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HomeMy WebLinkAbout020-1407-07-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFOh"'tMATION (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 Hudson, Town of CST BM Elev: Insp. BM Elev: BM Descri tion: TANK INFORMATION TYPE MANUFACTURER TY CAP ACI Septic ~ ~ y ~al~ ~ Dosing d Aeration '~j f~" 76 Holding ,~(~~ TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ,.. ~ / ____.-. osing .~ ~~ / Aeration Holding PUMP/SIPHON INFORMATION Manufacturer ~ n vJ _ Demand ,~~/,!i GPM Model Number ~ j~ h `'~ C/ [/ TDH 'fto t " 1 ~ Frict~n ~~ System Hiea A TDH ~ Ft Forc main Len th Dia. / / Dist. t W ll W Z OT /'N Cnll AQCnDDTInAI CVCTGM 1- ELEVATION DATA County: St. CroiX Sanitary Permit No: ~ ~ 479375 e/ State Plan ID No: Parcel Tax No: 020-1407-07-000 Section/Town/Range/Map No: 10.29.19.2554 STATION BS HI FS ELEV. Benchmark U Alt. BM Bldg. Sewer '3 ~.. Z 3 St/Ht Inlet ~ ' ~ SUHt Outlet ~- Dt Inlet /~ ~- Dt Bottom v ~ . ~~ eader/ n. ~, ,~ 7~ 3 7 Dist. Pipe ~~ S/ ~ ~~. ~ 3 q7. Bot. stem g.~3' gb. Final Grade - ---- ~t ` T !~ V c St Cove 7 C,' ~ 3 9 , 3 O~^- _11P.~C-~- /Pt~t 5 ~~~ ~ 'f" ~ l~~ BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ , ~ yi ~'~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM EACHING Manufact ;~' •/ TY 1~ INFORMATION ~ CHAMBER T e Of System: ~ ~ / Model Number. ~ _ 0 ~~ A r11SSRIR11TInN SYSTEM ( Q~1.. C„a J v/ I / f'a..ei/ //k~d11At1. Header anifold Distribution x Hole Size x Hole Spacing Vent to ~r ~ ~ ~ ~ Dia Length Length O y Dia Spacing .,. ~ i ~ enu env~D .. o-,........... C..~~,,...~ n..r.. .... Mn~~nr! nr D+-Gratlw Rve4oms C]nly Y ' CYL A~~r/~~/"°' Depth Over / Depth Over xx Depth of xx Seeded/Sodded xx ulched Bed/Trench Center, / S BedlTrench Edges Topsoil Yes [~~ No L~ Yes ~ i No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~/~/~~ Inspection #2: / / Location: 713 Zephyr Lane Hudson, WI 54016 (SE 1/4 NE 1/4 10 T29N R19W) Shepherd Park Lot 7 ~Q Parcel No: 10.29.19.2554 1.) Alt BM Description = ~3 ~}1a/'1 Ili~~ 2.) Bldg sewer length = ~ 7 r - amount of cover = ~/; / 7 _ _ -- ~ ---T- -- ~- _ _ - - ---- /' ~j ~7 Use other s de foruadditional information. No __~` ~ li ~_ ~~ i _ ~_ - ~L~!~~ J I G1~ ---~i ~_ I -- Date Insepctors Signature Cert. N . SBD-6710 (R.3/97) Safety and Buildings Division County aol w. washin ,~~~~~~ Madison, VVI 53707 - 7162 Sanitary Permit Number be filled in by Co.) Department of Commerce (~) 266-3151 ~.,, ~ ::4 cl 3 75 Sanitary Permit Application ~ stage Phm D. Number ~- In accord with Comm 83.21, Wis. Adm. Coda personal infomurtion you ~ e may be used for secondary purposes Privacy Law, s15.04(1 xm)? 6 Praject A (if different titan mailing address) I. Application Ioforrnation-PleasePrintAUInformation t.t; ~''~" ,~' G,rJ ~v log(/ Property owner's Name . , PatceJ # I.ot e Property Owner's Mailing Address Property Location City, State Zip Code Phone Number ~ B A/ t r~ ~ [ 0 ` ~ f~ -S ' d ~ S ^ G~~ s5 T ~~I N; R ~E o~ o Type of Baildi g (check all that apply) II ' , . ` Ce 5 ~- ~ ( ' t s"bM' Subdivision Name CSM Number 1~1 or 2 Family Dwelling - Number of Bedrooms ^ PubliclCommeroial - Descn'be Use ^ Sffite Owned-Describe Use ^City ^Village ~['ovmship of III. T ype of Permit: (Check only one boa oo line A. Complete line B if applicable) A. ~1CIew System ---~~ ^ Replatxvnerrt System ^ Treaimdrt/Hoiding Tank Replacemert Only ^ Otlrer Modification w Existing System B. ^ Perrnit Renewal ^ Permit Revision ^ Chao®e of ^ Permit Transfer to New Last ~~~ Perroit Number and Date Issued Before Expiration Plumber Owner ~, N. T of POWTS S s tem: Check all that s ^ Non -Pressurized hr-Ground ^ Mound >_ 24 in, of suitable soil ^ Mamd <24 m. of suitable soil ^ At-Grade ^ Siogle Pass Saad Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatmart Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) V. D' rsaVTreatmentArrea Information: .Z G,rrz"LL $ /' L Design Flow (gpd) Design Soil Application Rate(gpdst) Dispersal Area Required (sf) Dispersal Area Proposed (sf) S Elevation VI. Tank Info Capacity in Total Number Manufatxraer Prefab Site Steel Fiber Plastic Galbns Gallons of Units Concrete Construced Giass Tacks Tads Ltl Z/J't ~~ /~ /~~/ Septic ~ tioldmg Tsdc ~~ ~ 3~ ~ /z~-rS.(t. At7sit ~mliJ Doaa6 Chamber CJ ~ ~ ~ / VII. Responsibility Statement- I, the nndersigaed, sesame respaasi ' ' for installation of the POW'I'S shown oa the attachtd plans. Plumber's Name (Print) Plum s Si ~/MPRS Number Business Phone Number /.~v.,z~ v ~. o Tis- 6- omv v Plumber's Address (Street, City, S Zip e) .ZP.z~~ z,~~ ctiv - - o !- ~lTv- 7 VIII. Conn /De sr~dnent Use On Approved reapproved Sanitary Permit Fee (includes Groundv,~ata Issuing Signs S Surcharge Fee) ~ ~ /~ I Z U own ~ Reason for Denial IX. Conditions of ApprovaURessons for Disapproval Q J~ /~2~ 6 ~~~~ ~ VO Sv 1 7JiI , . SYBTEMOWNER: ,. ~~lt,.~t,t,~ertd P dispersal cell must all be t;ervices I maintained ~ ~ a. as per management plan provided by plttmbe(. 2. AU se(back requirements must be meiMainsd per applicable code /ordinances. Aftrxa eomprese pnm (m aye c:oaory oary~ arc me sysaw oa paper aoc ass u.an o,.~ . „ ,o..oo ... ,..~ I> SBD-6398 (R. 01!03) ~~ N ~" ~ n 1 b ~ ~ rr ~ ~ W ~' ro o j ~ ~ ~, ~, ~. t( ti ~ ~' b ~ ~ ~ $~~,,. ,. ~ ~ ~ ~~ A ~, ~~ti~' ~~~ y h ``, n ~' -~ ~ ~ ~ ~ ~ ~ ~~ V Ir ,~ ~, A, ~ ~ wM m r-; - w v ~~~ ~ G Q v ~ ~~ '~ ~~ ' ~' ~ -~ ~- _~ p ! ~~ ~~~ s ^'~/1 N o V C; ~ ~q G7 - n N ~/ 'V v ~ ' N~ W~~-r'C ~-~ ~C .o~~•°v. to w ~ w ~~ ~ ~ ~. ~, •- ~ ~ ~ ,s i N b ~"' ~ H , M ~ - ~ ~ o a ye ~ N I ~ ,, ,, ~ ~ ~ ~ ~j A ti y1 ~~ ~ 0 ~ ~ y h '^ ~' 0 p 1 ~ ~ r ` ~ 0 ~ ~~ v If ~~ m p1 ~ ~ ~~ m I w v ~~ -~ 1 N ~" ~~~ 2~ _~ ,_~ y I •---- ir`.~ Z~ ..z N o V C` ~ 0'4 V1 ~ ~ ii .~ Cil ~ N~ Gl-s j N w~~~~_v ~-~ tbC Op~p~'OO' t0 O ~ ~ !-' A ~ r s c a moo E~ ~~a~i ~ m- n. ;YAM U ._ 11~ ~ p,v N ~ O U .~ H V 1 H a ~ ~ O •~ .O V Q~ ~~ O _ W ~~ ~' q m w ~ i a f _ . 0 m Q ~ i i ~ I ~, f ~ i.~ ~ ~ ~ •~ o n r~ . .1 - o0 o ~ 3 t i m .~ w ~~ f ~! ~ f. O ~. ~ a ~; ;~ _, ~ -- _ s t --~---~ y. ~ _.~_ a ~ ".s ~ s: ~ ' '~ r. __~ ~--~._ • "'Q ' .~ - - .~ ~,:- ~-~~ -~ -'~ .. --~ ~ 1. ~'~, '_ i_ -.~~ ~'_~' :~ Q, ~~ -- ~ ., :. 3 +~ '- ~ f __ '~ ~ ~ a '- f q~i~~._ _v-- •----~ ~ Q ~ ~' ~i ,_ .fl e~i ~ .~ o o ~' ~ H ~i 0 .d; m V b 0 V .~ ~- ~; ~p. O ~- Fogerty Plumbing #221180 282E8 t!'IcKenzie Rd. Spooner, WI 54802 (715) X35-9609 _, Combination Tank Component Cross Section Approved Manhole Covers with Watmng Labels andLockingDevice / 4` Mia. Above Final Gzade 4" Sch, 40 Vent > or = to 12" Above Final Grade ~-~ Weather Proof Junction Box IIedrie per NEC 300 & CONflVI. 1628 wAC .... Attexnate outlet Location W/Approved 4° Sleeve _ Inlet p-ppmved E$lueot Filter /7 <or=tic 1/8" Me Particle Size - A B C Tank Mfr. L`8 ~ ~ D Force Main Diam. _ .2 'r I Hole or Anti Siphon_Hevice i Pump Off Elev. 2.~,s '-- Dose Tank Blev. Vertical Difference Between Pump off and Distributi~ Pipe = ~ ~D.R'1/ Requited Supply Pre~n+e ...................................... _ -- ~. 70 FT. of Force Main x Ls~ Friction Factod100FT.... _ ,~,~~ ? Total Dynannic Kead .................... _ ~L, f (• 6 !~ Number of Doses ... _~- Per Day Gal. Per Day/ #of Doses = jp0,0 GaL Volume of Bacacflow ..............................».................................... _ //. Nf Coal. Total I)ase Volame ..................................................................... =1 ii . ~Y Cal. Pub Tank t~pacit3- 1~-o Callous Pomp Tank Yohme lG. ~iGaVinch Pump Mfr, 6muLB Pump Model Minimum Discharge Itatie = 3o GPM Dions Inches Gallons A Z7.[z yys-36 B _~ j2.2 _ C ~~ ,i . L D ~_ J Alarm Mfr. ~~,_~~ Alarm Monet , fob _ o/ /~J~ Tota)= ~16.s ~ Bed Tank per COMM. 83.45(5} Anchor Talc as necessary to negate buoyant fon~es per COMM. 83.43(8. Bible Pump r construction purposes.} ,~ '~ ,r; -- z.~ .- ~f' NPT wsclratGe 3.1 ~.6 nimum Maximum Shippirmg tasin Solids Weight imeter Size Ibslka 18" ( .5" ( 31 / 14.1 Goulds Pumps ITT Industries GOULDS PUMPS Submersible Effluent Pump ~~ ~ E P04 & E P05 Series APPUCAiIONS • fuNy wbmerged in high ^ td'05 Impeller: Thermo- ^ Bearings: Upper and lower sper;fiony desigrced for the grade turbine od for Plastic erldosed design for . heavy duty ball bearulgcon- foflovrirlg uses: lubrication and efficient improved performance: stnlction. • Effluent systerra heat tran~er. ^ Casirg and Base: Ru99~ • domes thermoplastic design provides AGENCY LISTING • fanru Available for automatic and wperior strength and corrosial manual opera>iori. Automatic ~ canar~rrsrirscooamon • Water 1ra~ewrmP models iritfiide Mechanics resistance. ~' ~ # y float SWitdi assembled and ~.^ Motor Housing: Cast iron for • Dewatedng poet at the factory. ~l'ident heat transfer, strength, and durabiflty. SPECIFICATIONS ~~~ ^ Motor Cotrer. Thermoplastic • Sdids handling capability: cover with integral handle and ;/4" maldmum. ^ EP04 Impeller. Thermo- float switch attadlment points. • Capadties: up to 60 GPM. Pic ~n~O~ ~° with ^ Power Cable: Severe duty • Trial heads: up to 31 feet pump acrt vanes for medlanical rated al armd water resistant • Discharge srze: t'Jz NPT. seal protection. • Mechanical seal: carbon- . rotarykeramic-stationary, BUNG-N elastomers. • Temperature: 104°f (40°C) mMinuous 140°F (fi0°C) irNenrmittent • fasterrers: 300 series stainless steel. • Capable of running dry without damage to CornpOrlenLS. Motor: • EP04 Single phase: 0.4 HP 115 or 230 V, 60 Hz, 1550 RPM, buih in overload with autorrmatic reset • fP05 Siimgk phase: 0.5 HP, 11 S V or 230V, b0 Hz,1550 RPM, built in overload with automatic reset • Power mrd:10foot standard length,lGl3 SITW With three P~9 grounding plug. Optional 20 foot lerigtfm,lF/3 SJIW with three prong grounding Plug (standard on EP05). . MErEns SET ; __.____ to 9 30-~-- 8 ~ ~_ x u 6 2n-_ ___---- a 0 0 1 s _ ~ 00 10 20 3 40 50 GPM 0 2 4 6 8 10 12 m~/h cnPacllr Goulds Pumps ITT Industries ,~ rn acwraarrce wrar wrrun o~ vvrs, rwn+. a,u+c COUnIy Attach complete site plan on paper not less than 8112 x 11 inches in s¢e. PI~- must ~~~ - indude. twi not limited to: vertical and twrizonial reference point (H~). drection and Parcel I.D_ percent slope. scale or dimensions. nortli arrow. and t~cation and distance to nearest raad. ~ .- / 4 7 - ~~ Please print al! information. ~ Date Personal irNbnrraGorr you provide stay ee used for semraary prposes tFri~r taw. s ts.as m (m)}. / Q rr~ry vwr>Cr - -° - v ~ C,~ i~ 1/4~ 114 ' T ~ N R E Property Owners tiAai6iig Address Lot # Stock ~ Sited. Name or CSi~ r 7 _r-__ ~~~ ~ ~ City S Zip Code Phone Number ^ Cily ^ vi~ge oam Meanest Road ,i/ (/S i ~ 7775 u off/ ~ z'`= ~- New Constriction t1se: ^ Residenti~ / Uhanber of bedrooms ~_ Code ~~ design Bow rate 6[Jl! crL ^ Replacement ^ Public ~ cortur~erciat - besrxbe: Parent material ~~~~ - Flood Plain ele+ration ti appicabte _~~~iSZ ft. rE~arnrr~eridatioris: C'Oif/riE'~'I ~~'iy L mil// L. S~• . . ~ o ~ ® /~2 ~. ~ gprr Raa ®Pit Groruld surface elev. ~ . _ R Depth tO 6~9 HoriZOri Depth Dominant Color Redox Description Texltue Struc4rre Cor>siistenoe 8our>d~Y Roofs ~~ 'Effft'1 'Efft12 in_ ti~haiseq l]u. Sz. Cant. Color Gr_ Sz. Sh. F / ~ .~ L G S 7- im 6 - ~ - ~.6 S~ -/ L d -- G. G s - . 7 // .~O ~~ ~ ~ ~s (,(1V © Ptt Crauld ~~ elev_ >Z OcPih ~>i~~9 facaor ~' Sol App~ion Rate fiotizon Depth Doniardnt Cokx Redoz Desaiptiari Texhire Sbtit~ure Carte Boi>tidary Roots GPDlttr _ in. Munse{i ~ Sz Cont. Caior Gr: Sz Sh. 'Effayi 'Eff#2 . ~.. ~~ • wiRrrent S2 = B~ _ < ~ rrigll. and TSS < 30 tnglL'• - - Etnuent 87 = rswS ~ sv ~ ccv ~~y~. a.... w -w - ..- --~- ST (Please Print) ~-~ address Fogerty Plumbing & Perk T flag 2$288 McKenzie Rd s~dd~l+ri'/ Gcsr S~f~'~~ =-~i.s-,-96e~ v% ~ ~ .• 1 ~ Qom, X ~ ~ "~`• vC ~j ~ ~ ~ ~I f '~ ~ w ~ ~ y ~, , ~ ~ o ® ~ ~ ° °~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~ ~~~ a ~~_ ~ f..~ ~~ ~~ h ~ v ~; N p -A ~ v ~~ ~ '7 N Gl~ n N W~~--'~ to-~ NC .( ~ y~+ a OQ a~ r. I _Y I \~ ~~~~ r r, ~~~ ~ r - 1 - . ~-- . . ZO1 W. Washi c i ~~ ~Vi ~ton Ave., P.O. Box 7162 wt -7162 - permitNntnbec(to ~~~~~ n s~t~s t ("~ ~\f Department of Commerce _ S to Plan I.D. Number Sanitary Permit Appli ;t4 "~ i -= - Cormn 83.21, wis. Adm. Code, ptxsotal . In accord with , ~t ii Address (if ditferertt than mailing address) may be used for scoo>glary purposes prtvacy Law, s15. m) L Application Infa~on - Pie Prtnt ~ Ltt'oratahoa BONING OFFICE / 3 ~ LN y Parcel ~ Lot It Block A property Owner's Na trte ZSS'f - o -O ~-- . property I.ocadon ner's M ailit~ Address w propertyp p l 7D ~ ~ ~•~~• ~- Ci State ty. Zip Cock t~ Phone IVrmtba' _ ` 7c (Clrrle One) _ Typie of B ' ~ (~~ ~ ~ ~~ I I , S '"~ ~ Subdivision Name CSM Number ~ , ~ L!9" 1 or 2 Family Dwelling -Number of Bedrooms S ' ~ L' / J ~ ^ Publk/Commercial-Describe Use - -° --• _ - 'LL / buy QVSiage t~i_owrtsleipof ~t~~ ^ State Owned -Describe Use III. Type of Permit: {Check ody arse boz am ittae A- )sine B if a le) A. (N" New System ^ Re~acemem System ^ T Tank lacement Only ~~ ^ Other Modification to Existing System ~ Pry Number and Date Lssued B. ~ Permit Renewal ^ permit Revhion ~ Clmoge of ' Trat>s{er m New r - Before Expiration Plumber atta IV. T of POWTS System: (Check all that ) _ _ ~ ,~ ..- 2.D ~ ^ At-Grade ^ S' Pass Sand Filter (~'NOn -Pressurized In•Ground ^ Moutd > 24 ia. of suitable sotl < 24 in_ of sttieable soil M ^ Aerobic Treatrttettt Unit ^ Recirculating Sand Filter dt ^ ^ Consuuctcd Wetland ^ ~~~~ Itt-Gtuttttd ^ g~dyng T ~ Pea ^ Other (explain) ^ Recirculating Sytuhtxic Media Filter Learfiing C6atnber Drip PSpe V. Di al/Treatm~tt Area Information: d l) Area ~~ {s Dispersal Ar'~ ~P~~ s Sys Elevation Design Flow {gpd) s Design Soil Application Rm$gp X57 / S~/~ to ~_ ~ ya-,g' ~-Z p6, ` f Prefab Site Steel Fiber Plastic VI. Tank Info Capacity m Total N " actarer Mattrt Concrete Comorur~ad Ghass Galktns Gallons of tvew >: Z~ 3~L ~ /~ Tanks Talcs Septic or i(e1dltlirrSnk / 9 i~ .~ /.Z S!/ ~ - 1/ Treatornt Dosing Chamber for' of the POVYJiS r+ra on tau attached p~• VII.- Responsibility Statement- I, the" - as~e ' Si tore -i~d&tIMPRS Nutdter Business Phone Number Plumaer's Na me {Print) ~"~ Fogerty P1umb~ng ~ _ ~.z f ?/.i - 3s - 96~ ' Gode) -- _-~ _ /S-li3S = s 1 Ito F/FX ~. Pm"'~~et+~ ' -' - o.~ - v 6 c Spooner, WI 5480 -- _ O_ ~ ~ - VIII. C Ont Agent Sigtraanne o StamQs) Sanitary Permit Fee C Gtnnndwater Date Issued '~ Approved Q ~ Reason Demal Stuchazge Fee) ~~ - ~~ ~~ IX. Conditions A - SYSTEM O ' 1 Septic tank, effluent filter and dispersal cell must all be serviced /maintained • -as per management plan provided by plumber. 2. All setback requirements must be maintained _ as per applicable code%rdinances. - Attach complete plans (to the County only) roT the system oa Paper trot less thou 81/2 x 11 lathes m sift ~~ "t ~ a lr ~ I ~r p ~ ~ ~ _~ N ~~, ~~ 3 ~ ~~ ~ ~ ~ n ~ ~ J c., o ~ _ ~ ~ ~ ~ ~ ~ \ ~\ (~ - ~ ~ z e ~ ~ ~ h c ~ ~~ _ 4 V~ y ~7 ~s~~~~ ~ ~ ~~ T ~ 1 A ~ ~ ~ ~ e b ~ ~ ~ ~ ~ Z `Y ~ ~ _ N p '+1 `~ ' V~ C7 ~ F+ ~ (~ v ~~y~ N W vl~' ~ _ W nN'~ N O~ •Vs OW ~ ... ~ ~N~ ~ yv , t ~~ ~~ ,~ _ - ~ C-2 -~ - ~ ~~. w ~ ~t~- o N l o u ~ --~ ~ h ~ w h v N ~ ~ ~ ,3 w ~ ` J an © ~, `C .. '\ ~ 0 ~~ ~ `~ ~ 1 ~~ ~ ~ ;~ N ~ ~ ~ ~ ~ ~~ .~o _ cn ~ -n ' \_ ~J ~l ~ lA i~ V iJ ^7 ~ ~? '` NK ~ `. / Gl n (r3rz~-r~ ~ ~ to _. co ~ C ' ~ ~o ~ Na ~ \. ~~ ~~ ,.~ _~ o - - -2 ~l 70 ~ ~ '~ = `~ `^' ~ ~ E ~ b ~ ~,~ N \ ~' s Z ~ fi -~ n ~ ~ .Q , _ ~ __ - h ~ h Wisconsin DeQartment of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings Page ~ of 111 aWVwonw n~u1 VVInp~ Vv, •~Ml. /'~Y. n. vw~. County L r'D I X Attach canplete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must indude, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. paw pip - 14p} - o} - ots0 (.2 R Please print all i for~1~.E ~ V E D Date Revi wed by ~ ~ Personal information you provide may be used for rrdary Purposes (F'rivacY Law, s. 1 .04 (1) (m)). ~ ~ ,~ ~~ ~:~'~yV~y,-~ 3 Property owner APR 2 2 2 0 0 2 Location K e,rn ~ Go Lot ~ (~ 1/45'r 1/4 S (d T 2~' N R (q E (or) Property Owners Mailing Address ST. CROIX COUNTY Lot Block # Subd. Name or CSM# (~ ~ ~ r. I' '_' NING OFFICE 2 ~ ~ fi t Code hone Number State T.ip City ^ City ^ Vllage ~ own Nearest Ro ad n ~~ `` ~~l ~J'1~) (~~5) -7775 1 r !~ 1~I" ~~. ~ New Construction Use: ~ Residential / Number of bedrooms ~~ Code derived design flow rate t~ ~'f~ - ~e ~ Q GPD ^ Replacement ^ Public or t~mmerdal -Describe: Parent material O V f "~ +(,~„$ ~ Flood Plain elevation if applipble b f /~' ft. General comments s~ S~ ~ ~ ~ (e ~ ~ Cr'~ ~ 3 p and recommendations: Boring # ^ Boring ._ iri J t~ Pit vrouna sunacx CtCV. ~Lw ~ i v n. ucNu~ w uununy ~a~av~ ~ , c o ~~ ~. Sal Appiiption Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Caor Gr. Sz. Sh. 'Etf#1 'Eff#2 Z l2~ l0 . 5~ ~ m ~ c~ -- . 5 .s~ 4 `t~ Boring # ~ Boring _~ (, Pit vrvurra Sunacx ~v.! yv(rV ~4 ucpui tv ~u~uuny iauvi - u~. Soil Application Rate Horizon Depth Dominant Caor Redox Description Texture Stratton: Consistence Boundary Roots GPD/RZ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 ( 0~I ~ ~ ._ 5 ~ l 2 ~-~~ c (-~ . S . 8 Z 1 ~ I ~ 5. I 2v~s bk ~S - ~ 2 t0 r y (~ ms d~ I -- _ 1.2 ,s.e ' Effluent #1 = BODS > 30 < 220 mglL and TSS >30 < 150 mg/L CST Name (Please Zt13 £s`~Urt' ~~. S~wle~seF w I SUoZ~ ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mglL ~~ CST Number ~__ Zs33 0 9 :Evaluation Conducted Telephone Number `7l S' Z47 40©$ Party ~~ ~ Parcel ID # Page ~ of ^ Boring l ~\ BO1'"g # Q ft. Depth to flmitin factor ~ 1 LJ in. ®. Pit Ground surface elev. 99 3 9 Soil Application Rate l C Redox Description Texture S6uchue Consistence Boundary Roots GPD/ftz Horizon ~ Depth in. o_ l ! - or o Dominant Mur-sefl p ~ Qu. Sz. Cont. Color -- ~~I ° ~ Gr. Sz. Sh. 2 k LmS cS ~ -~ 'Etf#1 ~~ . FJ 'Eff#2 .~ - 3 i ID ~m5 - - • `~ ~-2 ~- 'Y.3j 9~ •lo ~ 9S Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Appliption Rate Horizon Depth Dominant Color Redox pescription Texture Structure Consistence Boundary Roots GPOfftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Etf#'I 'Eff#2 Boring # ~ Boring ^ Pit Ground surface elev. ft Depth to limiting factor ~. Soil Application. Rate t C l Redox Description Texture Stnrcture Consistence Boundary Roots GPD/ftz Horizon Depth in. or o Dominan Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 'Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 =GODS < 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 (R07Po0) PAGE~OF~ ~TA_1~~E L3a s f LOT# ~ LEGAL DESCRIPTION S~ ~~r ~ ,S f 6 T 2~{ ,N,R / Q E(or~ SCALE: 1"= ~-In' BM 1 ELEVATION / ~ G • U BM 1 DESCRIPTION ~ ~-~'y_~~-.~z ~. ~ le o BM 2 ELEVATION~q, ~f C~ i` BM 2 DESCRIPTIONT~ r~ 5~-~-G/ I~oc~ SYSTEM ELEVATION / y ~ ~ 3d ALTERNATE ELEVATION ~~(~ 3 a CONTOUR ELEVATION Q 4~ 3U ~- lGV. 36 r ~ !' ~ SIGNATURE ~~ ~ I r •> m~ ~/ ~t`~~ ~ ._ _ _ _ .~ N ~-e.C~ ~ a ~~ -a f6~.~ aq,3~ 3-~ 3~3 ~-- S K~~ ~-y f~- 3-~ p 6 ~ I ~~ ~~~Z DATE J` Z ~' O ~ is .c'o m ~ ~ . ~~ ~~a* a.~x~m U W # ~ p .-1 tai aNO Q-"' N ~ !~ O U ~ ~~ ~V *---~ ,--~ ~ V ~ , o v H ,~ ~ bdp O •~ O U O .~ a_ tom.. a~ ~, .~ O ~~j # V # O ~ ~ w g~ 5 t 1 N B ~ .Q C~. ~~ O ~ _ ___ ~ _ .. [[CC(11~~~ ~ ~ ' ; ~ ~ `~ '~ II, `\~` ' " '. ~ ` ` 1 `~ ~ ~~'. 1 ~~ -, -- ~: :: ~ - - _- ~ 0 =- -_ ~ ' - .z - _ ^'1 ;~ j ~ ~ C ~` it ~ b ~ M C7 s m t II F'! w ~ .° 1 i ., ~..J ` "1 = t ~ ~ ~ `'~ a ~ e 'a .a ~. ~ w 6 'i i'i ~ ~ .Fa 0 0 H of .V-~ Q O N ~ ~O .~ m t, .~ .~.i ~~~ -~ c ~. ~ ~ . , ~ y 'CI ---~ ~ . ' -~ ,d =~( _: ~ _`~ ~ :; ~~ zi~ ~ ~= i ~ • ~ ,~. ~i m ,' ._~ O S ....rwer~w7'~fNfC ~I.E NIFORMATION Owner I,EG~A- lDrf/l y`s Permit ~ ~.}c~ 3~S NWK7n revwva.. a.... Number of Bedrooms ^ NA Number of Public Fatx1ity Units _ ~~ Estimated fbw iaverage) gal/day Des+grt flow tpeak-, (Estimated x 1.51 (j aUday Soil Application Rate _ aUdayfft2 Standard Inflttertt/Effkrent Quality Monthly average` Fats. Od & Grease iFOG) 53Q ~ Biochemical Oxygen Derrtar~ (RODS) <~" 20 mgJL ^ NA Total Suspended Solids iTSS) 51 `~ m9n- treated Effhtertt Quality Pre Mon~Y average _ t3rochernical Oxygen Demand (BODsI ~i0 ~ Total Suspended Solids (fSSI QO m9~ ^ NA -. Fecal CoGform igeomettic meant 51 O• cfu/10pm1 Ma~umum Effluent Particle Size 78 ~ dm- ^ NA Other: ^ NA "Values tYPica1 for domestic wastewater artd septic tarNc etrpte<tt. MAINTENANCE SCHEDULE Service Event ~i~7~i7~ vrww.w.~.~._- Septic Tank Capacity •/~ S-p ~ ^ NA Septic Tank Martufactttrer .. ^ NA Effluent Fiter Manufat~ttre r G ^ NA Effluent Fatrx Model =~ ^ NA pump Tank Capacity pump Tank Manufacwrer Pump Manufacturer ~ Pump Model Pret+reatrnent Unit ~ NA ^ Sand/Gravel Fitter ^ Peat Ether - ^ Medtatitcat Aeration ^ Wetland ^ Otsirtfection ^ Oar= Dispersal CeHtsi ^ NA In-Ground l~h-) ^ In-Gr+wrrrd ipr~rized- ^ At-Grade ^ Mound ^ Drip-forte ^ Other: Off; ^ NA Off; ^ NA p~ ^ NA rtditiort of tank(s) At least once every: 1Manirrtum 3 years) (] NA Inspect co when combined sludge and scum equals ~'~ iX,1 of tank vohtrrte ^ NA pump out contents of tanktsl ^ rrtortthisl ^ NA eve : ~ S yearel 3 i ~l Inspect dispersal rdlis) ry At (east once year s . ^ monthisl ^ NA .. Clean effluent filter At least once event- ~ yearisl " ~ ^ rnonthlsl - ~A Inspect pump, pump controls & alarm At least once every: ^ year(s) • ^ monthisl Q NA Rush- laterals and pressure test At least once every: ^ yearlsl ^ monffiisi _ ~• NA other:- At least arse event ^ year(sl ANA ~~TBYANCE INSTRUCTIONS one of the fopowing licenses ~ certifications: inspections of tanks and dispersal cegs shah be-made by an individual cmnlin9 Operator. Tank Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector; POWTS Maintaner, Septage rxacfcs or leaks, inspections must incktde a visual inspection of ttte tanlcisl to iderttifY any rrnt'.sirig ~ broken ware. measure the vohune of combined sindge and scum arin to check fw any back up or P~mg ~ effluent on the ground sixface. The dispersal ce8tsl shall be visually inspected to check the effluent levels in the observation pipes arin to rfieck for any pending of effluent on the ground surface. The pending of effluent on the ground stxfat~ may ktdicaRe a f2aTmg cortditiort ~d ~~ the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third iY,l or more of the tank volume, the mtttre contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter ~ 113` Wisconsin Administrative Code. ants, pretreatment All other services, ir-cluding but not I"united to the servicing of effluent f'ihers, mechanical or pressurized compon mitts, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Mamtamer_ A service report shall be provided to the local regulatory authority within~l0 days of completion of any service event. . iaHT UP AND OPERATION of tin oducts or other chemicals For new construction; prior to use of the POWTS check treatment tank(s- for the presence pain g Pr that may `anpede the treatment process and/or damage the dispersal cellist. ff high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when sod conditions are frozen at the infiltrative surface. Durifl~ Power outages pump tanks may fill above nomnal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal ceU(s- in one large dose, overbading the cell(s- and may resuK ~ the backup or surface discharge of effluent. To avoid this srtuatwn have the oonterKs of the pump tank removed by a Septa9e Sig Operator prior to restoring power to the effluent pump or contact a Plumber a POWTS Maintainer to assist :in manually operating the pump controols to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersr-1 ce~ls~. Do not drove or park over. or otherwise d'~sturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the fife of the POWTS: antibiotics; baby wipes: cigarette butts; condoms: cotton swabs: degreasers: dental floss: diapers; disinfectants: fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease' herblcldes• meat scraps" medications; oil; painting products; pesticides: sanitary napkins; tampons; and water softener brine. - ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. . • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. After pumping, all tanks and pits shaft be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN if the POWTS fails and cannot be repaired the following measures have been, or, must be taken, to provide acode-compliant replacement system: . A suitable replacement area has been evawated and' may be utd"ved for the location of a replacement sod absorption system. The replacement yea ~~ be protected from d"~sturbance and compa~ and ~~ rtOt be fringed upon by structure, lot lines and wells. Failure to Protect the replacement area will required setbacks from existing and proposed ~. t systems must result in the need for a new sod and site evaluation to estabish a she feet _ comply with the rules in effect at that fame. ^_ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ~. The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. if no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ` ^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat ~at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTH@i TREATMENT TANKS MAY CONTAp~I LETHAL GASSES AND/OR MISU~IENT OXYGEN.-DO NOT EN7t'R A SEPTIC, PUMP OR OTHER TI~ATMENT TANK UNDER ANY ~~~~~ ~~ MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFRCULT OR IMPOSSIBLE. - , #221180 _ ~ c enz~e e-,ner W~ ~~~~ _ (715) 635-9609 ~ POWTS INSTALLER POWTS ~~ 1 ~` v - Netne - Name Phone ~-/.i ' lv3 _ 4~ Phone /.~'' - S - SEPTAGE SERVICING OPERATOR (pUMPE.R- LOCAL I~GUI.ATORY AUTHORfTY 7~f Namelj! ~.~~x C~~` ~ ~/ Name Phone ~s ~ ~ _ {~,~ phone - a~' This document was drafted in compliance with chaPt~ Conan 83.221211Wlllldl&{f) and 83.5M11, (21 Ei (3-, Mfe grative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer _~1,~'ir-b/~/:;;_ ,~i~T _ _ Mailing Address 9 Y1' L,i1~9S,C/,..c h~~r~tyx/ or,~ S~/o16 Property Address 7 (Verification required from Planning Department for new City/State LEGAL DESCRIPTION Parcel Identification Number m2D -jyo7 -D7-~i C• 2~) Property Location ~E' '/., ~l/,~ %,, Sec, l0 , TAN-Rf~_Vl~, Town of lJ~~!>~0i~ Subdivision ,Lot # ,? Certified Survey Map # ~- Volume ~- .Page # Warranty Deed # 7S6 lp/ Volume ~ S~ 3 ~ Page # ~~ Spec house ^ yes [9 no Lot lines identifiable des ^ 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 is 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, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in ro r o ratio condition and%or 2 after ' P Pe Pe g () inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification, stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days. of the three year expiration date. - / / SIG ATURE OF ICANT DATE OWNER CERTIFICATION 1 (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. / I SIGN OF ICANT 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 2523P 043 - STATE BAR OF WISCONSIN FORM 1-'1998 WARRANTY DEED Document Number ' This Deed, made between Rodney G. Nelson and Marvbeth R. Nelson. husband and wit's. Grantor, and Keeton J. Bast and Oonalda J Sceer-Bast. husband and wife, Grantee. Grantor, for a valuable consideralion conveys to Grantee the following described real estate in St. Croix County State of Wisconsin (the "Property"): ~s~><~~ 1lATHLEEN H. NALSH REGISTER OF DEEDS ST. CROIX C.O.. MI RECEIVED FOR RECORD 03/08/2004 12:30Pt1 MARRANTY DEED EXE071 # REC FEE: 13.00 TRANS FEE: 2175.00 COPY FEE: CC FEE: PAGES: 2 Area Name a RETLTRN~ ~ - Burnet Title _ 7550 France A~ ~ ~~ First Floor Edina.lrlN ;~~=' f 1'N- Past ' ~_ C'entr?l 00.1009 20 000/ 020 1010 80 000 Parcel Identlflcatkxi Number (PIN) This is homestead property. (is) (is rwt) See Exhibk A attached hereto Together with all appurtenant rights, title and interests. Grantor warra`nls that the title to the Properties good, indefeasible irr -r" simple fee and free and clear of encumbrances except ~ \ ~ ' - day of ~ C.'l_~ , 2004. i Dated this (SEAL) (SEAL) ••~l ~~Ec,~ ~ ~1~~ . Rodney G. Nelson Ma et .Nelson (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, authenticated this day of TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Slats) THIS INSTRUMENT WAS DRAFTED BY Cokiweil Banker Burnet 1301 Coulee Road Hudson, WI 54016 4-22808 (Signatures may be authenticated or acknowledged. Both are not necessary.) Names of persons sioninp in any caoackv must be typed r } ss. St. Croix County Sl ,npeQ rr~gy came before me this ~_ day of / / ~ r\ . 20~ the above named Rodney G. Netson and Marv Beth R. Nelson. husband end wife to me known to be the person who executed the foregoing instrument and acknowledge the same. Notary Publ tale of Wi in My commisslo is ~~~~~t, s to expiration date: NOTARY PUBLIC ) PAM A. SPENCER :slow their siunature_ NOTARY PUBLIC 1~ STATE BAR OF WISCONSIN Wisconsin Legal Blank Co, Inc. 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