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HomeMy WebLinkAbout040-1266-00-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit N 574307 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 1� / Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)]. 7 � -VI Permit Holder's Name: city Village X Township Parcgi T x No: Lane, Thomas & Dawn ro , Town of 040-1266-00-000 CST BM Elev: Insp.BM Elev: BM Description: Section/Town/Range/Map No: 0v L--0 9 T if _ / LST 16.28.19.1442 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER .,,%t� CAPACITY STATION S HI FS ELEV. // C S � /0Z, 0-0 Septic Benchmark Dosing / �;_D Alt. BM Aerate 101- B �CJv 5�G ,S 9 6- Z Holding St/Ht Inlet n r 13 �u-� y / TANK SETBACK INFORMATION �" St/Ht Outlet Gera —� TANK TO v P/L, E L Vent to Air Intake ROAD Dt Inlet Septic / ) .f a Dt Bottom 52 & b s /. S Dosing Header/Man. Aeration Dist. Pipe Holding Bit.System 12 Final Grade PUMP/SIPHON INFORMATION O / ee Manufacturer Demand St Cover 2 �p GPM ��J Model Number //[[//,l .��� `7v TDH Lift , Friction Los System ead TDH Ft ! Forcemain Length a ,, Dist.to well 2 SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length / No.Of Trenches PIT DI EN ONS No.Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L 15 BLDG WELL LAK /STREAM LEAQHING Z Manufacturer: INFORMATION _75—<7. CHAM R Type Of System: J / I u Model Number: ZXIAn Gy DIST SYSTEM Hea r/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake ? Pipes) el 2 / 2 /� /L / /7 d /r Length Dia Length Dia Spacing_ 7 L SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only 70 6 11 j__1No Depth Ov er Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes i`;= ] No v:! Yes COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / T/ I spection#2: �� Location: 306 Empire Builder Rd.Hudson',DW,1 54016(SW 1/4 SE 1/4 0 T28N R19W) Glover Sttat_ion�th Add Lot 1 Parcel No: 16.28.19.1442 1.)Alt BM Description= Top 11 t ' /7"�� �11�1 j1.0 ��" P10—i bk- 2.)Bldg sewer length -amount of cover Plan revision Required? [ Yes Use other side for additional information. _7 f SBD-6710(R.3/97) Date Insepctor's Signature Cert.N . PLOT PLAN PROJECT Thomas Lane ADDRESS 1800 Grev Fox Lane Hudson Wi 54016 SW 114 SE 1/4S 16 /T 28 N/R 19 W TOWN Troy COUNTY ST.CROIX MPRS Shaun Bird 226900 DATE 7/30/14 BEDROOM 4 CONVENTIONAL IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND XXX SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE 765 HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 600 # of chambers none hL BENCHMARK V.R.P. Top of steel fence post ASSUME ELEVATION 100° Filter BEAR Filter ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark SYSTEM ELEVATION 96.0' All piping shall be SDR 30/34,within 10' of tank,piping shall be Schedule 40. Scale = 1 /4" = 10' 315' Property Line Grading is to be done to divert run-off away from system 9 , 94' 95 96' Tank is to be properly bedded and provided with B-2 lockdown cover with El Well is to meet approved warning all WDNR labels setbacks Pro 4 Bedroom B-3 — -75- House 10% Slope Cle_ anout -�h�e, et&e-r` tua_& At-, B.M.* �I��y Prs /v� - Gi! � tt Acces � B- boTank Building To Empire Builder Road Area 15' below system is to remain undisturbed / - -fb I V 3 -perty Line �. County Y Safety and Buildings Division 1 t 201 W.Waste n v lox 7162 Sanitary Permit Number(to be fined in by Co.) c ��€ ` ` Sanitary Permit Application StmeTrensactionNmnnber In aceordan SPS 3832 de,1(2),Wis.Adm.Co submission of this form to the appropriate governmental unit 7 �y:3o ✓ is required prior to obtaining a sanitary permit Note:Application forms for state-owned POWTS arc submitted to Project Address(if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s.15.04(1)(M Stats. n / L Application Information-Please Print All Information Property Name Parcel# Property s Mailing Address Property Location / d.�, v<Lot <' �� City.State �J Zip Code Phone Number (� 1/. y., Section✓ T�N> R17E II Type of Building(check all that apply �r: �# 1 or 2 Family Dwelling-Number of Subdivision Name Block# ❑Public/Commercial-Describe Use ❑City of ❑State Owned-Describe Use CSM Number ❑Village of Town of,Z�r — III.T (Check only one box on line A. Complete line B if applicable) A" e w$yst ❑Replacement System ❑Treatment/Holding Tank Replace anent Only ❑Other Modification to Existing System(explain) B. ❑Permit Renewal Permit Revision ❑Change of Phunber ❑Permit Transfer to New List Previous Permit Numbs and Date Issued Before Expiration Ownez IV.Type of POWTS S stem/Com nent/Device Check all that a ❑Non-Pressurized In-Ground ❑Pressurized in-Ground ❑At ommd>24 in.of su je soil El Mound<24 is of suitable soil ❑Holding Tank ❑Other Dispersal Component(explain I tment Device(explain) C, r V.Dies areatment Area Information: c ✓►l e �'; �5 Design Flow(gpd) Design Soil Appli "on Rat�dsf) Dispersal Area 717 sf) Dis Area Proposed(st) S El n 6r�C� ✓� VL Tank Info �� 1DV Gallons Units Manufacnuer Tanks „ , a 23ew�,_ ds 8 .0 8 v °a a m m rn ii C7 a. septic Dosing Clatebe X ; VII,Responsibility Statement-Jf4c undersigned,ass ntibility for instatiation of the POWTS shown on the attached plans. Plan 's ame(Print} Plumber. MP/MPRS Number I Business Phone Number /J 7z, Plumber's Address(Street,City.State,Zip Z, ZZ C <--� VIEVtounty/Department Use Only Approvtd ❑Disapproved Sermit Fee Date sued Issuing Agent Si '? ❑Owner Given Reason for Denial J 7 1 l ' �` /i�<%Y✓� DL Conditions of Approval/Reasons for Disapproval 4 ' � i-c- c ��_ l A_("� el' e' tri. / -' A to eompkze plain for the system tad submit to the County only on paper not less Bun 8 in z l l inches in size, P, �t- .S �-S 3��•�vC� J7' SBD-6398(R.11/11) oEexMEn� DIVISION OF INDUSTRY SERVICES 141 NW BARSTOW ST Fl-4TH WAUKESHA WI 53188-3789 Contact Through Relay www.dsps.wi.gov/sb/ www.vAsconsin.gov �1 osBtpNP� Scott Walker,Governor Dave Ross,Secretary August 27, 2014 CUST ID No, 226900 ATTN.•POWTS Inspector SHAUN R BIRD ZONING OFFICE BIRD PLUMBING INC ST CROIX COUNTY SPIA 1432 120TH ST 1101 CARMICHAEL RD NEW RICHMOND WI 541011 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 08/27/2016 Identification Numbers Transaction ID No.2445302 SITE• Site ID No. 800500 Thomas Lane Please refer to both itlentiftc�on numbers,' 306 Empire Builders Rd above,m aII correspondeWe wtth the Town of Troy St Croix County SW1/4, SEI/4, S16,T28N,R19W Lot:81,Block:4,Subdivision: Glover Station 5TH Add. FOR: Description:Mound,4 bc&oom Object Type:POWTS Component Manual Regulated Object ID No.: 1475555 Revision;Maintenance required; 600 GPD Flow rate; 24 in Soil minimum depth to limiting factor from original grade; Sy-stem(s):Mound Component Manual -Vex. 2.0, SBD -10691-P(N.01 101,R. 10112),Pressure Distribution Component Manual-Ver. 2.0, SBD-10706-P(N.01/01,R. 10/12); Effluent Filter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. The owner,as defined in chapter 101.01(10),Wisconsin Statutes,is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: This system is to be constructed and located in accordance with the enclosed approved plans and with the"Mound Component Manual for Private Onsite Wastewater Systems VERSION 2.0" SBD-10691-P(N.Q,4 1,R 10/12)and the'Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems �QN 2.0" SBD-10706-P(N.01/01,R 10/12). Z OP The building sewer and distribution network piping shall be of material listed in Tab/10 119 d"384.30-5, Wis. Adm. Code. 4P In the event this soil absorption system or any of its component parts ma n as t reate a health hazard, the property owner must follow the contingency plan as described in the approv n addition,the owner must comply with the operation,maintenance and monitoring duties as described itl motion VIII of the mound component manual. A copy of this information must be given to the owner upon completion of the project. All holding/treatment tanks are to comply with SPS 384.25(7)(a). SHAUN R BIRD Page 2 8/27/2014 Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. Access to the filter for cleaning must be provided per SPS 384 product approval conditions. 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. Stats. Owner Responsibilities: • SPS 383.52 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. SPS 383.54(1). • SPS 383.52(2) A POWTS that is not maintained in accordance with the approved management plan or as required under s. SPS 383.54(4)shall be considered a human health hazard. • SPS 383.55 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. 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 cons``—ucLiory ins`allatioru upeiation. In granting this approval the Division of Industry Services 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 and the POWTS management plan to the owner and any others who are responsible for the installation,operation or maintenance of the POWTS. Sincerel , Fee Required$ 85.00 This Amount Will Be Invoiced. When You Receive That Invoice, Julia Lewis-Osborne Please Include a Copy With Your POWTS Reviewer 2,Integrated Services Payment Submittal. (262)397-6005, Fax: (608)283-7481 WSlWt '.gode',7Cs3 julia.lewis @wi sconsin.gov Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Industry Services (formerly Safety&Buildings)will be modified. Code references with prefixes starting with"Comm"have been replaced with"SPS"to recognize the relocation of the Division of Industry Services from the former Department of Commerce to the Department of Safety&Professional Services. Additionally,all IS(formerly S&B)codes have been renumbered and addressed in a"300" series. For future reference,the Wisconsin Commercial Building Code will be addressed by SPS Chapters 360-366. RECEIVED � AUG - Cover Page 4 2014 WDUSTRy SERVICES Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 7/30/14 Owner:Thomas Lane Location: SW1A SE1A S16 T28 N,R19W 306 Empire Builder Rd. Troy Manuals Used: Mound Component Manual Version 2.0 (01/31) Pressure Distribution Manual Version 2.0(01/31) Page# 1. Cover Page 2. Mound Plot Plan 3. Mound Cross Section 4. Pipe Cross Section/Pipe Layout 5. Pump Chamber Cross Section 6. Pump Curve 7-8. Maintance and Contigency plan 9-11. Soil test 12. Filter Specifications a cross section Shaun Bird Signature License num r 26900 � Ty f SF'R�c Np�N Mound System Cross Section and Plan View k Dimeasian Feet 1,77 J A t r. B l D T A E W 41 [ F , .. . . .. . ..... Z G . . . . . . . . . ..: t .. ......... ... . . . . .. t I I Y' :...... . . . . . . . .............. .. J K t �"'.. w iwi;..-wr-.wr..."-w.:.-wyt c.wrr nrr•..+iri-:vr...iW.rri ir':r wi+.'.w rYr-y.+Y. Yr ai►:..i: "rY +Yr:' K ,�.----- B 1 Z L S % f"" =Topsoil =ASTM C-33 =Clean aggregate =4 in. sch. 40 pvc t 1 Cap Material sand fill %to 2 %in. dia. observation pipe Geotextile H YJ- Fabric — F 4 , D E Ft Contour Plowed Surface . . . Y . Slope Direction ,ter GENERAL INSTALLATION: The mound area is staked out along the design contour. Existing vegetation is mowed and raked off the site. The mound basal area (L x V) is plowed with a moldboard or chisel plow. Plowing may not proceed if the soil is wet enough at the plow depth to form a '/4 inch soil wire when a sample is rolled between the palms of the hands. ASTM C-33 quality sand is placed immediately after plowing. Sand is placed with a tracked machine keeping 12 or more inches of sand under the tracks or is placed overhead by a backhoe. Special care must be used when placing sand of less than one foot thickness to minimize compaction of the plowed surface. After the topsoil cap is placed, the entire mound is seeded and mulched to promote vegetative growth, limit erosion and protect from freezing. The observation pipes are slotted in the lower 6 inches and secured in place with rebar or a closet flange. i 10/07lgj Page of Property Owner_ Parcel ID# Page of Boring# ❑ Boring L J Q pit Ground surface elev. ft' Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIT 1 in. Munsell Qu.Sz. Cont.Color �Gr.Sz.Sh. 'Eff#1 I 'Eff#2 a Boring# ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. DoiliEplication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIfF in. Munsell Qu.Sz. Cont Color Gr.Sz.Sh. 'Eff#1 'Eff#2 ❑ a Boring Boring# Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application Rate Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPDIfF in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'Eff#1 'Eff#2 Effluent#1 =BOD5>30<220 mg1L and TSS>30:<150 mgA- 'Effluent#2=BOD3 130 mglL 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. SBD4330(8.6/00) Pressure Lateral Layout Two Laterals — End Manifold o Threaded Cleanout Lateral Turn-up --10 Plug Manifold ' M X --� L T Long Force Main Sweep 90 Bend Distribution Network Specifications '� Pressure System Construction Lateral Diameter 2- In. Manifold Diameter 2- In. Laterals are constructed of Schedule 40 PVC Orifice Diameter In. pipe. Orifices are drilled perpendicular to X Orifice Spacing) In. the pipe with a sharp drill bit and face down. L (Lateral Len gth) Ft. Lateral turn-ups terminate with a threaded M 'fold Le Ft. ceanout plug and are enclosed in a 6-8 inch Force Main Diameter In. diameter lawn sprinkler valve box accessible Force Main Length Ft. I from finished grade. • • • • • Grade • • • • • • .:. • • • 6-8 Inch Lawn Sprinkler Valve Box Page of 03/05 Igi Septic-Dose. 'dank Cross Section Arid Pump Perfbima C Specifications Tank Manufacturer Pullnp atuacr is , Tank Model Number I moM Number Vo Total Talc 7, S A1ffim 1V1u L S Max.Bray Depth t r- Alarm Model Number e Switch TYpo Filter Wit•'twev, Tout Dyn=Ac dead(MM-Fact Fiiltec Model,Number DiNlal Pile11111111110 'a Netwock Loan Mmin�tms Pump Rr+duired Faace Mafm Loos �� Ft TDH Total - oudist Mme l et.4"Above Grads With Mombole Min.4"Above Grade Loddog Dodo*. b*Mamie Mowed With Locking Device <s"Below Grimb sealed WdKd& Wad JuNdou Boot 4% n4 i i � � r r �► s aa� r r �` � �.. — sl>tod Grade vm t)&• 12" Diworm" Above Onds Means With Vent Cap - Inlet },• A, 1/l, ovi Rleew" Weep Tank V ON B Hole •.►• Volume Gal. ►. .:, Dimeinaioa: •. • . IncMs If- :y B; 2 . :.d Bottom -S r` :: won r D .;. r ( D f J Ft ., Tatal as a .• .• ..ta acs aasaa• • • ••.• a ••:'�••.s a.,• �•�• •a a► i►Pa► i• •:'•a►:a a.►:•lla►a•:a•Y►.► J►: ►:•.r.•aa-:i►:..s�ti�•.,r ..,.aa E in Ce Welt the GZNgA,L WSTl TION: The.wptic/dose _%* is bailed r maY me®afaaaaor's gra bm as�°twe bdc O(*1 �cum be cx0e0&d L l, m the�W�f' itrlled. d1i inlet sled cadet is s t4 u ' . '6e 116m, 1, b sWrad r Sidi-44 PVC to 16�°the fork laid oa s wclitl�iE+G.3�1 cell CorsRt wwwvatlon and the sloe.im sMied.waoa • of 02/05 I,l SEW" ser,11" 4/10 hp Submersible Effluent Pump, 3/4" Solids Ce wb uctloa now-Umorwi ub 0 so 100 160 200 2so 300 CO, d r oxy col ed 1 AMW ss 110 so o IjpalllrrllAalttierll `fhautnoplaetie► 26 8 , 20 a }' f 18 f s s } 4 ti14 hrt ,And 4. to 3 - 2 1 6 0 9 ,�{ 0 20 40 60 so Flow- + F ON + UT SEN-40-AF SEN-40 SpecMlcartlstas 14 Franklin lilh•vtria 400 East spring street,BlufttoN IN 46714 Tel:260.824.2900•Fax:260.8242909 www frnnk2n4*bk.com Fpm:9110199 7-11 iai Soil Test Plot Plan Project Name Thomas Lane Shaun /ir Address 1800 Grey Fox Lane ,� Hudson Wi 54016 CST 26900 Lot 81 Subdivision Glover Station 5th Add Date 713 /14 S W 1/4 SE 1/4S 16 T 28 N/R19 W Township Troy ❑ Boring 0 Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of steel fence post System Elevation 96.0' *HRpSameasBenchmark 315' Property Line Scale = 1 /4" = 10' 93'94' 95' 96' B-2 B-3 10% Slope B.M. B- 1 To Empire Builder Road 325' Property Line Safety and Buildings Division/`l 201 W.Washington Ave.,P.O.Box 7162 Sammy Peo nit Number(W be Bad in by Co.) Madison,WI 53707-7162 `7 O�X GOVN p VV �� v Starve Traction Number MN,vN\ Sanitary Permit Application Z in with SPS 36321(2),W3a.Aden.Code,mbmbAm of d1k famm to rho appWinto govrom=al unk is reqused prior to obtammg a samtsay peami. Note:Appticatiae forma for stoto-owued POWTS we submitted to Pmpa Address Cif ddl=at then mailing addreas) the Dopmtmesn of Safety and pmfessiooal Savm peranoal mftmatm you provide may be mad for secondary VMMU io acoordmmce widr the Pdvwy Lay s.15.04(IXMI Stata. m L Laieraatioa—Pteaae Print AN Information rM �.v Property Owaer'a Name Parcd� 7-4 /a n� ©410-/26(0 r 04 DOD Property owm's Maiog Address Property Location Y&O �i o 1111 AA1 f p�, State Zip Code / Phone Number (� y,, J �V4 Section �f.C� V/IZ '27D '31917 TZ-19 N: R II. of BaNdis=(claork all that apply) 1 of# --f- 1 or 2 Family Dwdit–Number of Be>dio Name fvkl ❑Public K a —Dexcttbe Use t 4 J6 (� city of ❑State Owned—Describe use �/w (A'"m� 1 CSMN/umber �visage of of HL Ttp of Perm m('hem k only one box on line A. Complete line B if ap '+ S ❑Replacement System ❑Tns neaVf1olding Tank Only 'on to System(explain) B. ❑Permit Renewal ❑Permit RavWm ❑aungt ofPltmnber Before Expiration IV.Tvw of MW IS S S Cow ■4mvDeviem Check aN that a 1 0 Non pressnriaed brGroud ❑Pres crized in-(maid ❑Atdrprade >24 is of sortable s 1 <24 in.of suitable soil ❑Holding Tank ❑Odra Dispersal Component(emgmbm 0 + Pretr�arat Device{explain) V.Disporuffroatinent Area Information: DcOp Flow(Vd) Dearg► Dmspasal Area (sf) Digxrsal Area (� Dosing Climber VI.Tank itmafo C m Cmlloffi 0 Of v New Taoka Fla Tnalas ry v�1 in w TU 'a Septic a Holding Tads 7 VII Responsibility Sul wont-I,the for imma0atiaa otthe?ONM aimewmaos:the a ptaaa. 1�/( s Name(Print s Sigosture UIP/Mm Number Bumnem Phone Number Plumber's Address(street.City.State,Zip VIII. can ant Use Disapproved Permit Fee 00 Dare tvsued issuing ❑Owner Given Remaou for DeuW L -- IX. for Disapproval ' vu S-7 '"� ill 3 Gc�n r.�2.-tv-ri�7 1.Septic tank,effluent filter and y� "- 7 � �'yn dispersal cell must b-e serviced/malni alned t as per management plan provided by plumber.® �(�,�y, �� 2-000 Vr1Z"� 2.All setback requirements must be maintained as vei ea, ` Ur ties,] , lad wham e@e:ce®y o.paper am bra Uln E rR x 11 iami�es.a'ar/c SBD-6398(8.11/11) 8241142 Document Number Document Title TX:4197327 St. Croix County 998183 BETH PABST Affidavit for a single POWTS REGISTER OF DEEDS ST. CROIX CO., WI servicing Two Structures via Private Interceptor Main RECEIVED FOR RECORD 07/03/2014 11:21 AM EXEMPT #: Name—(Owner) Typed or printed REC FEE: 30.00 being duly sworn, states,under oath,that: PAGES: 1 He/she is the owner/co-owner of the following parcel of land located in St. Croix County, Wisconsin,recorded in Document Number__912670 St. Croix County Register of Deeds Office: Recordinx Area A parcel of land located in the SW'/, of the SE'/<of Section 28,T29N—R Name and Return Address 19W,Town of_Trov_, St.Croix County,Wisconsin,being duly Thomas&Dawn La described as follows(include lot number and subdivision/CSM or detailed /-wo ;* legal description: pS'D�, Lot Eighty-One(81), Plat of Glover Station Fifth Addition in the 040-1266-00-000 Township of Troy,St. Croix County,Wisconsin Parcel identification Number(PIN) As owner of the above described property,I acknowledge that a Private On-site Wastewater Treatment System (POWTS)serving the primary residence is sized for four(4)bedroom(s)with a design wastewater flow of 600 gallons/day(DWF is based on 150 gpd/bedroom @ 2 persons per bedroom). A maximum of eight(8)occupants are permitted; if the number of occupants exceeds the maximum for POWTS design,the system will be undersized to accommodate increased wastewater flows and/or contaminant loads and may be subject to premature failure. An accessory structure NOT to be used as a 2ad dwelling has been connected to the POWTS via Private Interceptor Main Sewer(PIMS)in compliance with SPS 382.30(12). I understand that disclosure of this information will be made to any parties interested in purchasing this property in the future. Dated this_�day of V d L�I 22014. * * UTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) )ss. St.Croix County. ) 2 authenticated this day of Personally came before me this day of (year) 1111�� �U lV (year)the above named NS►O * Tally, _ TITLE: MEMBER STATE BAR OF WIC Z to me known (If not, AuS`,G Je the person(s)who executed the foregoing 1`> rum d acknowledge th same. Authorized by§ 706.06'Wis. Stats'�, THIS INSTRUMENT WAS DRAFTEi`1�y F�W'`,`,`� Pamela Ouinn,Land Use Specialist Community Development Dent. Notary Rublic, State of Wisconsin (Signatures may be authenticated or acknowledged. My Commission is permanent. If not,state expiration Both are not necessary.) date: Date: "THIS PAGE IS PART OF THIS LEGAL DOCUMENT—DO NOT REMOVE" This information must be completed by submitter: document title.name&return address.and Eff(if required). Other information such as the granting clauses legal description,etc.may be placed on this first page of the document or may be placed on additional pages of the document.Sag, Use of this St.Qi �i$ I -AseRe1JA aQ uinent and 52.00 to the recording fee. Wisconsin Statutes,59.43. Axrng DIVISION OF INDUSTRY SERVICES 141 NW BARSTOW ST FL 4TH WAUKESHA WI 53188-3789 Contact Through Relay ru www.dsps.wi.gov/sb/ �4v www.wisconsin.gov Scott Walker,Oovemor Dave Ross,Secretary March 25,2014 CUST ID No. 226900 ATTN.•PO WTS Inspector SHAUN R BIRD ZONING OFFICE BIRD PLUMBING INC ST CROIX COUNTY SPIA 1432 120TH ST 1101 CARMICHAEL RD NEW RICHMOND WI 54017 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 03/25/2016 Identification Numbers Transaction ID No.2382408 SITE: Site ID No. 800500 Thomas Lane Please refer to both identilicaubu numbers, 306 Empire Builders Rd above,in all corresponden€ witli'.the Town of Troy a St Croix County SW1/4, SE1/4, S16,T28N,R19W Lot: 81,Block: 4, Subdivision: Glover Station 5TH Add. FOR: Description:Mound,4 bedroom Object Type:POWTS Component Manual Regulated Object ID No.: 1475555 Maintenance required; 600 GPD Flow rate; 30 in Soil minimum depth to limiting factor from original grade; System(s):Mound Component Manual-Ver. 2.0, SBD-10691-P(N.01/01,R. 10/12),Pressure Distribution Component Manual-Ver. 2.0, SBD-10706-P(N.01 101,R. 10/12); Effluent Filter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. The owner, as defined in chapter 101.01(10),Wisconsin Statutes,is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. 0 The following conditions shall be met during construction or installation and prior to cupancy o sm This system is to be constructed and located in accordance with the enclosed approved ans-:and oun Component Manual for Private Onsite Wastewater Systems VERSION 2.0" SBD-10 - .01/ l j(1 ) . the"Pressure Distribution Component Manual for Private Onsite Wastewater Treatin to s It SBD-10706-P(N.01/01,R 10/12). O Z 7 v The building sewer and distribution network piping shall be of material listed in Table and�A4.30-5, Wis. Adm. Code. .o © - Z In the event this soil absorption system or any of its component parts malfunctions so as e a health hazard, the property owner must follow the contingency plan as described in the approved plans. dditon,the owner must comply with the operation,maintenance and monitoring duties as described in secti n VIII of the mound component manual.A copy of this information must be given to the owner upon completion of the project. All holding/treatment tanks are to comply with SPS 384.25(7)(a). SHAUN R BIRD Page 2 3/25/2014 Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. Access to the filter for cleaning must be provided per SPS 384 product approval conditions. 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. Stats. Owner Responsibilities: • SPS 383.52 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. SPS 383.54(1). • SPS 383.52(2) A POWTS that is not maintained in accordance with the approved management plan or as required under s. SPS 383.54(4)shall be considered a human health hazard. • SPS 383.55 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. 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 Industry Services 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 and the POWTS management plan to the owner and any others who are responsible for the installation,operation or maintenance of the POWTS. Sincerely, Fee Required$ 250.00 This Amount Will Be Invoiced. ---� When You Receive That Invoice, Julia Lewis-Osborne Please Include a Copy With Your POWTS Reviewer 2,Integrated Services Payment Submittal. (262)397-6005, Fax: (608)283-7481 Wi !1rRT°per X633 julia.lewis @wsconsin.gov Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Industry Services (formerly Safety&Buildings)will be modified. Code references with prefixes starting with"Comm" have been replaced with"SPS"to recognize the relocation of the Division of Industry Services from the former Department of Commerce to the Department of Safety&Professional Services. Additionally,all IS(formerly S&B)codes have been renumbered and addressed in a"300" series. For future reference,the Wisconsin Commercial Building Code will be addressed by SPS Chapters 360-366. Cover Page FD lIV BAR 192014 Shaun Bird DUSrRYSE Bird Plumbing nc. RV�CES 9 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 3/ 18/14 Owner:Thomas Lane Location:SW1A SE1A S16 T28 N,R19 306 Empire Builder Rd Troy Manuals Used: Mound Component Manual Version 2.0 (01/31) Pressure Distribution Manual Version 2.0 (01/31) Page# 1. Cover Page 2. Mound Plot Plan 3. Mound Cross Section 4. Pipe Cross Section/Pipe Layout 5. Pump Chamber Cross Section 6. Pump Curve 7-8. Maintance and Contigency plan 9-11. Soil test 12. Filter Specifications an ross section J Shaun Bird p Signature Dn z License number 226900 r' mmv N < D c ° C PLOT PLAN PROJECT Thomas Lane ADDRESS 1800 Grev Fox Lane Hudson Wi 54016 ,SW 1/4 SE 1/4S 16 /T 28 N/R 19 W TOWN Troy COUNTY ST.CROIX SYSTEM ELEVATION 99.5' BEDROOM 4 CONVENTIONAL AT-GRADE CONVENTIONAL LIFT HOLDING TANK 1 2� :R-) MOUND XXX SEPTIC TANK SIZE 1?.-zgalions DOSE TANK SIZE 765 HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 750 # of chambers none BENCHMARK V.R.P. Top of 3/4" pipe ASSUME ELEVATION 1001 ❑ BOREHOLE O WELL *g,R.P. same as benchmark Grading is to be done to 98 divert run-off away 97' 99' from system 96' 98.5' B-4 315' Property Line Pro 4 Bedroom Area 15' below system is House to remain undisturbed 5% Slope B-3 Well is to meet all DNR B.M. 1 Cleanaut setbacks B-2 B.M.�2 �'` v► rf �N"Q B- 1 Huffcutt Combo Tank Tank is to be properly bedded and Pro 125' provided with lockdown covers with Accessory Building approved warning labels gpd Nor A Scale DW�Zt.I " — ' 2 acre lot To Empire Builder Rd 325' Property Line Mound System Cross Section and P1an'View Dimension Feet A J - B J ll D T E ,- A VY G Z. H.N' A I � V G.' I - J .. �. K 2. L K - B Z 'D3 R'. T. L I Slope S% ,.. h =Topsoil =ASTM C-33 =Clean aggregate =4 in. sch. 40 pvc Cap Material E=' .sand fill %2 to 2 V.in. dia. � observation pipe Geotextile E. MIN * R H Fabric D Hii E zY4 49�Ft Contour Plowed Surface Slope,Direction GENERAL INSTALLATION: The mound area is staked out along the design contour. Existing vegetation is mowed and raked off the site. The mound basal area(L x V) is plowed with a moldboard or chisel plow. Plowing may not proceed if the soil is wet enough at the plow depth to form a'/a inch soil wire when a sample is rolled between the palms of the hands. ASTM C-33 quality sand is placed immediately after plowing. Sand is placed with a tracked machine keeping 12 or more inches of sand under the tracks or is placed overhead by a backhoe. Special care must be used when placing sand of less than one foot thickness to minimize compaction of the plowed surface. After the topsoil cap is placed; the entire mound is seeded and mulched to promote vegetative growth, limit erosion and protect from freezing. . The observation pipes are slotted in the lower 6 inches and secured in place with rebar or'a closet flange. 3 10/071gj Page of Pressure Lateral Layout Two Laterals - End Manifold 4 Threaded Cleanout Lateral Turn-up ----10 Plug Manifold M X --� I L Long Force Main Sweep -Y'- 90 Bend Distribution Network Sp ecifieations Pressure System Construction Lateral Diameter 2.,. In. Manifold Diameter In. Laterals are constructed of Schedule 40.PVC Orifice Diameter . In. pipe. Orifices are drilled perpendicular to ' X Orifice SpEjnQ the pipe with a sharp drill bit and face down L ateral Len ' Ft. Lateral turn-ups terminate with a threaded M ' old Len Ft. cleanout plug and are enclosed in a 6-8 inch Force Main Diameter In. diameter lawn sprinkler valve box accessible Force Main Le Ft. from finished grade. • • • • • Grade 7i \6-8 Inch Lawn Sprinkler Valve Box Page of _ 0310519i 3 . Septic-Dose lank Crm S.w on And Pump Perf ma= Specffiitcati4ns Teak Manufaahuer Tank Model Number Model Number U Total Teak Capacity Alwm u Max.Bury Depth f Q A1lsm MOM Number c/ i sVdWh TM" 1,01e its Filter N( turer �R?- Total Dynamic lead f��-Foot Filter Wum�bor H Distal • IJaearork Las / Minimum Pump r R_oOtvd Fame Maya Lone / Ft TDH TOW Ou u Manhole 4"Above Ont4s,With Manhole Min.r Above Cnade. Locking Devisee. Inlet Manhole Sew+Mviiad Wilk Loelcuig Device 6"Below Sealad Wadert w,GR*Wvmd . Juncttoas Saar k. s '� � � i � r r ��i ••n Fiq�abed tirade . Vild)AFOL Ir Diaooaorx AbOMOM& Means • with Vent CAP i111�1. ••. balet BdMa {: •f A. 1/s Switch �� ti Weep }; a QPI .r, ;,;• Teak V ;y g. Hole .,. Voluaze t,,rai. .. .. Imes ,► Dimensi�► •App •• } •• Off Ewvafm C - B. 2 . .• .; 8lara� • . �ca Ft •: , fir'• BoOa O D �'3 Ft Z ••i Total i •, •:.• • • ••;► •,•► •ff • 's;►a s'i�f•.►•►•.• ••`i'a•;•i.;. •►�►••.►s•s►}•••'•;► • ,••� ..•r s►i s .' • a s. fled in &OOmIame, with the done."Ok is bedded.and lmk the tasn �� INl4'Tt LLA'i'ION: 'i'�e. dbWy as� not to 1a►e as eeotive looking daysce(padlock) be eneeMd wifout prior-tlPp '-Ihoie t fittings, and ,. nsaoceritr<t,t to��c wllh.wdartigist st the valet a d oudai i of ar The fmomihtwt is lime the tesdc laid on amble ti4 ► vo)MC-300 and. Coma 005 IJ SNOIIVIOOSSV 31380NOO 1SV338d NISNOOSIM V 1VNOIIVN o P wog-j}n:)d3nLI,MMM x 1111-E2L (S1U Xtl3 • :JO N38VUH �5 `7;� 91ST-bd6 (008) x 9W-£dL (SIL) VI 3�'3 a O V 07 ' �Ntll OI1d3S 2l0 dWOd (U 11n���nH NOTtl9 OSL/OSZ'I N � 62L4S IM 'Sl'1Vj VM3ddIH7 1NVld MUM 'd'D'd'N 133211S p�EZT bSTb '133f OJd z La o � rn ¢ z .J. w H r Zy 0 o W< J 0 Q p _ IY Vi d > 30 °Q U A J a LO ° a w x 16 ,Bb zl` oQ o 0 A Q H H U Q w y ""Q W WO Q q 3 W H 1I7 A L7 Ld q Q q W m w W W U �q m z HN z W .N Wcy Z:3 O m J W WU U O II 11 x W H O Vl d WO °q W W U Q ¢U ZZJ w U ?U O J W °° f Q J A Z W g U Q • ¢ Q. Q A W L7 O ai° U ti .S'9 �¢ J Q z O A 3o w in Y O W Q Q O ON U A A = A O O > Vl Ll IL ou co 4 W O N N F- N� > J 0 V I�L7 0 C6 m 05 N In M d Z i u II H O U Ku y W �q N J D Q l7 O J Y Z Q H v -----------------------, I � W L .OZ a F- l- r w � oc Cl)w ILL wN Z ih �NI -D °w ¢ V I I I I ? _ w U J � oD ICY N U Y =w LJ I N ^ I!7 O q z o W n Ln ,Lb ,E ¢ cu w A Ld ,L .09 H ¢ .LS W PD I J Y F- H v I I i I I � -----� INLET I I BAFFLE m {a n ey D D r- - o m Z z z C) 78' I 72' I 68' I I I cil � TI D r Z r3 7C E3 ^ W Z D D Z v Z yr � D - C3 Ln -0 m v to � v ut 78' I I 39 39' N m m Ln ED vI I ri 1\ L I a m OUTLET PROJECT, 4154 123rd STREET N.P.C.A. CERTIFIED PLANT HURCUTT CHIPPEWA FALLS, WI 54729 MP OR GALLON MEMBER OF: (u PUMP ❑R SEPTIC TANK C 0 A C R E T E. I n C (715) 723-7446 1 ■ www. 924-1516 � NABONAL k WISCONSIN PRECAST CONCRETE ASSOCIATIONS FAX (715) 723-7111 w www.huffcutt,caro ���$ h I��fiuent wast r _ SEMAO Series 4/10 hp Submersible Effluent Pump, 3/4" Solids 100 150 2M 260 300 :0 20 5 c r 4, •1 3 2 — s , 60 so > -- .r 121� wr dWELL 400 Eat Spring Street Bkftow%IN 46714 1�(+ � i;l!!ii!'ii:: i'�-ftf !',�9;�f(Ci t�.PF.I: . '>r... ;.:FF '.l: �}t•l�.�i.. . 1 : �.; POWTS*OWNER'S MANUAL&MANAGEMENT PLAN Page"t fIL.E FOSMATIOM gYST€M gpECIFLCAATIONS. Owner 7� �Q�JL� Septic Tank S p NA.: . 6e8 tl Tank Manus. NA . Permit s. 3 4 P S Egueut Fiker Mallubet+m E3 NA Nurtet of iedms O NA Fiker.Model on -Si a a.Ga1 Units ..,:.• pump-Tank. /� 1 DNA Number : . pump Ta*.Maomdfactww ,NA adimated low(a�'erar) F Doson tlf r,.. ..po*mnatewd x 1.5) SOY `� ~ piwoMwiufacturer O NA Sop 1pplicgloon Rafe 0 NA pump.Llodel y M0fw*' t P Utdt ©Peat.Fgter Q SwAV 4.vd F1W Fats,OU Grease (FOG) M mgA- a-Me.dmipid Aerad" O VVed&w. Biodhea"Q.Wqwoemand WW a20 mgA- Gooier. Total w) 51601mg& Maw I My ;areerage CeR ) . Pretr+�ed t�hrent Q Bbdmnkxd Demand ( s) M rr>9►i- 74tal <5oiids �'Fag�- G Otl�er: lOMW ecocAMformiceomew :S104 Maudcncn Effluent Particle Size K incur dtam v for.:. rao�r.nd VaN�es tYpk d for peatee Mrastswatx IIAiAtNTEdINCE SCHEDULE. Service gent Service Frequency (s) At least once orrery 0 months '�+9s) ( 3 Y+a•) scum equals erne-tt�ini{X);�tank volume Fnsped Conn of fa Pump out cats of tanks) When. combined skidge and �. s�s) (� VS.) tit mss) At°hst once every c� Clean t Ater At feasE once:every j!E3 t=amft!; S) Insped,p +PAP 8 alarm Atieast once every. t7,fit lad:ence.eve, O rrsh and Atleastonce every 0 months O year(s) NA cfrheri O months O year(s) Q NA At as , + &VUUTgRAICE INSTRUMONS one of°the foflo"V icenses or t �es of tanks aad&pm aF ce ft slid be made-by an 1r�vidua l carryur9 P© Vaster 11p i.q plumber;Master Pkuntaer Rid:Sewer:P©V1R$Inspector; Tank arspections Est ir>dude a visc�l'ktspec bn.of"the tanks)to iden"SW�°c;bcoken •/ soarn and to check fox airy back.up t we.�:w cracks or leaks:measure the volume Of COMS%d bev x and wcheck ft et$Vwt levels or.:pofg d,effluent Go?"ground surfwe. The dispersal eeN(s3 shah`be vlwa i msfa on the I i the:observetion pipes wW:to:d k for a� Of�le�Ort�t{f�" � Ttl@ P gr+oturd surface mW indicate a fafg condition and On lm�ed�be of e.locaf rtegul ocy a it- and scum in tank equals one-thmd(li or rnonz of ft u*volume,the 1iVtren fhe exxnbined ao + stixige �X e� �of in accordance.with ch. NR entire contents bf the tank shall be'. by a ge!;ng is"We Code: 115,Wwottsiri Adrrtin• - ts.Pretrea. .components,and any The eervidng:o#.efltuerd fps, or� � a certified pOVlfFS llAair�ir1ef. other ma intenanoe or mon g of•12 months or Jess shall be performed by A rem#gip;be Provided to the kx:at regulatory audio�ity within 1t)days of completion of any service event. STAFF(UP AND OPERATION prior to use of the Pt ucts or.other For new oor on, `IVTS d>adc tt it tanks)for the presence of. dwmkals that may impede the M3atnemt.Process and/or damage the dospersai tor.pn. -tD u h detected have,the contents of#w tank(s).removed by a seP�e sec kV operator.prior•to use. 41: Page �-- START UP AND OPERATION s for-the prosance of P� or 0 � tho the For new�,p� to use� P damage the d{sperSal ? if high oor�are detected have the conbcota of tab may impede the treatment �operator iron>'0 use. tank(s)removed by a sepla98n the Inflltrattwve surface. System start up shall not occur when loll condam is restored *0 eoarats wastewater will bo mp tanks may fill above normal homister levels. When p �backup�surface diedserge of efllusi t. During power ouft" PUMP in one large dose ovadoading the oeli(s)and may rowlt to to discharged to tits dispersal ( ) g Servicing Operate P th restoring power To avoid this sk.uation have the contents of ttne pump lank terr►on►� um oonKds to restore Norm levels effluent pump or contact a Plumber or pOWTS Maintainer to assist th manuethi opOmIn9 the P p within the pump tank. tmwise disturb or Compact,the area wghin Do not drive or park vehicles over tanks and dispersal oeas. Do not drive or park over,d o 15 feat dmm sbpe of any mound or ad-Orede 8011 ebeorP*m am&' and p the NO d the POW O: Reduction or elimination of the bilowirn0 from the wastewater stream may imprava the p°dOm�'° this ; fat; foundation drain bugs; condoms; 0011011 swabs: degreasers; dw*W 11048; � rrsedirortiossa oil; Painting produc�ls: antibiotics; baby wipe.; asoline; gmese; herbioides; +neat scraps; (sump pump) water; fruit and vega� brine. Pesticides;sanitary nook ,tampons; ABANDONMENT tstcsn out of service the following steps Shall betaken to insure that iha system ie PropetlY When the POWT3 fa8slawm �Comm 83.33,Wisconsin AdminisirdyS Code:. and safely abandoned canPU • • AN pIphV to teaks 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 SePIAP SwWcft OPeraw' • After pumping, all tanks and ids shall be excavated and removed or their covers removed and the void space filled with scpil, gravel or another Inert solid material. CONTINGENCY PLAN following measures have been, or must be taken, to provide a code ComPr If the POWTS fags and cannot be rspetrod replacerneM system. of a replacement sou absorption systefn. C3 A suitable replacement area has been evaluated and may be utilized for the den location not be in[VVW upon by roqui4ed The rop�emerst area should be pr+oEeded thin disdabatxw � area wit result In the need#*repleoemot setbacks Ilrom emstltg and proposed$111ftre,tot tines and wells. Failure ane. prate sn►aM systems n+1ed"" compty'"�tine nits in for a now sou and site eva luatlon to establish a suitade n�lsoern effect at that time. O A suitable replacement area Is not evelb ble due to setback and/or soli limitations. Barring advances in POWTS txhndogy a holding tank may be Installed as a lad resort to replace the failed Po WrS. The site has not been evaluated to idsn*a suitable replacement area. upon failure of the POWTS a soli and ails evaltsa�on must be performed to locale a suitable roplaoemeM area. If no replacement ales is availabb a holdNng tank real+be installed as a last resort to replace the failed POWTS. ' rid and g4ade soil ebs "on system may be reed m 1 � removal of the bbnnst at the IT OW" surface. Reconstructions,of such systems must comply with the rules In efFecot at that three. <aWARNING» SEPTIC,PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO T ENTER A SEPTIC,PUMP OR OTHER TREATMENT TANK TINDER ANY CIRCIJMBTANCE8. DEATH MAY RESULT' RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY 13E OlpRCULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER No Phone ,/f— -- �J� phone 7 J.� JP-- 8EPTAGE SERVICING OPERATOR MPER LOCAL.REGULATORY y Name Phone This docunrernt was dratted in Compliance with oheprer WS 393-nM(bX1)(d)a,(fl end 383.34(1),(2 a(3),WkmnWn Mmk+ialr "Coda. FILTER CADGE WrMUCTIONS Wrep_ °n' M"•" J yawl In r.t0*8 to aftem it is umq*pipe- a rJw!�.rr ,P==�ohm air�1 *a two mw*w ChM 6m dds ANOW MNWW.Is ask util:r„1, ifY�p FW WoWkibM uegln,r q� Gm oft tm a kd&Ow wwr WMbq t#M 0 �itlrk l�+pw. ri+arl pw err •� d"`ctwr ttl ld,bdl qw MaeF,as,par �w; - rpd VAS J1ZtiaS/1 is 'f".. c>IwiclAdia 8IM', d.iY..wd ipl v tlw�wr srroT wt t bar w ft �ft� lip,•�' L. Tt�Mldnr rlwultl iw J rwry pro k hnk Is 1. Om*A JJII"bmamm rpowdy kv the 9, wa.w"farJa1C!♦Mpit J i4fti1 to ry ya}Iw Jl . hvw a�UNI br6brr,of oft tank aJd�„�!�alp l O +Mlluu4 i. (wcr 11atr sahm*lwal lay Lma kvjw,W awkow +dtt 1Yf Ella iwn tMt eaWw•• •@nw bwmb w dam 1 5r 51MIr aw earpidw+J111 awd fait or pw o.#or ah�lNlw a ttt a v*s O*A p11MAIN!l,n aw WON lb wj*6 "L1�wr1r'awnwad w w+w`y Kr OW dwmW +• r. VrldNr bomb aM nrMM►'r11e a lb aw d.w�.)uw dw aas°M I�r 111' pur�ra'trd"" ten•Indd+s ants as J> tap nyp�rM b eNl a{ e*a r + r. aw vas swad�rt Mau M6 fte mw d alp. 9. YMir.ir�I!w i11Wr iorwidps bwk a*&Ik gift orwAo am0a1'waeM '� �k", 411 4, t11.Wrpboo wW JlrcYlr tfMJ i /Gu brill. ,. Iw •s Yr 1r••,,,t r•;.•+Jt'7Y;:W:Yt�Jfl,'i '1.'f."I IS( , /d? ~�� S1, tl� , �a i i rr ae JJJ f a r r� LLJ a° , ll w i e I r i I ' ', Pmjrn NCM1Nen: I SIT PLAN n^ ``��' AO ST. CROI K COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address 1&-o Property Address t aln:nL-z� (Verification required from Plar&ng&Zoning Department for new c lion.) City/State Yudsrv,, L� Parcel Identification Number t!�IylJ —/017 62—Grp LEGAL DESCRIPTION Property Location SLJ x/4 ,S '/4 , Sec. T N R W,Town of Subdivision , Lot# Certified Survey Map# ,Volume ,Page# Warranty Deed# �1 �f� 2 , Volume ,Page# Spec house 6 e Lot line., identifiabl yes o SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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,ii=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 Owner maintenance responsibilities are specified in§Comm 83.52(1)and in Chapter 12-St.Croix County Sanitary Ordinance. The property owner agrees to submit to St.Croix County Planning&Zon:mg 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 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 road 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 Planning& Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my/our knowledge. I/we arn/are the owner(s)of the property described above,by virtue of a warranty deed recorded in Register of Deeds Office. Number of ooms SIGNATURE OF APPLICANT(S) DAT ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning&Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV.08/05) li i 'A l i 01 10 'f IX:4lu IZIL STATE BAR OF WISCONSIN FORM 1 -2000 972670 BETH PABST Docmnent Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI THIS DEED,made between Timothy Jaynes and Amy Jaynes,husband and 02/04/2013 3.50 PM wife, Grantor, and Thomas J. and Dawn F. Lane Living Trust, dated EXEMPT#: NA August 2,2011,Grantee. REC FEE: 30.00 Grantor, for a valuable consideration, conveys to Grantee the following TRANS FEE: 330.00 described real estate in St. Croix County, State of Wisconsin (the PAGES' 1 "Property"): Lot Eighty-one (81),Plat of Glover Station Fifth Addition in the Township of Troy,St.Croix County, Wisconsin. Recording Area Namc and Return Address: Land Title Inc., File#394410 2200 W.County Road C.Suite 2205 Roseville,MN 55113 Together with all appurtenant rights,title and interests. 040-1266-00-000 Parcel Identification Number(PIN) This is not homestead property. Grantor warrants that the title to the Property is good, indefeasible in fee simple and tree and clear ol' encumbrances except Easements, Restrictions,Reservations; Roadways and Rights of Way, ifany,of Record. Dated this 14th day of.lanuary,2013. *-Tit thy Ja es AUTHENTICATION J e ACKNOWLEDGMENT Signature(s) TE OF WISCONSIN ) OIX COUNTY. )ss. authenticated this 14th day of.lanuarv,201 Y I •sonally came before me this 14th clay Of January. 2013 * i*a ve named Timothy .lavnes and Amy.laynes, husband IC fe to me known to be the person(s) who executed the TITLE: MEMBER STATE BAR OF WISC ing instrument and ackno v dged the same. (If not; �F W�c�G� I �K� authorized by§ 706.06,Wis. Stats.) e ilee J. Bune THIS INSTRUMENT WAS DRAFTED BY . Notary Public,State of Wisconsin My commission is permanent. (If not,state expiration date: Larry S. Mountain,Attorney at Law 10/27/2013 ) (Signatures stay be authenticated or acknowle(iged. Both are not necessary.) *Names o1'persons signing in any capxit)'muss be typed or printed below their sig naunc 1 of 1 WARRANTY DEED'`` STATE BAR OF WISCONSIN FORM No.1-2000 73 -. 1-y t r 4.'2�s 52 ACRES J25 SP. W CJ" t C2 5700 2 154 J` 86 2.596 ACRES 79 x 8d �46' s0"( _ 113067 sF. t:wc" L- 1�Y 3� ACRES 2.501 ACRES , C, 1 N •10 , W " I a g No 1N4 A t t 108 943 SF. a / 01 N 86010' THE SW 1/4 1 `-1 1 OF 2.525 ACRES 130' j 110.000 SF. 1 Ig 2. ,.tt N 86.10'36" W i J N 26ro; N 10138, Wt FOR �"' 7 41» (,rf� ORi�lEWAY ` f E , .49 20 ACS 0 109. 3 77 N 86.10'36" W 390.00' S ! f . ACRES r `' 78 /:+ ' i 6.888 S l a 8'�' �� , 'SFP r t t 299~175 S.F. f 7p, r 4.104 ACRES �-. r t t In 196 176,740 sF. 83 � ' I y 'r t 1S0 jai + t2 3A, t c NI 1 p N a.7ams•rlM.ri an'nswa+s. ...l4. y« ; ... . I I 4 as . .....a.. .. ........- i I x N 89"18"0 " Yf i 17r 341 rp s N WHY 36" W 11NPLATTED LANDS �ryr 390.00' " L _Z4-9d8",_ 82 CHO 17344 ACRES DETAIL OF DRIVEWAY EASEMENT � 119.071 SF. MFOR LOTS 76 AND 77 r ARr' CULWSAC 75 \ SCALD.: 1" '" '° 8600' EASE�IEI4T, SEE NOTE 4./ ' 2ar QL CANDY EANCER ar CIRCLE f' N ? cap. 1 " - 101 , c2 wit�s=,"` �t 3► z J . _ . ♦ � \zm VMS .r . 7.iT' 77 "It,ACRES t 109,„396 SF. �18 ACRES .r a PROPERTY OWNER N�S`IE �SCLtULYz SOIL DESCRIPTION REPORT Page?of 7� PARCEL I.D.k PF2./�jnJG Boring# Horizon Depth Dominant Color Mottles Texture Structure GPD/ft in. Munsell Gr. Sz. Sh. Consistence Roots Qu.Sz.Cont.Color ��Y �.,• Bed Trench 0-12 oti z -!z _= slJ .s ,6 Ground 3 �Z61 7. `�R A / L S S� 7.S4R S G ) O �'� elev. CL9,b It. Depth to limiting factor �N Remarks: Boring # { Z R-l3 l0`1R �fb `f sbh >n�t^ es •S -� Ground -7 tS`t 23/y _ S \oS b!t S Al elev. 31 56 7-S`IR 3! t�,S`/RS/$ Sj o Y►?`F)r • 3 �S! Qb-sfl. Depth to — limiting factor 3 L'' Remarks: Boring # }:;Y.v:•}}fix;{.K . ,.< Ground elev. It. Depth to . limiting factor Remarks: 3oring# around ?lev. It. )epth to imiting actor Remarks:— Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page I of Labtu and Human Relations g _ Divition of Safety&Buildings in accord with ILHR 83.05,WIS ZOCfe `. r y�rrJ.'God�e 'COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size.Ptatrrntist inc ,'f3�t ' not limited to vertical and horizontal reference point(BM),drection and%rcd slope,scalA dr' _. V 7s PARC I.D.# dimensioned,north arrow,and location and distance to nearest road. ' , � R DB DAT l/ ) APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATI f} U PROPERTY OWNER: R PE TTY mAMON 'S t~— e' $ E- ti\'S SCtiuc Z � 'J( ,,t j-6T N,R lq E(OOW PROPERTY OWNER':S MAILING ADDRESS• L .' iBLOC _ fa OR CSM# z Sfl �-t vEIZS t DE �2t uE 8 . G i STt Oki S CITY,STATE ZIP CODE PHONE NUMBER ❑CITY ❑ OWN ' NEAREST ROAD 1ZlU�`� _S I�1 S�IoZ2 (CIS) �1ZS- $tbt �Cp�-( EMP1Rlr WILV5L D1Z. j5(J New Construction Use V] Residential/Number of bedrooms [ ] AdditiQn to existing building Replacement [ J Public or commercial describe Code derived daily flow b t,Q�i gpd Recommended design loading rate bed,gpd/0 - trench,gpd1ft2 Absorption area required S 6f,) bed,ft2 S tip trench,ft2 Maximum design loading rate •S bed,gpolft2 6 gpd/ft2 Recommended infiltration surface elevation(s) \-O(3-S ft (as referred to site plan benc:�& Additional design/site considerations MD 1,J ' L3 ' B 1`I I AJ)Ivl uM Z k OF- � " l Paren t material Lo N5S oU\'Q Tt LL CUU s2 UMe%1 Dui Rood plain elevation,if applicable M It S=Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable for stem ❑S U ®S ❑U ❑S �U I ❑S U ❑S U ( EIS U SOIL DESCRIPTION REPORT ��r^ Bonin # Horizon Depth Dominant Color I Mottles I I Structure I GPD/:.r 9 Texture Consistence I Ro is in. Munsell Qu.Sz.Cont Color Gr.Sz.Sh. Bed Ground 3 vt-ZS L4 .S. elev. ft LS 3S !O`Z2 6 L3 LS13 — IvP tug Depth to limiting factor Z S" Remarks: Boring# 10-9 P_ -Z sf l 2�'sl�� LL-') El Ground 3 l9 30 S 1 1wn. Ioz vnvTy O-S -�I .S elev. 3L�_46 10�R 6l3 LsB cis$ft Depth to fimiting factor ' 3p� Remarks: CST Name:—Please Print Phone: Arthur L. We erer 715-425-0165 egerer Soil Testing & Design Service-P.O. Box 74 River .Falls,WI. 54022 ' Signature: Date: CST Number. IR3- 81 -aa 226254 PLOT P LAN Page 3 of 3 scPh LIz I c1b_S o Cl�w� o F �'� L'� •LD U,s 3 �J t� � �v��l-LL. 1oo.a' av q"����, 31c�'D►11• PVCP�PE �-tCss �Zt tis�- 3`I w/ 3.4� m6Ef PUC MAfdc-OZ- P/P4 r E LOT \-j (/J C, C 00- \C)3- !F�,1 -cc ( 715 1 L-1 Z.S-- 01 S Zz(:)2.S(. CST Signature Date Signed Telephone No. CST# �4 D (715)248,3010 ------------- --------------------------- - --- -------------- ------------------- 110�CEI�_ 6 - -------------- -----------------T--------- 1-0 -------------------- ------------- x ----------------------- ----------------------- Tom Lane Hww Plane 961 SO.Fr. UPPER LEVEL UPPER LEVEL o 2M-- WWII (715)248,3010 ------------------------- ------------ ------------ ----------------- ------------ -- --- -—-—-—-—-—-—-— -—-—-—-—-—--- - -------------- — k 0 o NCmCr ------------- ---------- ------------ Fig,, -0 - --------- --- -- i!lm I, MEW —7F 18 ri 1.4 Tom Lane House Plans ieos SO,FT. MAIN LEVEL MAIN LEVEL ----------- (715)248-3010 . . . ------- ----------------------------L---- -- --------------- - ------------- --- ----------- ------ ------ - ------------ ---- - ------------- -------- OTIC ----------- N—�El.'.E.— r;N x 11 ---------------------------- Tom Lane Hasa Plans— FOUNDATION T A2