HomeMy WebLinkAbout032-2053-60-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
567298 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)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Westerdahl, Lauren for William & Kell Somerset, Town of 032-2053-60-000
CST BM Elev: Insp.BM Elev: BM Description: Section/Town/Range/Map No:
10 6 . d
106, o 15.30.19.700A
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic D a U Benchmark D D 2 - /0,) V
Dosing C+ _ ` v &O D Alt. BM �- o
Aeration �+�5 Bid .Sewer
7 ,5-W
Holding St/Ht Inlet Z Y: /
T Gfr'Yt q s -
St/Ht Outlet 5 0
TANK SETBACK INFORMATION :rcy
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic / Of /r Dt Bottom ,, / O � q/. Z/
Dosing 7 > / 0h 3 Hea r/Man. 0�
Aeration Dist. Pipe 2-
r
Holding Bot.System
Final Grade
PUMP/SIPHON INFORMATION ------ l F�(h/z
Manufacturer Demand St Cover 1.0� ��
GPM ��
Model Number / (�V�
3D,�
TDH Lift FrictIln L s System Head TDH Ft
Forcemain L ngth�/ Dia. 2 a
It Dist.to Well /
-)>15 3s' t7. l�S ✓
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No.Of Trenches IT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth
DIMENSIONS -7 S/
SETBACK SYSTEM TO P/L BLDG WELL LAK TREAM LEAC Manufacturer:
INFORMATION CH ER OR
Type Of System: / / r 1 (a 7 UNIT Model Number:
DISTRY3.LqRN SYSTEM A S
Header/ anif d Distribution / Ix Hole Size x Hole Spacing Vent to Air Intake
I S Pipe(s) 2Z I s / i�. d. /Z �i Z. C{ r
Length Dia Length Dia Spacing r
SOIL COVER x Pressure Systems Only ound Or t-Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded/Sodded Mulched
Bed/Trench Center BedlTrench Edges Topsoil rp
- ICI Yes 0 No Yes g No
COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / Inspection#2: /
—LV46�)
Location: 1547 63RD ST SOMERSET,WI 54025(NE 1/4 SW 1/4 15 T30N R19W) NA Lot 1 Parcel No: 15.30.19.700A
1.)Alt BM Description=
2.)Bldg sewer length
-amount of cover=
Plan revision Required? Yes Nod
Use other side for additional information. --
SBD-6710(R.3/97) Da a Insepctor's Si nature Cert.No.
■ �,/eva/uu.�bhP,E
.Sa.red�T nyq rY)�tnfiar�
OSomas-.set,�.J/ sYo�.S
A&,/-Sk2 See. /S, 7-304,
6£, eroiX �•, �/,
acres.
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5 � Lrn 51/7 50'
u,/a.-6v�,es oe
wcvdt� ecyl
b�uS
dal/acs � B�
serf.c ,f! To be
�pe� lawn aba.,d�S2das/acfsos3e33$' 144au;(y
� Fla v►aun
Ma f le�'cc� 7
/(�PJ+clE dr;veu:ay Pu,;(%n� �c,,aye c �,� /8.s9;r9o.71'tiy(,'.r75'
al;socr.3a./de//P/a N e elan
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�e+ +o County
bej_' Safety and Buildings Division St.Croix
S / 14.4 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.)
T
Madison,WI 53707-7182
F
o
S 0 7 2 98
°'' -C A% Permit Application State Transaction Number
In accordance Q?.FP •'r-.,.,,� v Adm.Code,submission of this form to Qie''n, .. 'ate governmental unit 2333956
is required pktik to... : ,I' permit. Note:Application forms for state-o -• + are submitted to
the Department of,0„.1.1r , • fessional Services. Personal information yqy provide ma' a yor secondary
Project Address(if different than mailing address)
- 1r'p'i
sin accor� •.the Privacy Law,s.15.04 1 m Stats. .�`
purpose Y ( � )>
Same
I. Application I anon—Please Print AU Inf o rmation
3, ,
Property Owner's Name ,?T . -° . Parcel#
Lauren Westerdahl(Jared&Tanya Manhart,Buyers) At 032-2053-60-000
Property Owner's Mailing Address Property Location r DOA
1547 63rd Street Govt.Lot l
City,State Zip Code Phone Number NE vs, SW '/, Section 15
(circle one)
Somerset,WI 54025 (715)688-9274 T 30 N; R 19 E or W
H.jype of Building(check all that apply) Lot#
E/1 or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name
1
Block# CSM Vol. 1,Pg. 122
❑Public/Commercial—Describe Use
Na ❑City of
❑State Owned—Describe Use CSM Number ❑Vie of
@ Town of Somerset
327050
III.Type of Permit: (Check o y.elnrbaroM(pe A. Complete line B if applicable)
A' ❑New System Re lacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain)
B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Permit Num and Date Issued
Before Expiration Owner ,
IV.Type of POWTS System/Component/Device: (Check all that apply) PolyLok PL-525effluent filter to be installed at ST outlet
❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade f/ ound>24 in.of sui:•e sot i r oun 4< I in.of suitable soil
❑Holdin g Tank 0 Dis persal Component(e P Isin)ClEgM) of 1". ❑Pretreatment Device
(explain)
" !,
V.Dispersal/Treatment Area Information: 7x 7 6----) v i-v' I C��Lf v / O of /( D
Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area lltrooposed(stl System Elevation
450 Gpd 1.0 Gpd ASTM-C33 sand o-yt 450.00 S .Ft. 450.00 Sq.Ft. (J K- 98.25'at 6"above
Q9Gpd native soil O.S 6O /0 2'2. 737.75'contour
VI.Tank Info / Capacity in Total #of Manufacturer
Gallons Gallons Units
New Tanks Existing Tanks 1 2 �i 1 11
Septic or Holding Tank 1,000 Na 1,000 1 Wieser Concrete X
Dosing Chamber 600 Na 600 1 Combination ST/PC X
VII,Responsibility Statement- I, ,e undersig i , assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber's gnature MP/MPRS Number Business Phone Number
,
James K.Thompson /11^ . 2e /�S__ MPRS 30021 (715)248-7767
Plumber's Address(Street,City,State,Zi. '.s e)
340 Paulson Lake Lane,Osceola,WI 54020
VIIJ'County/Department Use Only •
Approved ❑Disapproved Permit Fee G Date Issued Iss ng Agent Sign re :—C(7A2A
❑Owner Given Reason for Denial W Z 2 3/Z d 0
IX.Conditions of Approval/Reasons for Disapproval��17 Q AZ d I A/� -/-44,,, �,�
WeattM OWNER. (�J ll� 1CZZ�i hlfz.to v"
1:Septic tank,effluent filter and / �— ,,
dispersal cell must be_serviced/maintained 3 a A s /.t. -10-* i� et4 .) �:f/e 2 dAt Gs►,
as per management plan provided by plumber.li 2' r� 'a ■ �/�' L
2 All sethark requirements must kg ai ai s rn�° d
as per applicable ctteorcg aii splana'for �ystem and sub; / the County only on paper not less ', n 812 x II inches in size
SBD-6398(R. 11/11)
Y ,
Manhart Residential Mound POWTS
1547 63"d St.,Somerset,WI 54022
This site is an existing residential dwelling that has been vacant for approximately I8months and has recently been
purchased and occupied by a new owner. The house was constructed in 1971 and is serviced by the original
POWTS which consists of a 1,000 gallon septic tank that gravity flows to a drywell. The drywell is hydraulically
failing,which has led to the necessity of its replacement. Soil conditions dictate that a mound system be installed.
The only area meeting all required setbacks and other design criteria requires that the mound be constructed over the
effluent pipe which connects the septic tank to the drywell. The effluent pipe is constructed of 4" solid walled pvc
with a bury depth ranging from 39"—42"below existing grade. Two hand dup soil explorations were completed
above the effluent pipe at the proposed mound site. The soil conditions were found to be conducive to allow the
construction of a mound system over the pipe. No compaction of the A&B horizons was encountered to a depth of
36". Both horizons consisted of moderate angular blocky structured sandy loam. The backfilled soil above the
effluent pipe has redeveloped natural characteristics of undisturbed consistence and structure. The original trench
width is estimated that the original trench was approximately 18"in width,
The effluent pipe will remain in place, with both ends capped at the time of abandonment of the septic tank and
drywell.
i
44,es 3c&Z/
Replacement Mound POWTS Index & Title Sheet
Project Name: Mnahart 3 Bedroom replacement Mound
Owners Name: Jared&Tanya Manhart
Owner's address: 1547 63rd St.,Somerset,WI 54025
Site address: Same
Project Location:
Subdivision: Lotl,CSM Vol. 1,Pg. 122
Legal Description: NE1/4,NW1/4Sec. 15,T.30N.,R.19W.,Town of Somerset,St.Croix Co.,WI.
Parcel ID#: 032-2053-60-000
Page 1 Index and Title Sheet
Page 2 State Approved Mound Design
Page 3 Treatment Tank Cross Section
Page 4 Filter Specifications
Page 5 Septic Tank Maintenance Agreement
Page 6 Parcel map
Page 7 Deed
Attachments: Soil Evaluation Report
Mater P ber Res 'cted Service: James K.Thompson,Dep't.of Comm.Credential#30021
Signature: `l A4 Date: 2)M •/6",-2-C/3
Page 1 of 7
Design pursuant to In-Ground Soil Absorption Component Manual for POWTS,version 2.0 SBD-10705-P(14.01/01)
DIVISION OF INDUSTRY SERVICES
.- 7.„,--",_, RT,
i��TO,4, 10541 N RANCH ROAD
( V°,ti HAYWARD WI 54843
3 0 ,,s Contact Through Relay
www.dsps.wi.gov/sb/
la $ 5 www.wisconsin.gov
(3, ssroNo1s� Scott Walker,Governor
Dave Ross,Secretary
December 09,2013
CUST ID No. 30021 ATTIC•POWTS Inspector
JAMES K THOMPSON ZONING OFFICE
ACE SOIL&SITE EVALUATIONS ST CROIX COUNTY SPIA
340 PAULSON LAKE LN 1101 CARMICHAEL RD
OSCEOLA WI 54020 HUDSON WI 54016
CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 12/09/2015 Identification Numbers
Transaction ID No.2333956
SITE: Site ID No. 797863
Jared&Tanya Manhart Please refer to both identification numbers,
1547 63RD St above,in all correspondence with the agency.
Town of Somerset
St Croix County
�'t
NE1/4, SW1/4,S15,T3ON,R19W N1�
S 1
FOR: CON
®■4 0
lrt
�p
Description:Mound,3 bedroom residence p` �E,�)
S
A
Object Type:POWTS Component Manual Regulated Object ID No.: 1459835 ,G.-T ov cad
Maintenance required; Replacement system; 450 GPD Flow rate; 30 in Soil minimum depth to limiting fad> f si0- �"
original grade; System(s):EZflow Mound Component Manual,(R.7/12),Pressure Distribution Componc ' Co,+ 1, • - ' I
Ver.2.0, SBD-10706-P(N.01/01,R. 10/12), SSWMP Pub.9.6; Effluent Filter p`V15\ON OF
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Code ay
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constru ed S
and located in accordance with the enclosed approved plans and with any component manual(s)referenced abo -. SEE roRF�GsP
The owner,as defined in chapter 101.01(10),Wisconsin Statutes,is responsible for compliance with all cot-
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:
Key Item(s)
• 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.In addition,the
owner must insure that the operation,maintenance and monitoring duties as described in section VIII of the
mound component manual are complied with.A copy of this information must be given to the owner upon
completion of the project.
• The gravelless system components must be installed in accordance with the manufacturer's printed instructions,
the plan approval,and SPS 383 system sizing criteria. If there is a conflict between the manufacturer's
instructions and the plan approval,the plan approval and code requirements will take precedence.
Reminder
• The orientation of the mound system must be such that the longest dimension is oriented along the surface
contour per SPS 383.44(6)(a)2.
• Limit activities in the area 15'beyond the down slope edge of the mound per Mound Component Manual.
• Surface water drainage shall be diverted away from the system area per Mound Component Manual.
JAMES K THOMPSON Page 2 12/9/2013
• Materials shall conform to the requirements of SPS 384.10.No fixture,appliance,appurtenance,material,
device or product may be sold for use in a plumbing system or may be installed in a plumbing system,unless it
is of a type conforming to the standards or specifications of chs. SPS 382 and 383 and this chapter and ch. 145,
Stats.
• The existing POWTS must be properly abandoned per s.SPS 383.33 Wis.Adm.Code.
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 Industry Services 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 and the POWTS management plan to the owner and any
others who are responsible for the installation,operation or maintenance of the POWTS.
Sincerely, Fee Required$ 250.00
Fee Received$ 250.00
Balance Due $ 0.00
pi
Patricia handorf
POWTS Plan Re • ' e i ,Integrated Services WiSMART code:7633
(715)634-78 I, Fax: (715)634-5150,M-F 8:00 a.m.-4:45 p.m.
pat.shandorf @, • con •.gov
cc: Edwin A Taylor,Wastewater Specialist,(715)634-3484,Monday-Friday 8:00 am To 4:30 pm
Note: Effective January 1,2012,all codes under the jurisdiction of the Division of Industry Services(formerly
Safety&Buildings)will be modified. Code references with prefixes starting with"Comm"have been replaced with
".SPS"'to'recognize the relocation of the Division of Industry Services from the former Department of Commerce to
the Department of Safety&Professional Services.Additionally,all IS(formerly S&B)codes have been renumbered
and addressed in a"300"series. For future reference,the Wisconsin Commercial Building Code will be addressed
by SPS Chapters 360-366.
- � I
EZflow®MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: Manhart 3 bedroom replacement mound
Owner's Name: Jared&Tanya Manhart
Owner's Address: 2547 63rd Street
Baldwin, WI 54025
Property Address: Same
Legal Description: NE1/4 SW1/4, Sec. 15, T.30N., R.19W.
Township: Somerset
County: St. Croix
Subdivision Name: Na
Lot Number. Na l ADD
B ock Number Na
1RUtCES S
Parcel I.D. Number: 032-2053-60-000 _( Sell
Plan Transaction No.:
Page 1 Index and title —�✓''�
Page 2 Data entry )N
s
Page 3 EZflow mound drawings
9
Page 4 Lateral and dose tank 3��� /,e
Page 5 Distribution media `t
Page 6 System maintenance specifications
Page 7 Management and contingency plan
Page 8 Pump curve and specifications
Page 9 Site Plan
Page 10 Attached Soil Evaluation Report
Designer Ja•,; K. Thom•son License Number 30021
Date: Eat Phone Number: (715)248-7767
Signature: Att.... A. ,i __
•
Designed Pursuant to the
EZflow Mound Component Manual Ver.August 20,2007,
SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST-SAS(01/81)and
Pressure Distribution Component Manual Ver.2.0 SBD-10706-P(N.01/01, R. 10/12)
•
EZflow Mound Version 3.0(R. 3/1/12) Page 1 of 10
Mound and Pressure Distribution Component Design
Design Worksheet
Site Information
(r or c) R Residential or Commercial Design
300.00 Estimated Wastewater Flow(gpd)
1.50 Peaking Factor(e.g. 1.5= 150%)
450.00 Design Flow(gpd)
4.00 Site Slope(%)
97.75 Installation Contour Line Elevation (ft) 100.00 Contour Length Available(ft)
30.00 Depth to Limiting Factor(in)
0.50 In-situ Soil Application Rate(gpd/ft2)
Distribution Cell Information
6.00 Cell Width(ft) 3, 4, 5, 6, 7, 8, 9 or 10 Only 75.00 = Dispersal Cell Length (ft)
1.00 Dispersal Cell Design Loading Rate(gpd/ft2)
1 Influent Wastewater Quality(1 or 2) Are the laterals the highest point
in the distribution I
Pressure Disribution Information network? Enter Y or N
(c or e) E Center or End Manifold
3 Lateral Spacing (ft) If N above, enter the elevation (ft)
2 Number of Laterals of the highest point. I 1
0.125 Orifice Diameter(in)(e.g. 0.25)
2.00 Estimated Orifice Spacing (ft)= 6.08 ft2/orifice
2.00 Forcemain Diameter(in)
35.00 Forcemain Length (ft) Does the forcemain drain back? Y
90.25 Inside Pump Tank Elevation (ft) Enter Y or N
0.00 Forcemain Filter Loss(ft)
6.50 System Head (ft)x 1.3 5.71 Forcemain Drainback(gal)
7.50 Vertical Lift(ft) 67.38 5x Void Volume(gal)
0.70 Friction Loss(ft) 73.09 Minimum Dose Volume(gal)
14.70 Total Dynamic Head (ft) 30.48 System Demand (gpm)
Lateral Diameter Selection Manifold Diameter Selection
in. dia. options choice in. dia. options choice
0.75 1.25 x �l
1.00 1 1.50 x I V
1.25 2.00
1.50 x 1 x 3.00
2.00 x
3.00 x
Gallons/Inch Calculator(optional)
Treatment Tank Information 602.82 Total Tank Capacity(gal)
1000.001 Septic Tank Capacity(gal) 51.00 Total Working Liquid Depth (in)
Weiser Concrete (Manufacturer 11.82 gal/in (enter result in cell B49)
Dose Tank Information Effluent Filter Information
602.82 Dose Tank Capacity(gal) PolLok Filter Manufacturer
11.82 Dose Tank Volume(gal/in) PL525 Filter Model Number
Weiser Concrete !Manufacturer
Project: Manhart 3 bedroom replacement mound Page 2 of 10
, .
, . . .
Mound Plan View
—7---- . . . . . . . . . . . . . . . . . . . . . . ''S-----,
. . . . . . . . . . . . . . . . . .....-..............-.............-...:.:.......x........:.... J
. • • • • • • • • • • • • • • • - •Observation Pipe . . . . . . . .
A
W ___t
...... . . . . ........,.......................... .. .-.-.....................•............... . .......-
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . • , . . . . . . . . . I
" . . . . . " " " . " " . " " " " " . . " " . . . " . " . . "
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
...............................................................................................................
........................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . ....................................................................................
. ..................................................................................................... .
• L •
Mound Component Dimensions
A 6.00 ft E 8.88 in H 1.00 ft K 7.86 ft
B 75.00 ft F 12.00 in 1 7.64 ft L 90.72 ft
D 6.00 in G 0.50 ft J 5.36 ft W 18.99 ft
450.00 (ft2) Dispersal Cell Area 1022.73 (ft2) Basal Area Available
6.00 (gpd/ft)Linear Loading Rate 7.50 (ft) 1/10 B Obs. Pipe Placement
Mound Cross Section View
EZflow Dispersal Area
Finished Grade 100.25 (ft) ---•
I H
F •:.:•:.:.:.:.. -
il :::ig?", 'IP Dispersal cell • • • • • • • •
98.25 (ft)—vs. — ..;:: :.:•i .§.".:;0:,..,................... :'..i•::'•;:'•.•":'•.•':•..::.•••i.•:...i::... 98.75 (ft)Lateral
Invert Elevation
Dispersal Cell .••::.:::.::.•:::.::.:::::•:::::::::::::::::::::::::
:.. u
:.:.:.:.:•:.:.:.:.:.: :::::::::::::::a.:.:.:.:.:
Elevation :::::•:•:•:•:•:•:•:•..:•:•:• •:•:•:.:•••:•:•••:•:. n • • • • • • • • • • • • • • • .
.:.:.:.:.:.:•:. .:.:.:•:.:.:•:..
:
...,...-.............."
. • • - , ,....,...„,....,,,, .{:,.....,16„. ' V A 4-1*VW, 'WA, 11.1•1•11k a iliplitolAp
'-k" .': 'N• „v,,, lor VilioVo1/4.V.4410 1.1.11. or 1001.
','•-?-,'-.),-.A-,<k.<,...,.' iit ,k, ,,k,,,
1 5 '-',
4 97.75 (ft) Contour Elevation
4.0 %Site Slope
Typical Dispersal Cell
Shading Key I-1 T- See Page 5
Efj Rox Topsoil Cap g 3 a
a.
Approved Geotextile Fabric Cover
H Subsoil Cap o
V TO S 2.0 ft —
Fl 1001111 ASTM C33 Sand in 4 va -,:...
2 V t
--41t* ...tr.:.iiiYV::::(trr::::.•
f' 555S5C:1555.7.. ..4:35.i..,.,i5i5i5 1:
I] ...,..:::::::::.:',Z EZflow Media
41 .::..4....=.1..
..IIL.
0 11. 0.5 ft ...., 4.,..p. .%*p...:."
—Iir— ,-------A --If
See details on page 4 for number,size,and spacing of laterals.
Laterals are located in the 4"gravity distribution pipes as shown on page 5.
Project: Manhart 3 bedroom replacement mound Page 3 of 10
End Connection Lateral Layout Diagram
Place Appropriate Lateral Diagram From Right Below
•s Turn-up wrbsli valve or otosnoutplug
1 < P 1
1 7 r •�) 1st orifice located at Z k-x--41
OrncCes point up except every 5th
one points down for drainage. JS
Face main connection via tae or cross to manifold at any point laterals b force mom of PVC Sch 40
AU laterals identical with orifices equally spaced. per SPS Table 38410-6
Number of Laterals 2 Orifice Diameter 0.125 in
Lateral Diameter 1.50 in Orifice Spacing (X) 2.04 ft
Lateral Length (P) 74.22 ft Orifices per Lateral 37
Lateral End (Z) 0.78 ft Orifice Density 6.08 ft2/orifice
Lateral Spacing (S) 3.00 ft Manifold Length 3.00 ft
Lateral Flow Rate 15.24 gpm Manifold Diameter 1.50 in
System Flow Rate 30.48 gpm Forcemain Velocity 3.11 ft/sec
Dose Tank Information Locking cover with warning
label and locking device and
sealed watertight
Electrical as per NEC 300 and —►
SPS 316.300 WAC r 4 in.min.
_,—.— Disconnect
Tank component is properly vented ED=E=D
E- Alternate outlet
location
1 r =
Forcemain diameter
Weiser Concrete Manufacturer �_ :,— ( 2 in.
Capacity 602.82 Gallons
Volume 11.82 gal/inch A
Weep hole or anti-
Dimension Inches Gallons i B d siphon device
A 30.82 364.25
B 2.00 23.64 C d 4 Pump off elevation(ft)___t_
C 6.18 73.09 �� 91.251
D 12.00 141.84 D
Total ( 51.001 602.82
Dose elevation(ft)
Bedding And Backfill As Per Manufacturer 90.25
Alarm Manufacturer SJ Rhombus
Alarm Model Number SJE 1011421
Pump Manufacturer Zoeller
Pump Model Number ;BN151
Pump Must Deliver 30.48 gpm at 14.70 ft TDH
Note: Switches containing mercury may not be used in this system.
Project: Manhart 3 bedroom replacement mound Page 4 of 10
EZflow® Distribution Cell Media Layout
6.00 Cell Width (ft) I 1.50 ISidewall to Lateral(ft)
Distribution Cell Cross-section Arrangements
Ar:IN .04 AMA WIN
6 ft Wide 11111.11.11►1111N11111►1..1011111
‘'Itt11 Var b`11Y Neer Vitt�11�1
Component Legend
:11y SR1-7A Bundle-5 ft or 10 ft lengths
•4441 SR1-12A or EZ 1201A in 5 ft or 10 ft lengths
►111111
►11111
X111 .ti`1ti . 111
Al A•;\ ►1111111•.1,.1111
►11we11 SR3-12H or EZ 1201P or 1111y11»1►1111A SR3-12H in 5 ft or 10 ft lengths
••1111 VOW `111> 1111
.y.�.
O 4" Perforated Distribution Pipe With Pressure Lateral Inside
• Turnup Enclosure Pressure Lateral
Bundles are covered with approved geotextile fabric as per the their product approval.
Distribution Cell Plan View Layout- Typical
6.00 Cell Width-A(ft) 75.00 Cell Length-B(ft)
Center Connection Lateral Layout Diagram
Force Main
6 ft Wide ~
End
Manifold
•
Project: Manhart 3 bedroom replacement mound Page 5 of 10
Mound System Maintenance and Operation Specifications
Service Provider's Name Jmaes K. Thompson Phonel(715)248-7767
POWTS Regulator's Name St. Croix County Zoning Dep't Phone (715) 386-4680 l
System Flow and Load Parameters,
Design Flow-Peak 450 gpd Maximum Influent Particle Size 1/8 in
Estimated Flow-Average 300 gpd Maximum BOD5 220 mg/L
Septic Tank Capacity 1000 gal Maximum TSS 150 mg/L
Soil Absorption Component Size 450 ft2 Maximum FOG 30 mg/L
Type of Wastewater, Domestic Maximum Fecal Coliform, >10E4 cfu/100 mL
Service Frequency
Septic and Pump Tank Inspect and/or service once every 3 years
Effluent Filter Inspect and clean as necessary at least once every 3 years
Pump and Controls Test once every 3 years
Alarm Should test periodically
Pressure System Laterals should be flushed and pressure tested every 3 years
Mound Inspect for ponding and seepage once every 3 years
Other
Miscellaneous Construction and Materials Standards
1. Observation pipes are slotted and materials conform to Table SPS 384.30-1, have a watertight cap
and are secured in as shown in the EZflow Mound Component Manual Ver. August 20, 2007.
2. Dispersal cell media conforms to EZflow products approved for use with the EZflow Mound Component
Manual Ver.August 20, 2007. Media is covered with an approved geotextile fabric.
3. All gravity and pressure piping materials conform to the requirements in SPS 384,Wis.Adm. Code.
4. Tillage of the basal area is accomplished with a mold board or chisel plow.
5. The mound structure and other disturbed areas will be seeded and mulched to prevent soil erosion
and help reduce frost penetration.
Lateral Turn-up Detail
Finished Grade
(�to: : : : . . Threaded Cleanout
6-8" Diameter Lawn ■
Sprinkler Valve Box Plug or Ball Valve
Lateral Ends at Last Orifice Where
Variable Length Cleanout Begins • • , • • , • • • • . : . . . . . . . .
1111►1111111►1111111W4 ∎111111111111
1r11. 1. 11. 1. 1. 1. WO, li l► 111. ♦ 1. . Long Sweep 90 or Two
ti1 v w w w 45 Degree Bends Same
■ 111 11111111111; Diameter as Lateral
11 11111111111,
11 EZflow S nthetic Media 11111111111,
111. ..-_- 11.11 AVPIPY 1.25 Feet
f---Distribution Lateral –'► 4`—"' Lateral Cleanout
Project: Manhart 3 bedroom replacement mound Page 6 of 10
Mound System Management Plan
Pursuant to SPS 383.54,Wis.Adm.Code
General
This system shall be operated in accordance with SPS 382-84 Wis.Adm.Code,and shall maintained in accordance with its'component
manuals[EZtlow Mound Component Manual 8/20/07,Pressure Distribution Component Manual Ver.2.0 SBD-10706-P(N.01/01)and
SSWMP Publication 9.6(01/81)]and local or state rules pertaining to system maintenance and maintenance reporting.
Septic and pump tank abandonment shall be in accordance with SPS 383.33,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 a tank or component.
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks under s.281.48,Stats. 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 as to
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 be approved for septic tank use by the Wisconsin Department of Commerce.
Pump Tank
The dosing(pump)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. If the force main has a weep hole,it
should be noted if it is functional during pump operation,and if not,it should be cleaned.
*****No one should ever enter a septic or dose tank since dangerous gases may be present that could cause death."'"
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 compaction may hinder aeration of the 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 as protection from freezing.
Influent quality into the mound system may not exceed 220 mg/L BODE,150 mg/L TSS,and 30 mg/L FOG for septic tank effluent or 30
mg/L BOD5,30 mg/L TSS,10 mg/L FOG,and 104 cfu/100 mL for highly treated effluent. 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 3 years. When a pressure test is performed 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.
Continaencv Plan
If the septic tank or any of its components become defective the tank 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(s)shall be immediately
repaired or replaced 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 by removing biologically clogged absorption and dispersal
media,and related piping,and replacing said components as deemed necessary to bring the system into proper operating condition.
See Page 6 of this plan for the name and telephone number of your local POWTS regulator and service provider.
Project: Manhart 3 bedroom replacement mound Page 7 of 10
• PUMP PERFORMANCE CURVE
. MODEL 151/152/153 TOTAL DYNAMIC HEAD/FLOW
Sp_ PER MINUTE
,4- 153 EFFLUENT AND DEWATERING
■
12- MODEL 151 152 153
75 152~-•
$ 10-
\ \ Feel Meters Gal. Liters Gal Liters Gal. there
=
u 5 1.5 50 189 89 261 77 291
0 8- 10 3.0 45 170 61 231 70,li _.. 15 4.6 38 144 53 201 81 231
5 'eggiirol 6.1 29 110 44 187 52 197
6- 25 1.8 18 61 34 129 42 159
IliS, 30 9,1 - - 23 87 33 125
15 35 10.7 - - - - 22 85
4- -■t-;, -
10 40 12.2 11 42
\\ Shutoff Head: 30 ft.(9.1m) 3818(11.6m) 44 8.(13.4m)
2-
5
0145089
0—.
10 20 30 40 50 60 70 80 90 1.. ,
GALLONS
LITERS 0 l0 e0 1i 1io z0 24 i0 31l0 3i0
FLOW PER MUTE 014508A • Model 151 Models 1521153
r
' CONSULT FACTORY FOR
SPECIAL APPLICATIONS r 67152 —•- 61/4
3718 4578 1 3/1132 4S0
•Tuned dosing panels available. } •,
•Electrical alternators,for duplex systems,are available and /,/
\ 37/5 327/32
supplied with an alarm. f; \/ CCI_ ���`,.•
•Variable level control switches are available for controlling
'` `• �� 327732
single phase systems. 9 l srls V
•Double piggyback variable level float switches are available I I
for variable level long and short cycle controls. I 1
•Sealed Qwik-Box available for outdoor installations.See
FM1420. I _) �j+
•Over 130•F.(54•C.)special quotation required. 'l��
MIMI��)± I =�=
151/152/153 Series 1111/16 _I l 121/8 —1•
151/1521153 MODELS Control Selection t 1 Ii —r i ,Ij�s�
Model Volts-Ph Mode Amps Simplex Duplex .� 5
i.ltNat�M111I1 1 4 S � 1I\1s' Iva
N151 115 1 Non 6.0 1 2 or 3 •��•—���_ rlttllltttttPM- ,
BN151 115 1 Auto 6.0 Included 2 or 3 iitt7TU•_- I� I IIr n E II
E151 230 1 Non 3.2 1 2 or 3
BE151 730 1 Auto 3.2 Included 2 or 3 51(2444 51(2054
N152 115 1 Non 8.5 1 2a3
BN152 115 1 Auto 8.5 Included 2 or 3
E152 230 1 Non 4.3 1 2 or 3
8E152 230 1 Auto 4.3 Included 2 a 3
N153 115 1 Non 10.5 1 2 a 3
13N153 115 1 Auto 10.5 Included 2 or 3
E153 230 1 Non 5.3 1 2 a 3 SELECTION GUIDE
8E153 30 1 Auto 5.3 Included 2 a 3
1. Single piggyback variable level float switch or double piggyback variable level float
14 CAUTION I switch. Refer to FM0477.
AU installation of controls,protection devices and wiring should be done by a qualified 2. See FM0712 for correct model of Electrical Alternator E-Pak.
l.censeo electrician.All electrical and safety codes should be followed including the most
recent National Electric Code(NEC)and the Occupational Safety and Health Act(OSHA). 3. Variable level control switch 10-0225 used as a control activator,specify duplex(3)
or(4)float system.
RESERVE POWERED DESIGN
For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump.
MAIL TO:PO.BOX 18347
fr' 'n �.�_ LoukStI KY 40256.0347 Manufacture's of..
�� SH IP TO:3649 Cane Run Road
Loukvl6e,KY 40211.1961Puciaa SA�/99hap J/www.zoellercom PUMP !O, (�)T7 311••0 8�928•PUMP
®Copyright 2004 Zoeller Co.All rights reserved.
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` • 2349
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3
Division of Safety and Buildings in accordance with Comm 85,Wis.Adm.Code A.C.E.Soil&Site Evaluations
`jam County
Attach complete site plan on.: , 8%z 11 inches in size. Plan must St.Croix -
include, 'ude,but not limited to: v •.ontal reference point(BM),direction and
percent slope.scale or,'. • .,' + arrow,and kxx+tion and distance to nearest. %* ParceIl.D.n 032-2053-60-000
e • nt all information.'
y Date /f3 Personal inrmation ,maybe used for seco dary purposes(Privacy Law,s.15.�,(,1)(m)). ty :,, „ �i 1 2/Z
Property Owner )Proeocatior'i"-,T'
Jared&Tanya Manhart t(/ d �4� Govt Lot* ,co NE 1/4 SW 1/4 5 15 T 30 N R 19 W
Property Owner's Mailing Add Lot# Bloat# Subd.Name or CSM#
1547 63rd Street na na Na
City State Zip Code Phone Number J City J Village t/J Town Nearest Road
Somerset 1 WI i 540251 (715)928-2821 _ Somerset 1 63Rd St.&155Th Ave.
J New Construction Use: e Residential I Number of bedrooms 3 Code derived design flow rate 450 GPD
! Replacement J Public or commercial-Describe:
Parent material Glacial Till Flood plain elevation,if applicable na
General comments
and recommendations: Soils require mound system with 6"of ASTM-C33 sand placed on 97.75'contour. Infiltrative surface
elevation to be 98.25'.
i Boring# J Boring
, l Pit Ground Surface elev. 98.17 ft. Depth to limiting factor 32" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots WPM
in. Mussel Qu.Sz.Cont.Color Gr.Sz.Sh. "Eff#1 *Eff#2
1 0-17 10yr3/2 none I 2fgr mvfr cs 2fm,1c 0.6 0.8
2 17-21 10yr3/6 none sl 2msbk dsh cs 2fmc 0.6 1.0
3 21-32 7.5yr4/6 none sl 2msbk dsh cw lvf,f 0.6 1.0
4 32-67 7.5yr4/6 cmd 7.5yr5/8 sl/sil lcsbk dsh aw - 0.4 0.6
5 67-85 7.5yr4/4 f2f 7,5yr5/8 sl Om mvfr - - 0.2 0.6
H#4 consists of many 1"-6T layers(1st&sil too numerous to differentiate. Redox.concentrations appear in sil.
Boring l
2 Boring# p limiting Pit Ground Surface elev. 98.09 ft. Depth to limitin factor 30" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPO/ft"
in. Munsell Qu.Sz.Cont Color Gr.Sz.Sh. `Eff#1 "Eff#2
1 0-10 10yr3/2 none sl 2fgr mvfr cw 2fm,1 c 0.6 0.8
2 10-20 10yr4/4 none sl 2msbk dh cw 2vf,fm 0.6 1.0
3 20-30 7.5yr4/6 none sl 1 msbk dsh gw 1 vf,f 0.4 0.7
4 30-46 7.5yr4/6 f2d 7.5yr5/8 sl 1 csbk dsh - - 0.4 0.7
Effluent#1=BOD5>30<220 mg/L an. TSS>30<1 + mg/L * r,- uent#2=BOD5<30 mg/L and TSS 1.30 mg/L
CST Name(Please Print) -.1.nature. w CST Number
James K.Thompson i1"►T".•e' ,- 3602
I
Address A.C.E.Soil&Site Evaluations Date Evaluation Conducted Telephone Number
340 Paulson Lake Lane,Osceola,WI 54020 10/9/2013 715-248-7767
Property Owner Jared&Tanya Manhart Parcel ID# 032-2053-60-000 Page 2 of 3
3 Boring# J Boring
✓) Pit Ground Surface elev. 96.20 ft. Depth to limiting factor >58" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu.Sz.Cont.Color Or Sz.Sh. *Eff#1 *Eff#2
1 0-12 10yr3/3 none sl 2fgr mvfr cs 2fmc 0.6 0.8
2 12-37 10yr4/4 none sl 2msbk dh cw lfmc 0.6 1.0
3 37-45 10yr4/4 none Ifs Osg dl cw 1vf,f 0.5 1.0
4 45-78 10yr5/6 none fs Osg dl cw - 0.5 1.0
5 78-95 7.5yr4/4 f2d 7.5yr5/8 sl 1 csbk dsh - - 0.4 0.7
4 Boring# J Boring
e Pit Ground Surface elev. na ft. Depth to limiting factor 31" in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDift2
in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2
1 0-8 10yr3/2 none sl 2fgr mvfr cw 2fm,1c 0.6 0.8
2 8-23 10yr4/4 none sl 2msbk dh cw 2vf,fm 0.6 1.0
3 23-31 7.5yr4/6 none si lmsbk dsh gw 1vf,f 0.4 0.7
4 31-52 7.5yr4/6 f2d 7.5yr5/8 si lcsbk dsh - - 0.4 0.7
.
Boring# J Boring
J 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
•
*Effluent#1 =BOD5>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
P 9 PPo tY P
ent at 608.266-3] 1 or TTY 608-264-8777.
need material in an alternate form�please contact the department S
P
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IICAETE DS1/4 1'-O” PRE-POUR:SEPTIC MANUAL - DATE:. POST-POUR:
1 \ Z W3716 US HWY 10 MAIDEN ROCK, W1 54750
9 REVISED JAN. 2012 800-325-8456 FILE: W'1000/600-MR
PO. ,c r
�a♦` ""ft 4F+A a'r` l ,r 47� .1 ��rFi.� .Y�'��2 it 5
f @ 1C Filters
PL-525 EFFLUENT FILTER
Polylok, Inc is pleased to add its
new commercial filter to its existing
line of quality effluent filters.The
PL-525 is rated for over 10,000 GPD Alarm /' '!^
(gallons per day) making it one of accessibility Accepts PVC
the largest commercial filters in its extension handle
class. It has 525 linear feet of 1/16"
filtration slots. Like the Polylok
PL-122, the new Polylok PL-525 has
an automatic shut off ball installed 525 linear feet
with every filter. When the filter is of 1/16"
removed for cleaning, the ball will filtration slots Rated for over
float up and temporarily shut off
10,000 GPD
the system so the effluent won't
leave the tank. No other filter on
the market can make that claim! Accepts 4"& 6"
SCHD.40 Pipes;;.
PL-525 Maintenance:
The PL-525 Effluent Filter should
operate efficiently for several years
under normal conditions before ..
requiring cleaning. It is recom-
mended that the filter be cleaned
every time the tank is pumped or
at least every three years. If the
installed filter contains an optional NSF..'
alarm, the owner will be notified = � '�
by an alarm when the filter needs
servicing. Servicing should be c4E014.'J"' Gas deflector
\1sJ/M1'ac�
done by a certified septic tank , Automatic shut-off
pumper or installer. '" ball when filter
is removed
1. Locate the outlet of the U.S.Patent No#6,015,488
septic tank. 5,871,640
2. Remove tank cover and pump 0.11
tank if necessary.
PL-525 Installation: 1. Locate the outlet of the
3. Do not use plumbing when septic tank.
filter is removed. Ideal for residential and corn- 2. Remove the tank cover and
4. Pull PL-525 out of the housing. mercial waste flows up to pump tank if necessary.
5. Hose off filter over the septic 10,000 Gallons Per Day (GPD). 3. Glue the filter housing to the
tank. Make sure all solids fall 4" or 6" outlet pipe. If the
back into septic tank. filter is not centered under the
access opening use a Polylok
6. Insert the filter cartridge back Extend & Lok or piece of pipe
into the housing making sure to center filter.
the filter is properly aligned and 4. Insert the PL-525 filter into
completely inserted. its housing.
7. Replace septic tank cover. „: 5. Replace the septic tank cover.
icf
Po.,10,r7
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner uyer Jared & Tanya Manhart (AitatV),i2dteikdezice, -iii k {uoldi/ J
Mailing Address 1 547 63rd Street, Somerset, WI 54025
Property Address Same
(Verification required from Planning&Zoning Department for new construction.)
City/State Parcel Identification Number 032-2053-60-000
LEGAL DESCRIPTION
Property Location NE 1/4, SW 'A, Sec. 1 5 ,T 30 N R 9 W,Town of Somerset
Subdivision Plat: Na ,Lot#
Certified Survey Map# 327050 ,Volume ,Page# 122
-�o �l2 �r T�C✓�d - See, TD D - uu1Gf. pvi xtel
Warranty Deed# C 7 3 g 2 Z (before 2007)Volume ,Page#
Spec house DyesOno Lot lines identifiable r1 yesOno
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner,if needed,by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in§SPS.383.52(1)and in Chapter 12-St.Croix County Sanitary Ordinance.
The property owner agrees to submit to St.Croix County Planning&Zoning Department a certification form,signed by the
owner and by a master plumber,journeyman plumber,restricted plumber or a licensed pumper verifying that(1)the on-site
wastewater disposal system is in proper operating condition and/or(2)after inspection and pumping(if necessary),the septic tank is
less than 1/3 full of sludge.
I/we,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 Safety And Professional Services and the Department of Natural Resources,
State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St.Croix
County Planning&Zoning Department within 30 days of the three year expiration date.
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.
Number of bedrooms
a- IA1\ 11/11 /13
NATURE OF APPLICANT(S) DATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning&Zoning Department.***
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV.04/12)
5
iii in li, i
i
8 1 3 4 5 9 3
State Bar of Wisconsin Form 9-2009 Tx:4108823
DESIGNATION OF TOD BENEFICIARY 973822
Under Wis. Stat. §705.15
BETH PABST
Document Number Document Name
REGISTER OF DEEDS
ST. CROIX CO., WI
THIS DESIGNATION is made by William J.Westerdahl,a single person RECEIVED FOR RECORD
02/22/2013 09:12 AM
(collectively,"Owner')of the following EXEMPT #: IOM
described real estate located in St. Croix County,State of Wisconsin(the"Property") REC FEE: 30.00
(attach Exhibit.A if more space is needed): PAGES: 2
SEE EXHIBIT A ATTACHED HERETO AND MADE A PART HEREOF
Recording Area
Owner transfers the Property without probate upon death of the sole owner,or upon the last to Name and Return Address -2
die of multiple owners,to the following TOD beneficiary,without warranties: Barry C.Lundeen
110 Second Street
Select A or B: Hudson WI 54016
Lauren Westerdahl
® A. Insert name of beneficiary,whether one or more. This revokes all previous 032205360000 and 032205380000
TOD beneficiary designations.
Parcel Identification Number(PIN)
❑ B. The sole purpose of this instrument is to revoke all previous TOD beneficiary This is homestead property.
designations. (is)(is not)
This designation is effective only upon the recording of this instrument.
This transaction is Fee Exempt under Wis.Stat.§77.25(10m),and exempt from the filing of a transfer return
under Wis.Stat.§77.21(1). The transfer contemplated by this instrument may he subject to encumbrances,
liens and other matters created by or affecting Owner,including claims in Owner's estate.
Dated 21 ` 13
(SEAL) A's ?` Gj/Lvu+� , (SEAL)
* * William J. Westerdahl
(SEAL) (SEAL)
* *
AUTHENTICATION ACKNOWLEDGMENT
Signature(s)
STATE OF WISCONSIN
authenticated on )ss.
ST.CROIX COUNTY )
* Personally came before me on 21 20) 1.3
TITLE: MEMBER STATE BAR OF WISCONSIN the above-named William J. Westerdahl
(If not,
authorized by Wis. Stat. § 706.06) to me known to be the person(s) who executed the foregoing
instrument and acknowledged the same.
THIS INSTRUMENT DRAFTED BY: Jessica L. Keslnskas
Notary Public
Attorney Barry C. Lundeen * �C°�,�C�� �c�4�r,SI<4-t5 State of WiacorU
Hudson WI 54016 • Notary Public,State of Wisconsin
My Commission (is permanent)(expires: 71 0-1112,
(Signatures may be authenticated or acknowledged. Both arc not necessary.)
2 f� NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED.
I)?S9C'n'ATlON OF TOD BENEFICIARY STATE BAR OF WISCONSIN FORA NO.9-2009
*Type name below signatures.
EXHIBIT A TO DESIGNATION OF TOD BENEFICIARY
FROM WILLIAM J. WESTERDAHL TO LAUREN WESTERDAHL
Parcel 1: A parcel of land located in the Northeast Quarter of the Southwest Quarter of Section
15, Township 30 North, Range 19 West, Town of Somerset, St. Croix County, Wisconsin,
described as follows:
Commencing at the Southwest corner of Section 15; thence S90°00'00"E 1312.04' (bearings
referenced to the South line of the Southwest Quarter,previously recorded as S90°00'00"W);
thence N00°41'34"E 2189.16' to the point of beginning; thence continuing N00°41'34"E
363.62'; thence S90°00'00"E 1309.16'; thence S00°37'41"W 573.40'; thence N90°00'00" W
860.71'; thence N00°47'18"E 208.75'; thence N89°51'59"W 449.43' to the point of beginning,
containing 656,804 square feet
Parcel 2: That certain parcel of land located in the NE1/4 of the SW1/4 of Section Fifteen (15),
Township Thirty (30)North, Range Nineteen(19) West, Township of Somerset, further
described as follows:
Commencing at the SW corner of said Section Fifteen(15), thence go N 90° E (assumed
bearing) along the South line of said Section Fifteen(15), a distance of 1311.39 feet, thence N
00°39'17" E a distance of 1975.60 feet,thence N 90° E a distance of 33.00 feet to the East Right
g of the parcel to be herein described:
town road and the Point of Beginning of Way line of the o g
thence continued N 90° E a distance of 417.50 feet;thence N 00°39'17"E a distance of 208.75
feet; thence N 90° W a distance of 417.50 feet to the East Right of Way line of said town road;
thence S 00°39'17"W along said Right of Way line a distance of 208.75 feet to the Point of
Beginning.
g.
Also described as: Certified Survey Map filed in Vol. 1 of Certified Survey Maps on page 122
as Document No. 327050, being a part of NE1/4 of SW1/4 of Section 15, Township 30 North,
Range 19 West.
AND:
A parcel of land located in the Northeast Quarter of the Southwest Quarter of Section 15,
p .
Somerset, St. Croix County, described as follows:
Township of S `y,
Commencing at the Southwest corner of said Section 15; thence N90°00'00", E 1968.08'
(bearings referenced to the South line of the So uthwest Quarter,previously
recorded as
"
° Beginning; continuing N
Point of Be innin
S90 00 00 , W); thence N00 39 59 , E 1344.63' to the Pom g g, g
00°39'59" E 634.73; thence S 90°00'00" E 654.68; thence S 00°37'41" W 643.32'; thence N
89°14'53" W655.07' to the Point of Beginning, containing 418,464 square feet(9.61 acres).
Reserving unto grantor, his successors and assigns an easement for driveway purposes along the
Rese g
g g
Southwestern corner of Section 15 to the south line of the Southwest corner. Any cost to install
or maintain an easement 33 ft. wide along said Southwest line shall be the expense of the
grantors successors and assigns. This is a conveyance of land to an adjoining landowner which
does not create a new parcel.
TRANSFER ON DEATH 11,111,111111111111
IIITO BENEFICIARY
;Use black ink. , � �, 8 1 8 0 7 3 7
Tx:4149457
DECEDENT'S NAME DATE OF DEATH 985440
WILLIAM J. WESTERDAHL 06/29/2013
BETH PABST
ADDRESS OF DECEDENT AT DATE OF DEATH CITY ST ZIP REGISTER OF DEEDS
1547 63RD STREET SOMERSET WI 54025
ST. CROIX CO., WI
RECEIVED FOR RECORD
PRESENTATION OF DEATH CERTIFICATE 09/05/2013 3:30 PM
I certify that I have viewed a certified copy of the decedent's death EXEMPT #: 11M
certificate.
•
REC FEE: 30.00
_� ,t/ PAGES: 6
REGISTER OF DE DS SIGNATURE DA Recording area
•
Name and return address:
THE INTEREST OF THE DECEDENT IN THE PROPERTY NOTED HEREIN IS
HEREBY TRANSFERRED UNDER THE FOLLOWING STATUTE: Attorney Barry C. Lundeen
110 Second Street
s.867.046 which pertains to nonprobate transfer of real property under 705.15. Hudson WI 54016
An interest in real property may be transferred without probate to a designated
TOD beneficiary on the death of the sole owner or last to die of multiple owners.
(You must provide a copy of the document establishing interest in property.)
032205360000 and 032205380000
Presentation of recorded document establishing interest in real estate. Parcel Identification Number
SEND TAX STATEMENTS TO:
DOCUMENT# VOLUME/REEL PAGE/IMAGE RECORDS/DEEDS Lauren Westerdahl
973822 1547 63ftl Street
973587 Somerset,WI 54025
Description of the real estate. ® See Attached
DECLARATION: l(We) declare that this document is, to the best of my(our) knowledge and belief, true, correct and
complete and is in conformity with the provisions and limitations of the Wisconsin Statutes.
Name and Address Applicant's Applicant Signature(Notarized) Date
(List all beneficiaries. If more Interest in Property (Print or type name below signature)
space is needed, attach pages.) (ie: beneficiary)
Lauren Westerdahl Daughter
E‘,(44.017101/ q 13113
This document was drafted STATE OF WISCONSIN, County of St. Croix
by:(print or type name below) Subscribed and sworn to before me on: co 3 t3
Attorney Barry C. Lundeen by the above named person(s): LLtl.t(t?n VA/•e erc 2 k(
Signature of Notary or other person •
NOTE: SEE DIRECTIONS. y ^
Wisconsin Register of Deeds authorized to administer an oath (as per A...a", �•
Association Form TOD-110 s 706.06, 706.07)
Website Version 05/2010
Print or type name:
� l���ti �s
�u5
Title: NO Y11,- 9Jb1't(, Date Commission Expires: (p 141 0
THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE C LAMODU IJ?MiNtkes
...wry Public
1 of 6 State of Wisconsin
itro inr-'---, N u ey,s-------7 ,
3270 +..,,
i
r
CERTIFIED SURVEY MAP
1/4 Section 1 Township 30 North
Part of the NE 1/4 of the SW 1./ of Secti n 5 , p 3 North,
Range 19 West, Town of S merset, St. Croix County, Wisconsin
N
I r I
0 A190°00'00"yY 1/7. 50 ' O
•W. line of ti 9O'p. yoce� N.
Elk of- sWyq >.,
33 33 N NI
iN
\ lAri
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0
v° 9C.
`9pi
as 33 h Q.�' Al 90°00'DO''" 1/7. 50' ?
4
N 9D°00'00"E 33. 00' Al. ling c f 534 of W%,
SW Corner w O ent E 'i of SWV4 of Sac, 15
Sec . 15,T3ON, R1c1W o. `9
'NI o Indicates iron pipe stake 30" long
S. tin¢ Sac. 15 -p weighing 1. 13 #/ft.
__afy.44 N
N 90°00'00',- /31439
Description:
That certain parcel of land located in the NE 1/4 of the SW 1/4 of
Section 15 , T 30 N, R 19 W, Town of Somerset, St. Croix County,
Wisconsin, further described as follows: Commencing at the southwest
corner of said Section 15 , thence go N 90° 00' 00" E ;(assumed bearing)
along the south line of said Section 15 a distance of 1311.39 feet;
thence N 00° 39' 17" E a distance of 1975.60 feet; thence N 90° 00' 00" E
a distance of 33.00 feet to the east right-of-way line of the Town
Road and the Point-of-Beginning of the parcel to be herein described;
thene continue N 90° 00 ' 00" E a distance of 417.50 feet; thence
N 00 39' 17" E a distance of 208.75 feet; thence N 90° 00' 00" W
a distance of 417.50 feet to the east r.o.w. line of said Town Road;
thence S 00° 39' 17" W along said r.o.w. line a distance of 208.75
feet to the Point-ofBeginning.
Certification:
I, James L. Murphy, hereby certify that i have surveyed and divided
the lands shown hereon and that the map and description shown hereon
are a true and correct representation and description of the lands
as divided; and further that I have complied with all provisions of
Chapter 236.34 of the Wisconsin Statutes in surveying, dividing,
mapping and describing said lands by the direct` crli1bifft4p. owner,
Dennis Bell. 'i "7(,�
) c ``�� SGO/V .,
Dated: )5 May 1975 3 [1 _ too --,: .
1 T:: r ,4-:„.
„it�_
.\\..T., ,�03$ 6' /1 73 S - 1 0 1. 2_ a
15.s o `�'�00 .1 Re .0erealVIICand.• u eyor
GY
il *I' 4.148/11111111100
0
x6111 6
1
Volume 1 Page 122 Certified Land Survey Map
St. Croix County, Wisconsin •
,eoof7