codr 83.33. Any quratlane regarding thia code pieaar r~ar,taCt your bval2onin~ OKiCe or conhot tlw Irniruiliing plumber. ~c-.~- ~ ~ ~ 'Qs„~ ice.. ~'~ ~ 5~3 8 4 - y b8 0 Sc.~,v.,rr, a~~,ti.~t, ~'1, u„~, b »~ ~ Z i S~ 3 ~ I. ~ 3 t ~ 1 ST CROTK COUNTY SEPTIC TANK MAINTENANCE AGREEMENT -AND OWNERSHIP CERTIFICATION FO1tM . ~ ~ ~~va ~wner/Buyer ~° Mailing Address Properly Address ~ ~ -~ . (Verification required from Planning Department for new City/State ~" ~/~'~~~~~, ~L~~ Parcel Identification Number , LEGAL DESCRIPTION Property Location t~_ '/,, G~_ '/,, Sec..L7 • T,~.~N-R,.j~-w~ Town of tea- r~ ~ eN C~. ~ ~ ~ Lot # ~_• Subdivision ~xa- `k ~' ° Certified Survey Map # Volume --,.Page # Deed # /~'/ `/ 7 .~~ ,Volume ~ ~~~~ .Page ## ~ g'' ~ Warranty Speo house D yes ~no Lot lines identifiable (~, yes O no SYSTEM MAINTENANCE Lnproper use and maintenance of yoga septic system could result in its premature failure~to handl~t you put~int~thetbe'Y~~ consists of pumping out the septic tank every three years or sooner, if needed by a licensed p Pe can affect the function of the septic tank as a treatment stage in the waste disposal systeu~. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner ~IIs stem n lumber, restricted lumber or a lice»sed pumper verifying that (1) the on-site wastewater dispose y mast~rplumber, journeyma p p tf necessary), the septic tank is less than 1/3 full of sludge. is is proper operating condition and/or (2) after inspection and pumping (~ Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with We standards set forth, herein, as set by the Department of Conunerce and the Dep~ and returned to theist. Cracx C°unty Z°°mg 0 cn ~~n 30 stating that your septic system has been maintained must be comple da of the three year expiration date. ~ ' .7 , 0 DATE IGNA OF APPLICANT , 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) o the perry described above, by virtue of a warranty deed recorded iu Register of Deeds Office. / 7 / o .Z DATE NATURE OF APPLICANT «~*~** Any information that is mis-represarted may result in the sanitary permit being revoked by the Zoning Department. «**•a• •~ Include with this applieatlon: a stamped warranty deed from the Rf gcfercn a fsemade in the warranty deed a copy of the ccrtifiui survey mal u DOCUMENT NUMBER 1908 f~ 285 WARRANTY DEED 6 1 4 7 5 KATHLEEN H. wALSH REGISTER OF DEEDS sT. cROIx co., wI RECEIVED FOR RECORD William E. Hawkins, Grantor, conveys and warrants to James C. Revoir and Molly C. Revoir, husband and Nife as survivorship marital property, Grantee, the following described real estate in St. Croix County, State of Wisconsin: LOT FIVE (5), PRAIRIE RUN, TOWN OF HAMMOND. 06-11-2002 1:00 PM WNRRANT1f DEED EXEMPT # REC FEE: 11.00 TRANS FEE: 114.00 COPY FEE: CERT COPY FEE: PAGES: 1 NAME AND RETURN ADDRESS J a[.rnGS G. (2ecX~~r r X695 l~ens~a~v ~4v~-•~• Octkda 1,~ !nn ~s/a8 oa~4' ~ ~- 18-1036-80-000 Parcel identification Number y g~1~~,~ This is not homestead property. Exception to warranties: All easements, res~Grrs,~ions and rights-of-way of record, if any. Dated this ~ ~ day of June, 2002. AUTHENTICATION Signature(s) (SEAL) ~` (SEAL) illiam E. Hawkins (SEAL) (SEAL) authenticated this day of 2002 (Signature) (Name Printed or Tvaed) TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Stats.) THIS INSTRUMENT WA3 DRASTED BY: Joseph D. Boles Rodli, Beskar, Boles & Krueger, S.C. P.O. Box 138 River Falls, WI 54022 ACIQTOWLEDQ~NT STATE OF W~N ) ss. COUNTY ) Personally came before me this ~ day of June, 2002 the above named William E. Hawkins to me known to be the persons(s) who executed the forea~9~instrum~nt and acknowtP,r a~~-the same. Notary Publi My commissio County, ifla,/,~/rt/j ration date:) `.YPtR:S W W fV 0 W W 2 w o_ 7H 0 t0 rn N O .~ 0 1 i 0 - ~ f v cn +_ ; W N I ~ LOT 2 °° `~ r• : I ' U I : 48 ACRES ~ Z : I I, m : ~ Is I 64, 426 S0. FT. ® I I i 50' I I `SS3 p ~ 1 ~ I 4 ~ I 3S ~ ~ I e, ¢o- / ~ , ~, ~ /r ~ i ~ ' lO I . LOT 3 ~ ; ' ~ ~ ~ . ACRES / •~/ / ' I. 52 .~ 66, 361 S0. F7~ . •/ ..,~• ~~• . .:. ~ , 45; O°2~~ 3T ~.' ST u}/ I O ~' ? ~ 14 - 3 s~ _ ~ _ _ - - - - - -~ ''TEMPORARY Cl/L A ~' TO BE TERMI TE T THE ~ %. TIME OF ST E NSION ' 34. 33 0 2, 9 ACRES 25, 894 SO. FT. O ~ , I Z a' ~` ~~ .~. ° ~ff0 Lor b~ 6 4 N ~ 2. 59 ACRES ~ -~'~ ~ ! 12, 958 S0. FT. f~: ; ~ n ~_ , b° r z n, - f f co ~ O ~P f • ~,. ~~~ a Ss~ 269.4 ~ N89° 04' 14" E LOT 7 2, 13 ACRES 92, 744 S0. FT. -~ F 3T3 2/ LOT 6 2.54 ACRES 1 f 0, 593 SO. FT. Z ~~. w ~ W'~- N i ;$ ;i o -; ~ c t~ ~ ~ W 00 w N ~0 ~_ •~-~1ry ~1!`~,ryb • w w F ~ o~ s~ ~ /'f ,. ~:- ,~~ . i \~ ~a2,'t \, ~ a1f a. ~ ~~ ~,.~~ g8.~ , 5N 'f ~ 6'( ~ c~ , fY,, 32 323, N _ ~ ~ . ,s T ,.':- 3 ,. ~ ~ f ~ APPROX. ~EASyCE \ NORTHiSH v~ ~X ~ _ _~ _ _ ~_ _ ~.~-- - - L INE ~ -- -' ~ ~ ~~~ ~ .~ `f ~~~° ' ° ~C ~~ ~ 1