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018-2011-48-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m) Permit Holder's Name: ~ City Village X Township Bast, Kernon Hammond, Town of CST BM Elev: Insp. BM Elev: BM Description: l0~ -D /b b~ G /1~~ ~e-tom-- ~'_.rT~, TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ` / U Dosing ba i6b~ Aeration ~ _ Holding TANK SETBACK INFORMATION TANK TO P/L ~' WELL l BLDG. Vent to Air Intake ROAD Septic > ~j 7~t ~Z / ('~1~~' Dosing ~~ ~ ~~ t Aeration ~~ Holding PUMP/SIPHON INFORMATION ~~ Manufacturer ,,,_, /~ Demand ~ ~ f~(! ~ GPM Model Number /~ D ~, fo TDH Lift (~ i Friction~gsb Syst m Head TDH Ft `fit'' ~~~ /3.0~ Forcemain Le / Dia. ~ Dist. tQ Well SOIL ABSORPTION SYSTEM ELEVATION DATA county: St. Croix Sanitary Permit No: ~ - 4 280 0 State Plan ID No: Parcel Tax No: 018-2011-48-000 Section/Town/Range/Map No: 30.29.17.1063 STATION BS HI FS ELEV. Benchmark ~- •2~ .2 /~U O Alt. BM ST. BIdg.Sewer SGN ~ ~3~ gY~ 9~ St/Ht Inlet ~• ~ - SUHt Outlet / ~ Dt Inlet / `/ Dt Bottom /Z ,D ~2. 2 ~ Header n. ~ .,Q.T`+ ~~7 ~~~ . Q~ U Q~- ~// ~l `~ Dis~e ~ Bot. System 7. 7 Final Gr e s~ j ~•/'~ ~ • ~ ~Y`-~ ~Wv - ~7 ~~ BED/TRENCH DIMENSIONS Width ~ ~ LengtOh~/ No. Of Trenches PIT DIM S No. Of Pits Inside Dia. Liquid Depth SETBACK INFORMATION SYSTEM TO P/ BLDG WELL LAKE/STREAM ING C R OR Manufacturer: Type Of System: ~ ,~ ~-+/ ~ q O / / r/ / DNI Model Number: DISTRIBUTION SYSTEM c _ „ _ ~ 1 L~~ d7~~ a/: Header/Manifold Length Dia ~ Distribution length ~ 1v Dia 5 Spacing ~ /'T x Hole Size / x Hole Spacing ~'I" Vent to Air Intake SOIL COVER x Pressure Systems Only xx Mound Of At-Grade Systems OnIV Depth Over f~ ,t Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center I "l ~' l Bed/Trench Edges Topsoil Yes ~ No ~ Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~ /7i~~f~7/1l~~~//--)y ~~rr Inspection #2:~/ G ~/ 0 5 Location: 786 154th Street Hammond, WI 54015 (NE 1/4 NW 1/4 30 T29N R17W) Emerald Acre 1 p1dd~CoC~B~Parcel No: 30.29.17.10 1.) Alt BM Description =~ ~~~ 2.) Bldg sewer length = ^~ Z ~ ` ~ ~ rr ~ ~, ~ ~~ -amount of cover = J _ _ ~ -, Plan revision Required? ~ Yes No 4 ~ ~ 5~ Use other side for additional information. ~ ? ~ ~ '~ ~~~^-~ Ck Date Insepctor's Signature Cert. o. SBD-6710 (R.3/97) Y~ r~ ci dr-, ' Safety and Buildings Division Cour-tY ~, ~ 201 W. Washington Ave., P.O. Box 7162 f ~S~On~,~ Madison, WI 53707 - 7162 (608) 2C~6-31 . ~ Sanitary Permit Number (to be filled in by Co J ~ Department of Commerce : z ~ Sanitary Permit crate Plan LD. Number In accord with Comm 83.21, Wis. Adm. Code, ~oation yon pro ~()5 ~ / y 3 s'~3 ' may be used for secondary purposes Privacy La s15. j, ~ Project Address (if different than mailing address) -(Y ~ I. Application Information -Please Print All Information GRO~X F~GE Property Owner's Na the Parcel y Lot ~ Black ~ /l/ l ~ '_ Property Owner's M ailing Address Property Location ~ ~ a ~E '4~W ~ ~on City, State Zip Code Phone Number ' . ' ~ .~ _~~ (circle ) R~ E ~ T ~ N _ o ; . Type of Building (check all that apply) OK ~t5 ~ a/i Dt~S (~1 or 2 Family Dwelling - Ntunber of Bedrooms 3 ~ Subdivision Name CSM Number ^ red~ 3d~~ ~` ~ ^ Public/Commercial - Describe U e ,~~- l rt 1 ^ State Owned -Describe Use ~~ C2,1 \ (p k f68 / _ -r-r-~ ~-~- ^City ^Village (~6wnship of - III. Type of Permit: (Check only one bos on line A. Complete line B if applicable) 1'!` A' New System ^ Replacement System ^ TreatmendHolding Tank Replacement Only ^ Other Modification to Existing System B. ^ Permit Renewal hermit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Phunber Owt~r y` ? Z A tQ~ J IV. Type of POWTS System: (Check all that a 1) ^ Non -Pressurized 1n-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ~At-Grade ^ Single Pass Sand Filter - ~ ~ ^ Constructed Wetland ^ Pressurized In-Grourd ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ R~in~vlating Sand Fi lter ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ Drip Line ^ Gravel-less Pipe p ^ Other (explain) ,r / V. Dis reatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elev a tion r / / ~ r VI. Tank Info Capacity in Totat Number Manufacturer Prefab Site Steel Fiber Plastic Galloru Gallons of Units Concrete Constructed Glass - New Existing Tanks Tanks ~ Septic or llsai9ing?ank ~/ ~ / LC/~.3r Aerobic Treatment Unit Dosing Chamber /~~~ ~/ VII. Responsibility Statement- I, the'undersigried, assume respo for installation of the POWTS shown on the attached pl:uts. Plum(ter's Na me (Print) PI tuber's Si gnatur~ -ivH'/MPRS Number Business Phone Number Fogeli'ty Plumbing ~x ~ ?/~ - .~s- 9~0 Plumbr~~e~ .~t~~tate. ode) 7/S-~3S = 5-.2 ~lv !~X Spooner, WI 548Q~. 6.ri- vl- a~ w Co se Onl - y7o - 7 L Approved Disapproved Sanitary Permit Fee (includes Groundwater S h F Da Issu Issuing nt Signature o S ) ' urc arge ee) Oi~ r 2' D~ l rer n for De P IX. Conditions of Approval/Reasons for Disapproval ~ S ,~ 3 Cs~~~-i / ~-a~ / n o~. SYSTEM OWNER: rn ~ ~ 1: `Septic rink eFfluattt f r nd lt ~~ -e ~' ~' t ~~ tp ~~, V ` -o ~1 C ~ ~- , i e s ~ ti t .. CJ .~.r ~ ~ e w~ . dspersal cell must all be services /maintained as per emeM plan provided by plumber. 2. AN satbadt ratlttirerrtetits must be maintained ~~ Q ~ - ~ ~ J t ` nn~s " 5 c ` 2 - ~i as per appNcabls tide / ordirtar~es. - . - - wC~,~v Gt Y" ~6 ytn 4J~~ ~~a Attach complete plans (fo the Comty only) roe thersystem on paper not less than 8112 a 11 inches in sine ~ ~ ~ + Site Plan For: Kennon Bast Lot 48 of Emerald Acres Sub. NEl/4-NWl/4 Sec. 30 T29N-R17W Town of Hammond - St. Croix Co. i / _ ~ aSya ~ of-anode li[ouod Cdl / / / / /~ ~ / ~~' / /~r_ - ~ 9QOD' ~ _ _ ~ '~~ ~~ ~ rrur 97.00'~~~f 9a.oa p~~ sue. ~o F Proposed 4" 99.00' Bidg. S~ 3 Proposed Combination Tanrt ~ BM • WELL 154tK Street ~, BMI Top i i/4" Steel Pipe FlaOged+Staked HRP ~ Same ASSUMED ELEV. ~ 100 #2 BM =Top of Garage Lip. EIeU. = 102.60' #I Poge 8 0l8 o xs so ~ ee.~. (may 1 1no~ - 60 ft .~ commerce.wi.gov isconsin Department of Commerce Safety and Buildings 10541N RANCH ROAD HAYWARD WI 54843 TDD #: (608) 264-8777 www. commerce.wi.gov/sb/ www.wisconsin.gov Jim Doyle, Governor Mary P. Burke, Secretary June 15, 2005 CUST ID No.224059 ATTN.• POWTS Inspector ZONING OFFICE KEITH E STONER ST CROIX COUNTY SPIA 23220 WOOD CREEK RD 1101 CARMICHAEL RD SIREN WI 54872 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 06/15/2007 Identification Numbers Transaction ID No. 1143583 SITE• Site ID No. 699676 Kernon Bast Please refer to both identification numbers, 154TH St above, in all corres ondence with the a enc . Town of Hammond St Croix County NEl/4, NW1/4, S30, T29N, R17W Lot: 48, Subdivision: Emerald Acres FOR: Description: New at grade system, 3 bedroom residence Object Type: POWTS Component Manual Regulated Object ID No.: 1022138 Maintenance required; 450 GPD Flow rate; 44 in Soil minimum depth to limiting factor from original grade; ,-1, ;^R °,' System(s): At-grade Component Manual, SBD-10570-P (R.6/99) , ' ~ 9 : l F - The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes -~~~ and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in ! ~' chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. - ,;~~~~`` F ,l No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, ~~ stats. r.- r The following conditions shall be met during construction or installation and prior to occupancy or use: ;~_ r- C'J Key Item(s) • The designer proposes to install an effluent filter to achieve the requirement of wastewater particle size. Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the septic tank outlet filter will be required. The outlet filter shall be installed per product approval stipulations. Reminder • The orientation of the at grade system must be such that the longest dimension is oriented along the surface contour per COMM 83.44(6)(a)2. • Limit activities in the area 15' beyond the down slope edge of the at grade per At grade Component Manual. • Surface water drainage shall be diverted away from the system area. • Materials shall conform to the requirements of COMM 84. A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality- shall be obtained prior to commencement of construction/installation/operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. KEITH E STONER Page 2 6/15/005 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, Patricia L Shand POWTS Plan Reviewer ,Integrated Services (715) 634-7810, Fax: (715) 634-5150 , M-f 7:45 am - 4:30 pm pshandorf a~commerce.state.wi.us Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 WiSMART code: 7633 cc: Leroy G Jansky, Wastewater Specialist, (715) 726-2544 D. B. Fogerty, Fogerty Plumbing & Perk Testing, Inc. (Plans Mailed To) . ,~ RESIDENTIAL AT-GRADE DESIGN Pressurized -Sloping Site INDEX AND TITLE SHEET Project Kennon Bast At-Grade Lot 48 Emerald Acres Owner Kemon Bast Address 948 La Barge Rd. Hudson WI 54016 (715) 386-7775 Legal Description NE1/4-NW1/4 Sec. 30 T29NR17W Township Hammond County St. Croix Subdivision Name Emerald Acres Lot No. 48 ~ Parcel ID Number 18-1066-60-000 `~ ~~~y ,,~ Plan Transaction Number ~ M~ cE Lp1N Y Index sheet Page 1 Calculations Page 2 At-grade drawings Page 3 Laterals and dose tank Page 4 Spec cations Page 5 Management & contingency plan Page 6 Pump Specifications Page 7 Plot Plan Page 8 ii ~3s ~ Designer Keith St er -ce-rH • = License Number Designer #1575-007 a Signature ,,~.~ ~_ Phone Number (715) 653-2324 ~ :d'- •.• ~ •. Date 05 6%~ d~ ''~••••'•• o Designed pursuant to: At-grade Component Manual for POWTS SBD-10570-P (R.6/99}, and SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST -SAS (01!81) Version 3.11 (05/01) Page 1 of 8 PRESSURIZED AT-GRADE DESIGN At-grade Design Worksheet -Sloping Site Flows and Site Data Entry. (r or c) r Residential or commercial? 300.0 Estimated wastewater flow (gpd) 450.0 Design wastewater flow (gpd) 8.00 % Site slope 97.50 Contour elev. below lateral (ft) 44.00 Depth to limiting factor (in) 0.T0 In-situ soil application rate (gpd/fM2) Distribution Cell Information (1 or 2) 1 Influent wastewater quality 4.20 Linear loading rate gpd/ft 6.00 Effective absorption width (ft) 6.00 Max, effective width permitted (ft) 108.00 Aggregate length (ft) Pressure Distribution Data Entry (core) c Center or end lateral connection 2 Number of laterals 0.125 Orifice diameter (in) e.g. 0.188 Not a final 1.50 Estimated orifice spacing (ft) calculation 2.00 Forcemain diameter (in) 3.02 Forcemain flow velocity (ft/sec) 18.00 Forcemain length (ft) y or n 91.00 Pump tank elevation (ft) y or n 6.5 System head (ft) x 1.3 ~,~~ 6.00 Vertical lift (ft) 0.34 Friction loss (ft) 12.84 Total dynamic head (ft) Lateral Diameter Selection Designer must select one lateral diameter Pi diameter Design options Design choice t in 1.25 in X 1.5 in X X 2 in X 3 in X Does forcemain drain back? Are laterals at highest point? NA 2.9 Forcemain drainback (gal) 48.5 5x Lateral void volume (gal) ~1 A ~ inimum dose volume (gal) 29.6 system demand (gpm} Gallons/lnch Calculator (optional) Total Tank Capacity (gal) Total Working Liquid Depth (in) Galin (enter result in cell G46) Treatment Tank Infomtation 1000 Se tic tank capacity (gal) Wieser Concrete Manufacturer Effluent Filter Information Dose Tank Information Zabel Filter manufacturer 602.8 Dose tank capacity (gal) A100 Filter model number 11.8 Dose tank volume (gal/in) Wier Concrete Manufacturer Project: Kernon Bast At-Grade Lot 48 Emerald Acres Transaction Number: Page 2 of 8 AT-GRADE PLAN VIEW D -• 1/6 B Observation pipes (2 typical) 1D T W ~ D B L ~~ =Total aggregate cell A x B ~~ =Plowed area L x W A 6.00 ft B 108.00 ft 1/6 B 18.00 ft C 8.00 ft D 5.00 ft E 2.00 ft L 118.00 ft W 18.00 ft A x B 642.86 ft^2 ~- Cap Typical obs. pipe. Sbtted in the lower 6", and anchored securey. 6" AT-GRADE CROSS SECTION Synthetic fabric cover Lateral invert elev. 98.00 ft ~~' ~' E Surface contour ~- ' 97.50 ft C ~'~-- and system elevation ® = 12 in. topsoil and subsoil over aggregate and tapered to toes. ~"~ = 6 in. aggregate below pipe(s), and 2 in. above pipe. Finished grade elevation ~..- Observation pipe at aggregate toe 8 °~ Slope "' D --} Plowed layer below L x W Project: Kernon Bast At-Grade Lot 48 Emerald Acres Transaction Number: Page 3 of 8 ' ~ PRESSURE DISTRIBUTION AND DOSE TANK Lateral Specifications Weather-proof junction box ' ~ P ~I Last hole drilled neat to end cap Holes drilled on t he bottom ai the lateral. equapg spaced Laterals & force maa~ of PVC Soh 40 (per COMM Table 84.30-5j • =Turn-upvNlballvahreoraleanoutplug 0.125 Orifice diameter (in) Cer X 1.49 Orifice spacing (ft) 36 Orifices/lateral P 14.8 Lat. discharge rate {gpm) 1 2 29.6 Sys. discharge rate (gpm) ~ 1s 12.84 TDH (ft) Final grade Lateral Diagram -Center Connection Lateral connection point Number laterals Lateral length fftl Lateral diameter (in) Forcemain diameter (in) Forcemain Length (ft) Typical Pump Chamber Layout Tank component is propery vented C o q .c B ~ C o D Totals Electrical as per NEC 300 and Comm 16.28 WAC Inches Gallons 32.7 386.2 2.0 23.6 4.4 51.4 12.0 141.6 51.1 602.8 Tank full A Alarm on Pump on B 92.00 ft C Pump off D Approved manhole cover with warning label and locking device 4" Alternate ~~ outlet I - ^location 18" min. /r -Approved outlet ~ joint Provide 1 /4" weep hole or antisiphon device. ~- 91.00 ft Goulds _~_ Pump manufacturer EPO-4 I Pump model number disconnect S.J. Electro Alarm manufacturer 101-01H Alarm model number Project: Kernon Bast At-Grade Lot 48 Emerald Acres Transaction Number: Page 4 of 8 At-grade System Maintenance and Operation Specifications Service Provider's Name Tri-County Sanitation ~ Phone (715 386-0114 POWTS Regulator's Name St. Croix Co. Zonin Phone (715) 386680 System Flow and Load Parameters Design Flow -Peak 450 gpd Maximum Influent Particle Size 1/8 in Estimated Flow -Average 300 gpd Maximum BODS 220 mg/L Septic Tank Capacity 1000 gal Maximum TSS 150 mg/L Soil Absorption Component Size 642.9 ftz Maximum FOG 30 mg/L Type of Wastewater Domestic Maximum Fecal Coliform >10E4 cfu/100 mL Service Frequency Septic and Pump Tank EfFluent Fitter Pump and Controls Alarm Pressure System Mound Other Ins ect and/or service once eve 3 ears Ins ect and clean at least once eve 3 ears Test once eve 3 ears Should test month) Laterals should be flushed and ressure tested eve 1.5 ears Ins ect for ondin and see a e once eve 3 ears Miscellaneous Construction and Materials Standards 1. Observation pipes are slotted and materials conform to Table Comm 84.30-1, have a watertight cap, and are secured in as shown in the at-grade component manual. 2. Dispersal cell aggregate conforms to Comm 84.30 (6)(i), Wis. Adm. Code. 3. All gravity and pressure piping materials conform to the requirements in Comm 84, Wis. Adm. Code. 4. Tillage of the basal area is accomplished with a mold board or chisel plow. 5. The at-grade structure and other disturbed areas will be seeded and mulched to prevent soil erosion and help reduce frost penetration. 6. Areas within 15 feet of the downslope toe will be protected from compaction. 7. All other construction details are as per the at-grade component manual SBD-10570-P (R. 6/99). Lateral Turn-ua Detail Finished ..~~~~........ ............... Grade ~~ 6-8" Diameter Lawn Threaded Cleanout Sprinkler Valve Box Plug or Ball Valve Distribution Lateral Long Sweep 90 or Two 45 Degree Bends Same Diameter as Lateral Project: Kernon Bast At-Grade Lot 48 Emerald Acres Transaction Number: Page 5 of 8 At-grade System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code This system shall be operated in accordance with Comm 82-64 Wigs. Adm. Code, and shall maintained in accordance with its' component manuals [SBD-10570-P (R. 06/99) and SSWMP Pub. 9.6 (01/81)] and local or state rules pertaining to system maintenance and maintenance reporting. No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tanks are no longer used as POWTS components. Septic or pump tank manhole risers, access risers and covers should be inspected for watertightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defedave, 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 acciderkal or unauthorized entry into a tank or component. Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stets. 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 deaned 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 finer when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 113 the liquid volume e 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. 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 finer is installed within the tank it shall be inspected and serviced as necessary. At-sa~ps'~~.s and PregsUre DtstributtOn SYStem No trees or shrubs should be planted on the at-grade. Plantings may be made around the at-grade's perimeter, and the at-grade 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 at-grade 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 at- grade be heavily mulched as protection from freezing. Influent quality into the at-grade system may not exc~d 220 mg1L BOD5, 150 mg/L TSS, and 30 mgll FOG for septic tank effluent or 30 mg/L BOD5, 30 mglL TSS, 10 mg/L FOG, and 10~ du/100 mL for highly treated effluent. Influent fkanr may not exceed maximum design flow specified in the permit for the ir>stallation. The pressure disMbution 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 leaning 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. Corrtinoencv Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component(s) shall be immediately repaired or replaced with a component of the same or equal performance. If the at-grade c~mmponent 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 renovating the biologicaly dogged absorption and dispersal media, installing new piping, and repladng other components as deemed necessary to bring the system into proper operating condition. See Page 5 of this plan for the name and telephone number of your local POWTS regulator and service provider. Project: Kernon Bast At-Grade Lot 48 Ems Transaction Number. Page 6 of 8 Page 7 of ti ~GOULDS PUMPS • Fully submerged in high grade turbine oil fa lubrication and efficient heat transfer. Y APPLICATIONS Specifically designed for the following uses: • Effluent systems • Homes • Farms • Heavy duty sump • Water transfer • Dewatering SPECIFICATIONS • Solids handling capability: 'l,"maximum, • Capacities: up to 60 GPM. • Total heads: up to 31 feet. • Discharge size: 1'/z" NPT. • Mechanical seal: carbon- rotary/ceramic-stationary, BUNA-N elas[omers. • Temperature: 104°F (40`>/} continuous 140°F (60sC} intermittent. • Fasteners: 300 series stainless steel. • Capable of running dry without damage to components. Motor: • EP04 Single phase: 0.4 HP, 115 or 230 V, 60 Hz, 1550 RPM, built in overload with automatic reset. •EP05 Single pphhase: 0,5 HP, 115 V or 230V, 60 Hz, 1550 RPM, built in overload with automatic reset. • Power cord: 10 foot standard length, 1613 S1TOW with three prong grounding plug. Optional 20 foot length,16l3 S.1TW with three prong grounding plug (standard on EP05), GPM , 0 2 4 6 8 1'0 12 m~/h caPaaTv Goulds Pumps Available for automatic and manual operation. Auto- matic models include Mechanical Float Switch assembled and preset at the factory. FEATURES ^ Ep041mpeller: Thermoplas- tic Semi-open design with pump out vanes for mechanical seal protection. METERS 10 9 e Submersible Effluent Pump EP05 ~ 3871 E~ ^ EP05 Impeller: Thermoplas- ticenclosed design for improved performance. ^ Casing and Base: Rugged thermoplastic design provides superior strength and corrosion resistance. ^ Motor Housing: Cast iron for efficient heat transfer, strength, and durability. ^ Motor Cover: Thermoplastic cover with integral handle and float switch attachment points. ^ Power Cable: Severe duty rated oil and water resistant. ^ Bearings: Upper and lower heavy duty ball bearing construction. AGENCY LISTING Cenerr'an Standards Associaoan (CSA listed model numbers end in "C" or "F".) Golds Amps is 1509001 FEET 2.5 FT 25 7 x u_ 6 20 5 o t5 o a ~ 3, ~ 3 10 2 s 1 0 ®2001 Goulds Pumps ~/ ~/ ITT Industries Effective May, 2001 V~~jj 83871 I 00 10 20 X30 40 50 ~ . . j Site Plan For. Kernon Bast Lot 48 of Emerald Acres Sub. NE114-NW114 Sec. 30 T29N-R17W Town of Hammond - St. Croix Co. i / Pr~wred 65c108'At-lssodeD[ow~d Cdl / / ~/ / wtdi a System Elev. of 97.50' / / #1 9600' ~ / i / Propo~a wle~e. ~ t 600 Com ~ra~ation Ta~lt 9~ 00' ~ BM Pg~dewtn Scl-.40 ~•~ F ~Pm~ ~" 99.00' Bldg. .WELL E~daeing 3 Bedroom Home 1 S~tli Street BMl Tep i 1/4" Steil Pipe FIt~Od+5toked -~E IIRP =Same ASSITMED ELEV. - 100 #2 BM =Top of Garage Lip. Elev = 102.60' Page 8 oj8 o ~ ~ arvbe ea.tis (~ >~n - ~o i< ~~ .~ ~~ ~ ~`, ~~M/MN~M^ f-' _s~'` ST. CROIX COUNTY WISCONSIN ZON=NG OFF=CE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 FAX (715) 386-4686 Page ~ of 3 COUNTY ON-SITE VERIFICATION FORM Inspector: ~~,y~ r.. 7a n^,' nom, ~a ~- Date: 5 z3 a S Parcel ID Number ol8 - 2 o i l - ~ S - 66~, /, /alo3~ PropeRyOv-ner PropartyLoca'on ~ Gorvt. Lot A1~ 114 ~t,/114 S 30 T Z`t R l7 E(ar~N Properkyowne~s Mailing Address Lat # 61ock# 5~bd. Noma ar C$ ~$ ity State ZLp Code one umber ^ City ^ silage ~'fawwn Nearest Road 4 1 ~~ NevrConstruction tf sa: ^ Residential 1 Number of bedrooms ..._. -......~...__. _ Code derived design fbw rate_....-_--.---_..--.--...-.._._-_---...-.- GPD ^ Replacement ^ Public oraommercial - Desrribe : ..................................................--..._..._................_.-.._.... _......._-.-._.............-..__.-._----__. __......._._._..__.._.._.___...-- Parer>imaterial _ `_.._,_„_ ___- .-~--. _ ._ __ Flood Plain elevati if applicable _-_.__-._-____ _ ~_-_.._-.._ ft. General canments p ~ ~ ~ ~ . ~ ~ 6 and recommendations; ~-- G(~~ a v Sew ne.~J sa ~ l d-~s d- C~,~t~1 b I~~@..- F Being / .~Baing 1 ^ Pit Ground surhace ebv. _98 ' Z, ft. Depth to limiting factor _ _ _ _- in. gdl Applicatim Rate Horizon Dapih DaminantCobr RedoxDescripticn Texture Structure Cansis~nce Boundary Roots GP DIiI~ in. Munsdl Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Effi~2 D-I(o 1-5 6 -37 37-5~ 5 •5 l1?~~1e5 5 5~-~3 5 l~3 -~ 5 76-81 1101}-~,e 5 V~ 5 may, '~D v\ n r Ua~.. ~o5).e,(~ o ~ l~C.~ Conditions: ~oCd-1,~,,, G~o~d1~.~ 5{c~e..5 t~• ~ r `(, ~1<.- Soil Survey description: Notes: FEE: ST. CROIX COUNTY ON-SITE VERIFICATION .FORM Property O+nnar__._.__._------_ Parcel IDrY---_.--------- Page - Z-°~-3-- Boring # Baring q L,( ^ Pit Ground surface efev.._._/..g_!...z. ft. D®pth to limiting factor..._.._! ..~._....... in. Sal Anoli~tion RaEa Horizon [~pth DomirrantCobr RedaxDescription Texture Strudure Consistence Boundary Roots GP DdFF in. Mansell Ctr. 3z. Cait. Cdor Gr. Sz. Sh. 'F1fA1 `Ef(»1 o-~Z 1-S 12 -LEI `j Z -3Z 3Z • yl + o,~eS ,,.~-; n Notes: a Boring ~ Boring 95 ^ Pit Ground surface elev. _ /--~ ~ _ft. Depth to limiting factor-! ~ _ in. aryl Ann6raten Horizon Depth Domirent Cobr Redo~x Description Texture 3Gudure Casistence Boundary Rods GP DAF ~. Mansell Ciu. Sz. Cori. Cdor Gr. Sz. Sh. 'l7f#'t ' -/5 15.3 ~- ~7-SZ a ~ 52 ~- G .,.~-' ~. ~ S Notes: ^ F3oring ~ ^ Baring ^ Pit Ground surface slaw. _.._.._,..,.._.._ft. Depth t[r limiting factor-._._...-_ in. Shc MoGation Rabe Horizon Depth Dominant Cobr F~edaaDesaiption Texture 5trudun3 Consistence Boundary Rods GP DAF in. Mansell C1u. Sz. Cart. Caor Gr. Sz. Sh. 'fit `~ Notes: ,~ Page 3 of ~j ST. CROIX COUNTY ON-SITE PLOT PLAN Scale: /U~ ~" ~o S~ ~ ~ Owner Name: IJaS ~ Parcel ID Number: Inspector: y .~.... ~ ~ ~ ^ ~ ~ ld- L.~~. ' -- _ ~ z~' '~ 0 ~ z ~g~ ~-3 9D, r ~l1 0 p-I 0 pMl q3~ .~, .T. ~s ~~ Rn ~~ - - Wisconsin`DepartmentofCommerce SOIL EVALUATION REPORT ~ e of 3 C Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code - County Attach comptele Site plan On paper not tens than 8 ,/2 x 7 7 inchesvt size. Plan must inrJude. but not Grnited to: vertical and horizontal reference point (BM), direction and p~~ t.p. percent slope, sple or dimensions, north arrow, and tobation and distance to nearest road. ~..._ _~ Please print all information. Reviewed by Date Personal infam~ation you provide may he used for saondary purposec (Privacy taw. s. 15.04 (S) (m)). Property Owner Property Location ~s~-- Govt. Lo! ~F 1/4~/k/ 1/4 '3 ~a T N R E (or~ Property Owner's Mailing Address Lot # Block # Suhd. Name of ~a y~ -- City late Tsp Gode Phone Number ^ City ^ V'dlage Q'fown Nea~esf Road ( ir) - 77-~ aN ~ ('New Construction tJse: (y~ResidenBal / number of bedrooms 3 Code derived design How rate ,y Sl] GPC ^ Replacement ^ Publ;c or commercial - Desaibe: Parent material T-t'LL ~ _ _ Flood Plain elevation if app6eble /r~~!{ (L General comments . . and recommendations: /}rT ~i~~ Boring # ^ Boring •!~~ Y Q Pil Ground surtace elev. ~z n. Depth to limiting factor ~_ in. S~~V Soil Application RaG Hormon Depth Dominant Cdor Redox Description Texture Structure Consislenoe Boundary Roots GPD1fl= in. Munsetl Qu. Sz. Cont. Color Gr. 5z. Sh. •Eff#, •Eff#2 l 6 •s 3 LS 7 2 .S Z S r,/ 3 0 -s G G '~ y6 s m ~ z o s' o~s~ rxL - . ~ ~ S D is ~ '^ S OSG L '"` 3- o z •S s oSF ~ .~~p rBonng C~i.>yt,Q.v/nrcU '~ ys.~ ~6-~ ~ Boring # Pit Ground surface elev. 9~. ~ fL Depth to limiting factor _yZ_ irl. Boil AppACatlon Ralf Horizon Depth in. Dominant Color Munsell Redox Description t]u. Sz. ConL Color Texture Suuc4tre Gr. 5z Sh. Coruistence Boundary Roots GPD1ft2 •Eff#1 •Effix2 ~ v- ~ ~s z 3 3 s v -Z -3 S _ SL ~ S ____ 3 -Y7 s ~ ~ ~~ ~ "~ SL 6 3 .S SG G G S ~ s~- p >~ s G ~ ~- ~. ~~-.rr v • Effluent #, = BODS > 30 < 220 mgJL and TSS >30 < 150 mglL - iuenc Rc = nvus ~ .w n~yy~ a.~ . JJ, JV ...a.~ - ~5T me (Please Print) CST Number r ~ pate Evaluation Conducted Telephone Number Address Fogerty Plumbing & Perk T sting c~~,E 7/S--(P3.r 9~9 28288 McKenzie Rd_ r~ c~~/91~~ CE~G 6~~r~ ~,~0 6 t ' d 98zSSE9S T L t 9N I HWfl~d 1,1213904 eZZ = LO 50 9Z FE'W /O~v-~iQ -dom. Page ~ of ~T Parcel ID aY ~11~ `. Property Owner D l3oru~9 # Q Botxr9 Ground surface rev. ~S. ~ ft. DePW to IirnitAing fads' ~ ~' Sad C,POII Rit istence goturQary Roots Redooc {}escripfian Tex4tre ~tue Carts "Eff#1 Ho~on p~h Doninartl ~. Sz 5h. ~ ~sen ~. sz cont. Cotes _ ~ LS F ~ - Z 3 a' S L GS ~-' 2 -zS ,~ SG -- ~ _ ~ - .~- - u 7~ .. S/[/ ~ yR . _ . --- ~ _ 7 S ~ ~~ ft. Depth to Iimiting fadar .- in- Snit ication Rai Bortng # Ground surface elev. __--- ~ GPD1tF (toots Pit Struck ~tenoe eowtdarY Redox pescriplron Texture •Effp1 •EtHf2 1-{aizon Depth pominant Q'. Sz 5h- t„IunseR Qu. Sz Coral- Color in. ~~ 1---.---- ~ 8om9 R pepth to fimNn9 factor ~--- ~' ~ tion Rai Boling # r7( Ground surtace elev. _---• GPD1fF` 5!J Pit g ~~{er~ce BouAdary R°°ts •Etffll Domiftanl ~~ Redox Dew Texrise ~~ Horizon fleP~ tar. Sz. Sh. Qu. Sz. Coral. Color in. • Eflluert t:2 = BOD, _ ~ rrr9~ and TSS < 30 mglL • Effluent Nt = 80D, > 30 <_ 220 mg7L artd TSS >30 < 150 mgR. t of Commerce is an equal opportunity scrvrcc pcovacer and~cmato608~8~31~1coc'Ctfl~ 608-2G4-8777. services or - Tttc Dcp:~rlmcn _ raced material in an alternate format, please contact tttc sno-u~o c~.r~l Z ' d 9BZSSE9S I L I JN I HWfl~d r11Z13~J0~ eZZ = LO SO 9Z ReW r - ~ ~.~T LmT ~~P .~/~ dos Fogerty Plumbing -'.-?222130 1~ 2f32fi3 ".1cKenzie Rd. Sp~~~°r, VJI 54801 (715) X35-9609 ~~~~ ,,~ ., 12° -'~- ,f ~ ~ 3s ~'v~- '' ~'~ i' ~/ ~' = /~ i ~- NvTE ~ d~ z.v crvF X~ ~ xi ~i ~o~TOU,c q S Lain irs' ~osS1=B~ { ~....~-r~,c a~ ~, ,~ J ~3~ ~._ ~.~ ~! s<.~u`' l K = yo i ~L~G.~-v ~ STih~'a0 l®m•® /a~• L X = ,r3oc,r,,r~~ ~. = w,~ LL ~u~.p ~mr GOr~~/E/ZS ~iGt~ous Bo~~~ f~'°'~ cT-y o,ur~r~' - _ ., , s•d sezssessiLt 1f JN I HWfl~d ~1121390~ EEZ =L0 SO 9Z ~eW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INI=ORMA'TION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Ho 's Name: City Village X Township Bast, Ke n Hammond, Town of CST BM Elev: Insp. BM Elev: BM Description: TANK IN FORM ON TYPE NUFACTURER CAPACITY Septic Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer mand PM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. towel SOII ~RSORPTION SYSTEM county: St. Croix Sanitary Permit No: 463280 0 State Plan ID No: Parcel Tax No: Section/Town/Range/ No: 30.29.17. ELEVATION DATA STATION BS FS ELEV. Benchmark Alt. BM Bldg. Sewer SUHt Inlet SUHt Outlet Dt Inlet Dt Bo H der/Man. Dist. Pipe Bot. System Final Grade St Cover BED/TRENCH DIMENSIONS Width Length No. Of Trenches PIT DIMENSI S No. Of Pits Inside Dia. Liquid Depth SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING AMBER OR Manufacturer: Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distri ion x Hole Size x le Spacing Vent to Air Intake Pip Length Dia L th Dia Spacing SO11 COVFR / ., ore~~~~re c.~~+o..,~ n.,t., Y,. Mni~nrl nr Ot.Gradp Svctems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes i No 1 Yes No COMMENTS: elude code discrepencies, persons present, etc.) Inspection #1: / / fns ction #2: / / Location: 786 4th Street Hammond, WI 54015 (NE 1/4 NW 1/4 30 T29N R17W) Emerald Acres 1st Addition Lot 48 Pa I No: 30.29.17. 1.) Alt BM D ription = 2.) Bldg s r length = - am nt of cover = _ , - -_ _ - _ _ -- __ _ _ - _ i -- Plan revision Required? 'Yes ', No Use other side for additional information. Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) . Safely and Buildings Division ?Al W. Washington Ave., P.O. Box 7162 62 C~~' be titled in by Co.) is~o~sin Maw, WI 53707 -71 ' z ~ t-3151 (6013) 26t 3 Department of Commerce - Sani~taiy Permit ~pplicati ID L ~~. " In aocamd with cotmn 83.21. Wis. Adm. Cade. petaooai ' y~ rr~y be rued for seoond~y P Ynvacy Isw, a15.04(Ixm} ~ ~ +' Z~ r>f a;t~ tdan address) 1~J°hU~ o~ . . ~ S~~ (# ~ A11 Information I' ~'o ~o r ao - Plt~se I. Application ormati , - ~ .~ ~~ i~ GOUN7Y ZONIN ' Block y s Na PropertyOwner ~ ~~ / N ~Y M ailing Property Owr~r's / L4 ~ .~'d.section _„~ D City. State Zip Cade Phone Number ~ 'i^"'~ 'Type of Buis (cheek aIl that ~ ~ -4u - - ;~ ~~ c;SM Number ,,,/ LrJ 1 or 2 Family Dwelling -Number of 3 SF . ~! ~~ ~ "' ^ Public/Commercia! -Describe Use == ~ ~3J S - rty ^V"dlage ~iwrrship of ^ State Owtted -Describe Use r e-~ ~~ III. T ype of Perms (Check Doty one boat on tine A. lime B if ap~Cab A. l~New System ^ R~ System ^ T ohlittg Tank Ody ^ Other Modification to Existing System B. ^ Permit Renewal ^ Permit Revspn ^ Cbaege ^ Trattskr oo New I.>st Previotu Permit Ntttnber noel Date Issued Before Expiration ~~~r O IV. Type of POVY'1'S (Check all that ) L S on -Pressurized Itt-Ground ^ Motmd > 24 ia. of suitable soil < 24 in. of suitable sotl ^ At-Grade ^ Single Pis Sand Filter ^ Cot~sarrcted Welland ^ Pressurized In-Ground ^ Holding T ^ ^ Aerobic Treatment Unit ^ Recacnlating Sand Filter ^ Rectrcolatiog Sys Merin Fifer ^ Ixacltiog C6amba I.ioe vd-tas Pipe ^ Ot6er (exphin) V. Dis reatment Area Information: -- ~- "" Design Flow (gpd) Design Sod APplicadon Rate(gpds0 Area Recptira - i Dispersal Area Pmposod (s>f) System Elerati~ L- / Q~ %~ f / 3 3. tip' e 3 9 . -1 _ ~2 y Y VI. Tank Info Capacity in Gallons Total Galbns Ma®tfacwrer Prefab Ct>ttaae Site Ctrt>3utrtcxod Steel Fiber Glass Plastic New Tanks Exitona Tadts r., ~~ Septic or 8aktieg~ardc f - s Aerobic Trgtmcnt [)nit Dosing t~amber - VII. Responsibility Statement- I, rite.. - - ante "fat iosta>mtioo of the POWTS wn fro the attached plans. Plumger's Na me (Prim} s Si goadae Number Brrs>~ Pltotte ~~ Ft;iget'ty P[umbmg ~ „~~ ~ T/.i - 3s - 960 p~,~ _ _---_ L~LtRS tM ~ Code) _ `_` _i /.S-aiL3S- .S 1 ~~ ~X ~ 6 - vt- 06 c " Spooner, WI 5480 vm. ° - ~ ~ Sar>hacy Permit Fee (iocmdes Groondaraar Date iastted Sigmare o Staffs) d ^ eel rov A - e pp ~ Fee) s~ ~-~ ~ r7 " ~ ~ 0 Z x.~ i ivm for Denial o'~- lX. Con 3~ ~5 ~ ~ ~ ~ - ~ SYSTEM O NER: ~ S `~.-~ //~ D a~"`xx ~~ `' Q -~U ' om., y 1 Septic nk, effluent filter and ~ ~'.~..,,(,~.~-K ~~- ~-~ ~ disper I cell must all be serviced /maintained Wes- ~s per management plan provided by plumber. Z. Alt setback requirements must be maintained ~ 5 Y c ~ as per applicable code/ordinances. - f Attach complete phms (~ the Comity o®ly) for the system on paper ~t less than tilt x it inches in sine 1 ~ ~' I y ~.? ~ ~ ' 47 /os ,~~. ~ %i- a-: x "'_"' t G'~ Fogerty Plumbing X221180 I ,~ 282`'8 '1cKenzie Rd. Spy=:; 154801 i ~ I , (71 ~) 6/~--9609 ~/~ / I !3~' x I d•'~ ~ ,~/6l~ , . ,,, ~~. ~ ~~~ I ~" -----, ~- i g~ ~ . . ~6r '~ Y~ ~ ~C„cc ~" - yB ' 4~ , ~O.f / jv~ ~v~ ,~ ~~ , ~ ,. 9'Y~ DG3~oc~r/,€"~c. ~r~s ' ~ =•~u.~9 Lam'' ,~ 00 ~) ~v ~'v~'dE~)E ° 4's ~= GvF- c L 7 5"~ ~ sEQrrc ~) /~~/' !j- 3 l~u ~ -' S yST~n-~ ~ sysrrsirl 6LEl~ O = ~~6~ GY1L~_ ~•%• w~ r.~R ~~ cor~.~c7' _ >`~Y~ l3A~~' • s ysr.~~ : c- r $0 ~ G,ticl~`i7~ 3~ vu~ ra far[. rt•J s , UcK c ~ i3~r s , ~ 9Y.~ d.~~ `~ Ldc~rtoaJ' .~7c . m/~.r~/6S' ~c d~ do.v~ o,r c-2 fD ~ Lcn/67i`~ 'o ~ / ~.~--~ 93~5/~~Tt/ ~~~ rNi>s 4~ EGQ. . kI ~ -3 76 ~ L~~d~hY 91 y '~'~` ioi ~~ i,.. niiGOL.FA ~ ~~ 3~ ' ~ ~ 1 9~ y I ,v - ' I q7 ~ s' /os ~ I S=D' ~- B- i G X Fogerty Plu mbing I / pp T~~21100 2~_~3 P~1cKenzie Rd. I #Z ~/ ~ S~;c: ;;=r, WI 54801 (71 ~) X35-9609 / ! I ; ~° ~~ r `30 r x u~~ ~l~cr~ow ~~T ,, so , ~~~6~~ 710 /Sz'/~ ~~0~ i 3a~~. ~ r ~{e~~ III --- - - i -~ I ~ i i ~6r '~ y~ ~ SG,~c,~ ~ rf = yo r '~ a~x =ate, ~0 >r / jvc ~~~o ' rr re r r rr r -~i ~T'!1~^ I'Y~ ' _~eo s~r~rr c~-.vE - - dc3~~/1/,€".Y- /L"Dl~' '. • =/a~u~f//~ GfY" (tyt~~ .e Ov ,vv ,EV.~~,z',E o ~ ~1s y~l = ~~f- t [ ~ 5-a' f,~rl-~ s~-~~rrc ~~Lr l1-3 fmuni~ - SysrF.,-~ ~ sy~.~ 6z~d. ~ o = ;~~ cnl. ~'.j, c,,~~r~r,~~z ~~ cor~s,~ac7^EI~ i=.ro ~`H~ /~~~' • s y s r,~~ : c- ~ BO ~ L~ ~J~7~`! dur ra f~z-c ,y~ s , [,,~c~c ~ 13~ S r3o~~' QY r d~~~ ~ .~ LdG1~TtO.v~1' ~ .~7c . ~, Gc.v/~~ ,0 1~~ cvslc /J.E .do.~i= O~ e'2 fD I ~ qs y "~~ wi~~t~n,sin oepertrnerrt of commerce SOIL EVALUATION REPORT Ulvision of Setety and BuNd' C RE E~t~arrce Ut Cornet 0 Wis. Adrn. Code [~ //~~ Cuurdy Attadr oonrplete site p rr on paper ,rot toss Uran,,QQ~~1/2 x arcl ' ~siz'e Plan must tndude, hid not limited : vertlra~attd ttprf~ori~~td~teren point ( M , r~r, and Patuel I.U. percent ~ tope, scale or Imens ,ot r row, and local n and dls rc t2~,eal~sl road. Please ~t.~~'y~g4l~r~natl t. ~~ (f ~vrew\ ~y . ~ Paye _ I _ ut _~ Pmsonal InfomrMbn yov p~OVide rlia~jrprren~ rpoaoa (Privacy Lew, a. ,~' A t) ~ ). ---~~F-°'L= ~ ~ . ~ S) (~ hfDpaflyOWnar `\ LIJr~ PIUp4rty ocalfun . _~ Guvl Lut ~E 111 ,N WIf4 S 30 1 ~ N Il lZ E (or t Properly Owner's Melling Address Lol # F31uck # Sulxl. Name or CSb1# City Slate 7Jp Ccx1e Phone Number ^ City ^ Villaye Q~,G'bwn Nearest Road ~-r~ew Construction Use:I~-Residential I Nwnber of bedrooms ~ ~- Cude derived desiyn Iluw rate ~~~Q~_s~~_____-_ GPU ^ Replacement ^ Public orcommercial - Describe: _ _ _____-_____ __ _ _ _______--_ -- -- -- R. rlicabin ~~~ d Plain elovatiun if a Flo ~'I~ ___.__ ____ _ _______ pl o -_-_ ___-__-__- Parent rnelerial _ General corrnnerrls 5^ C~~-C f/ ~ y y. Z J and racomrnerrdalivrrs: ~ ~ ~ ~ ~~~ /) r _ ~ r ' --~ ~,. I~ ~ ( I III "' III Boring # ^ Bunny ~~ 0.~ ~it Ground surface elev. ____ It. Depth to Ilndliny lector _ 1?_ ___ in. _ _----_~~--- ----- J-- Sol Application Rate Horizon Ueptit Uorninant Color Redox Uescriplion Texture _ Struclwe Consistenre Boundary Rrx~ls GPDlIP br_ Munsell Qu. Si. rCont. Cobr Gr. Sz. Sh. _- __ _ 'Eft#1_ 'Eft#2 I i0 IZ - s. ~ 2msb~ m~ _~~__ _ ~'~-~ _ _ ~ 5 -8 3 4 -~2 ~Z- 85 to r ~+h ro s m ____ C ~ P ~1.5 ~t 1~ ~ ~,~ ®~_ O ` m 1 ~1- cS _ - - _ 7 ' ~ f ~-_ ~- ~---- - ~_ 2s. 2 ref . Z Boring # ~ Bonny (] - Pit Ground surface elev. -"-~ • ~ ft. Depth to limitiny factor _ ~~ in. ~`"-~- Sol Application Rate Horizon Deptlr UorninarA Color Radox Uescriplion Texture Slruduie Consistence Buundaty Roots GP UIt>: in. Munsell 17u. Sz. Cont. Cobr lt. G r . . S Sz 'Ett#1 'ER#2 f 1 Z - ~ 'I'1 Iq "39 -qd ID~r31z 1'l~-vim ~ -- CtP~. ~ ~~ --~=~J__ -~s `~ ,, , ,~ ~ i ~-r!l,~ ~m~ ~ ~~,, (~_ -11"f"Y _~_ ~~~ (' ~ ~+_- c-~--- _ ~ V~ -- - _-~ -, `-1 - ~ _ ~' . ~ _ ' ERkrenl tM1 = 80D > 30 < 22U n-g/l aril TSS >3U <_ 1 rU my/L ' ERluent #2 = BOD < 3U my1L and Y SS < 3U mg/L CST Narrte (Please Print) ~,~~,. ~,~,Siynature ~ SST Nwnber Address -T ~ Dale Evaluation Conducted Teleplwne Number ~•~! r Properly Owner __'_ ~ t ti~ -- i" _~ 1 (-1 Boring ~, ParcellD # ~ ~ ~ of f ~~-------- Page ---- -7 r Bornrg # - ~ (C.1 It• U L --Pit Ground suriar:e elov. Horizon DepUr Dominant Color RedoxDesaiption Texlue in. Mrnrselt Qu. Sz. Cont. Cobr _ Z ~9- © ~ ~~ o ~ 1 S ~- 10 r-51 (~~ P ~ ~ 5 yr `-~' ~ `f f S epUr to GnNting F Strur~we Gr. Sz. Sh. _ -~--- ~_ actor ~ Consistence ~ m ( ~ ~ irr• Boundary __ ~s c 5 Roots _ Sod n r ic .EIUIGPD ~ ---~ - _ ~-f aGrnr Rate IffEF!#2 ~- - ~` ~ - to ,_ LJ Boring Boring # ' ^ Pit Ground surface elev. __ Ft. Depth to limiting [actor _____- in. SoU A plicaUon Rale Fiorizar DepUr in. Dominant Cokx Munsell Redox [krsaiption Qu. Sz. Cont. Cobr Texlure SUudure Gr. Sz. Sh. Consistence Boundary Rvols _ GPDItF _ 'EIF#1 'EFFN2 U Boring Boring # Ground surface elev. _,~_- Il. Depth to limiliny lactvr _ __ in. - ^ Pit _ Sorl A licatiar Rate Horizon DepUr in. Dominant Color Munsell Redox Description Qu. Sz. ConL Cobr Texlure Strudure Gr. Sz Sh. Cvnsistanr.~e Boundary Roots GPDIfF 'EiF#1 'EFF#2 'Effluent #1 = BODS> 30 < 220 rnglL and TSS >3U < 150 mglL 'Effluent tYL = BODS < 30 my1L and TSS < 30 rnyll_ 7 he I)epariment of Cvrnmerce is an equal opportunity service provirlcr anJ employer. If you need assistance to access services or need n-atcrial in an alternate Comrat, please contact the rleparUncnt at G08-2GG-3 F 51 or "I'I'Y G08-2G4-8777. sad uro ra.ouonr t •, ~ . ~ L~.>crr ~~ -.ecinl. i)Ia~~ktt~rlc)rl:~/~Il~l.(~wll-I,S I Z .N,It, )~-I:(~n)~ NAIvIL•: u ~ q ~ - SCALL_ 1„----- Q_.--- --- _ - ~m~ELLVA'I'ION:__-l~-a.6 _ ___ ___ I . - _ -- ~ ,~ - fi [3hl t UL• SCRIf'1'IOhI: .~1.~~~_.~.."~2_ -- E3ht 2 GLLV~\'IIUN:_ ---L ~_~ . ____ _ / ____ I _ __ _ _ ~ ~d_-_ L aNt 2 ~escwrrtut~l: ~b~6-~_/. jw~n~;4~ ___ . SYS'I'LTvI LLL;Vn'1'li err: _~~'Z ~ _ _ SYS"1"L•NI'1"1'1'I;:_ ~o/lue~~_y__y~a.1 _ - - - - -- - NW ~o~' cad rv ~/ _ _~ Nr lo'~ Nofnu l ~~.L~ Q~`2O Z S1GN~TURL::~ %~ -~`~-~ Un"l l:__-- ---~~ ~ O ~ ~ ~` - 'I ~ II II ~ ~ ~ I! ~ ~Of31 M II ~ O N ~ ~ .-r ~ r+ ~ W ~~ m-~j ~ 'd ~ U a~ ~~c~ U ~ ~ '~ o ~'~~ ~,~ ~~ ~ ~ o ~ N (J ~ \ \ ~ `~ _ - ,~ ~~ . ' '~ O '`--_ - a .' Y -i O ~ u r" o, .. ~ i w° - y ~ ~ .r V '~1...._v__..._._..__+. _ i+ ~ ~ '~j U ~ taA ~ ~ ~ `., - v ,. `y •. "-- _ - ~, .~+ ~ ~~., 0 ~ ..H.,;.,: ~ ~ -~.~ ~ I ~' '~ • ~- _ •~ ~1~ _____~~-=..-- - y C ~ II II g ~ ~ ~ ~' / w U w ~ ^.' ~ ~ ~~ `~ ~ o a ~ a I~ ' POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of ~ FILE INFORMATION SYSTEM SPECIRCATIONS Owner ~ ~ Septic Tank Capacity pap ai ^ NA ST CROIX COUNTY SEPTIC TALK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner!&tyer _-_ fl.~,e.G~'.1~ ~i¢ST Mailing Address ~ yy ~Q Property Address (Verification required from Planning Department for new Ci !State ~~ ~' -~~~~~!~~~ ~~ Parcel Identification Number /J'..~o~~_ Gv LEGAL DESCRIPTION Property Location ~ '/,, ~_ '/,, Sec. 3 a . T~~N-R~_W, Town of ~Y.s~,~r®.NL~ Subdivision _~.~ .~r~c' ~ r~-r`" ,Lot # ~~. - CertiCed Survey Map # ~- Volume ,Page # Warranty Deed # ~~ 6a 9 a Volume ~ ~ g 7 ,Page # 3~ Spec house D yes Ca'no Lot lines identifiable D yes O no ' SYSTEM MAINTENANCE Improper use.and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pwnping 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 masterplumber, jonmeyman plumber, restricted plumber or a licensed pumper verifying that (I) the on-site wastewaterdisposal system is in proper operating condition ancUor 2 _after () rnspection and pumping (if necessary), the septic tank is less than I/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, asset by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. s- ~ ~ S AT[JRE O 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 pr rty described above, by virtue of a warranty deed recorded in Register of Duds Office. ~~~ ~ ~ SIG ATtIRE OF LICANT DATE- ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ****** ~-- ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed .u 2ss~~ soo • " ' ~ STATE BAR OF WISCONSIN FORM Z - 1999 Document Number WARRANTY DEED This Deed, made between Gillis Farms. Inc. Grantor, and Kern~n J. Bast anal Rijchard O. Stout, tenants in commtL, as to ri4 interest each Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin {if more space is needed, please attach addendum): NW t/~NW'/,, Except Certified Survey Map Vol. 14, page 3829 and also except Certified Survey IVfap Vol. 14, page 3829 and also except Certifies Survey Map Val. 14, page 3967; NW1/~NE1/~, NE'/. NW 1/•, All in Sec. 30-T29N-R17W. St. Croix County, Wisconsin. Recording Area RETURN T0: METRO LEGAL SERViCES,1NC. ~M1 NNEAPOUS, tdN 5540IS22 7250 76t=.eZr~2 KATHLEEN }l. MALSH REGISTER OF DEEDS ST. CROIX CO.. WI RECEIVED POR RECORD 06/16/2004 01:20Plf IiARRAHTY DEED EXE}WT # REC FEE: 11.00 TRANS FEE: 3300.00 COPY FEE: CC FEE: PAGES: 1 ~' ' /i Name and Return artiiress ~~..`(tra ~ ~ j~ SAS - ~ ~ S ,..'x{5(7 ~~ ~~ ~~ #- ~~~~L1 ,q~1~=t6 1$-1066-60-000: 18-If)66-90-000: 1&1067-00-000 37U744 ~~~) Parcel Identification Number (PII~ This is not homestead property (is) (is not) Exceptions to warranties; Easements, restrictions and rights-of--way of record, if any. `/y Dated this r y' day of June 2004 Gil 's Farms Inc. ~Cfis~v rvr, * By: * `~ -- -- ----- . AUT1iENTICATION ACKNOWLEDGMENT ~1'Ietro Legal Services FDIRF'!' 4339? 1 ?+ Signature(s) Gillis Farms, Inc. By: authenticated this f ~ day of June , 2004 i~ * Kristine Ogiand TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.Ob, Wis. Slats.) THIS INSTRUMENT WAS DRAFTED BY Attorney Kristine Ogiand Hudson, WI 54016 (Signatures may be authenticated or acknowledged. Both are not necessary. " Names of persons WARRANTY DEED STATE OF ----- ) ) ~S. County ) Personally came before me this _ _ day of _~ ____ the above named to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. Notary Public, State of _ __ _ _ _ ______ My Commission is permanent. (If not, state expiration date .) any capacity must be typed ar printed below their signature. STATE BAR OF WLSCONSL~ FORM No. 2 -1999 laformation Professiomts Co., Fond du Lsq. WI r' } . ;`:~ z 4 n J z 3 Y ~ ~ O OJ ,„ c: ~ v z ~ 3 `~ ¢ o ~`wq~ ~ o ~ = u~] o } "' ~ mZ wz z w O C7 0 ¢ Q ~ ~ a ¢ r a Jw ~03 ~ i ~ • ~ I[ p ~ ~ ~ ~ In J l(') J - i ~ 3~ j II i ~ J .~z~~. ~r ~:: ~ ~~ ~~ ~~ . ~~w~~~ a ~~ 0 ~~?g~~~ m~~~~~ O~-¢a~U~ WQ~N~m am~oz~~o W~FZ~50!2 mQQ~OQw~C3 C3oOmrjOw J J W ~~pZQFI=-~ 4u~~ac~is~~> gmZC7r ai¢~p~Zw~ H ~wgQ~c°~aw O Jp~fA ~yLLO_ Z sz?>OOwS r-, -----------a1r0~1 NMOl~~~,-~------ i d9'Z5L N1.9£~LO>OON ~ ~ ~ ~- O ...... 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