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018-1098-05-000
r _ — 40 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 430582 0 GENERAL INFORMATION 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: Baumer, Jacques I Hammond Township 018 - 1098 -05 -000 C BM Elev: Insp. BM Elev: BM Description: Section/Town /Range/Map No: loo, 0 VG PI PC7 6M 1 30.29.17.812 ANK FORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STAT ID FS ELE. Io Septic Benchmark m I v� tj 0 /DoZ. l00 O Dosing /- Aft. BM Aeration J Bldg. Sewer I 9s Holding St/Ht Inlet O St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL 13LDG. Vent to Air Intake ROAD Dt Inlet Septic i Dt Bottom Dosin 3 !n Header/Man. 3 CA Aeration Dist. Pipe Holding Bot. System rd 9d 23 Gt/ Op -iv �6 Final Grad / d �— PUMP /SIPH N INFORMATION (�' Manufacturer GP ^and St Cover 1, Model Number U [ / l OT TDH Lift Friction,lj9js System head TD j • , w � Ft �/ b lfi Ford in Ler�glh / Dia. p u W I Dist.toWell SO L ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT DI ENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS b / SETBACK SYSTEM TO P/LW BLDG WELL LAKE/STREAM L CHING Manufacturer. INFORMATION CHA R Type Of�S, stefUim:/ UN dode l Nu ber: DISTRIBUTION SYY EE�M ^tom/ Header /Manifold n Distribution I xRoleSize I x Hole Spacing Ve Length Dia Length Dia Spacin �(7 SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only D Depth Over xx Depth of xx Seeded /Sodded 1 xx Mulched [So dfrrefi — ch Center Bed/Trench Edges Topsoil .—. � � Yes :f� No Yes LJ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: N - 06 / 0 Inspection #2: ! a3 1 1T•3i:�t'h Location: 1512 73rd Avenue Hammond, WI 54015 (NW 1/4 SW 1/4 30 T29N R1 7W) Emerald Acres Lot 5 OlL Parcel No: 30.29. .89 1.) Alt BM Description = T ' T�" Ori►� 2.) Bldg sewer length `- J j ^ -�� 2 . pl ow inn a - amount of cover = S a Oyt Cv; . n VV-L a . � u . PI tnu r [u wi Ni k.�-t2 sad s 6 S _ Plan revision Required? j ] Yes [tNo Use other side for additional information. G? % -/ - - -- SBD -6710 (R.3/97) Date �LTit.Gft�'' Ins epctor's Signat re / Cert. No. O\ 1 Vl Saf 201 W. hin ox 7082 � County cA-,A •L ry� ® as / seonsin M icon, WI 53707 — 7082 t Sanitary Permit Number (to be filled in by Co.) 608 26l -65 6 (1 L Department of Commerce ( ) L.U� �3 S Sanitary Permit App ation State Plan I.D. Number _ 5 ;U �� i� In accord with Comm 83.21, Wis. Adm. Code, personal i ormatrti ybt���vt r �,F may be used for secondary purposes Privacy La s 15.04( ect Address (if different than mailing address) I. Application Information - Please Print All Information A d 73 ��/, Pro Owner's Name Parcel # Lot # lueek 0 0 1X14 — b? . Property Owner's Mailing Address _ Property Location City, tale Zip Code Phone Number 't V., Section /� a / - 5 7 ircle one) II. Type of Building (check all that a I G/ C9 T N; R�E or W PP Y) � S � 1 S 1 or 2 Family Dwelling - Number of Bedrooms Q. ubdivision Name CSM Number � ❑ Public/Commercial - Describe se ❑ State Owned - Describe Use = 9 c � tt 1 Z I ( ty ViilagWTownship of f. I III. Type of Permit: (Check only one box on line A. Complete line B if applicable) Q 0,5 LTD(, 12- A. New System yst C1 Replacement System ❑ TteatmentlHolding Tank Replacement Only C] Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: Check all that apply) . ❑ Non - Pressurized In- Ground ound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chambsr ❑ Drip Line yel -less Pipe Oth (explain) V. Dis ersal/Treatment Area Information: Design Flow (gpd) Design So' Application Rate(gpds Dispersal Area Required (so Dispersal Arefi Proposed (so System Elevation S of S 0 o / 0 Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank / © _ e0o Aerobic Treatment Unit Dosing Chambcr ! e VII. Responsibility Statement- I, the undersigned, assume Les onsibility for ( lation of the POWTS shown on the attached plans. PI (Print) lumber' gna re MP PRS Number Business Phone Number o 3s`� mss- a s lu tier's Address (Street, City, State, Zip C ) 6 / U /6 t-� VIII. Coun /De artment Use Onl Approved ❑Disapproved Sanitary Permit Fee j(ludes Groundwater ate Issued Issuing ge ignature jo� s ) Surcharge Fee) 2 ❑ Owner Given Reason for Denial J �� O� IX. C ' r A r k, �ay fReasons for Disapproval 3MO effluent filter and ) t! must all be serviced / maintained .l as per rrlanagement pl vided by plumber. a. All setback r uiremen�st be maintain un� � as perfhpplitll le code lard note$ Attach complete plans (to the County only) for the system on paper not less than 81/2 x It Inches In size SBD -6398 (R. 08/02) 4 . trench mark S S rvaU U�' 5- Divert surface water around system to prevent ponding at the uphill side. Safety and Buildings 4003 N KINNEY COULEE RD LA CROSSE WI 54601 -1831 TDD #: (608) 264 -8777 isconsin www.w wvvw commerce s iscon s i n.gov isconin.gov Department of Commerce Jim Doyle, Governor Cory L. Nettles, Secretary November 12, 2003 CUST ID No.220254 ATTN POWTS Inspector ARTHUR L WEGERER ZONING OFFICE WEGERER SOIL TESTING & DESIGN SERVICE ST CROIX COUNTY SPIA PO BOX 74 1101 CARMICHAEL RD RIVER FALLS WI 54022 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 11/12/2005 Identification Numbers Transaction ID No. 941907 SITE: Site ID No. 668403 Jacques & Jo Lynn Baumer Residence Please refer to both identification numbers, 1533 73RD Ave above, in all correspondence with the agency. Town of Hammond, 54023 St Croix County NW1 /4, SWl /4, S30, T29N, R17W Lot: 5, Subdivision: Emerald Acres FOR: Description: Three Bedroom Mound System Object Type: POWT System Regulated Object ID No.: 931020 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 co chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. API The following conditions shall be met during construction or installation and prior to occupancy or use: DEPART rNIA OF General Approval Requirements: SEE CO • This system is to be constructed and located in accordance with the enclosed approved plans and with the "Mound Component Manual for Private Onsite Wastewater Systems VERSION 2.0" SBD- 10691 -P (N.01 /01) and the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems VERSION 2.0" SBD - 10706 -P (N.01 /01). • Per manual cited above, limited activities are allowed in the area 15 feet down slope of the component area. Soil compaction, excavation, vehicular traffic and other similar activities that impact the treatment and dispersal are prohibited. • The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption area. chs. NR 811 & 812c • A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stat • Comm 83.22(7) A copy of the approved plans specifications and this letter shall be on -site during construction and open to infection by authorized representatives of the Department, which may include local inspectors. PLOT PLANT Scale 1 " = ,Ac Page of '1 i i / h �'1 S AIWA ► l S �(VVZ,13 vim _4 f 6= Q V) �t z , 5 - 2 3o'or 14 ''t7vc G= N V�>m E i I i > S o' r'►Z -c'1 N V > - y do's -r-n ry of S o - s-r NOTES: 1. Elevations shown are existing ground elevations unless otherwise noted. 2. Install 4" observation pipes with approved caps. ( Z required). 3. Septic tank to be 10 /650 gallon capacity manufactured by wt�s�Z CouGZs1 (wLP J000 /650 Mt►z w /)4 1800 Zpn3e_ FLT . 4. Bench mark S. - S rT V Q 5. Divert surface water around system to prevent ponding at the uphill side. Distribution Pipe Layout Pace S of —] Place the 'doles at the bottom of the distribution pipes at'equal spacing, Remove all burrs from the pi -Pe and holes. Extend the end of each lateral up with the use of Iong tars or 45' £rzinz to a rout ,7 jtEa sL; inches of the frnal ode. Te nni= th e ends of the la t e r al s with a valvs,:threaded can or threaded plug. Provide access from final Cade for the valve; threaded eaa or threaded^ ,.C`SS T't CT L `-L Laterri — 'aniioid L ter <I x x x x11 1 xr x x z x Lver(Lencth -� Later; Lncth = Y I oistr hb cn Line C - YD Q >r^� P =_ Ft. Hole DiametEr Inch S 3 Ft. Lateral I Inches) X Z 4 Inches Manifold 1 ��z Inches Force Main " Z Inches #of holes /pipe 19 Invert Elevation of.Laterais 9 Ft. _ - Combination Sept,ic;Tank and PUMP CHAMBER CR055 SECTION ARID SPECIFICATIONS ' PAGE OF -V LIT CAP WEATHER PROOF JUIJCTIOW BOX . 'f C.Z. VENT PIPE APPROVED LOCKING lO FROM DOOR. hl�l1JHOLE COVER cJIV u1N00W OR FRESH wA(itJIIJG LAgEI., ups? oN PIPE ALP � coratw�r w /HtcL -�1 s ttT• rnp � t F1IULSI}© i -� PROVIDE IA7 LE T ' AIRTIGHT SEAL I ( 8�t rLC • „, I ( ( v Approved A I II( Approved joint w/ �_ UU I i(I joint w/ pipe PVC ALARM PVC pipe "I II 6 I t ( Ow C I I LLE1r FT. PLIMP� OFF ��s� D CO►JCRETE �!.LeN3. ci 0 (D I 9LOCK - RISER EXIT PERMITTED OQLtI IF TAWK MA),UFACTURER HAS SUCH APPROVAL 3"AAPRti.F: • BEtx� I ry 4 SEPTIC F SPECIFICATIOtJS DOSE TAWKS MAQUFACTURER: WUM15ER OF DOSES: PER DA-w TAMK SIZE 120o /(DSO GALLOQS D05C VOLUME t ALARM MANUFACTURER: SLLgT 'MCLUDING 6ACKFLOW: 1 � Z ' GALLOht,� MODEL QUMBER- 10 HW CAPACITIES: A= INCHES OR 3O GALLONS SWI TZI PE: _ Yt- lgZC04,�L PU f 5= _ ' INCHES'OR � G�LLOASS MP MAIJUFACTURCR: GO DS C= b INCHES OR ly Z GALLOW MODEL HUMBER: c, D= t� - INCHES OR Z � b GALLOWS SWITCH TYPE: - ZL ( lZ - 1 IJOTE: PUl1P AUpALARM RC TO � MIMIMUM DISCKARGE RATE GPm INSTALLED ON 5EPARATL CIRCUITS VERTICAL DIFFERENCE DETWCEN PUMP OFF AIJO..D157RIBUTIOQ PIPE.. FEET (( ' r l + KtLtIMUM IJ ETWORK SUPPLY PRESSURE , , , . , 6 • S0 FILET + OF FORCE MAIM X� F j O 3� Ioo FLFRICTIOLI FACTOR -- FEET TOTAL - Dy)JAMIC. HEAD = L ` , FEET 13 - As per manufacturer b gal /in. Liquid depth 38 `' Goulds �c ' - 7 O -= Submersible Effluent Pump - EPO4 38 EP05 APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron Specifically designed for stainless steel. grade turbine oil for for efficient heat transfer, p Y g o the following uses: o Capable of running lubrication and efficient strength, and durability. • Effluent systems dry without damage to heat transfer. ■ Motor Cover. Thermoplas- • Homes components. tic cover with integral handle Motor: Available for automatic and • Farms manual operation. Automatic and float switch attachment • Heavy duty sump • EPO4 Single phase: 0.4 HP, models include Mechanical points. • Water transfer . 115 or 230 V, 60 Hz, 1550 d Float Switch assemble and ■Power Cable: Severe duty • Dewatering RPM, built in overload with automatic reset. preset at the factory. rated oil and water resistant. SPECIFICATIONS 115 V, 60 Hz, 1550 RPM, FEATURES 'heavy duty ball bearing Pump: EPO4 built in overload with ■ EPO4 Impeller: Thermo- construction. • Solids handling capability: automatic reset. plastic Semi -open design /a °maximum. •Power cord: 10 foot with pump out vanes for AGENCY LISTING • Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. SP CanaaianstanaardsAssociation ° Total heads: up to 24 feet. with three prong grounding • Discharge size: 1 NPT. plug. Optional 20 foot ■ EP05 Impeller: Thermo- CSA m ( listed model n umbers • Mechanical seal: carbon- length, 16/3 SJTW with plastic enclosed design for rotary /ceramic - stationary, three prong grounding plug improved performance. end in `I" or "AC".) .) BUNA -N elastomers. (standard on EP05). ■ Casing and Base: Rugged • Temperature: thermoplastic design provides 104 °F (40 0 C) continuous superior strength and 140 °F (60 °C) intermittent. corrosion resistance. • Fasteners: 300 series M ETERS FEET stainless steel. 10 • Capable of running dry without damage to 9 30, �� ° N i components. I ! Pump: EP05 -- - - - -- — -- ;P � L F a S FT;,. • Solids handling capability: 0 25 -- 3 /" maximum. a • Capacities: up to 60 GPM. _ • Total heads: up to 31 feet. S2 6 20 • Discharge size: 1W NPT. z 5- — • Mechanical seal: carbon- 0 15 I rotary/ceramic - stationary, 4 ! BUNA -N elastomers. • o - -- EP05} -... Temperature: 3 10 104 °F (40 °C) continuous 140 °F (60 °C) intermittent. 2 .- 5 � I 0 00 10 20 30 -40 50 1 GPM L ' 0 2 4 6 8 10 12 m'/h CAPACITY C 1995 Goulds Pumps, Inc. Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County i Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must .x include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Re ewed by Personal infomnation you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). v 3 Property Owner Property Location Govt. Lot , k(1 1/4!5;&/ 1/4 S TZQ N R / E (or)f Property Owner's Mailing Address Lot # Block # S d. Name or CSM# I 'Tr . 5 St i [ngowd A City State Zip Code Phone Number ❑ City ❑ Village UTown Nearest Road Wl ( 115) 549-(o n'e/ / S� (51) New Construction Use: Residential / Number of bedr 3 - y Code derived design flow rate 1"'a 0 a GPD ❑ Replacement T ❑ Public or commercial - .Describe: Parent material Flood Plain elevation if piicable ft. General comments and recommendations: Y'S h. =� COn-(nur of (/_ ❑ Boring © Boring # Boring Ground surface elev. ,. Depth to limitin ctor ( Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure d3 ! Boundary / ts GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. \ / 'Eff#1 *Eff#2 C} 1 IU 12 Si l c',b f CS I V� 5 . �S F —2-1 Boring # ❑nn Boring . � Pit Ground surface elev. it. lam. Depth to limiting factor Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I *Eff#1 'Eff#2 b -2 Lb Z -- 5 2 m c5 v.Q .5 8 2 r C 9- 1.5 k 5 ' Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L ' Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L CST Name (Please Print) gnature CST Number k er 4 Address � b2S Date Evaluation Conducted Telephone Number 2t4 � e r � w� /Z-l7- o i Q7/5� Property Owner S-� b Parcel ID # Page of ❑ Boring Boring # ❑ 3 (S pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure konsistenm Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 S i 2 5 i c 1 IL c `f e ❑ 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 /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 i i 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 /ftz In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 - 264 -8777. SBD -8330 (R.07 /00) PAGE 3 OF 3 NA S � � LOT# J LEGAL DESCRIPTION Nw 15W f ,S 30 T z 4 N R I SCALE: 1"= yQ (@>EVATION /06. y BM 1 DESCRIPTION �a P Q ,0 J c PT M ELEVATION 9 � d S aC , 3 0 B 2 DESCRIPTION a ©etc -- SYSTEM ELEVATION�� ALTERNATE ELEVATION , t/ ` K CONTOUR ELEVATION 9 00 b ( f 7. P� � 5� 2 �2 0 SIG � ►�. r ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP C'_RTIFICA T ION FORM OwnerBuyer G` d �r,n 1'r'�`' 5 33 r `� Avel� o �T5 (/ ► Mailing Address 7 3 Property Address e G'M erAQ Ac F i� 05 Iz (Verification required from Planning Department for new construction) City /State S� 1 Parcel Identification Number 0 0 Le)jg — ©,57" co o (. 81 LEGAL DESCRIPTION �} Property Location �� ' /,, `7 ' /,, Sec. � L . T N -R I� W, Town of ! i A 0 4o"OAL . Subdivision 6vy ep A) � L V_tS Lot # Certified Survey Map # e---- . Volume �- . Page # Warranty Deed # _ Z V7 7l ! Volume Z V Page # d/. *ec house 0 yes ❑ no Lot lines identifiable 0 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. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restrictedplumber 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. 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 sta ' that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 da s the three y expiration date. r�' 'M 1'l / / °3 SIGNA 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 p o rty described above, by virtue of a warranty deed recorded in Register of Deeds Office. t� Z1 /03 �GNA O 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 .1 2460P 04 4 747113 � STATE BAR OF WISCONSIN FORM 2 - 1998 WARRANTY DEED i KATHLEEN H. WALSH REGISTER OF DEEDS Document Number j ST. CROIX CO., VI -- - ° -- - `'� RECEIVfiD FOR RECORD This Deed, made between 11120!2003 11:30AM RTCHARD O AWAIT and JANET P STOUT husband and wife, , WARRANTY DEED _ Grantor, n EXEMPT / 1 and REC FEE: 11.00 httchan TRANS FEE: 149.70 tl COPY FE EEE: 2.00 C Grantee. PAGES: 1 Grantor, for a valuable consideration, conveys and warrants to Grantee the following ',I described real estate in St. Cro1X County, State of Wisconsin: Fn rd N Lot 5 Plat of Eme rald Acres, Town of Name and Return Address ond, St. Croix o , isconsin. Ifoo Soa ft 7 .id 9 ff It s I t &ASO M, w 1 9fD16 i I y 151 Zo 018 - 10 98 -05 -000 Parcel Identification Number (PIN) This it c nnt homestead property. (is) (is not) I � I � II (i Exceptions to warranties: easements, restrictions, rights -of -way and covenants �! of record. t�fa Dated this day of November . 2003 (SEAL) i�/l/IA -u- i /W� (SEAL) li .Richard-` Stout Janet P. Stout I (SEAL) (SEAL) w I' AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. — S t. Croix Coun I' authenticated this day of Personally came before me this day of II Novemher 2001 , the above named l Richaul ^. Si - -ut and Janet I� Stout _ TITLE: MEMBER STATE BAR OF WISCONSIN to (If not, me known to be the person s_ who executed the foregoing authorized by §706.06, Wis. Stats.) Pamela A. Wilimag nstrumepf] nd acknowledge the same. Notar ublic g THIS INSTRUMENT WAS DRAFTED BY State O} Wisconsi :�-a- Janet P. Stout 1 353 Awatukee Tr. ?atnnr 14.- A Hu dson, WI 54016 Notary Public. State of Wisconsin My commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) Names of persons signing In any capacity must he typed or printed below their signature. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. WARRANTY DEED FORM No. 2 - 1998 Milwaukee. Wis. i ""•. � alb s ' SAI 1owal so OrT 4 SO Vii' "N .► IO TOWN ' ® XA SaTash County x t 201 W. n ox 7082 S / ,�COn�',� M n, WI 53 707 — 7082 Sanitary Permit Number (to be filled in by Co.) De artment of Commerce �8) 261 -65 6 � (�0"a �/2 o5 State Plan I.D. Number Sanitary Permit Appli ation x�tU�)w S In accord with Comm 83.21, Wis. Adm. Code, personal it ormattiai r F F I CE may be used for secondary purposes Privacy Law sl5.04( ect Address (if different than mailing address) I. Application Information - Please Print All Information /37 -� � 1 1* Property Owner's Name Parcel # Lot # Meek-# - Property Owner's Mailing Address roperty Location /-5 1 7 3 lez 114 l/i. City, tate Zip Code Phone Number ~ ��''�'' Section ^ S 7 one) II. Type of Building (check all that apply) C/ t T N; RE or w S Subdivision Name CSM Number 1 or 2 Family Dwelling - Number of Bedrooms S. �- ❑ Public/Cormne. ial - Descnbe se ❑State Owned - Descnbe Use = 9 T • << tt 1 2 1 ( ty Villag�Township of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) 0 oS -- Lvo C , Y f 2 — A ' New System ys ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System B. ❑Permit Renewal 11 Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: Check all that apply K ❑ Non - Pressurized In -Ground ound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Ch!Tbg ❑ Drip Line yel -less Pipe P Oth (explain) V. Dis ersal/Treatment Area Information: Design Flow (gpd) Design Soi Application Ratds Dil Area Required (st) Dispersal Proposed (SO System Elevation sno e(gp spersa ,s ygr Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank /D _ � Aerobic Treatment Unit Dosing Chamber ! , VII. Responsibility Statement 1 , the undersigned, assume res onsibility for i latiou of the POWTS shown on the attached plans. P (7RPrint) lumber' gna re MP PRS Number Business Phone Number Z � X� 1_ I a 3 s`"� mss a s lu ber's Address (Street, City, State, Zip C ) VIII. County/Department Use Onl Approved 11 Disapproved Sanitary Permit Fee (i ludes Groundwater ate Issued Issuing a Surcharge Fee) 2 �- ❑ Owner Given Reason for Denial J �� O IX. C io tyt � )/Reasons for Disapproval �` � r T A r k, /� � effluent Filter and ) p must all be serviced /maintain JJJ as per management pl vided by plumber. a. All setback r uiremen�st be maintain �, Q _ _ & as perfApp Gti a code /Ord nodo ri�Aarw� Attack complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches In size SBD -6398 (R. 08/02) BLOT PLAN Scale 1 " =1AC ' Page 3 of - 7 `\4 0T C\) �-N Pre. 02 / � b � S �vVZl3 Tti'LS 19'Pcs'A ��, ti5 Z V) .� ,3. • 5 30'0 y y YN c a' 0 I 6M 1#- lah NH 41 '9M * — EL . i u o- O ' av Oj>v c n) nt , . S br1 t't-Z.- EZ 4 8.9 , n 1 COP 2 16.CtS ' y do's l �F �S0 -r.+- S: VE .. NOTES: 1. Elevations shown are existing ground elevations unless otherwise noted. 2. Install 4" observation pipes with approved caps. ( Z required). 3. Septic tank to be lO /6SO gallon capacity manufactured by GZel (1A J 1 P 1 nooI6so -)%I ti� w / Zm r, LTm . 4. Bench mark S - S rrr3O U* �. Divert surface water around system to prevent ponding at the uphill side. Safety and Buildings 4003 N KINNEY COULEE RD LA CROSSE WI 54601 -1831 r TDD #: (608) 264 -8777 isconsin www.commerce.statemi.us /sb Department of Commerce www.wisconsin.gov Jim Doyle, Governor Cory L. Nettles, Secretary November 12, 2003 CUST ID No.220254 ATTN: POWTS Inspector ARTHUR L WEGERER ZONING OFFICE WEGERER SOIL TESTING & DESIGN SERVICE ST CROIX COUNTY SPIA PO BOX 74 1101 CARMICHAEL RD RIVER FALLS WI 54022 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 11/12/2005 Identification Numbers Transaction ID No. 941907 SITE: Site ID No. 668403 Jacques & Jo Lynn Baumer Residence Please refer to both identification numbers, 1533 73RD Ave above, in all correspondence with the agency. Town of Hammond, 54023 St Croix County NW1 /4, SW1 /4, S30, T29N, R17W Lot: 5, Subdivision: Emerald Acres FOR: Description: Three Bedroom Mound System Object Type: POWT System Regulated Object ID No.: 931020 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 COi chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. PF The following conditions shall be met during construction or installation and prior to occupancy or use: DEFART(i Sl OF General Approval Requirements: SEE COF • This system is to be constructed and located in accordance with the enclosed approved plans and with the "Mound Component Manual for Private Onsite Wastewater Systems VERSION 2.0" SBD- 10691 -P (N.01 /O1) and the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems VERSION 2.0" SBD - 10706 -P (N.01/01). • Per manual cited above, limited activities are allowed in the area 15 feet down slope of the component area. Soil compaction, excavation, vehicular traffic and other similar activities that impact the treatment and dispersal are prohibited. • The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption area. chs. NR 811 & 812c • A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stat • Comm 83.22(7) 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 ` ARTHUR L WEGERER Page 2 11/12/03 Owner Responsibilities: • Comm 83.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(1). • Comm 83.52(2) A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. • Comm 83.55 The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. 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. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 175.00 Fee Received $ 175.00 a Balance Due $ 0.00 Charles L Bratz POWTS Reviewer 11, Integrated Services WiSMART code: 7633 (608)789 -7893 , 7:45 am - 4:30 pm Monday - Friday c bratz @commerce. state. wi. us cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544 TITLE SHEET Page of - 7 MOUND SYSTEM FOR A 3 BEDROOM RESIDENCE This plan has been prepared in accordance with the Mound Component Manual SBD -1057 P and the Pressure Distribution Manual SBD- 10573 -P C Cz 6l9q� C 1`_ U 1-�a LOCATED IN THE NW 1/4 OF THE SW 1/4 OF SECTION 3O , T Zat N, R 1 W TOWN OF S--, etz_0 L x COUNTY, WISCONSIN. -- INDEX PAGE 1 of 7 TITLE SHEET PAGE 2 Of 7 SYSTEM MANAGEMENT PLAN PAGE 3 of 7 PLOT PLAN PAGE 4 of 7 PLAN VIEW -CROSS SECTION PAGE 5 of 7 DISTRIBUTION PIPE LAYOUT PAGE 6 of 7 PUMPING CHAMBER CROSS SECTION PAGE 7 of 7 PUMP PERFORMANCE CURVE PREPARED FOR vth S � � U � 3 ►4 �v p � Sc, �� �l Yv $Y�v�I C-�2 tizu���^�rs, w� s4uZ3 PREPARED BY of tEy MMERcE W1 =CBE=FZEFZ Sv I L_ . TEST 2 NG ? GS AND DES I CCN SE= S CE DF NCE P.O. Box 74 421 N.Main St. River Falls, WI 54022 �����,sm�r� Phone 715- 425 -0165 RECEI Fax 715 - 425 -6864 `'��''P GVG YG � �� A r�' a sti d} NOV - 7 2003 SAFETY & BLOGS DIV. JOB NO. Mound System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code Page �- of 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 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, Safety and Buildings Division. Pump Tank The pump (dosing) 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, 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 for frost protection. Influent quality into the mound system may not exceed 220 mg /L 6005, 150 mg /L TSS, and 30 mg /L FOG. 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 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. General This system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall maintained in accordance with its' component manual [SBD- 10572 -P (R. 6199)] 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 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. Con tfnaenc 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 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 adsorption and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. Questions about the operation or maintenance of this system should be directed to: The County Zoning at 1S _ 3 e 6 q � 80 The. system installer at — L LS -ZG — (� C. The tank manufacturer at Z) O6 3 :ZL4 — �lLsb t.J tQM N.1Z The effluent filter manufacturer at 8aoo - Z - SS - 7 qZ Z�t3�z The pump manufacturer at ���_ �_ �C8 Y C]UVL,o PLOT PLAN Scale 1"=,A0 Page 3 of - 1 i C', Q V) of ° Z 3o'0r 3 a D 1Z.►'1 r i � I > s o T* s - i . NOTES: 1. Elevations shown are existing ground elevations unless otherwise noted. 2. Install 4" observation pipes with approved caps. ( Z required). 3. Septic tank to be IO /6S() gallon capacity manufactured by :?L CW G� �w�P I )ool6so Mtz� w/6 l8a0 3�c t_ , 4. Bench mark S. - S rT-j-�y U< 5. Divert surface water around system to prevent ponding at the uphill side. Pace �l 0f Approved Synthetic Covering Distribution ASTi�1 C33 o Pipe Medium. Sand Topsoil H - F G E?ev. �'8•y 3 „ \ . 5 % Slope Distribution Cell of Force Main Flowed 2" to 2- Aggregate From Pump Layer �-0 Ft. E 1.09 Ft. CROSS SECTION OF A MOUND SYSTEM F Ft. G O -S Ft. A Ft. y Linear Loading Rate= b - o GPD /LN FT B _1 Ft. Design Loading Rate= 0 -3a GPD/SQ FT I Z Ft. 1 - 7 Ft. K 9 Ft. - `�'�trMft4e Position L q 3 Ft. of Force Main W ZS Ft. — L I ' j 1 - Observation Pipe a-- ( �----------------- - - - - -- -------- - - - - -- --. Qox W - - —= — - - -- ------- - - - - -- a Distribution \ ---Cell of %" 2 to 2 ' Pipe aggregate Observation* Pipe (Anchbr securely) PLAN VIEW OF A MOUND SYSTEM Distribution Pipe Layout Pa e S of Place the 'roles at the bottom of the distribution pipes at*equal spacing. Remove all burrs from the pipe and holes. Extend the end of each lateral un wirh the use of long turn or 45' fr-.:ng to a point wi ' 1-+ s i x , inches of the final made. Te . ^Ttlnat e the en dS of the laterals with a valvs,: thr ed can or threaded plug. Provide access from final gmde for the valve; threaded er_D or threaded plug. 7 `r =, (_ LASS 5 — �i�0}�7 FVC p��v PVC _ Lat eni — niioid Lateral x x x [ (xQ x x x x L3teri Length - Lateral Length - r OistrioUmn Line tom- �_t• -N V \` — =� sc4x C.-. C i P =_ Ft. Hole Diameter �Uu Inch S 3 Ft. Lateral 1 Inches) X .2 4 Inches Manifold l'I-, Inches Force Main " Z Inches #of holes /pipe Invert Elevation of.Laterais 9 Ft. _ - Combination Sept4c;Tank and . PUMP ER CROSS SECTICIM AND SPECI CHAMB FICATIOIJS PAGE OF NEWT CAP WEATHER PROOF ' JtlUCTIOW 80X . 'i VENT PIPC APPROVED LOCKIWG 110' FROM DOOR. � ""')JHOLE COVER I- :JIuDow OR FRESH wP+RtJ11JG LA6EC.. ua8p� t� IPE AJ_IIJTAKE coi.�Du�r tj Fl MISt}p 6 "+mow. Lam. I YMiW. G�oE I __ 18'MIAJ IAJLET PROVIDE I - - -- '` � AIRTIGHT SEAL I I II B+�FrLC I I I Approved z�s8�t H� A APProved joint w / �} —`43UV I ill Joint w/ pipe PVC ALARM PVC pipe .i 11 a I I I ON a1 ` -t3 I I CLEV. f7 PUMP -� ' J OFF COUCKETE c i ( 0. k3 (z) I BLOCK f RISER EXIT PERMITTED O IJLy IF TANK MANUFACTURER Do FACTURER HAS SUCH APPROVAL 3••INr. *r BbIN4 SEPTIC F SPECIFICATIC)JS DOSE TAWKS MAIJ UFACTURCR: IJUMBER OF DOSES: PER DA- TAMK 51ZE : GALLOAI DC5E VOLUME I ALARM t,AIJU FACT URCR: S\+gT t- r � INCLUOIIJG 6ACKFLOW: GALLON: P%ODEL ►.!UMBER: \Q Y �4yj CAPACITIES: A. U IMC14ES OR 3y GALLOIJS WITCH TtiPE: GALLOWS 8 = / INCFIES'OA 3 PUMP MAWUFACTURCR: GC)VLDS C= 6 IIJCHE5OR 1 yZ GA LLOLJ S MODEL IJUMBER: D'. Y " Z INCHES OR Z�b GALLOWS SWITCH TYPE: )J0TE: PUKP AM RARE TO 15L MIWIMU DISCHARGE RATE I - GPM IN5TALLEO 0M SEPARATC CIRCUITS VERTICAL DIFFERENCE DETWEEIJ PUMP OFF AIJO..DISTRIBUTIOIJ PIPE.. ` q () FEET + MI\h NETWORK SUPPL'y PRESSURE , . , , , 6 So FE ET�S.pxl,3� •f- FEET OF FORCE MAIM X Z ' F Y0 tt .3\ FKtCT10IJ FACTOR.. O FEET TOTAL- OtIMAMIC. HEAD = "� ", FEET i3.to� As per manufacturer ,b gal /in. Liquid depth aB*" Goulds ��G Submersible Effluent Pump u EPO4 EP05 APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron Specifically designed for the stainless steel. grade turbine oil for for efficient heat transfer, following uses: • Capable of running lubrication and efficient strength, and durability. • Effluent systems dry without damage to heat transfer. ■ Motor Cover. Thermoplas- • Homes components. tic cover with integral handle Motor: Available for automatic and • Farms manual operation. Automatic and float switch attachment • Heavy duty sump • EPO4 Single phase: 0.4 HP, models include Mechanical points. • Water transfer . 115 230 V, Hz, 1550 Float Switch assembled and ■ Power Cable: Severe duty • Dewatering RPM, , built in overload with automatic reset. preset at the factory. rated oil and water resistant. SPECIFICATIONS 115 V, 60 Hz, 1550 RPM, FEATURES 'heavy duty ball bearing Pump: EPO4 built in overload with construction. • Solids handling capability: automatic reset. ■ EPO4 Impeller: Thermo - 1 /a maximum. • Power cord: 10 foot plastic Semi -open design AGENCY LISTING • Capacities: up to 55 GPM. standard length, 16/3 SJTO with pump out vanes for • Total heads: up to 24 feet. with three prong grounding mechanical seal protection. o. Canadian Standards association =� • Discharge size: 1 NPT. plug. Optional 20 foot ■ EP05 Impeller: Thermo- • Mechanical seal: carbon- length, 16/3 SJTW with plastic enclosed design for end i listed model numbers e rotary/ceramic- stationary, three prong grounding plug improved performance. end n "F" or "AC ".) BUNA -N elastomers._ (standard on EP05). ■ Casing and Base: Rugged • Temperature: thermoplastic design provides 104/F (40 continuous superior strength and 140 (60 0C) intermittent. corrosion resistance. • Fasteners: 300 series METERS FEET stainless steel. 10 • Capable of running —� dry without damage to s 30 components. I i Pump: EP05 A • Solids handling capability: o .25 -- 3 /" maximum. a UJI • Capacities: up to 60 GPM. s 20 ! i • Total heads: up to 31 feet. 9 • Discharge size: IIN NPT. z 5 • Mechanical seal: carbon- } ro stationary, ° 4 15 `J 1 BUNA -N elastomers. • Temperature: 3 10 1 Q4 F (40 cont inuous r�nuous 140 60 intermit I ! •t� — ent. Yw ( ) 2 I i 1 5 I I 0 00 10 20 30 -40 50 I GPM 0 2 4 6 8 10 12 m'/h CAPACITY C 1995 Goulds Pumps. Inc. .. r 666 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of -3 Division of Safety and Buildings in accordance with Comm 85, Ws. Adm. Code County � Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Re ewed by Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 0 3 Property Owner Property Location e x �ad �b Govt. Lot ,416-1 1/454/1/4 S jai Tof N R E (or)(9 Property Owner's Mailing Address Lot # Block # S d. Name or CSM# a T 5 C -) cJd A City State Zip Code Phone Number ❑ City ❑ Village QjTown Nearest Road Wil 15461 1 ( 5494"131 m k" A - ef / Sf New Construction Use: JR Residential/ Number of bedrooms 3 _y Code derived design flow rate 'W._a ,"a 0C' GPD ❑ Replacement ❑ Public or commercial - .Describe: Parent material Flood Plain elevation if plicab)e ft. General comments C (e l/� 99,00 / `'i and recommendations: (� C O ✓�-(a u r e(-e. V- V7 .00 '► 1-1 Boring # ❑Boring Cni ® Pit Ground surface elev. Depth to limitin6-facfor tG` Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure rfstence Boundary is GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. \ ;; *Eff#1 *Eff#2 o-- Iq IU i Z Si l f CS I VY 2 - 1 to 1 9 S i d Zm s b k mCr e 5 — . . (a 3 23-Ap t Fria I ia for k — F Boring # ❑ Boring �^ ® pit Ground surface elev. - 5 - 0 ft. Depth to limiting factor t � Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 - X 51 - 2rra& m c5 vV 5 8 % F 1.5 4 * Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 _< 150 mg /L * Effluent #2 = BOD < 30 mg/L and TSS _< 30 mg/L CST Name (Please Print) gnature CST Number Z o 9 Address i r fD2s Date Evaluation Conducted Telephone Number 12 - 1 7 -61 b15)2` ? qWe Z 3 of Property Owner S�O Parcel ID # Page Boring # ❑ Boring Pit Ground surface elev. 2520- ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 -1 lO Z S 2 m C,s 1 V � 5 - (b F-1 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 /ftz *Eff#1 *Eff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. F I I F-1 Boring # ❑ ❑ Pit Boring Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz In. Munse II Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ` Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608- 264 -8777. SBD -8330 (R.07/00) PAGE 3 OF 3 NAME TOT# JC LEGAL DESCRIPTION Nw YSW t4 ,S 3cJ T Z i ,N,R 1 4 E(O SCALE: I "= 4 14 (I,EVATION dad • y BM I DESCRIPTION M ELEVATION B 2 DESCRIPTION �eP a ®UG P� d -e S PC • 3 4 SYSTEM ELEVATION O ALTERNATE ELEVATION Z /g _ X CONTOUR ELEVATION 00 1 `b G c� 60 2 p -2 0 SIG N=E DATE l z � Y ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT i • AND OWNERSHIP C':.'RTIFICA T ION FORM Owner/Buyer 15 33 73 C2 A vvoi "� �0�e �T (,� I Mailing Address Property Address ,'rner4 AC Fes 05 (Verification required from Planning Department for new construction) KPL City /State S, �''y 1 Parcel Identification Number 0 001 LEGAL DESCRIPTION Property Location N '/4, C 7 '/., Sec. � . T � N -R �� W, Town of CI A ✓��'^ � Subdivision 6vyeP ° d C V�f5 Lot # Certified Survey Map # �— , Volume . Page # Warranty Deed # r L l 7// ! , Volume Z Page # d D ec 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. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restrictedplumber 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. 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 Commerce -and the Department of Natural Resources, State of Wisconsin. Certification sta ' that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 da the three y expiration date. 11 / _0 / � SIGNA APPLICANT DATE OWNER CEATMCATION 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 p o rt described above, by virtue of a warranty deed recorded in Register of Deeds Office. I@GNA O C 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 2460P 044 ,4113 STATE BAR OF WISCONSIN FORM 2 - 1998 WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS Document Number ST. CROIX CO., MI - - -: -- - — =_ RECEIVED FOR RECORD This Deed, made between 11/20/2003 11:30A?I ITrHARD O STOUT and JANET P STOUT husband and wife, WARRANTY DEED _ Grantor, EXEMPT i 11 and QUES M BAUKE2 aod jQLTENN R BAUME REC FEE: 11.00 TRANS FEE: 149.70 II COPY FEE: 2.00 CC FEE. Grantee. PAGES: 1 Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County. State of Wisconsin: in-m, 1i Lot 5 Plat erald Acres, Town of I Name and Return Address ond, St. Croix o , isconsin. j! Ede Soao 7 5+ fibs '' 1 1 l�G�dso �r w i �tDIG � �_y I51zo I 018 - 10 -05 -000 Parcel Identification Number (PIN) This i e; not homestead property. (is) (is not) i! P ii I if i I' Exceptions to warranties: easements, restrictions, rights -of -way and covenants of record. Dated this f day ^ blovembor 2003 l ®t 1 fJ t M (SEAL) ' /a" °' —` (SEAL) l Richard :o. Stout Janet P. Stout I (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) I' State of Wisconsin, 55. St. Croix Coun authenticated this day of Personally came before me this day of NnvpmhPr _ 200' the above named I Richavd O. Stut and o d Zat P� i Stout TITLE: MEMBER STATE BAR OF WISCONSIN to .' (If not, me known to be the person g_ who executed the foregoing authorized by §706.06. Wis. Stats.) Pamela A. Willmag nstrum7;;t()tnd acknowledge the same. Notary Public THIS INSTRUMENT WAS DRAFTED BY .Stet@ of WISC011si Janet P. Stout 1 353 Awatukee Tr. �GUVtt 2. lw>'. J 1 fvto Hodson, WI 5401 6 Notary Public. State of Wisconsin My commission is permanent. (If not, state expiration date (Signatures may be authenticated or acknowledged. Both are not 6 2— �s ' h1 _ J necessary.) Names of persons signing in any capacity must be typed or printed below their signature. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. WARRANTY DEED FORM No. 2 - 1998 Milwaukee, Wis. 1 � 1 i i «. 1 • ��+ ,� pro ' 1 I ' .► �oosra�a ' I / ic . . .. . i • 1 • . 111W4� • >•4w� r .� ° • a/�W. • - Mid • . � 1 . . .. ............. .. ett+L+Ki. ni FU..; ,��� .., m +wfYfSnbYS��.rm.awu