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020-1200-10-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 572891 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: Grancorvitz, John Hudson, Town of 020-1200-10-000 CST BM Elev: Insp.BM Elev: BM Description: Section/Town/Range/Map No: (o, 3/'V$1 ID v4-tek t5 L 1 L.-42— 21.29.19.1201 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER 44/•-''' S CAPACITY STATION BS HI FS ELEV. Septic EX∎5�}-�`,n („).` 6J4-ttBry- blrX .3 I12•t7 91. '7 -Bas ing / ' I A/lt.BM }b..r{2.. J.L , Aeration Bldg.Sewer J Holding St/Ht Inlet J , L St/Ht Outlet 3 ��. dal TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. ()to Air Intake ROAD 1,nig/ �r,•t jc... �.,iI l94$* 7 ! , y Septic / Di8ottom�1I • ddb k.l5 7 1• S Z-> 4-6 10 2.41 _ ____ i / Header/Man. -Basin 7 5io ' '7$ 5/ — 7. 0 95 . 17 Aeration Dist. Pipe 7.C 10• 17 Holding < Bot. System 4. 0 14, f`7 g .Z 93,9'7 al Final Grade PUMP/SIPHON INFORMATION 3. 3 /1.17 Manufacturer Demand St Cover ' ' a GPM rr"itL Go 0-e n-- , v . ! 7 Model Numbe TDH j Lift Friction Loss System Head TDH Ft Forcemain —Length •la. Dist.to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width 1 Length ` No.Of Trenches PIT ID MENSIONS No.Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 b L L. Ile o-( SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufactur ,t -_ INFORMATION / CHAMBER OR �� la Ty Of Syst./ :,, 'gyp ' 39 / '/ AA— UNIT Model Number: DISTRIBUTION SYSTEM 060J1-L. / !e+,4 = 3 Z Header/Manifold 1 Distribution x Hole Size x Hole Spacing Vent to Air ntake �/ Pipe(s)�. \— `_ So J ��� Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over � // / Depth Over xx Depth of xx Seeded/Sodded xx Mulched 4. Bed/Trench Center • 7 Bed/Trench Edges Topsoil S es _ No Yes No COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2: / / Location: 818 Harbor View Rd Hudson,WI 54016(SW 1/4 SW 1/4 21 T29N R17W) Jacob's Landing 1st Addition Lot 18 Parcel No: 21.29.19.1201 1.)Alt BM Description= r"'a"'�' 6a.4z.�— CO,/-e..--- / L�; + Lo 0 2.)Bldg sewer length= E,C■.6� CJ ,��-�,Mlle-amount of cover= // `� fall(, it Plan revision Required? Yes 'No q —, /5 i / I` �4 F34/ i J Use other side for additional information. / ` J ! --- ff.". Date Insepc• ' Signatur- Cert.No. SBD-6710(R.3/97) Property Owner_ Parcel ID# Page of 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 GPDtIf in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. •Eff#1 *Eff#2 Boring# ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *OW *Eff#2 ❑ Boring Boring# ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon lepth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff 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=BOD5<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(8.6100) Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85,Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size.Plan must County .57c' (7.,0 include,but not limited to:vertical and horizontal reference point(BM),direction and Parcel I.D. n percent slope,scale or dimensions,north arrow,and location and distance to nearest road. w/l� /_, .1//,)•-49,1/v Please print all information. Revi ed by Date G� Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). f , X3/1 Property Owner / �' /1 L Property Location ,,--Ni/} ___!O t r,./ 1 .^�/,/_2(,∎.); Govt.Lot��JJ a�/ 1/42(e}4 / T - N R /I E( r)W� Property Owner's Mailing Address/ /� Lot# 'Block# Subd.Name • CSM# V/ ? /46,,,..- f_/ ,�� Oe.-! JI City State Zip Code Phone Number wn Ne st Road Jri� I�'� 1 VOif�I ( ) / .�-..t, 1 �r� 1�j /Z'-"- -''° New Construction U 'dential/Number of bedrooms , Code derived design flow rate �=��_ ' -— GPD acement ❑ Public or com erclal-Describe: _ Parent material 49-714.56.,�, /... 1 Flood Plain elevation if applicable � / ft. i 4-4 General comments 42," 11L,___, and recommendations: System Type ZIP/C/[,'� System Elevation 7y 7 a 7 Boring# Boring �, Pit Ground surface elev. PS./ ft. Depth to limiting factor 7`0 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Efi#1 'Eff#2 t o-i /yi tz, ,, ,-,�� ��, (7.re „---, _ 4 , v / / a `3 3 -%1 p f _ cam. c-, AI/ /k/ ivii . 1 / 4 73 . T-----, - lii Boring# ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. l Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. •Eff#1 'Eff#2 i Effluent#1 =BOD.>30<220 mg&and TSS>30<150 .// •Effluent#2=BOD,<30 mg&and TSS<30 mg/L CST Name(Please Print) ..i,ture CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1432 120th St, New Richmond, WI 5401 7—/. '– 715-246-4516 PLOT PLAN PROJECT John Grancorvitz ADDRESS 818 Harbor View Rd Hudson Wi 54016 SW 1/4 SW 1/4S 21 IT 29 N/R 1 '4 W TOWN Hudson COUNTY ST.CROIX • Z�� SYSTEM ELEVATION 94.2/93.9' 3/28/15 3 DATE BEDROOM CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of cham ers 32 BENCHMARK V.R.P. Top of 2" survey iron ASSUME ELEVATION 100' Filter BEAR Filter ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark B.M. * 250' Property Line A Vent Scale = 1 4 = 1 >6,, LQuick4 Standard of Cover eaching Chamber with 20.0 ft2 of Area .6ft^2/pair of end caps 4' Long 239' 34" Grade at System Elevation All piping shall be SDR 30/34,within 10' of tank,piping shall be Schedule 40. valve B-1 B-3 • 55' ■ro.1 166' 18' X 36' bed 25' 'ailed 40' ST Vent 25' • ;_2 10' 25' 25' �, 50' Well uffcutt Filter tank A 15' • 55' Existing 3 B 4 Bedroom 2-3' X 66' cells with>3' spacing House 60' 4 • B-6 Harbor View Road vents t �, E + County cJ �° �^• �6 Safety and Buildings Division ' r j <] ;�. :i,� 201 W.Washington Ave.,P.O.Box 7162 ,� Sanitary Permit Number(to be filled in b}'Co,) i �S� .1. < (A `1 t - Madison,WI 53707-7162 % s V� OU -� / ! ' 57 289 �., .0 Et.. E State Transaction Number .C, ;d,' >' anitary Peiiiiit Application-- N/ In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to ! Project Address(if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary ��r�D purposes in accordance with the Privacy Law.s.15.04(1 Xm),Stets. 06 V,Vie k) / I. Application Information—Please Print All Information PareeI# { Property Owner's Name / e i�vv C, ic, n,C�,r t 1 - " 0 2. - lacy-- 10 -- ao 0 Property Owner's Mailing Address Property Location ( '20l� v eu/�� C J �� � izeZor � Govt.Lot City,State I Zip Code � Phone Number 3Jy V4, Section J f i n G v`' ; 44 / d T77 -N; R //E'le on IL Type of Building(check all that apply) Lot d ' /> Subdivision Name i�Family Dwelling—Number of Bedrooms_ IF � 6 II Block# I / f� { ` 0-.0 �� < na( 0 Public/Commercial—Describe Use El City of kk , CSM Number ❑ Village of ❑State Owned--Describe Use - l 1 Own Of y.Il 2 — � � xCo� one X III.Type of Permit: (Che . .. y one ox A. Complete line B if applicable) A. 1 New System C • .. ___ent System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) 1 List Previous Permit Number and Date 1s ed B. ❑Permit Renewal I El Permit Revision I ❑Change of Plumber I ❑Permit Transfer to New 1/2 75 t/ Before Expiration Owner / i 0 I IV T•.e of PO' S Sys •:./Component/Device: (Check all that apply) 1 { lU .! cm-Pressurized In_Crroun• ❑Pressurized In_Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mour n.of's le S'I ❑Pretreatment Device(explain) y i fr trd Q Bolding Tank ❑Other Dispersal Component(explain) V.Dispersal/Treatment Area Info m on: �� .del 7, Desi Flow(gpd) Desi o , 'cation Rate dsf) ( Dispen Aria Requsc sf) I Dispersal Area Proposed(sf) Sys m Eieva'o ff Capacity in Total #of Manufacturer d I c F .Tanklnfo Gallons I Gallons i Units gr I t JNew Tanks Existing Tanks J 1 I •I l„p,{� ?? 1 3 03 b V// J V�--. 'c Septic or Holding Tank V Gr..70 i (/ (1/-e—, k ! Dosing Chamber I t , VII.Responsibility Statement- I,the undersigned,assum sponsihility for installation of the POWTS shown on the attached plans. 1 Plumber's Name(Print) Plumber' ature I MP/MPRS Number I Business Phone Number Plumber's Address(Street City.State,Zip Code) . 17-2'oreZ) ; 474/7—p2 etc'Kr,7.141 VI ounty/Department Use Only ' .. Permit Fee Date Issued Issuing� c t. e Approved / $ De z z /mil \)/ 1 " 0 •ter Given Reason for Denial { 73• ✓ ✓ / IX.Conditiot mo pnEoxal/Reas ns for Disapproval 1.Septic tank,effluent filter and dispersal cell must _serviced/mainta_fined as per management plan provided b I 2.All setback requirementsapms y Plumber dS per applieElt ' ggt(]Inance3� it to the County only as paper not Its than 8 se a 11 inches in size SBD-6398(R 11/Ii) Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 3/26/15 Owner:John Grancorvitz Location: SW1/4 SW 1/4 S21 T29N,R19 818 Harbor View Road Hudson Manuals Used: In-ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cross Section 4-6. Maintanance and Contingency Plan 7. Filter Specifications Sh:.,/- 8. St.Croix Existing Sep; an) Form Signature A i , License number , "6900 PLOT PLAN PROJECT John Grancorvitz ADDRESS 818 Harbor View Rd Hudson Wi 54016 SW 1/4 SW 1/4S 21 /T 29 N/R 19 W TOWN Hudson COUNTY ST.CROIX SYSTEM ELEVATION 95.0' 4.5' below grade 3/28/15 3 BEDROOM DATE CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32 BENCHMARK V.R.P. Top of 2" survey iron ASSUME ELEVATION 100' Filter BEAR Filter ❑ BOREHOLE O WELL *H.R.P Same as Benchmark B.M. 250' Property Line A Scale = 1 /4 = 1 All piping shall be SDR 30/34,within 10' of tank, piping shall be Schedule 40. 239' III valve B-1 B-3 55' ■❑■ 166' ► 18' X 36' bed 25' ailed 40' ST Vent 10 25' ►❑B-2 25' 10, 50, Well Huffcutt Filter tank A vents 55' ►❑ xistingl B-5 B-4 I:edroom 2-3' X 66' cells with>3' spacing ouse imo II Vent >6,, L Quick4 Standard of Cover eaching Chamber Harbor View Road with 20.0 ft2 of Area .6ft^2/pair of end caps 4' Long 34" Grade at System Elevation Cross Section of Infiltrator Quick 4 Leaching Chamber Typical cross section for 2 of 2 cells Quick 4 Standard Leaching Chamber with 20.0 ft2 of Area per Chamber 5.6ft^2 pair of end plates To be >1' above grade Finish grade elevation Typical Installation 100.0' Vent Grade Vent 3' 4„ 3, X30/34 Septic Tank 5' Long 5' 5' Long 1 Grade at System Elevation 3 6" Grade at System Elevation Spacing 5' 2-3' X 66' ' Cells Same on other end Observation tubeNent 4 At end of cell A B 16 chambers per cell System elevations: A_95.0' B 95.0' ST. CRNIX C'OQNT)/7 SEPT)C TANK MAINTENANCE /\LREEMEhJT AND OWNERSHIP CEKTT[|C/\T|GN FORM -���� / / - L. [)\�n«zfBuyur _ ^, ��;-~~ �� [clye0r.^h 1^� _________ __ _. Mailing �� / ��--� �-�4 / jg Q 6,1\c-- l'ittzeat Property Address___________ . --- (Vrrd�aduuzogn�rJ6n.nPbmuing&%u�ngDopalt.uoml�u/emcouu|rnc�uuj --- '-- -- City/State _______ Parcel @������ �m�� 0_20 I O - 6 0 � _ _....,. . .._„.. LEGAL DESCRIPTION u� _ _ , I--�_� "1/4 Property -� ) � , ..5-2(1 1/4 , 6u Z 2� � _/, W, Town of /-_-___-~ _--__ Subdivision ��it Lot ��� - ��-��r�^����c-__-____-__-- __-'__-'__- '__-�_-__'_-, �--'�� Certified Survey��ap # �_�_ _____ ______ _ _ __. Yr'}�nnc _�_�_ _, P��gc# ~--- ^� 3� ~� ^� ��mxrantvU�w�� # L�c� �� � � \/oixon� (' ~)u� , f`�Ac# -� 3�� ` ----� ,� v-- -+- _ ---'------'-'---^ -- - -- ---- ---'���- -_ 0 spec.house yet. l',nlino: identifiable ies o SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could i esult in its ptmatUre failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, d needed,by a licensed pumper, What you rim into the system can affect the function of the septic tank as a treatment stage in the wasie disposal system. Owner maintenance tesponsibilities are specified in§Comm. 89 52(l) and Chapter 12 St. Croix County Sanitary Ordinance. The property Owner agrees to submit to St. Croix County Planning &/Aiming Department a certification form, signed by,bc owner and by a master plumber,journeyman plumber,restri /eJpinmbm",uUcoz.xo6poopoverU7in&dwt(i)theou-site wastewater disposal system is in proper operauhig condition oud/o/(2)udozioupoe.ion and pumping,(it ze,eusary)^ the septic tank is less than 1/3 full of sludge. Iiwe,the undersigned have read the above requirements and agree to main taM the private sewage disposal system with ihe shanctaids set Ibitli,herein,as set by the Deparruient v[Commerce and the Department vf Natural Resources, State(if WiScOtitiu. Certification stating that your septic system has been inaintained must be completo I and returned to the St. Croix County Planning& Zoning Department within 30 days of the three year expiration date. ]hp*certif 'that all statements on this form arc true to d,, best of`/'y/oqckoo=lodge. }/we xovuzuthu owner(s) of the property described above, by virt a Warranty deed recorded in Register of Deei Is Office. ' ' / Number of bedrooms ~~~_ -�= ^~� �, / �� � (u ���]-Ul�� " [l� }�P ����xi `[(�) --- ' '—�- -' ' �-�w�� ` . 1}A'[E ~ Any information that is misrepresented may result in the sanitary permit being 0-Noked by the Planning&Zoning Department. *^* Include with tins application a recorded warranty deed Flom the Register of Deeds C ffice and a copy of the certified survey map i[ reference is made iii the WalTarltv deed, . POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM'SPECIFICATIONS �' Tank Manufacturer: IVi 2 ❑ NA ownery /tom/ ra ,.iC r (9 i tom- Permit# Septic 0 Dose 0 Holding Volume:/ ) (gal) Tank Manufacturer: NA DESIGN PARAMETERS • Number of Bedrooms: —3 ❑ NA ❑ Septic ❑Dose ❑ Holding Volume: (gal) Number of Public Facility Units: IA Vertical Distance Tank Bottom(s)to Service Pad: / (ft) Estimated(average)Flow 300 (gal/day) Horizontal Distance Tank(s)to Service Pad: '9 (ft) Specific servicing mechanics must be provided if vertical is>15 feet or Design(peak)Flow=(estimated x 1.5): ‘ '‘...1.0 (gal/day) If horizontal is>150 feet. Specific instructions to be provided on back. In Situ Soil Application Rate: , —7 (gal/dayift2) Effluent Filter Manufacturer: St-- -t ❑ NA Standard(Domestic)Influent/Effluent Monthly average Effluent Filter Model: Fats,Oil&Grease (FOG) <_30 mg/L Pump Manufacturer: q Biochemical Oxygen Demand (80Ds) s220 mg/L ❑ NA - Pump Model: Total Suspended Solids(TSS) 6150 mg/L High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L' • Manufacturer. q (BODs) >220 mg/L NA ❑Mechanical Aeration ❑Peat Filter (TSS) >150 mgt 0 Disinfection ❑Wetland Pretreated Effluent Monthly average ❑Sand/Gravel Fitter ❑Other. (BODs) 530 mg/L Soil Absorption System (TSS) , 530 mg/L NR round(gravity) ❑In-Ground(pressure) ❑ NA Fecal Coliform(geometric mean) s10` ❑At-Grade ❑Mound Maximum Effluent Particle Size X in dia. ❑ NA ❑Drip-Line 0 Other: Other. / \A Other. ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency hen combined sludge and scum equals one-third('h)of tank volume Pump out contents of tank(s) When the high water alarm is activated ❑month(s) (Maximum 3 years) ❑ NA Inspect condition of tank(s) At least once every: gyear(s) Inspect dispersal cell(s) At least once every: 0 ear(s)s) (Maximum 3 years) 0 NA month(s) ❑ NA Clean effluent filter At least once every: /, � ,ear(s) ❑month(s) ❑ NA Inspect pump,pump controls&alarm At least once every: ❑year(s) — ❑month(s) NA Flush laterals and pressure test 'At least once every:. ❑• year(s) ❑month(s) NA Other: At least once every: ❑year(s) NA Other: MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper). Tank inspections must include a visual inspection of the tank(s)to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The soil absorption system shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any treatment tank equals one-third (}S)or more of the tank volume,the entire contents of the tank shall be removed by a Septage Servicing Operator (pumper) and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code: All other services, including but not not limited to the servicing of effluent filters,mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months,shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 30 days of completion of any service event. GMW 005(02ro5) • Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil absorption system. If high concentrations are detected have the contents of the tank(s)removed by a Septage Servicing Operator(pumper)prior to use. , Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these overload erl that may It in the backup excess rf coldischarge l ofeefflu t and tda age soil tothesystem St To in one large dose d this situation have the is Y contents of the pump tank removed by a Septage Servicing Operator(pumper)prior to restoring power to the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. the life of the treatment Reduction or elimination of the following from the wastewater stream may improve the performance and prolong tanks and soil absorption system: acids, antibiotics, baby wipes, cigarette"butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps,medications,oils,painting products,pesticides,sanitirty napkins,solvents,tampons, and water softener brine discharge. • ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with s. Comm 83.33,Wisconsin Administrative Code`. • All piping to tanks,pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed. PPi9 y • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator(pumper). • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN compliant If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code coin replacement system: • ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure,lot lines and wells. Failure to protect the replacement area will result in the the e need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply effect at the time of their permit issuance. system cannot be A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption y ehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. Q Mound and at-grade soil absorption systems may be reco tlstructed in effect at following ing that of the biomat at the infiltrative surface. Reconstructions of such systems must comply with WARNING TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE EVER ERA ANY TANK N DER BE ANY CIRCUMSTANCE.POSSIBLE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM ADDITIONAL INSTRUCTIONS: . v 1 te et. `I red-4A POWTS INSTALLER POWTS MAINTAINER. r Name �) r CQ Name� � � � ) � �, � �/ '/ p 1 Phone Phone /IJ _ l k -vs-eh h LOCAL REGULATORY AUTHORITY SEPTAGE SERVICING OPERATOR PUMPER) L n I Names, (� , _ ,«..� ..� Name A 4 -AA Phone e2 I,— a/01 � • Phone r-,....pZ •l This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f)and 83.54(1),(2)&(3),Wisconsin Administrative Code. • ri r { ' FILTER CARTRIDGE INSTRUCTIONS''9 . . , , Installation :4 , `" STEP 1 Dry fit the filter case onto the end of the outlet pipe to ensure it is centered under the access opening. If not, then either insert more pipe into the tank through the outlet or solvent weld (glue) additional pipe onto the outlet pipe. STEP 2 While the case is still dry fitted on the outlet pipe, measure the length of 3/4-inch pipe needed to brace the filter to the tank end wall if utilizing the optional supplemental side support. If side support method is not utilized, proceed to step four. STEP 3 For installations utilizing the optional supplemental side support: > , solvent weld the 3/4-inch pipe onto the filter case. If side support method is note utilized, proceed to step four. STEP 4 Solvent weld the filter case onto the outlet pipe. Insert the filter �« , M cartridge into the case, pressing down until the filter locks into the bottom of the case. STEP 5 If a VRS switch is utilized: insert into the filter and lock by turning clockwise 90°. Maintenance 1. The effluent filter should be cleaned every time the septic tank is t " serviced. , 2. Open the outlet access opening to inspect the tank and filter. " t w ' 3. Pump the septic tank completely, making sure to remove the sludge :F 4rk layer on the bottom of the tank and not just the scum and effluent. 4. Once the effluent level has been lowered below the invert of the , outlet pipe, firmly pull up on the filter handle to dislodge the cartridge from the case. - 5. Slide the cartridge up and out of the case for cleaning. 6. If a VRS switch connected to an alarm is present, the switch - s�4 , should be removed by turning counterclockwise 90° and cleaned z with water only. _' 7. While holding the cartridge on its side (large flat surface facing I rx '4 , down) over the access opening, rinse off the cartridge with water , only, making sure all septage material is rinsed back into the tank. <. " 8. If VRS Switch is utilized, replace by inser inserting into filter and r ,, , turning clockwise 90°. r ' 9. Insert the filter cartridge back into the case, pressing down until * � r y � the filter locks into the bottom of the case. �=. 1:r ,� -.;. . I0.Replace and secure the access opening on the tank. BEAR ONSITEE'FILTER CARTRIDGE-FIVE-YEAR LIMITED WARRANTY ,r ,. f"......,., ,_ .. P BEAR ONSITE'"Filter Case-Lifetime Limited Warranty ,.i - ...,,f',,:.' _ , r r .u_ e J r J t G E t C � P iii' �.. i ' i l' 7 { t "G h l^` ie " '�' ._-: dt - n 5u(r a s .a r ie k f e is e ._"tee _ r < Dina:s �e e.^ ..e p r r,1c _ r �I it .., f i r '7117_ .., ^54 .k r r ' ,a ss T �, x x F '` '3 ++ s xt} ,I.,,,,;1; ., y„ s ^.4,4,-"';',q A2; a ,. rI y s y ;1 ,, . ,, ,7 . .-t' 4,:...,,- q 4 $ '3 r n 5',d xF a . .o a j � 7} E Ir a r Y 33 1 L 1 4 4 .„ya', iF;;,,, y F; E, DOCup4 .IT lam. i's STA-TX BA) Or WIS.fJOH�j 1 I:—•i1am Li 1YtnE srACir t 9m rasa Winos l*w.A ii �} 7 R WARRANTY DEED it El fi _ ri Sam E. Miller, a single ;., REGISTER'S oFna This Deed, made between. S: DC CO.,_Wi erson ln(RC[ for sw__s r 4¢ if Grantor, APR2 41 ${t and John A. Grancorvitz and Susan C. Grancorviez, d 4 t husband e , as eurtrt ,..ar�+�.Y property (,, fi Vlitnessetil, That the said Grantor, for a valaab'1e oorusIderatioa. St. Croix $ Rcruas ro conveys to Grantee the following described real estate in _ t County. State of Wisconsin: r l C Tax Parcel No: i iI Lot 18, Jacobs Landing First Addition in the Town of Hodson St. Croix County. is li Wisconsin EXCEPT Commencing at the Northwest corner of said Lot 18. also being 1 II the point of beginning of this description; thence S18°40' 10"W 419.10 feet along the Westerly line of said Lot 18; thence N22°04'53"E 420.03 feet; thence N71°46104s u:. c.-,.vv >:ccc uaong the nortner.ty -Lane or said Lot 15 to CI]e point or beooinni noo_ li ,} i II TRANSFER 361_1(4.41, FEE I 1 I This 1 1s not I homestead property. I MO (is not) Together with all and ular the hered'tamente and appurtenances thereunto belonging; " And Sam E. Miller, a single person :i warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except :4 easements, covenants and restrictions of record, if any, '1 4 and will warrant and defend the ame. Dated this 2.1. day of April 1989 . (SEAL} ��._.. ` _ t (SEAL) li 'Sam E': .tri i r . II . 14 (SEAL) (SEAL) li v li i! AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN I {1 SS. St. Croix County. ) authenticated this day of , 19 Personally came before me this _. l�� day of April 1989 the above named Sam E. Miller TITLE: :riEM1LEE STATE isAIi OF WISCONSIN (If nest_ - authorized by $ 70(3-O6_ Wia_ Statx.) forfig, pings instrurneegt and_krtcllnowlndiye the same. PA-.1_ hnv 774 ::zda .r e:: - c!JAI gircliat (Signatures may he authenticated nr ar::n.acrlrri„-....i 11,,•i• \t-..• r -l.tn;�c t.-n t rnarpg��g} .g 'zNitfi c1- r:Aie.: are not nr c•.l ,l:ai.,: .. ct.ttJOfVCiSCOfsln . l9-a"I .a WARRANTY DEED STATE. DAR OF W1SCONtiI`r MI:,,ii,.... V.'L. •,._ - o$ . I �° 11 co .. "-.A. / t ..". r --4.446074" .-'-,..'%"' i , . , -----.......... .--"-----......., / +4► ' I 97901 SO FT :' , �`�•.. ,.' .' �..�it- a 249 Ac ' ...***"."..."7 a 0 �' Q. , • 151 • �� «, • 0 96e0O SO FT --+-1 • /. •t: � �' 2 199 AC I w t ,,o' .i 1 O S 3'19 SO FT / R=90 I 2 418 4C 0 R •I ti / • ( i ti ' t[RSi JIM- t 16 . , s 1o140e So FT �4l.. _ 'J##U'3t. so FT 1~ I 2 32S AC. AC o. tis I 1 I el I I r - DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS INDUSTRY, DIVISION L4BOR AND PERCOLATION TESTS (115) MADISON WI 6376097 HUMAN RELATIONS (H63.09(1)&Chapter 145.045) LOCATION:s SECTION: TOWNSHIPMY.I&LLCLBAltTY: OT NO.:BLK.NO.:U D)I ION NAME: l ul1/w1/ - /T.29N/R/-11o"$l /8 . :d, COUNTY: OW - =t'E- 'AT : GA,/ 1 .a'. S Se, t•s .S' o 6 S • Clro,` S- r '7;0 LL- ��.. �.--.. �� USE DATES OBSERVAT •NS MADE NO.BEDRMS: COMMERCIAL9ESCRIPTION: PROFILE DESCRIPTIONS:'PERCOLATION TESTS: Iesidence 3 N/, CkNew ❑Replace .5"./8-Ste .s.--/c-Ore RATING:P. Site suitable for system U=Site unsuitable for system e S 1; Ms CO S la•L: MOUND:❑U IN GZS ❑U ❑S 21.0 OS GRIU RECOMMENDED 1,tw oe,,vOw..4�p84.(0#1)(/‘)n IIf Percolation Tests are NOT required DESIGN RATE/ : I If any portion of the tested area is in the /4.1,49� under s.H63.09(5)Ibl,indicate: //7 Floodplain,indicate Floodplain elevation: PR•FILE DESCRIPTIONS B BNGG s TOTALS ELEVATION • :; i s r.UN� A7�[sf.I TO BEDROCK IF OBSERVED(SEE I ABBRVS'ON BACK.)TEXTURE,AND DEPTH •88/.S/,/•/Oh Si i A azi p-iGS, A/ �si B- / MI '�.7' Al.,,ta Mica 3. - as V FrA 8,6' !!! Ill�E! �° /' i , , 8 B/S/, . 7 8,+s/, /•t'ftiin fr/c S,/•V B.+S', a461. i' A . � �� e. / / G 81s/, .YB„ s/, . S B0I,rsl,.?zB.r1rlcs. ral: Aholi[¢._ 7 ;,O' 3y PS/.-V BNS/, /,/ BnfirS/, /./B��r/CS, B- PERCOLATION TESTS TEST DEPTH/ WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER 1.181414 AFTER SWELLING INTERVAL-MIN. PF 1011 7 PERIOD RI OD2 _ PE PER INCH PERIOD L 3 P_ / y.v Ala 3 6 6 6 <3 P.2 'f,9' AIo 3 6 - P _3 'I.I' 4/o 3 6 6 P-.. - P- P- PLOT PLAN: Show locations of percolation tests,soil borings and the dimensions of suitable soil areas.Indicate scale or distances.Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan.Show the surface elevation at all borings and the direction and percent of and slope. SYSTEM ELEVATION . 9'Y. S' tr.."'`" T k ECC19/e.../"-YaJ Ze f _ f `, l \ ■ f r _ `� i! Wi /!mac—...T. .r..- _..__. ` _.{__._i _ �s '-' -_ '1 ._ _ � _ L-_1 "IL i;. ; i T _ el=l 1 �-. f� 4- t i —7177-1" t r— t - vvI 4.e I- - + ! . _ -_ = }. j ct.4414._ .__ : L...- rtA,ur,41, et.-Pei,/ tt /Pt,Q4=wc K �ote, SP/0/1 C.t th alto.or� B Z TO I,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified In the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. i,I NAME(print): TESTS WERE COMPLETED ON: i -?' % j' 3--2 c dr �, CERTIFICATION NUMBER: PHONE NUMBER(optional): ADDR S • .!/ ' / • ,4.c riL. Sou V / S DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. 01 LHR-SBD-6395 IR.02182) -OVER- § ° d & ( 2 0 # � K )$ k> i EC % 7\ £ 22 \ . j\Zo a 0 % z , 522 U. ) f / < « § � � z L k § ® E Z CL / B z k 2 0 ■ — J a 0 2 7 ƒ E 2 N ? CO) k e § S $ @ b a � g \ � z m \ ) E . k k 2 a § / \ = k 2 { k IL ; f 3m k2 } 12 K K ® V) t z t � a a a ' B �; a 0 _ _ $ j v = § § / 2 )» j o% \ ° o■ /_ a )k a$/ » m E _ I E _ L Cl \ } o k \ \ k ) ) § f § . ) z 0 6 ) Co = % 2 / § m ) - G § 2 £ o z _ e ■ q � ® � � . ■ § . � 4) CL E e c c a § k (oj a 2 o 3 L r' Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Say 4h �� TOWNSHIP SEC. a T N-R ADDRESS �Q�if Q D.YgZ ST. CROIX COUNTY, WISCONSIN SUBDIVISION �ac�� �� `; LOT I LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•I.HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM • y �a 1 /�Va►/ /t '_-� eta ��_d¢- Q. - i as' llcks,� y0' I. 0 � v o I . n 0 INDICAT NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: �u�l.b� Proposed slope at site: % W�s� SEPTIC TANK: Manufacturer: Liquid Capacity: 1Q 04 QQ, Number of 'rings used: ( Tank manhole cover elevation: q7• 41� Tank Inlet Elevation: 0 M.9j5" Tank Outlet Elevation: 1761- 11 Number of feet from nearest Road: Front'(Qll Side Rear, O (pp ' feet From nearest property line Front, Side 10 Rear,0 CI© feet Number of feet from: well 6_ __, building: act ' .V�/ ��r6 IV&j c,N,, (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSFI SIDE PUMP CHAMBER MWufacturer: (J f Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear,0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: js( ' Length: 3 r Number of Lines: Area Built:.(.'-/ r Fill depth to top of pipe: [�p Number of feet from nearest property line: Front, O Side, Rear,O Ft . Z V0 Number of feet from well: Number of feet from building: 7 s' i.k (Include distances on plot plan). SEEPAGE PIT tl,��// �/ Size: l Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above ,soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: �� Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number: — S 3/84:mj \ ,DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS ON I LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMB DIVISING P.O.BOX 7969 MADISON,WI 53707 y State Plan DD.Number: Sw4,Sw4,S21,T29N-R17w 1=)CONVENTIONAL ❑ALTERNATIVE (it assigned) Town ojj Hudson ❑Holding Tank ❑In-Ground Pressure ❑Mound Lot 18 Jacobs Landi n NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE: Sam M-rUen Route It Box 282, Hudson, wi54016 9-9-II? 3 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: ICSTRE1.PT.ELEV.. Name of Plumber: MP/MPRSW No.: Cou my Samtety Permit Number: l. S;r.ohbeen i5432 St Cnoix 112757 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY. TANK INLET ELE V.. TANK OUTLET ELEV.. KING COVER 11 T IDED fa;t�� ❑YES NO BEDDING. VENT DIA. VENTMATL. HIGH WATER NUMBER OF ROAD: PROPERUILDINGALARM FEET FROM LINE /��c� qQ+ ❑YES NO .L ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED'. PROVIDED. DYES ❑NO DYES ❑NO E YES El NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. N ROPE RTV WELL BUILDING AIR NLE FRESH (DIFFERENCE BETWEEN pF INE PUMP ON AND OFF) DYES 1-1 NO SOI L ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing MATERIALANDMARKING or excavation. (If soil can be rolled into a wire,construction shall cease until FORC the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH'. LENGTH. NO.OF DISTR.PIPE SPACING. COVER INSIDE DIA SPITS LIQUID BED/TRENCH TRENCHES t MATERIAL' PIT DEPT" DIMENSIONS ,1 (i GRAVEL DEPTH FILL DEPTH UISTR PIPE DI TR.PIPE DISTR.PIPE MATERIAL. NO.DI TR NUMBER OF PR OPERTV WELL BUILDING VENT TO FRESH BELOW PIPES ABOVE COVER ELpE�V INIET E V END /� Q PIPE/ FEET FROM LI^NEB^ I�� AIR INLET 11_y O E X71 3t Of��I L0 NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES ❑NO SOIL COVER ITEXTURE PERMANENT MARKERS OBSERVATION WE LLS 1:1 YES ❑NO OYES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER. EDGES. DYES ONO ❑YES El NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH. NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES. DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DI STH ID ISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKIN(, ELEV.. ELEV.. DIA. ELEV.. PIPES D ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY ICO VER MATERIAL P`ARNSCAL LIFT CORRESPONDS TO APPROVED DYES ❑NO 1YES ❑NO COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS. NUMBER OF IPOPERTY WELL: BUILDING FEET FROM ) .go ❑YES ❑NO ❑YES ONO NEAREST 9,s Sketch System on Retain in county file for audit. Reverse Side. TUBE. TITLE. � DILHR SBD 6710(R.01/82) !/Ct� C Zoning Allmi,ni,6Piatoti =:EaQz!�� SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm.Code STATE SANITARY PERMIT# �Ja y� —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches in size. -See reverse side for instructions for completing this application. PETITION � 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE El ^L'�l YES NO PROPERTY OWNER PROPERTY LOCATION /I�✓ :5`J`/'/4Sw'/4, S a ( TZ , N, R /7 E (or PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME f2 I ::�r -t. /8' Jacob Lo, CITY,STATE ZIP CODE PHONE NUMBER El CITY NEAREST ROAD,LAKE ORI LANDMARK w S d t 3g(o 27 I VILLAGE: I �d p 6�r V�.w P_ II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. ® New b. ❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) 1. a. DiConventional b. ❑Alternative (❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ® Seepage Bed b. ❑Seepage Trench c ❑ .apit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPT160 AREA' 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): G IS `) 2° Feet Private ❑Joint ❑ Public VI. TANK CAPACITY " Site in allons Total #of Prefab. Fiber- Exper. INFORMATION Manufacturer's Name Con- Steel Plastic New xisting Gallons Tanks Concrete structed glass App. Tanks I Tanks Septic Tank or Holding Tank /000 (Jl1cc' Q,i Lift Pump Tank/Siphon Chamber _Y_�- --R—H+1 Li 0 VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: 3 2 ' z 3 Plumber's Address Street,City,State,Zip Code): Name of Designer: (P-*'v �J w i L N,64 W-z Vlll. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# c0. S �• ` k.-; TO S� S CST's ADDRESS(Street,City,State,Zip Cod Phone Nu ber: /() L ,.—r�,1 Its-v,- 7/ IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Saq(tary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Approved F7 Owner Given Initial l'`� S rcharge Fee Adver a Determination ` `� � �aQ� ' '�'Cc_� X. COMMENTS/REASONS FOR DISAPPROVAL: Pal a1q;2Wa_1d by SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION ' TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; . 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; Ill. Purpose of application: Check only one in ##1. Complete##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/1 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form. I ------------------------------------------------------------------------------------------------------------------------ ---------- GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground Ater included the creation of surcharges (fees) for a number of regulated practices which Wisco in'S can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reas,r�l. is used in your building is returned to the groundwater through your soil absorption e system or the disposal site used by your holding tank pumper. a . The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. ------------------------------------------------------------------------------- Owner of property _�+ i'�' f4,r Location of property :cam 1/9 S w 1/4, Section ! , T" � N-R /I- Township Mailing address -, Address of site 4-bpi u Subdivision name_--J-Zca IL - , Lot number -"�/s Previous owner of property `s �`, ��a th, V\G,-So y Total size of parcel Date parcel was created - s a- '8 8 Are all corners and lot lines identifiable? �' Yes No Is this property being developed for resale (spec house)? X Yes No Volume '605 and Page Number `��z as recorded with the Register of Deeds. ------------------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. ---------------------------------------------------------7--------------------- PROPERTY OWNER CERTIFICATION I (We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. (7• ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Registe of Deeds, as Document No. act., r v� Signature of Owner Signature of Co-Owner (If Applicable) 9 — [Z - Z � Date of Signature Date of Signature L DOCUMENI NO. WARRANTY DEED THIS SPACE RESERVED ,OR RECORDING DATA STATE BAR OF WISCONSIN FORM Y—Tilsit 435417 REwyEn OFFICE �N $Ta CRax CO., wl %ed fa ftcW Virginia.M.. Hanson, a single woman . . _ _. . ..... ..... . ........ ........... .. ...... . ... MAR tt 10 ...... ..... . ... . ........ ... .. .. .. ._ ........ . .... . . ..... .. .... M 8:00 AM .. .. ...... . ... . . . ...................... conveys and (currants to . Sam.-E. Miller...a..single man... ..... . . . &-- J ........ ... . ....... . .. rslMu of O�Bi ....... �._ .. . ..... .... _..... ... . .... .... . .... .... .. . .. ......... . .. .......... .. ........ . . .. .. ......... ..... .... R[TURN TO ... ... ..................... ... ... ....... .. ... ...... .......... ... .... _ .......... ....... ... ..... .. ..... .............. the following described real estate in ......St. Croix ..,County, State of Wisconsin: Tax Parcel No: .............................. West Half (W11) of the Southwest Quarter (SW's) of Section Twenty–one (21), Township Twenty–nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin except that part South of the Public highway and except Lots 5, 6, 7, and 8 of Certified Survey Map in Vol. 6, Page 1747, Doc. No. 419479. That part of the West Half (141g) of the Northwest Quarter (NW11) of Section Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin lying South of the right of way of the Chicago, St. Paul, Minneapolis and Omaha Railway Company. EE£ This . s .not.. ....... homestead property. *b* (is not) Exception to warranties: easements of record and protective covenants and restrictions of record, if any. S� Dated this ) day of 0-C 19.88 (SEAL) .r,/(SEAL) • .Virginia.M.—Hanson . . ..... ....... ... .. .(SEAL) (SEAL) AOTSSNTICATION ACBNOWLSDGURNT Signature(s) ............................................................ STATE OF WISCONSIN as. ................................................................................ %+k. y ............County. authenticated this .......day of........................... 19...... Personall• came before me this ... . .......day of ........Mpt.nc.T,................. the above named ......................................................----.---................... Virginia.M.. Hanson................. ........................... • ........................!..................................................... ----............................................................................ TITLE: MEMBER STATE BAR OF WISCONSIN .............................................................. ...... (If not.............. ..... .. ........... .... ...... .......... ... ...... authorized by (1 ? 6.116. Wia. State.) to me known to be the rergon ...... .... who executed the foregoin r trument and a.Knowledge the same. TWS INSTRUMENT WAS DRAFTED BY ut ;•sQ�$.Ar..riul:l:HY.x..Neywood,..Cari..b..Murray.... ...... . ...... _.�.�. ^. . .. � '•., ..... . .. .... • fq P..O....flox..2�9...Hi1f��fQt1s..WI.---X4016,-,.-•-,.._.._..-- tiotn ufllic '-•�y'. . (�•.". county Wis. (Signatures may be authenticated or acknowledged. Both My Co mi .ft M EP&AAent.(if not, state expiration are not necessary.) date: •Y T .. .. .. . 19 ..) .. ..... •Nuns of xenon,Janina In any capacity should be typed or print.d halos• th.ir rianut.:rc+. WARKANTT DEED STATE BAR OF WISCONSIN Wwonsin L.-cal nln,A 1'... N "RN No a— 0%2 �Irw.•ke, wf•. i STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER Smarr► A/, J&Y ROUTE/BOX NUMBER (,�'( oX z FIRE NO. CITY/STATE_Pct.i�o�� '•1 ZIP PROPERTY LOCATION: 1/4 S w 1/4, Section T_22 N, R / W Town of (a�sbJ, St. Croix County, Subdivision=�, Lz �wl ; ,, r , Lot No. 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 SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning 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 (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNE DATE _ St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (H63.09(1)&Chapter 145.045) LOCATION: SECTION: TOWNSHIP/ RACY: OT NO.:BLK.NO.: SUBDIVI ION NAME: f Sw �/ova/a 1 /T,29N/R/ 1(o /qua( 0,r� J- c� s s d� COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: S COO,IL S 1411 1v1_e0^ TrOCL,t- so t`s USE DATES OBSERVAT ONS MADE NO.BEDRMS.: COMMER IAL ESCRIPTION: PROFIL�DESCRIPTI0NS: ER OLA IONpTESTS: Residence CKNew�El R eplace s Af t a S �W RATING:S=Site suitable for system U=Site unsuitable for system (_ -5 a -f,4 CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN- ILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) IK S E- �S ❑U ®S DU ❑S ZU ❑S ®U CB ' 'x ' If Percolation Tests are NOT required DESIGN RATE: [Fl f any portion of the tested area is in the under s.H63.09(5)(b),indicate: oodplain,indicate Floodplain elevation: !/ PR FILE DESCRIPTIONS BORING TOTAL# DEPTH TO GROUNDWATER�F4ES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) . 9B/S/, /• /.A2 Qrr�h/�s, �/ Bnsi v : 8 BI.S/, A•Z 01"04#- /. v �•! �N /CSC /.G Bns B- 2- �r V ' /L IOAA 0-- , t).v 3 v q p 8 ,q I.S/, . 7 Bc+ S/, /.� / ,�r/c s, /• v f��s, B--3 O V O. B C- r 14 g/SIB . Y �n S�, . il QYS�, �.�f3n�l^/esi B- PERCOLATION TESTS TEST DEPTHJ# WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE PER INCH ES NUMBER 'P'Gljr- AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER D P- .a• A110 3 6 -3 P_ 2 1f.9' A1160 3 6 3 P 3 •P a G--3 P-_ P- P- _ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION M�E / __ tN — 3 3 [ VV KKJJ T I� V 4SSCGitiIaS t f - 0 ` C _ i LI t ( a { 110tc .�Sr��It Cwfi /Qi�.c�� Z T'd M&'Zufk/ j dtr f°cot Q.ej�>y. �LQcc.i�c ,ms s I,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME(print): ® TESTS WERE COMPLETED ON: 06;_r?�ADDRESS: / CERTIFICATION NUMBER: PHONE NUMBERIoptionall: CS�151VAi� � r DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — � rV i INSTRUCTIONS FOR COMPLETING; FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3, MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 6. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE•RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here-,for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 0. Complete all appropriate boxes as to dates, names,addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain,elevation)does not apply, place N.A. in the appropriate box; 1 1. Sign the form and place your current address and your certification number; 12- Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 GAYS OF-COMPLETION, ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st — Stone (over 10") BR -- Bedrock cols __ Cobble (3- 10") SS — Sandstone gr — Gravel (under 3") LS - Limestone `s Sand HGW - High Groundwater cs Coarse Sand Perk Percolation Rave reed s - Nledium Sand W .-. WeII fs Fine Sand Bldg — Building 1s — Loarny Sand -. Greater Than "sl Sandy Loam < - Less Than ,1 --. Loam Bn — Brown %I Silt Loam BI - Black Si — Silt Gy --- Garay *cl -- Clay Loan) y ... Yellow sc1 -- Sandy Clay Loarn R — Red sicl - Silty CI'ay Loam riot — Mot:tle� se Sandy Clay vi ivith sic -- Silty Clay %, f f f .- few, fine, faint c - Clay cc __ common,coax e, PI - Peat . rnnl — Many, mediorn ni -- Muck d distinct p prominent HWL — High water level, Six general soil textures surface vvat i for liquid rite disposal BM Bench Mark VRP -- Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary pern,it.The county orthe Departmenii may request volih,"ation of this soil test in the field prior to purrrair issuance, A complete set of p€arts for the private sr 4 zac-, system and a permit application must be sujmr lit ed tr, tl,(! api)iop,iate local authority ii,, ordrxr to obtai=a a permit. The sal itary wIrrnit must be ohtaiiWd U101 Posted Pl for to tlaL start of any cons'lruction. ,+ w 0 e2 39� F a �l4+cr rist< Ca � � a -- � - L H oa a ` 1 s �! P I Seta)CL f p 1A n �� m A Nun kA S # tr I o N 'r, o �� -b • N LA c,. rt Olk N tr' 2 ti G P Ff Ad ID f; I }h w'I•'. ...' H s s