HomeMy WebLinkAbout008-1094-95-025 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 574333 0
GENERAL INFORMATION State Plan ID No:
Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)).
Permit Holder's Name: City Village X Township Parcel Tax No:
Bartko, Chad & Katie I Eau Galle, Town of 008-1094-95-100
CST BM Elev: Insp.BM Elev: BM Description: 2 Section/Town/Range/Map No:
X17,' lv M Z-. ��a 6!5 T 33.28.16.
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic �, —� Z / /Z Sb Benchmark
Dosing
Z�b��� Alt. BM � �
o .!L,,4 14
Aerat" Bldg.Sewe
o d
.L �i7. 8
Holding j St/Ht Inlet g,✓ q.3 -
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG. Vent t Air Intake ROAD Dt Inlet
Septic r6/ AM—( 54 Dt Bottom l3 05 �,� 9
Dosing / ELI / Header/Man. 740, v
7 io o C
Aeration Dist. Pipe
Holding Bot.System
5 .zg �` r
PUMP/SIPHON INFORMATION A AV Final Grade
Manufacturer Demand St Cover �' ;i
GPM b , O �rti.
Model Number � � tf, D /6���� � �•� ��• �/.
TDH Lif Friction Loss System Head,, TD1
r 1
Forcemain Len Dia. IDist.toWell ,L, 16041 Ze�
SOIL ABSORPTION SYSTEM I A IM l bj,^
BED/TRENCH Width / Length No.O en ch s PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth
DIMENSIONS /0 (00 1--- ��
SETBACK SYSTEM TO 1IVVVV P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: �\
INFORMATION T stem: , CHAMBER OR
Y ?� „ /� ` 'Q� UNIT Model Number:
o0 /v N[T
DISTRIBUTION SYSTEM
Header/Man fill / Distribution I ) / I/ / x Hole Size Q / JxHoleSpacing ac o f Ven t Air Intake
Length (! Dia ' Pipe(s)
ength `d' Dia /,6 Spacing 4 Z ' V 4 I v
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only a'ujvJ J,A
Depth Over Depth Over xx Depth of xx Seeded/So ded xx Mulc efi d
Bed/Trench Center q Bedlrrench Edges �1 Topsoil , � Yes No \ /Ye/ No
COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: 16 / Z 9'/ H nspection#2: / /
Location: 2390 Pierce-St.C i�C Rd.Spring Valley,WI 54767(SE 1/4 SE 1/4 33 T28N R16W) NAgot j - Of, I P el 33.28.16.
1.)Alt BM Description= ` c.� `!' C'j�Q,� A.5 � f 0GK U�-
2.)Bldg sewer length=
-amount of cover
Plan revision Required? ] Yes No
16 11 3 Y�
Use other side for additional information.
Date Insepctor' ignature Cert.No.
SBD-6710(R.3/97)
06/17/2014 20:03 7157723387 BEN PAGE 03/03
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CGPP�c�c. (970
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s ue"S F Sewieee Division GS/
:m �`>.:> •`` 1400 E Washington Ave gi
Y ..t# tary Permit Number(to be filled in by Co.)
P.O.Box 7162
AUG Madison,WI 53707-7162
TLL���S�¢R uta efmit Application State Transaction Number
In accordancE"13'383,21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit /
is required prior to obtaining a sanitary permit Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address)
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary
purposes in accordance with,the Privacy Law,a.15.04 1 m Stall. �
I. Application information-Please Print All Wormati /Jai
Property Owner's Name LL Parcel#
Property Owner's Mailing Address Property Location
y� e
City,State f rp Code Phone Number Govt.Lot
f , 1 C_ 1,7 v Y.,�_Y., Section 33
4 W /S 7799 73l T .2$ N; R /, (circleeonw
IL ype of uilding(ch k all that apply) of# / �
W1 or 2 Family Dwelling-Number of Bedrooms J Subdivision Name
4a Block#
❑Public/Commercial 6K ial-Describe Use
❑ City of
❑State Owned-Describe Use t— CSMM Number a ❑Village of
9/ 7 6 Town of
IIL Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. &,h New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain)
B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber List Previous Permit Number and Date Issued
B ❑Permit Transfer to New
Before Expiration Owner
IV.Type of POWTS stem/Com onent/Device: Check all that a �1/ 0�r
❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade L•7 Mound>24 in.of suitable soil ❑Mound<24 in,of suitable soil
❑Holding Tank ❑Other Dispersal Component(explain) Pretreatment Device(explain)
V.DispersaVrreatiqent Area Wormation: Qw
Design Flow(gpd) Design Soil App]jcation Rate(gpdaf) 177;�r Dispersal Area Propos sfj System Elevation
oo ' �p A - 1 j' tb
VI.Tank Wo Capacity in Total #of Manufacturer
Gallons Gallons Units u
New Tanks 1b Tanks w
6✓ o �o�t. S da c� gg
Septic of Holding Tenk 5-0 ��O
Dosing Chamber 0/e e-
JO 5'U 1 ( l�
VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumb Signature MP/MPRS Number Business Phone Number
PSo� �
r► c7a
Plumber's Address(Street,City fate,Zip Code) 7
"'074,Y9 /mn
Vill--Xcoun /De artment Use Only _J
Approved ❑ Permit Fee Date ssu Issuing entSignature
n Reason for Denial $ �25. Or5
IX.Conditi psons for Disapproval
1 Septic tank,etlluent fiR®r and "3 �'��"�
'04orsal cell.must all�e servkes!rnai aine�+ le.f e i J� G�Cv�- t�J1 Cln•,
t p P."geme►►t plan provided by plumber.
2 ; kgtl�eFnents must.be.maintained
ttach to comp ete p sm or a system and submit to the County only on paper not less than 8 /2 x 11 inches in size
SBD-6398(R0313)
BENNM W HELGESON Page 2 6/18/2014
Owner Responsibilities:
• The current owner, and each subsequent owner,shall receive a copy of this letter including instructions relating
to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and
maintenance manual and/or owner's manual for the POWTS described in this approval.
• 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).
• In the event this soil absorption system or any of its component parts malfunctions so as to create a health
hazard,the property owner must follow the contingency plan as described in the approved plans.
• 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.
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
Fee Received$ 250.00
Balance Due $ 0.00
erard M Swim
POWTS Plan Reviewer,Integrated Services
(608)789-7892,Mon-Fri, 7:15 am-4:00 pm WiSMART code:7633
jerry.swim@wisconsin.gov
cc: Edwin A Taylor,Wastewater Specialist,(715)634-3484,Monday-Friday 8:00 am To 4:30 pm
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.
�tipAxrargN DIVISION OF INDUSTRY SERVICES
�ti� Tom 3824 N CREEKSIDE LA
m HOLMEN WI 54636
Co) t Contact Through Relay
www.dsps.wi.gov/sb/
P wy www.wisconsin.gov
o�ssroN�LS� Scott Walker,Governor
Dave Ross,Secretary
June 18,2014
CUST ID No. 220292 ATTN:POWTS Inspector
BENNIE W HELGESON ZONING OFFICE
HELGESON ENTERPRISES ST CROIX COUNTY SPIA
N7649 STATE ROAD 128 1101 CARMICHAEL RD
SPRING VALLEY WI 54767 HUDSON WI 54016 .
CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 06/18/2016
SITE: identification Numbers
Chad&Katie Bartko Transaction ID No.2409799
Pierce/St Croix Rd Site ID No. 802632
Town of Eau Galle Please refer to both identification numbers,
St Croix County above,in all correspondence with the agency.
SETA, SE1/4, S33,T28N,R16W
FOR:
Description:Four Bedroom Mound System/ 14%slope
Object Type:POWTS Component Manual Regulated Object ID No.: 1487515
Maintenance required; 600 GPD Flow rate; 27 in Soil minimum depth to limiting factor from original grade
System(s): Mound Component Manual-Ver.2.0, SBD-10691-P(N.01 101,R. 10/12),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. CON
The owner,as defined in chapter 101.01(10),Wisconsin Statutes,is responsible for compliance with all code
requirements. AP
No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, pR�Pr OF
stats. DIVISION OFsN
The following conditions shall be met during construction or installation and prior to occupancy or use:
Reminders: 1%
• 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. 4 SEE CORK
• 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.
• A state approved effluent filter is required.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.
• All POWTS component piping material shall be SPS 384,Wis.Adm.Code compliant.
• The area within 15' downslope of the dispersal component shall remain undisturbed.Vehicular traffic,
excavation or soil compaction is prohibited in this area.
• 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.
INDEX SHEET
PROPERTY OWNER: CHAD & KATIE BARTKO
N424 MC KAY AVENUE
SPRING VALLEY, WI 54767
PROJECT NAME: CHAD & KATIE BARTKO
PROJECT LOCATION: SE 1/4 , SE 1/4 , S 33, T 28 N, R 16W
MUNICIPALITY: TOWN OF EAU GALLE
COUNTY: ST. CROIX
DESIGN: PRESSURE DISTRIBUTION MANUAL VERSIQN 2.0"
SBD-106706-(N.01/01) Tov _Cy
MOUND COMPONENT MANUAL VERSION 2M;
10691-P (N.01/01) AFE
CONTENTS: V L S r�,A&D
V
Page 1: Plot Plan STRYSE'RV`S
CFS
Page 2: Cross Section and Plan View ofMo ,
Page 3: Distribution Pipe Layout &
Page 4: Septic Tank and Pump Chamber Cross Section and
Specification
Page 5: W1000/600 - MR Zabel Tank Specifications
Page 6: Pump Specifications
Page 7: POWTS Owner's Manual &Management Plan-Pg 1
Page 8: POWTS Owner's Manual &Management Plan-Pg 2
Page 9: Payment Voucher
Name: Bennie Helgeson Signed-
Address: N7649 Hwy 128
Spring Valley, WI 54767
Credential Number: 220292 Date: 05-29-2013
06/17/2014 20:03 7157723387 BEN PAGE 03/03
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Synthetic Covering
A57-M C 33 Distribution Pipe
Medium Sand Ft�� 97 97
H
Topsoil
C
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G;EUL0f i"— 2 Force Main Plowed
Aggregate From Pump Layer
D _y 7.� Ft.
Cross Section Of A Mound E ..��Ft.
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Date: L 79,�� Ft.
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McAIqur's n� Pipe Baja�14rea.-/0 Aggre got e
0bservation Pipe , - Sat
45,1 ,orer, XeeJed = /000
Plan View Of Mound
Perforated Pipe Detail
Cleanout
Access r'
Threaded 'End vi w
Cleanout
Perloiola°
PVC Pip(
jot v° End Manifold
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Holes Located on Bottom
R Are Equally Spaced
Force Main From Pump
X S �/ First Hole Next to Manifold
e
Cleanouts� •
Distribution Pipe Layout
P �-7 9 "/
R L ^ r�
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Hole Diameter Inch
Lateral a Inch(es)
Signed:
Manifold" /r Inches
Force Main" Inches
License Number:
Date:
Invert Elevation , to
Holes Per Lateral _
Number of Laterals
Total Holes / Z3
Page q Of_
SEPTIC TANK E PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
4 " PA-VENT PIPE 12" MIN. ABOVE GRADE E WEATHERPROOF
25 ' FROM DOOR , WINDOW OR JUNCTION BOX APPROVED
FRESH AIR INTAKE WITH CONDUIT MANHOLE COVER
W1 PADLOCK E
POUunc� _ WARNING LABEL
MIN.
zy
18" IN. .r.b.
`• u
INLET
�
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' .33 WATER TIGHT SEALS GAS-
TIGHT - � APPROVED
F 1 LT E R ---+- A SEAL
APPROVED �� f o k _}•,_ � JOINTS WITH
ALM APPROVED PIP;
PIPE 3' �5. B ' ON 3' ONTO
ONTO SOLID T ' SOLID SOIL
SOIL PUMP OFF ELEV . FT. –i— OFF
D
3" APPROVED BEDDING UNDER TANK
CONCRETE PAD
SPECIFICATIONS
SEPTIC / DOSE _�otr.l C��i_ Iv. Ld��rrtlS
TANK MANUFACTURER:
TANK SIZES: SEPTIC 4960 GAL. DOSE VOLUME INCLUDING
DOSE -7<, Q GAL. _).j.g,a &0_j,_*F LOWBAC K: /D.�,Q GAL.
ALARM MANUFACTURER: A_TE Rjj()j, ,S CAPACITIES: A = ;' INCHES = 03 GAL.
MODEL NUMBER: /p/
SWITCH TYPE: e-r A CA( Nomt- B = 2 INCHES = �GAL..
PUMP MANUFACTURER: Gott ®s C = `y INCHES = GAL.
MODEL NUMBER : ,387/ FP0,S7
SWITCH TYPE: F/oaf D = 13 INCHES = AO95_�v9AL.
REQUIRED DISCHARGE RATE 411,8 a GPM PUMP E ALARM WIRING AS PER ILHR 16.23 WAC
r
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE `/s` FEET
+ MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . . . 6.s FEET
+ IUD FEET FORCEMAIN X *_3_-7 FT/100 FT. FRICTION FACTOR . .5'/A FEET
TOTAL DYNAMIC HEAD = FEET
INTERNAL DIMENSIONS OF PUMP TANK: LENGTH WIDTH DIAMETER
LIQUID DEPTH !Z 7#
SIGNED: LICENSE NUMBER : DATE:
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MODEL:3871
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CAPACITY
Pump:Specifications. Features and Benefits
'/10 and 1/2 HP 9E'PO4 impeller-semi-open design
Up to 60 GPM . with pump out vanes.to protect
Maximum head to 32' ,mechanical.seal.
Discharge size 11Y NPT •EP05 impeller!..enclosed design
Solids:'/4"maximum for improved performance.
Motor •Rugged glass-filled.thermoplastic
All motors feature ball casing and base design provides
bearing construction. superior strength and corrosion
Single phase:.115V resistance, r
Materials of Construction •Cast iron motor housing for
Cast iron efficient heat trahsfer,strength,
Thermoplastic and durability.
Stainless steel *Corrosion resistant threaded
stainless steel shaft.
•Available for automatic and
manual operation.
•CSA listed models available.
operation and feature sta.inless steel hardware.
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page7 of
FILE INFORMATION
Owner SYSTEM'SPECIFICATIONS
re. r Tank Manufacturer: of a-Saar ❑ NA
Permit#
9 Septic ❑ Dose ❑Holding Volume: I�4 Sb (gal)
DESIGN PARAMETERS Tank Manufacturer: �, ��tr r' ❑ NA
Number of Bedrooms:' ❑ NA ❑ Septic p %Dose ❑ Holding. Volume: n5feet
Number of Public Facility Units: [ NA Vertical Distance Tank Bottom(s)to Service Pa
Estimated(.average)Flow: o t5 (gal/day) Horizontal Distance Tank(s)to Service Pad:
Design(peak)Flow=(estimated x 1.5): Specific servicing mechanics must be provided if vertiJ dp (gal/day) If horizontal Is>150 feet. Specific instructions to be p
In Situ Soil Application Rate: (gal/day/ft2) Effluent Filter Manufacturer:���y ❑ NA
Standard(Domestic)Influent/Effluent N�onthly average Effluent filter Model: , G S
Fats, en&Grease (FOG) 530 mg/L Pump Manufacturer:
Biochemical Oxygen Demand (BODs) 5220 mg/L ❑ NA '7 e
Total:SuspgndeO S�lids..(T$S p ❑ NA
-.51°S:O mg/L _ Pump Modal: - ._ ca•_"f�- Ss�u�
High Strength Influent/Effluent Monthly average Pretreatment Unit
(FOG) >36 mg/11 Manufacturer:
(BODO >220 mg/L NA l NA
(TSS) >150 mg/L ❑Mechanical Aeration ❑Peat Filter
Pretreated Effluent Monthly average ❑Disinfection ❑Wetland
❑Sand/Gravel Filter ❑Other:
(BODE) s30 mg/L Soil Absorption System
(TSS) 530 mg/L NA -
Fecal Coliform(geometric mean) 510' ❑ In-Ground(gravity) ❑ In-Ground(pressure) ❑ NA
Maximum Effluent Particle Size Y8 in die. El NA El Drip-Line X Mound
❑ Drip-Line El Other:
Other: ❑ NA Other:
. ❑ NA
MAINTENANCE SCHEDULE
Service Event - -
Service Frequency
Pump out contents of tank(s) ® When combined sludge and scum equals one-third(X)of tank volume
❑When the high water alarm is activated
Inspect condition of tanks) At least once eve El month(s)
every: a- [$year(s) (Maximum 3 years) ❑ NA
Inspect dispersal cell(s) At least once every: [I month(s) (Maximum 3.years) ❑ NA
Clean effluent filter At least once every: ' �0-month(s) ❑ NA
year(s)
Inspect pump,pump controls&alarm At least orice,every: mont (s)
I� ❑'year(s)
[I NA
Flush laterals and pressure test At least once.every:. ❑month(s)
Other: . .ld;year(s) ❑ NA
❑month(s)
At least once every: ❑ NA
Other.
❑year(s)
❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and soil absorption systems shall be made by an Individual carrying one of the following licenses or certifications:
Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper).
Tank inspections must include a visual inspection of the tank(s)to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined.sludge and scum and a check for any back up or ponding of effluent on the ground surface. The soil
absorption system shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent
on the ground surface. The ponding of effluent on•the ground surface may indicate a failing condition and requires the immediate
notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any treatment tank equals one-third (' ) or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator (pumper) and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code:
All other services, including but not limited to the servicing of effluent filters, mechanical or=pressurized components, pretreatment units,
and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 30 days of completion of any service event.
GMW-005(02/05)
START UP AND OPERATION Page of
For new construction, prior to use of the POWTS
chemicals or s .check:treatment tanks) for the presence of painting products, solvents or other
ediment that may impede the treatment process'and/or damage-the soil absorption system. If high concentrations are
detected have the contents of the tank(s)removed by a Septage Servicing Operator(pumper)prlor to use.
Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these
conditions is not recommended, as the excess wastewater will be=discharged to the soil absorption system`In.one large dose causing an
overload that may result in the backup or surface discharge of effluent,and damage to,the system: To avoid 1thIs situation have the
contents of the pump tank removed by a Septage Servicing Operator(pumper)•prior to restoring power to-the
Pump or contact a Plumber
or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
Do not drive or park vehicles over tanks or the soil absorption system. Do not drive or park over, or otherwise disturb or compact, the
area within 15 feet down slope of any mound or at-grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance a'nd prolong the life of the treatment
tanks and soil absorption system: acids, antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss,
diapers, disinfectants, fats, foundation drag (sump pump)discharge, fruit and vegetable peelings,.gasoline, greases., herbicides, meat
scraps,medications, oils, painting products, pesticides,sanitary napkins,solvents,tampons,'and water softener brine discharge. .
ABANDONMENT. _
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure That the system is properly
and safely abandoned in compliance with s. Comm 83.33;Wisconsin AdministratiVe.dodo:
• All piping to tanks, pits and other soil absorption systems 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(pumper).
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil,
gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken,. to provide a code compliant
�repl ement system;
] A suitable replacement area has been evaluated and may be utilized for the location of a replacement
The replacement area should be protected from disturbance-and compaction and should not be Infdng iedaupon by required
setbacks from existing and proposed structure,-lot lines and wells. Failure to protect the replacement area will result in the need
for a new soil and site evaluation to establish asuitabie replacement area. Replacement systems must comply with the rules in
effect at the time of their permit issuance.
❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be
rehabilitated and barring advances in POWTS technology,a holding tank may be installed as a last resort.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation
must be performed to locate a suitable replacement area. If no replacement area is available a holding tank maybe installed as a
last resort to replace the failed POWTS.
P. 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 TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK
SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY
RESULT 7ESCAPE',OR RESC-UE.:FROM.T HEIN.TERI:O.R.OF'yti�NKltltyll''iilOT,:l3fPOSS4BtE:
�r _
ADDITIONAL INSTRUCTIONS:
POWTS INSTALLER
POWTS MAINTAINER
Name ` -t' "rr<fV_
Name
Phone •-7/ 5 y �
179 Phone 7i ': Q_
Ff J
SEPTAGE SERVICING OPERATOR PUMPER
LOCAL REGULATORY AUTHORITY
> Name �-
�etn/ i N Name -rotsCw
Phone ��5 _�•7 fl JC Phone haw►c-t
"°Ifs—
This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections
Comm 83.22(2)(b)(1)(d)&(f)and 83.54(1),(2)&(3),Wisconsin Administrative Code.
T
STATE OF WISCONSIN
partment of Safety and Professional Services
•`:'t `''zri' De SPS Fiscal Plans
PO Box 8602
:.:
"'° Madison WI
S'�O13A' Governor Scott Walker 537os-8so2
Secretary Dave Ross
Payment Voucher
If you are requesting to be invoiced for your plan review, DO
NOT use this voucher form.
Transaction ID:
(Leave blank if this review has not been pre-scheduled)
Check# 1A 4 t 1 Dollar Amount:_ o?�ab.oa
Payer Name ��4 e�o,z ��e nt^
(Individual or Company name as printed on first line of check)
Payer Address Al 'Tee 4 q i
(As printed on check) QA
Payer City 111;0r I n 0 l,{ �� State W Zip Code
Phone
Plan Submitter Name q2 LD W ,eA
(If different from Payer)
1. Mail your check (payable to Safety & Buildings Division) and this completed
form to:
DSPS Fiscal Plans
PO Box 8602
Madison WI 53708-8602
2. Send a copy of this completed payment voucher form along with your plan
submittal documents to the office that you select below.
Plans submitted to: ('circle or check one of the offices)
Madison ❑ Hayward ❑ LaCrosse/Holmen VrQNI Green Bay ❑ Waukesha ❑
Madison S&B Hayward S&B LaCrosse/Holmen Green Bay S&B Waukesha S&B
201 W Washington Ave 10541 N Ranch Rd S&B 2331 San
3`d Floor 53703 Hayward WI 3824 N Creekside La Green Bay,Luis
WI PI 141 NW Barstow St
PO Box 7162 54843 Holmen WI 54636 4'Floor
Madison WI 53707-7162 54304 Waukesha WI
53188-3789
� y
Property Owner V e( Fw"n k'C-- Parcel 10# 8/C I sC'C�C) Page of 3
FBoring# ❑� Bo g
9 Pit Ground surface elev. /y ft. Depth to limiting factor Q'7 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
In. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 *011#2 14- XV
F-1 Boring# 0 Boring
Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDA?
In. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 *E11#2
Ong# 0 Boring
Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft°
In. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. •Eff#1 *EMV2
Effluent#1 =BOD5>30 1220 mg/L and TSS>30<150 mg/L *Effluent#2=BOD6<30 mg/L and TSS 130 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.
ssD-9330(rt07ro0
Wisconsin �mmerce I RECUkq ,
LUATION REPORT
Division ofS a Page of .3
In accorrmr)pa w2h 45,Ws. Adm. Code
Attach complete site plan on paper not less than 1812 x 11 inc a 8�e.Plan must County '
include,but not limited to:vertical and horizon"r IG&M irecti n and
percent slope,scale or dimensions,nort Parcel I.D.
nearest road. (%8 C�yq S-�.0 G)
Please print all Information. Rev wed Date
Personal information you provide may be.used for secondary purposes{Privacy Law,s,15.04(1)(m))..
Property Owner d Property Location
T e- I?rca Ch�Q ,�
Q re .�C Govt.Lot .5E 1145E 1/4 8 N R t b E(or W
Property owners Mailing Address Lot# Block# Subd.Narn CS
City State Zip Code Phone Number City �Ilace own Nearest Road
RI New Construction Use: Residential/Number of bedrooms `2;� YY Code derived design flow rate -5_t_ Z00 GPD
❑Replacement ❑ Public or commercial-Describe:
Parent material L C SS 00-e, '7";/l Flood Plain elevation if applicable JV4 g,
General comments <"1 f
and recommendations: S E Jl�t�r d u�^ {�'' L��%� r. `y5 e o C e.
p �C-nL 4-C)LLe-
/ Boring# �E]�Boring
l�Pit Ground surface elev.-! g. Depth to limiting factor In.
Soil ADDlication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft:
In. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 *EfI1#2
a �s6 Fr c w
SC E c ic Cr� i Y
lL_ C Sb Ivy � ' 3
aBoling# � Boring !,
Pit Ground surface elev. 7 f',y ft. Depth to limiting factor 'O
In.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots WON
In. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2
f G -y 01 '3 _s lrl 1, to /L /u Co 8
3 -30 V lu , 1.1'
10
*Effluent#1=BOD >30<220 mg/L and TSS>30<150 mg/L *Effluent#2=BOD <30 mg/L and TSS<30 mg/L
CST Name(Please--Erint) Signature 7 CST Number
h( -eS c, IA
Address Date Evaluation Conducted Telephone Number
77�-3a 8
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3 of 3
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Spikear�e�, � �bo •� f�,ly. 97.'! �p,ke ,y�r�+
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ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer (I hco ao6( 1&-tie
Mailing Address N kL ANt
Property Address 3
(Verification required from Planning&Zoning Department for new construction.)
City/State W
Y �t�=. ' p1 arcel Identification Number U O$
LEGAL DESCRIPTION
Property Location SE �/, , _ 1/ , Sec., 3 N R /6 W, Town uf_
Subdivision Lot#
Certified Survey Map# q q7 to Le u , Volume c 2t , Page# too aCQ
Warranty Deed# qC 01 _262 5 , Volume — , Page#
Spec house❑yes l,Cno Lot lines identifiable X yes❑no
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,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. 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&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 proper operating condition and/or(2)after inspection and pumping(if necessary),the septic tank is
less than 1/3 full of sludge.
I/we,the undersigned have read the above requirements and agree to maintain the private sewage disposal system wid,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 thi orm 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 w anty deed recorded in Register of Deeds Office.
Numb r of bedrooms
SI ATURE OF A ICANT( DATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning&Zoning Department. ***
Oclude 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)
IIII! 1 1 1 1!1 1
III
IIIIIIIIIIIIII
8 2 4 6 5 1 0
State Bar of Wisconsin Form 3-2003 Tx:4201604
QUIT CLAIM DEED 999265
BETH PABST
Document Number Document Name REGISTER OF DEEDS
ST. CROIX CO., WI
THIS DEED,made between Jeffrey J.Brooke and Dianne M.Brooke(aka Diane 07'2 2014 12:22 PM
Brooke),husband and wife as survivorship marital property EXEMPT#: 8
("Grantor,"whether one or more), REC FEE: 30.00
and Chad M.Bartko and Katie L.Bartko,husband and wife as survivorship marital PAGES: 1
property
("Grantee,"whether one or more).
Grantor quit claims to Grantee the following described real estate,together with the
rents, profits, fixtures and other appurtenant interests, in Saint Croix
County, of Wisconsin ("P pace is need lease attach Recording
ty, ("Property") (if more needed, p
addendum): Name and Retwn Address
A parcel of land being part of the Southeast Quarter of the Southeast Quarter of __ _ ._,_ _.__
ane rt�o
Scctioft`33;Tow Tiip Z8�Torth,Kange l6 West,l own o Eau Galle,Saint Croix N424 McKay Avenue
County,Wisconsin,more particularly described as follows: Spring valley
Commencing at the Southeast Corner of said Section 33,thence north W1 54767
N86°58'13"W,along the south line of the Southeast quarter of said Section 33,a
distance of 544.59 feet to the point of beginning,thence continuing N86°58'13"W,a Part of 008-1 094-95-M
distance of 575.00 feet,thence NO2°34'02"W,a distance of 381.00 feet,thence
S86 058'13"E,a distance of 575.00 feet,thence S02°34'02"E,a distance of 381.00 Parcel Identification Number(PIN)
feet,to the point of beginning. This is not homestead property.
The described parcel contains 218,030 square feet(5.00 acres),and is subject to (is)cis not)
easements of record.
This parcel was created by certified survey map dated June 12d'2014 and recorded V .
June 24d'2014 in the Saint Croix County Register of Deeds as document number
997666. C Sl-1 Y01 a tp "a to ba& "4 1
Dated -
(SEAL) (SEAL)
Jeftre r ke s Dianne M.Brooke(aka Diane Brooke)
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT ,
Signature(s)
ST TE OF WISCONSIN )
authenticated'on )
,(` Q COUNTY )
x
Personally came before on ,"•"
TITLE:MEMBER STATE BAR OF WISCONSIN t- CLVVf\.k-
authorized ve-named KA
(If not, by Wis.Stat.§706.06) to me known to be the person(s) who executed the fonigoing
ent and a owle ged the same_ J
THIS INSTRUMENT DRAFTED BY: -
Rory E.O'Sullivan,Esq. * '
No c,State of Wisconsin
My Commission(is permanent)(expires: jib )
(Signatures may be authenticated or acknowledged. Beth are not necessary.)
NOTE: TMS IS A STANDARD FORM. ANY MODIFICATIONS TO TV'S FORM SHOULD BE CLEARLY-Y IDENTIFIED.
QUIT CLAIM DEED ®2003 STATE BAR OF WISCONSIN FORM NO.3-2803
'Type name below signaures.
997666
BETH PABST
REGISTER OF DEEDS
ST. CROIX CO., WI
MAP FOR RECORD
CERTIFIED SURVEY 1V AP 06,2EXEM T * 8 PM
REC FEE: 30.00
PART OF THE SOUTHEAST QUARTER OF THE PAGES: 2
SOUTHEAST QUARTER, SECTION 33, TOWNSHIP 28
NORTH, RANGE 16 WEST, TOWN OF
EAU GALLE, ST. CROIX COUNTY,WISCONSIN.
U N P1,_AT_TED
--LANDS -
S86'56'13"E
575.00'
z
LOT ,
N I �
�3 I N
218,030 3q.ft.
UN_PL_AT_TED 5.00 acres o
?LANDS incl r—o—w shed
---- 199,056 sq.ft. UNPLATTED
4.57 awes LANDS
W
excl. r-o-w -
co � - ---Z soil
o _____ building-setback-line _-- tests
1522.86' 33.16' _ _ 575 00'
�'� ----- centerline
4 N86'S8'13°W N86'S8'13"4y cN 33 16' 54_4_5_9'__
_ 1
South 1/4 corner~ _ — —`� ��s_oo' N86•S8'1,3-
33-7.8-16 2642.45' �'?cr'cf.—St...Croix Kd
Socf,°n "`---_ Soullie"Isl Corner
1" Steel Survey N,-,` Section 33-28-16
UNPLATTED 1" Steel Survey Nail
PREPARED FOR: LANDS
Chad & Katie Bartko
,P0 Box -45
Spring Valley, W'
NOTES: Each parcel on I his map is subject to State and County laws, rules and regulations
(i e wetlands, minimum lot size, access to parcel, etc ) Before purchasing or developing
any parcel, contact the St Croix County Zoning Office and Town Board for advice
DRAFTED BY:
gC4l�
Jce. ,A. .3rar••dl-
� l8,'`
t eawDT
t =: cffy.,
SCALE: 1' _ 1S0' t„F`•••
o' 1501 Sao' � `a
North is rer'e,-enced to the
LEGEND
,ouch line of the Southiast ® ....Found Ciov'rnment Corner (as noted)
Quarter, of Section 33-28-16 o.... ....Set 3/4" x 18' Iron Rebar weighing
which bears N86°5813"'W 152 lbs. per lineal foot
(Sf. Croy Cott-)ty Grid Sys`em; Sheer 1 of 7
St.Croix County 997666 Page 1 of 2 Vol 26 Page 6026
�
�
CERTIFIED SURVEY MAP
PART OF THE SOUTHEAST QUARTER OF THE
SOUTHEAST QUARTER, SECTION 33, TOWNSHIP 28
NORTH, RANGE 16 WEST, TOWN OF
EAU GALLE, ST. CROIX COUNT Y,WISCONSIN.
DESCRIPTION
A parcel of land being part of the Southeast quarter of the Southeast quarter, of
Section 33, Township 28 North, Range 16 West, Town of Eau Cialle, St Croix County,
Wis(onsin, more particularly described as follows
Commenting at the Southeast Corner of said Section 33, thence N86°58'13"W, along
the south line of the Southeast quarter of said Section 33, a distance of 544 59
feet to the point of beginning; thence continuing N86°58'13"W, a distance of 535.00
feet, thence NO2°34'02—o/, a distance of 381,00 feet, thence S86°58'13"E, a distance
of 575.00 feet; thence S02°34'02"E, a distarce, o` 381,00 feet, to the point of
beginning. The described parcel contains 218,030 square feet (5.00 acres), and is
subject to easements of record.
SURVEYOR'S CEKTWICArI'IE,
I, Joel A. Brandt, Professional Land Surveyor, hereby certify: That I have Surveyed,
Divided, and Mapped the above described parcel of land in full compliance with the
provisions of Chapter 236.34 of the Wisconsin State Sta-utes, along wifh the
provisions of St. Croix County and the Town of Eau Cialle in surveying, dividing and
mapping the same. That such map is a correct representation of the exterior
boundaries of the land surveyed and the subdivision thereof made, and was done by
the direction of Chad and Katie Bartko.
Dated this ��Cl� (� 2014. `NCO-AF&
* r , •* APPROVED
Joel A randt, P.L.S. S-2603
J B SURVEYING L L C �:a�ii�Cmr,•' JUN 2 4 2014
CERTIFICATE OF COUNTY TREASURER PLANNING&ZONING OFFiGE
STATE OF WISCONSIN )
COUNTY OF ST. CROIX ) SS
the duly elected, qualified and acting
treasurer of the county of St. Croix, do hereby certify that the records in my office
show no unredeemed tax sales and no unpaid taxes or special assessments as
of re H. 2-01Ll affecting the ia7ds of this Certified Survey Map.
G�u I A
Date Treasure'
Sheet 2 of 2
St. Croix County 997666 Page 2 of 2 Vol 26 Page 6026
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