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HomeMy WebLinkAbout018-1086-34-000Wisconsin Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM INSPECTION R'L=PORT 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 Jacobs, Jim Hammond Townshi CST BM Elev: Insp. BM Elev: BM Description: ~Q~ ~J ic~o.vo Sc.- dta a.w TANK INFORMATION TYPE fG1ANUFACTURER CAPACITY Septic is ~ Dosing ? , 'tJ ~D Aeration Holding '- ~~ ie ,/ TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ' ~ / ~ ~/ -~- Dosing ~~~ ~ , 1 Aeration Holding PUMP/S[PHON INFORMATION Manufacturer Demand GPM Model Number L~~ G~ TDH Lift ^~ Friction~oss System ~~ _' TDH Ft t ~ 13.02- Forcemain Len th` ~ Di y~ Dist. tol~e~ ^ ^ ~ ~~ ~/ ~f ~ ~1 SOIL ABSORPTION SYSTEM ELEVATION DATA 3 su.3~ STATION BS V V ~ / IFS ~~ Vim. Benchmark 2.aa /oZ.v ~~' Alt. BM /- ~ /o ~ f 5 Idg. Sewer ~~ ~~ ' c SUHt Inlet D' , / D (~ ~ 8 J SUHt Outlet _-_- !--_ Dt Inlet Dt Bottoms / I. . ~ Head an. Z„ ~ ~ 90 ~ ~~ o Dis~ . ~ r7 ~0 •~i Bot. System ~, D ~~-~ Final Grade ~--- - `~ ~ 9 9- ~ St Cover / ~Z' ~d, 7 1 d ,,.~ C~ •.~.~ 5.9 0 9 G .1 / c W~r`~,GL,~~I tp. to . / ~ 10 i / i J BED/TRENCH DIMENSIONS Width ~ ~Q Length /~ D No. Of Trenc es PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth SETBACK INFORMATION SYSTEM TO P/L BLDG WE LAKE/STREAM EACHING CH ufacturer. Type Of System: ~ 3o k ~ / ~" ' ~ I Model Number. DISTRIBUTION SYSTEM / p Headerr/M~plfolc~^ 2 'I , Distribution I A Pipe(s) Len th J Dia 2 Len th Dial Z5 S acin g g p g SOIL COVER x Pressure Svstems Only x Hol ize x Hole Spacing Vent to Air Intake xz Mound Or At-Grade Systems Only ~Il; S Depth Over Depth Over xx Depth of xx Seeded/Sodded /_ „ ,„ ~`-'~~~ ~ BedlTrench Center BedlTrench Edges Topsoil ~ °, fJ Yes ~ No Yes No U COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 4 / L3 / a ~ Inspection #2: / (l / '7 Qlow~~ OK. Kwl Location: 862 16 nd S eet Ham//m//ond, WI 54015 (SW 1/4 NW 1/4 2~~9N R17,W) Hammond Oaks Lot 34 Parcel No: 20.29.1 .654 1.) Alt BM Descript~~ 't'LJ'D'4.. lP~~ `~ ~ 3~ C• r~-1~ 6 ~f ~ 9 (. • ~ 2.)Bldgsewerlength=~ / ~`r~~,,,,~, ~yy~~ l{> plewSwa ; ~ ot. Plow~~--~ w~ - amount of cover = ~ O ~ ~C+ZQN' ~~ Nc w( $~l•~l~ ~- ~-~- i ~ Plan revision Required? _ Yes ~~,I No ~ ~~ ~ ~ a• Use other side for additional information. ~~ '~ -----GG~~~-~-'" _~L~~ J L _1_ _; ert. No. Date Insepctor's Sig ature C D-6710 R. /97 ""~"_ ~ County: St. CroiX Sanitary Permit No: 463014 0 State Plan ID No: Parcel Tax No: 018-1086-34-000 SectiontT'ownJRange/Map No: 20.29.19.654 ~ ~ ~ 201 W. Washington Ave:, W`.`a. Box 7162 ~seons~n Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) (608) 266-3 I S I D~ De artment of Commerce State Plan I.D. Number ~ ` Sanitary Permit Application s • ~ J\ In accord with Comm 83.21, Wis. Adm. Code, petsorul information you pr ' Q-.- y ~ may be used for secondary purposes Privacy Law, s15.04(1 xm) O' ~~ diff t than mailing address) L Application Information -Please Print All Information t~dG O~ ~ ~~ST'' Property Owner's Name ce # Lot # Block # 3 X CU~N ,~,~- Property Owner's Mailing Address r Z ~%, ~W., Section p~0 i ,State Zip Code Phone Number ty /moo ~/ Z , / ~- n ~, ~ ~circlep}g:) ~~ J J 7/ 7lS" (~ T_~N; R~~- Ea~J [I. Type of Building (check all that apply) ~ Subdivision Name CSM Number /`~` or 2 Family Dwelling - Number of Bedrooms ~ ' S ^ publiclCommercial -Describe Use ^City ^Vi ago~fownship ^ State Owned -Describe Use til. Type of Petrtttit: (Check only one box on line A. Complete line B if applicable) ~ - O ~o ^ " 0'~ • A' ~lew System ^ Replaoement System ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System -- \\ List Previous Permit Number and Date Issued B. ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New Before Expiration Plumber Owner ~ ~ N. T of POW'CS S tem: Check all that a t ^ Non -Pressurined_In-Ground ^ Motatd > 24 in. of suitable soil owd < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sartd Filter ^ Conshucted Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Rocirculating Sand Filter ^ tl r ' 1 Recirtatlating Synthetic Media Filter ^ Leaching Chamber ^ Drip Line ^ Gra el-less Pipe ^ Other (exp ) ~ ~~ V. Dis tsaUi'reatmeut Ares Information: tem Elevation r Design Flow (gpd) Design a^~' • -~ cation Rate(gpdsf) Dispersal Area Requi sf) Dispersal Area Proposed (sf) Sys ~~ VI. Tank info t.:apacity in To Number Manufacturer Prefab Site Stcel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank ~ __ Aerobic Treatment Unit ~~ - [bsingt:hamber D/~ _~ t VII. Responsibility StatemJent- I, the enders ed, assume responsibility for i llatioa of the POWT'S shown oa the attached plans. PI tier's Nam (P 'nt) _ ~ Plum Si ee P PRS Number Business Phone Number Plumber's Address (Street, Ciry, State, Zip ode) /-~ ~~jt~ VIII. Count ~/De artment Use Onl / / Sanitary Permit Fce~ncludes Groundwater Date Issued Issui g nt Signer ure o Stamps) Approved ^ Disapproved Surcharge Fee) 35~-~ ~ ^ n for Denial ~ ~ 7 - ' " _ !a. Conditions o pprov / I ~ ~ I/IV1~ SYSTEM R: ,3~ ~l( r--'~'-$ t 1 Septic tank, effluent filter and ~~ U~,~ ,~~ _ _ `~, dispersal cell must all be serviced /maintained ~- ~ ~ ~"~t'~L '~' as per management plan provided by plumber. ~ ~ ~ ~,~,,,\~ 2. All setback requirements must be maintained ~ .~~ St, ~ cQi J t SI as per applicable code/ordinances. th bti Attach eompkee places (to the County aoty) far the system oa las eh^a atR x 11 loeha to size ~ -~ ,~.,2 -~e.~ vim.. SBD-6398 (R. Ol/03) ~ `~ 111~1i Mb °~ ~ ~ `~ - ~ d0 ~~ l^~ 7 ~ M Q. G~~ commerce.wi.gov ^ isconsin Department of Commerce Safety and Buildings 10541 N RANCH ROAD HAYWARD WI 54843 TDD #: (608) 264-8777 www.commerce.state.wi. us/sb www.wisconsin.gov Jim Doyle, Governor Cory L. Nettles, Secretary August 23, 2004 CUST ID No.220357 BRADY J UTGARD 110 KELLER AVE N APT 112 AMERY WI 54001-1034 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 08/23/2006 SITE: James Jacobs 160TH St Town of Hammond St Croix County SW1/4, NW1/4, S20, T29N, R17W FOR: ATTN.• POWTS Inspector ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 Identification Numbers Transaction ID No. 1047812 Site ID No. 687794 Please refer to both identification numbers, above,. in all correspondence. with the agency. Object Type: POWTS Component Manual Regulated Object ID No.: 974466 Maintenance required; 600 GPD Flow rate; 30 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual -Version 2.0, SBD-10691-P (N.O1/O1) 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 "SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST-SAS (01/81)". • Changes made to this plan 08/23/04-, by this reviewer were acknowledged and approved by the system designer: A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. (1 ~i ~ !` 1 BRADY J UTGAI2D Page 2 8/23/2004 Inquiries concerning this correspondence maybe 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, Thomas E Devereaux Plumbing / POWTS Reviewer II ,Integrated Services (715)634-3026 , 7:15 am - 4:00 pm Mon. -Fri. tevereaux@commerce. state.wi.us Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 WiSMART code:'7633 cc: Leroy G Jansky, Wastewater Specialist, (715) 726-2544 d i ~ K MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Project. Name: Owner's Name: Owner's Address: Legal Description: Township: County: JAMES JACOBS JAMES JACOBS 16440 3RD ST. LAKELAND, MN 55043-8400 SW1/4NW1/4S20T29NR17W HAMMOND ST. CROIX Subdivision Name: HAMMOND OAKS Lot Number: 34 Parcel I.D. Number: Plan Transaction No.; Block Number: N/A Index and title Data entry Mound drawings Lateral and dose tank System maintenance specifications Management and contingency plan Pump curve and-specifications PLOT PLAN soil test a r -~ [` .~s'~~ Cf,~a~~ ~ ~~' ~``a'~ r ~ ~~ ~~ BUILDINGS E - ,~~spor~l~Er~ic Designer: BRADY UTGARD .License Number: 220357 Date: 07/27/04 Phone Number: 715-268-6995 Signat signed Pursuant to the Mound Com Went Ma ua or POWTS Version 2.0 SDB-10691-P (N. 01/01), and SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST-SAS (01/81) Version 3.11 (R. 06/01) Page 1 of 9 Mound and Pressure Distribution Component Design Mound Plan View . 1/10 B_• • ~ 'observation Pipe '0' . .~' .. .. •Je~ ..•..... ... ... .... ... • E: .. a -T _} _~ -1 L Mound Component Dimensions ~ nv~UNSLr=r'c Ek~'='~'-`''oF~ -~'~A°~ A 6.00 ft E 8.88 i n B 100.00 ft F 9.25 in D 6.00 in G 0.50 ft 600.00 (ftz) Dispersal Cell Area 6.00 (gpd/ft) Linear Loading Rate H 1.OOft K 7.17ft I ,; L 114.35 ft J 4.74 ft W (ft2) Basal Area Available 10.00 (ft) 1/10 B Obs. Pipe Placement Mound Cross Section View Aggregate Dispersal Area Finished Grade 98.63 (ft) ,,,. ~I H teral F . • : ~ ~ ~ : ~ ~ Dispersal Cell ~ 97.36 (ft) La 96.86 (ft)-- - Invert Dispersal Cell ~Q : ~ ~ ~ ~ ~ ~ ~ Elevation E ~ D ~ ~ ~: • t : _ _~ .,K :. ,~., ; . ~,~; i,. i • ] • i ~ ] ~ },. ;i, r{.;]. ] ;{ ;i, ;]. ~ i ~ .{ }. 7. { /. i, i, ] ] i i, }• ~i ~] }.: ~ : i.,_ ~.: % .].` },~}, : { i`_ ,4 .}: %..: i..~,. f _ __ _ _ _ _ _ _ __ _ __ _ .,~.,,: ,ti ,_ , _ _ _ ~ _ - ] ] ~ ] }, ]. _ i, ]_ _] 4 .} i ~ ] - i, i { ] ] Sri ] r i ~. J.,-!. _ 4 _ 1~,4.~5.:~.1 }. ~ _ ]. ~J .~.~?.~, }~ , l i 1 i, i, ;{ i, i ~ .. ~. . !, ~, -] -i i, ;i. -] ~ ] ~, ~ ] i ] i } i ] y ] ;i '] .~. ] li, ,i, { ;t i i --] -l l•~'i' ~'' 96.36 (ft) Contour Elevation 4.0 % Site Slope /~ Geotextile Fabric Cover Shadin Ke ~ ~- g y ~ . [] Topsoil Cap c ~ 1.5 ft © "~~~ Subsoil Cap w ©~ ASTM C33 Sand :~ ~ -~i:-~]--i: Tilled Layer ~ ~ ~ 0.5 ft ^5 Aggregate o Dispersal Cell :' Typical Lateral :~~; --:~~: -- A ---~ See lateral details on Page 4 for number, size, and spacing of laterals. Laterals are equally spaced from the distribution cell's centerline in the distribution cell (AxB). Project: JAMES JACOBS Page 3 of 9 Center Connection Lateral Layout Daigram Force main connection via tee or cross to manifold at any point. Laterals are identical IE P S •= Turn-up wlball valve or IE- X-.-~IExl2 I xf2~l Laterals & force main of PVC Sch 40 cl ea n out pl u g per COMM Table 84.30-5 Hales drilled on the bottom of the lateral. Number of Laterals 4 Lateral Diameter 1.25 in Lateral Length (P) 49.29 ft Lateral Spacing (S) 3.00 ft Lateral Flow Rate 10.49 gpm System Flow Rate 41.94 gpm Total Dynamic Head 19.21 ft Orifice Diameter Orifice Spacing (X) Orifices per Lateral Orifice Density Manifold Length Manifold Diameter Forcemain Velocity Dose Tank Information Electrical as per NEC 300 and -~ ' Comm 16.28 WAC ~ Disc\onnect y_ Tank component is properly vented WIESER Ca aci 800.00 Volume 22.24 Manufacturer Gallons gal/inch ~' A B C D Dimension Inches Gallons A 18.41 409.52 B 2.00 44.48 C 3.56 79.12 D 12.00 266.88 Total 35.97 800.00 3" Bedding under tank. Alarm Manuafacturer LEVEL Alarm Model Number DLV Pump Manufacturer GOULDS -~ Pump Model Number EP05 Pump Must Deliver 41.94 gpm at 19.21 ft TDH 0.188 in 3.18 ft 16 9.38 ftZlorifice 3.00 ft 2.00 in 4.28 ft/sec Locking cover with warning label and locking device and sealed watertight 4 in. min. -~_ F- Alternate outlet location Forcemain diameter ~l 2 in. Weep hole or anti- siphon device Pum off elevation (ft) 85.00 Dose tank elevation (ft) ~ 84.00 Project: JAMES JACOBS Page 4 of 9 Mound System Maintenance and Operation Specifications Service Provider's Name _ _ UTGARD PLUMBING~~ Phone 715-268-6995 POWTS Regulator's Name [ ST. CROIX ZONING Phone 715-386-4680 System Flow and Load Parameters Design Flow -Peak 600 gpd Maximum Influent Particle Size 1/8 in Estimated Flow -Average 400 gpd Maximum BOD5 220 mg/L Septic Tank Capacity 1200 gal Maximum TSS 150 mg/L Soil Absorption Component Size 600 ft2 Maximum FOG 30 mg/L Type of Wastewater Domestic Maximum Fecal Coliform >10E4 cfu/100 mL Service Freuuency Septic and Pump TanN Effluent Filter Pump and Control Alarrr Pressure Systerr Mounc Other Ins ect and/or service once eve 3 ears Should ins ect and clean at least once eve 3 ears Test once eve 3 ears Should test month) Laterals should be flushed and ressure tested eve 1.5 ears Ins ect for ondin and seeps a once eve 3 ears Miscellaneous Construction and Materials Standards 1. Observation pipes are slotted and materials conform to Table Comm 84.30-1, have a watertight cap, and are secured in as shown in the mound component manual. 2. Dispersal cell aggregate conforms to Comm 84.30 (6)(i), Wis. Adm. Code. 3. All gravity and pressure piping materials conform to the requirements in Comm 84, 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 ~~ 6-8" Diameter Lawn Threaded Cleanout Sprinkler Valve Box ~ Plug or Ball Valve Distribution Lateral Long Sweep 90 or Two 45 Degree Bends Same Diameter as Lateral Project: JAMES JACOBS Page 5 of 9 Mound System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General This system shall be operated in accordance with Comm 82-84 Wis. Adm. Code, and shall maintained in accordance with its' component manuals [SBD-10691-P (N.01/01) and SSWMP Publication 9.6 (01/81)] and local or state rules pertaining to system maintenance and maintenance reporting. No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tanks are no longer used as POWTS components. Septic or pump tank manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or sut~ject ko 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 113 the liquid volume of the tank. If the contents of the tank are not removed at the time of a triennial assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such products are used they shall be approved for septic tank use by the Department of Commerce. Puma Tank The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alamts, and um s shall be tested to veri r operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary. p ~ p ~r 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 BODS, 150 mg/L TSS, and 30 mg/L FOG for septic tank effluent or 30 mg/L BODS, 30 mg/L TSS, 10 mg/L FOG, and 10" 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 18 months. When a pressure test is performed lt 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 6 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. Continaency 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 contrds, 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 tce 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 5 of this plan for the name and telephone number of your local POWTS regulator and service provider. Project: JAMES JACOBS Page 6 of 9 '' ~`y/~ " d I t~ ~J J _9~ ~~ ~~ ~IV1 w ~- ~'6 f C~ ti M _~ ~~`~ v' b ~ •~ , ~ , i t N V /1 $ ~ r?Q T `llav $OIL DESCRIPTION REPOR page Z' a 3 PROPERTY OWNER n p u ~}'~ K S 'S ~ Cf (/ !! ~HH OA1~ PARCEL 1.0.11 Horizon HDr)r1g # Depth Dominent Color Mottles Color Coral Sz Q Toxlure Structure Gr. Sz. Sh. Con9;stence gpu~ery Roots 2 Bsd ~ Trenc In. Muns ell . . u. ~.. ~. . , , Ground 3 ,o ~p / -- °,~ 1 HOTS t!.~ s b M+ . ' ~ olev ,~ y,Q /./L rI rP• .wp. 9"~ Depth to Itmlting ; lector ~In. Boring # ~:;v= :~ ..ti . ~ Q ;.. , ~.,!r7sl Ground olev. _11. J„ Depth to nmiting factor In. -- Remarks: .. _.._._ in~. Munsell Ou. Sz. Coral. Color ~' ac• ~"• Boring # '•:~ . ~.~`• ;,'. s>. ' ..„t'r""~ * , Ground alev, --n~ Depth to limiting . factor ` . ' _.In. os.,..~.be • Boring # a Ground elegy. n. Depth t0 nmtOng factor . -I"' Remarks: S9OW-8330 (R. 08/85) Y ~ 07/27/04s TCfE•19:52 FA% 715 J88 4888 ST CR% CO ZONING i~1001 .. ._'x ,' ! Wiswnsin Department of Industry, SOIL AND S17E EVALUATION ~ 2 l.atwr end Human Relations ~.- . - ,_„ page _ of oMslon of sarery and euudings in accordance ~ 1s:+(L• F(F~ 83:09 Wis. ) ' ~. Attaoh complete ehe plan on paper not less Oran 8 t/2 z t t inches kusrm. , r(rus~•~'r_R C'~y ST ~RQ/'~ include, twt not NrMted to: vertical and horizontal reference pdnl ( rectlon eid::~:: ;:;,~ percent dope, scale a dimensions, north arrow, and location and ~ t nearest road. Pero@I .D. M D ' i. Cr±Cfk APPLICANT INFORMATION - Please print aft inforrb~fon. I~v~e~//by Date Personal inlomull0n you provide may 6o uead for sOCOndary WryeSH 1"~1B°y'/; ~s• 16.~~~~1jF~ICe ..~. 1i ~, I / i'/~/~ 9 Property thvrrer ' M V M Q ~ e `'111V.,Q,^ ~ Pyft}~• • ~o~ertY LocatiotL~ : U k~ ~Zo ' if 7 AJ I'~c 1 ~ I Q ~, t~ ~• t/4 ~/ 1/4,S .. :7 .N.A ~ ~ lor/ w property Ovmer's Mel nq Addrsss ~ Lot R BlackM Subd. Name a CSM>f 332. hiv~~5d1'/1 sr. E+1sr I~lo 3 ~1•MHD~tJI7 ~/r~E"r l sky Sroro ZIp Coda Ptrona Number ST• 11L• NA). ~S/0~ (toS/)2a2'SSSS Nearest Road /fJ ^clty OVill a Town ,~,~ I(ib [flew Conswcdon Usa: [~S~esldendal /Number of bedrooms '3 AddlUon to exlsUnq brildinq ^ Replacement ^ Pudic or commercial • Describe' Code derived daily dow ~,~. gpd Recommended design loading rata ' ~ bed, pp6/1tZ ~ vencn, gpdMfz Absorptbn area required bed, Rz, 37S trench, flz Masimum design badinp mte • y Dad, gpd/flz • 3 wrench, ppdAt~ Recommended inlUtredon surface eleva6o..n~(s)pSCI.,L, •~ n (as relerted to site plan benchmark) AddlNOnaldeslgNslleconeldaratbns [~G~ • ~ ~Q~~y ^~~y/~~ Parent material ~4 ~ f s D ~~ DFNSt~ T/YES Flood plain elevadon, it applicable ~/~~' K S Suitable for system Convand~on~l ,M,ouj' In•Ground P~res3/ure A Grade ystem In Fitl Hddinq Tank U Unsutade Ior system ^ S Liu lSS ^ u ^ s W ^ s u ^ s [)"('' ^ s Boring # Grourxi elev. 9~•3b-ft. DepUrto fimldnq lector h / In. Boring # Z SOIL DESCRIPTION REPORT Horizon Depth. Dominanl Cobr Mottles Structure i t d B Roob Gp In. MVnseN Ou, Sz. ConL Color Texture Gr. Sz. 3h. ence Cons s oun ary Bed ,Trench iv Sid z,»a b,~ ,.~ /~ c . s :. ~ L ~ P ~ tip Remarks: ~ o' s ~~ yR L/ --- Si G ~ h,~ ~fR . ~. ~ . 3 /o c>.~ Profs S/t: sh,C - ~ ~ Ground elev. GG • ~n. __1I DepM Io NmlNng lector .. r ,_ .L.. ~R,. r101,14..~. ST Name (Please Print) RoaER•r• ~`(~(~ G~•1"' Signature Telephone No. ,ddress Date CST Number Ulbrlcht b Aseodates QGt,~_ ~ Sg ~r ~t x 4 3 7 5 ~+ .. r' 855 O'Neil Rd. Hudson, Wis. 54018 'k f^ ~. ' ` ~. ~ ~~ 1` ~r r/ r I^' ® ~> { Y `~(~ v ~ Q \~ V ~ Es T ~- 0 7~ t. ~',v~ .~ r o _ -~ w N W ,~ oc! s%t ~~ ~ ~ ,~ v - '~ - ~ o ~~ -~ ~ ~ ~ W ~~ ~ ~ ~ ~ ~~ ~ o--~ -~ .. ~ Z '~ ~ b b ~ ~ ~, ~ N "~' -i ~ ~ i~ ~~ J p ~~ ! . *. Wisconsin Department of Industry, Labor and Human Relations Division of Safety and Buildings Remarks: Attach complete site plan on paper not less than 8 1/2 x 11 inches i ize./flan r~itfct,_ ,: ; include, but not limited to: vertical and horizontal reference point ( ?c)freetion a~+d _ ~ .~. ~ ~ percent slope, scale or dimensions, north arrow, and location and i{ce to nearest road. p$~ i -i i1.~,i_. `dry _. APPLICANT INFORMATION -Please print all infor a~pn. '~~'~' ~`" ) t U V'!"Y Personal information you provide may 6e used for secondary purposes (Privacy aGiy?s 15~~g~FFICE ~ Property Owner ~{ ~ H a ~ ep ~ ~,~ Q, ~ d Property Property Owner's Mailing Address Lot # 33z. hiuN~E5oT~4 sT E'~15T -yo~ 3 City State Zip Code Phone Number 5T• PAu~ _ 14~. ~S/o I cb5/ )z22.5555 ^ ~i~' .S~T~CiP~O~'JC_ ~. # 01 d -7~ C~/g• /d~ Page / of • S"Q ' Ua Date ,_ , /- _ Gatio~ ~ ~~) " ' 1/4Nw1/4,S •Z~ TL7 ,N,R ~ 7 d(or) W lock# Subd. Name or CSM# r},y,~go~vD O~9'~E's' ~~ Nearest Road w ~ ~- ^Village . ~LJ Town i qy~~ ((~ ~j []'Flew Construction Use: [~sidential /Number of bedrooms ~ Addition to existing building ^ Replacement ^ Public or commercial -Describe: Code derived daily flow y~o 9pd Recommended design loading rate ' ~ bed, gpd/flz ~ ~~, trench, gpd/fl2 Absorption area required ~_bed, ft2 37 trench, ft 2 Maximum design loading rate Z bed, gpd/ft2 '~7 _trench, gpd/ft2 Recommended infiltration surface elevation(s) •~~ ~ ft (as referred to site plan benchmark) -f-pi ~ ?~l ~' .~101J.v~ Ie~~~Jl~~ Additional design/site considerations N ft Parent material ~D E't'S ~ V ~ ~FNS~ T~ ~~f Flood plain elevation, if applicable S = Suitable for system Conventional MMoun~d In-Ground Pressure AT-Grade System in~ ids 9 C ~~ LT5 ^U ^S 0,` ^S U ^S LTU U = Unsuitable for system ^ S L.J ~ Boring # Morizon Depth Dominant Color in. Munsell ~ o•~ ! ioyR~Z ~~~ ~ ~s ~oy~3~y Ground elev. qG•3~,--ft. Depth to limiting factor ~in. ~~ Boring # Ground elev. ~G ~ft. • Depth to limiting factor Z / in. ~ 4 ~ SOIL AND SITE EVALUATION in accordance~ti~h's.~ tLNR 83.09,,Wis. ~'~`•.,'' CouAty SOIL DESCRIPTION REPORT Mottles Texture Qu. Sz. Cont. Color Structure Gr. Sz. Sh. Consistence Boundary Roots E _._- S ~ ,r.. h~ ~ ~ ~ ~ c - ~ • C // ~ y I t Z S • ~o ye 3/ /. ~o Remarks: Bed ,Trench .L..3 .t~.3 5:•~ . ~,. v. p ~ .. CST Name (Please Print) Ro~~R'1" ZI~(3~'iehT Signature C,~N,,,,,,o ,..,. ~~s• 38G • ~~ ~ s Date w, ,.~,,,.,~. Address oGt Zy ~~q~ ~z4375 I Ilhricht & ASSOCIat88 ~* L f t, ^' VH Q ~ ~~ L ~''~~ SOIL DESCRIPTION REPORT page ~ of PROPERTY OWNER !~ 6~ ~, ~ S ~ ~ ,{~ ~~ M ~ O ~ v !/ PARCEL l.D.# 2 BOfing # Horizon Depth Mottles Texture Structure Dominant Color Gr. Sz. Sh. Color Cont Sz Qu Consistence Boundary Roots Bed i Trench in. Muns . . . ell Z i~ ~fsh~ ~-~i2 cs .. ~f . ~ o ~~ ~o y Z - S~~ ~» h ~~~ cs _ , s . ~ ,o ,~ ~ .-.. - s s MOT C1~ ,. Ground ?~ ~Q . ~ v~P ' 1 ~P' elev. 1 Y /0 y~ / ~ L ' ~~~ft. Depth to ; limiting , factor ~in. # i B ng or Ground elev. tt. Depth to limiting factor in. - - Remarks: .,~,~ < Horizon Depth Dominant Color in, Munsell Boring # Ground elev. ft. Depth to limiting , factor in. r,_.___~..,. Boring # Ground elev. ft. Depth to limiting factor 'n' Remarks: Mottles ~ Texture Structure Consistence Boundary Roots `" Gr. Sz. Sh. Bed , Qu. Sz. Cont. Color , ~ r ~!R X E~ ,~ UH $ I ~O ~' ~'V~ SOIL DESCRIPTION REPORT page Z of PROPERTY OWNER lfAMho~t~ ~~ ~ ~ S S g~ PARCEL I.D.# 2 Boring # Horizon Mottles Depth Dominant Color Color Cont Sz Qu Texture Structure Gr. Sz. Sh. Consistence Boundary Roots Bed 'Trench . . . }n, Munsefl Z ~ ~~ /f sb~ ~~/2 cs /~ . . 3 ~ a ~~ ,o y Z ____ _ a« S~~ h ~~~ cs s'. ~ ' Ground ~ 3 ~~ ~ ~ ~ y nn fIOTf ~~ yC20~ ~Q GL IBS ~ /-M~~~ _ ~ , . ' . ele v ~G ~~ V~ /_/.y 7 Y y-P '~P. p ~ ~ ~~--ot~n~ -"- ' Depth to lirnlting -- , factor - - ~in. # i ng Bor Ground elev. n. Depth to limiting factor in. ---- Remarks: D/f12 Horizon Depth Dominant Color Mottles Structure Texture Sh Sz Gr G Consistence Boundary Roots Bed ,Trench . in, Munsell Qu. Sz. Cont. Color . . , Boring # ~_ , Ground _ - ' elev. , __ft. - - Depth to limiting , factor ' in. ~_.v__~.,.. _ Boring # Ground elev. ft. Depth to limiting factor 'n' Remarks: ,.. • ,i " ~ ~ ~..k~Qa~ ~~ `` ~\ s . ~ ~Q -~ --j ~.c~,~~-5., w~, SST- ~~c't~"~~ 2~3~" r SN ~ ~` ~q w ~\ "~ 00 ,~~ d :~ ~ _~ a ~ -' ~ ~ ~ - w N r o~ ,___ ~~ ~ O r, w ~ ~ ~ ~~ ~ w ~ ~ ~, i ~ ~ w^ V- -~ `I ~ _ oo _ ~ ~*, N ,~- ~ ~ N o c~ '~ ~ Z r ~ G ~ ~ ~ ~ '~ • ~ ~ .~ N ~ n ~,~~ ST CRgI~, COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer ~ ; ~ rt ~ ; (~ fir. c -~ S Mailing Address ~(o~ Property Address ,v ~ ~.oa -~~ (Verification required from Planning Department for n w construction) City/State ~G~-vvyr~rn~c~, ~ ~U~ parcel Identification Number ~,3 a n'-mvr~o( (~ ~ D~~r'- IoS(6- 3~{-ate . ~5~~ LEGAL DESCRIPTION Property Location ~ %,, ~ y,, Ste, ~ To~ ~ N-R~W, Town of Subdivision Certified Survey Map # Lot # ~. ~-.. Volume .Page # Warranty Deed # ~ 7 ~ ~ ~ Volume ~~, ys .page # ~,~. Spec house ^ yes ~ no Lot lines identifiable yes ^ no SYSTEM MAINTENANCE 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. The property-owner agrees to submit to St. Crouc 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 wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. ~ iAQ (~o~cab 5 / c~/ v SI- GNA~T[JRE F APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. /sn o`er gi/ o~(/~/ SIGNATURE APPLICANT DATE * * * * ** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. * * * * * * ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed u 2sysP ~s7 .ri ~ .Y STATE BAR OF WISCONSIN FORM 2 - 1998 WARRANTY DEED Number This Deed, made between Hammond_ Land, LLC,_a Minnesota Limited Liability Company _ __-___ Grantor, and Tames P. Jacobs and Jillene M. Jacobs, husband and wife Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin: Lot 34)Hammond Oaks Subdivision,Town of Hammond, St. Croix County, 7~28~3 REGISTER OF DE DS sT. ceolx co. , MI RECEIVED FOR RECORD 08/27/2004 11:55AII MARRANTY DEED (_XEIPT i RfiC FEE : 1 l . N TRAINS Ffifi: 98.70 COPY FfiE : CC FEfi PAGfiS : i Nazne and Return Address Ov\ -l~ 018-1086-34-000 Yazcel Ident~cation Number (FIN) This is not homestead property. (is) (is not) Exceptions to warranties: Subject to notes, easements,restrictions,covenants and rights of way of record, if any, including but not limited to those for drainage,water retention,ponding,and or utilities as may be shown on the plat of Hammond Oaks Subdivision recorded in Vol. 8 of Plats, page 2, St. Croix County, Wisconsin.The warranties of this deed, either expressed or implied are limited by the grantor to the grantee, or anyone in the chain of title, to an amount not to exceed the consideration expressed }terrrit~ that being the sum of $32,900.00. Dated this 23rd day of August _-_-_-_-___, 2004 Hammand Land, LLC * * AUTHENTICATION Signature(s) authenticated this day of ,_ TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stets.) THIS LNSTRUIvLENT WAS DRAF'T'ED HY Paul A. BaiUon, Attorney at Law _ (Signatures may be atthenticated or acknowledged. Both are not necessary.) * by c.~ ~6,-,,,~ ~_',~ President * Austin J. Baillon ACKNOWLEDGMElYT STATE OF WISCONSIN ) ss. Ramsey - _ County- ) Personally canie before me this 23rd day of August ,2004 the above muted Austin J. Baillon to me known to he the per9on(sj who executed the foregoing instrt/un)ent awnd acknowledge the same. ~~.~~~ f • t. A. au.ot~ * Paul A. Baillon c ~ NOTARY PUBLiC-MINNESOTA +ealTSwk~cxPiRES+~aiaocs Notary Public, State of Wisc My Commission is permanent. not, state exp January 31 ^_ 2005 .) ,t •Names o[ persons mi° ;„g in any capacity should bo typed or printod Ixlow their signatures WARRANTY DEED STATE 8AR OF W[aCON3[N FORM Nu. 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