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020-1447-23-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Builo~ng Division ' INSPECTION REPORT GENERAL INFORVIAATION (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 Description: 1 ~ ~'M GSA TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~ .5 ~ IZ~ i ! `- p I- t 1'~- Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ ~ ~~ ~ ~ ~~ ~ + „_ Dosing ,-.»..~.... _....,....._.. Aeration 1.... Holding """"""'"' PUMP/SIPHON INFORMATION Manufacturer Demand GPM M el Number T Lift Friction Loss m Head TD Ft Forcemain Cerig Dia. Dist. to Well Cf111 ARC[1RPTIf1N SYSTEM ELEVATION DATA county: St. Croix Sanitary Permit No: 79466 0 State Plan ID No: L Parcel Tax No: 020-1447-23-000 Sectionlrown/Range/Map No: 15.29.19.2854 STATION BS HI FS ELEV. Benchmark Z .~.b i~Z `~ / d'6 Alt. BM w~~~k a~ ~~ .~ ~ az ~~ 3~ Bldg. Sewer S~ 9(y . `'FZ St/Ht Inlet ~ ~~ ~5. ~ 7 St/Ht Outlet 7, ~b 95. ~ Dt Inlet i 1 Dt Bottom ` ~, Header/Man. ,.7' ~ 9~' 7~ Dist. Pipe 7 ~ ~ ~b.3c 5 4 ' ~ ~~.1 Bot. System ' Final Grade ,,,~ G1~" 5, lo~j 9~ ~ ..75 St Cover ~r :A~.~. ~.c> 4, 36 ~-r', g .~S ~ ~3 S~ TZ ~ . 3 93.65 BED/TRENCH Width ~ Lengt No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 ~ G a ~ 3 ~ ~~~~ \ --.. -~ ~. SETBACK SYSTEM TO P BLDG WELL LAKE/STREAM LEACHING Manufacturer. ,1 INFORMATION CHA uBER OR 1 Type Of System: ~•a ~ ' Z~ ~ ~ `t ~ i~1~h1- N ~' Model Number. ~ , ~ ~,n~e,n - 1'11_CTRIRI ITIntU CVSTPM Header/Manifol~ ~ ~ Distribution x Hole Size x Hole Spacing Vent to Air Intake ( LU T ~ ~ Pipe(s) in ` th ~ Di ` S L \ ` ~ 5 Dia Length g pac a eng Cf111 (_(1VFR ., o...«...e c.,~Fe...~ n..r., .,.. IUr,..nrl llr A4-l.radta Svsft±ms Only Depth Over ` Depth Over xx Depth of xx Seeded/Sodded xx Mulc ed Bed/Trench Center ~ ,~ Bed/Trench Edges Topsoil \ ~~I ~_; Yes ~_, No Yes ~ ; !, No "``~~~~ COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / i~+ Location: 920 Coyote LaLne udson, 154016 (NE 1/4 SE 1!4 15 T29N R19W} Coyote R,i~d'Jg~e Loot 23 ~[~ L'P_arcel No: 15.29.19.2854 1.) Alt BM Description = [~'~ (~ ~4~21ti-. ~~e,,:vt~ ~"' a~~~ ~ °`„ ~~C~~ ~~"/~-~~T/-~//Lr~ ~--5~`~~ 2.) Bldg sewer length = /rJ b~. '1~~ P/L- .SLR- Sr~~~ ~ T -amount ofi cover = Z t Plan revision Required? j J Yes I` No ~!~ ~ ~ ~ i ~ !~ i Use other side for additional informa~ ~ - -- --~ Date SBD-6710 (R.3/97) (~ 3 ~7 --- Cert. No. \ ^ ,Fil/~-,//~ 1~lir.~ Safety and Buildings Division County ~ ` 201 W. Washington Ave., P.O. Box 7162 l~~O~~,~ Madison, WI 53707 - 7162 Sanitary Permit Number (to be fill by Co.) t Department of Commerce (608) 266-3I //~,/' L/ Ito '~ Sanitary Permit Applic 'o State Plan i.D. NuttFber I ^ i h/ In accord with Comm 83.21, Wis. Adm. Code, pens fo n you pr may be used for secondary purposes Privac 5.04 1 Project Address (i different than mailing address) I. Application Information -Please Print All Information Property Owner's Name ~ ~ ~' ~ ~ 2005 Parcel # Block # '. ~ ~ - Property Owner's Mailing Address ~ ~ ~ ~~ ST. CROIX COUNTY ZONING OFFICE Property Locatio , ~~ C ~••- y' / / < /, , l~ Jay Section ..7 City, State ] ' ` / ~/~ //v -E-~ Zip Code ,/ ~ yd~G9 Phone Number c~ ~~•S - a6 S" ~ / f arcie one) ~ ~~~~ f T ~N; R<~E or W II. Type of Building (check all that apply) or 2 Family Dwelling -Number of Bedrooms t ~ Subdivision Nam CS Number ^ Public/Commercial -Describe Use ^ State Owned -Describe Use ^City_ Vil ag Township of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) ,$-a S A' New System ^ Re lacement S stem p y ^ TreatmenUHoldin Tank Re lacement g p ^ Other Modification to Existing System B• ^ Permit Renews Before Ex iration Permit Revision ^ Change of Phunber ^ Permit Transfer to New List Previous ermtt umber and Dateglssued Lam/ " l I ~l ~~ t p ~ ~ "(~ _( ! ! (O V I T a of POWTS S stem: eck all that a 1 - 5 ~~'' r 11n tuciton -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ nd < 24 in. ble soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand ^ Recirculating Synthetic Media Filter ~Lzaching Chamber rip Li ^ Gra 1-less Pi Other (explain) V. Dis elsal/TreatmentAres Information: 6t, Design Flow (gpd) Design Soil Appli ation Rate(gpdsf) Dispersal Area Required (sfj Dispersal Area Proposed (st) System Elevation J - ~. 9`a 1000 ~ ~ o .~""? ~s 7=a= 9/.~ -3= VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Conswcted Glass New Existing Tanks Taiilcs Septic or Holding Tank q c{O CtJ s ~D / l Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for i Ilation of the POWTS shown on the attached plans. Plumber's Name (Print) ~ ~~ ~TU~~~ Plum r Sign re MP PRS Number ~3s7 Business Phone Number ~~s-a~g-6.~,s- PIu1n~~s Address (Street, City, State, Zi C e) ~O VIII .ount /De artment Use Onl Approved ^ Disapproved Sanitary Permit Fee (includes roundwater Surcharge Fee) ~ Date Issued ~ (~ (/ Issu' g Agent gnat ( at ps) ~ ^ Owner Given Reason for Denial ~ O • vi l U G~~Z ihJ2 IX. ('onditions of Approval/Reas ns for Disapproval _ S~Q Q~ a.,(l~1 `1~~ ~ ST~c.I' (/~"~ ~ T" /f ~ - ~~i t/ ~ ~ U ~~?a~ ~ ~ ~a`_ s~ ~,~~ ,17 yr,~che. ~ ~~ 1~1•. Ste- 0.7 h~cd. St~'`~`-" J I ~ ~ (/Attach complete plain (to the County only) for the system on paper not less ffian 81/2 x I1 inches io size -a3 ~ (7C (o jy ~ t(z,, ~ /~` ~~ SBD-6398 (R. 01/03) ~- /3~*~- ~'S q y 3 - ~s ~C~ /d.sn c.~.~.~.;,... ~~ ,~ sa.~ . '~ °~ ~-a ~~- a3 ~y~/,~Sr ~Y 9f ~ -~G, I~ I~~ y°~ ~ ~~- ~~ s~ ~aao35 ~ ~- %'.~- ~S R y ,3 - is ~C~ /dso c.u.~.;1-.. 7-/ Sy ~,?s ~-a ~.~- a3 ~. ~~ ' ~=~ ~y~~,~sf ~ ',, yD ~ sy9/`~ S~ ~~aa o35 l r Wisconsin Department of Commerce Division of Safety and Buildings SOIL EV ATION REPORT - ~- Page ~ of 111 PIiWIVP1IVG WIUI VVI111 V:lr Y 1. 1rVVC County Attach complete site plan on paper not less than 8 1/2 x 11 inches in . Pla u include, but not limited to: vertical and horizontal reference point (BM), di lion a percent slope, scale or dimensions, north arrow, and location and distance Bares Parcel I.D. ~ - f ~(l~'7 ~ 3-{Y~ Please print all i form~E'~E~ eviewed b Date Personal information you provide may be used for se ndary purposes (Privacy Law, s. 15.04 1) )). ~ ~ /Q ~ ~Q Property Owner ~ S~ ~, ~ T ~ ~ z~ rope Location ~ ' ' ~~ n ~~ L,.JVL ovt. t l~,C ~ 1/4jE 1/4 S (s T ~ ~ N R ~ E (or) Props Owner's Mailing Address „ A ST. CROIX COUN ' of # IY Block # Subd. Name or CSM# "t FC/- '/'~ ZONING OFFIC ~ ' (` c:( City State 'p Code Phone um er ~ ' ~~5 ity ^ ~Ilage ~ Town Neares cad I. SIA1 W- S4f?Ib ( ) ~(o =7 ~~ ~~ a2G C Lttn~ New Construction Use: (~ Residential / Number of bedrooms Code derived design flow rate ~~ ~ GPD Repiacement ^ lic or commercial -Describe: ______ ___ _ __ r_ Parent material ~ U~ Flood Plain elevation if applicable ~~ ~ ft. General comments / _ tj . r and recommendations: S ~/s?~1/h 2~ C11. ~/ ` ~ ~ a r / ~ t~~ Uti+.> rte Boring # ^ Boring ~ . ®Pit Ground surface elev. ~ ft. Depth to limiting factor ~ in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fl= in. nsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2 -- ~ i ~ Z ~.. S a ,.v~ -~ ~ ~~. r ~ 5 I Cr.. ~ ~ ~ -Y _ vac yv~ l ~ ~'-~- , © Boring # ^ Boring ~ l ~°~ ^ pit Ground surface elev. ft. Depth to limiting factor ~ in. _ Soii ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP DlfF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Ef(#2 6- ~ r~ z _ 1 ,-- ~ s 1 , ,~- ; ' C ~ ~ f G ~ yr r/ C v '~ /U~ ,s ~ USc ~ .1, "Effluent #1' = Bt7D > 30 < 220 mgil and TSS >30 < 150 mgll "Effluent #2 = BOD < 30 mgh and TSS < 30 mgll ~~ ~ Prrnt~ i'v~ a. ~, -Q, ,~ S' re . ~'" / ~~Number Address Date Evaluation Conducted Telephone Number ~ ~_~ `1 ~ `~'~ ~~ • /(Jt~/~~ti,~n ~n fry~~.i1I ,~Y~/~- /~ -~- -~ ~ 7iS-7~ cs -y L ~-c 1 r ~~ '~ ,. z Property Owner P,acyxll ID # ~ ~ e- ~"'` ~ ' Page ~ of Boring #^7 B°ring pit Ground surhace elev. ~_ Depth to limiting factor ~G ~ in. Soil lication Mate Horizon' Depth Dominant Color Redox Description ' Texture Structure Consistence Boundary Roots GP D/fl' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#9 •Eff#2 ~ -~c~ `. _ , `C Zwl.ih ~ C I Boring # ^ Boring ^ pit Ground surtace elev. ff. Depth to limiting factor in. Sal lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ff in. Munsell Qu. Sz. Cont. Caor Gr. Sz. Sh. •Eff#1 •Eff#2 ^ Boring Bonng # Ground surface elev. ff. Depth to limiting factor in. ^ Ptt Sal licatwn Rate Horizon Depth Dominant Color Redox Description. Texture Structure Consistence .Boundary Roots GP D/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 • Effluent #1 = BODS > 30 <_ 220 mglL and TSS >30 <_ 750 mglL • Effluent #2 = BODS < 30 mglL and TSS c 30 mglL 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 608-266-31 S 1 or TTY 608-264-8777. SBD~8330 ~Rb/00) • ' ~ U~ a.~G ©~~J GHQ PAC3E ~~ OF~ NAME LOT# d '~ LEC3AL DESCRIPTION ~/a ~/a,S T ,N,R E(OR)W SCALE: 1 " _ / D ! -r BM i ELEVATION Lt Chi G BM f DESCRIPTION •~+, ~ ~^~h,~` ~t p BM 2 ELEVATION ' BM 2 DESGRIPTION ~~ SYSTEM ELEVATION ~ ~ ~ w Cif' ~(Q`~ ~,{,~;~' (~~ SYSTEM TYPE C~ iR U ~Q. (fit ,.~iY'~-a.~ %,z // II c~, t~ ~~ j~ c.~/~ ~~ • ~.~ ~b~ _ _______ $IC3NATURE iyi~ `,---°°--._ DATE ~~ '~/ p.. _ Safcty and Buil mgs Divt t, ~ GRuntY , ~'°` ` ,~ ~ 201 W. Washington ve., P.O. Box 7 ~~ '~ ,SCO~ c'~ Madison, W 53707;Ij~t~82 ani Permit Numbu (to be filled is by CoJ De artment of Commerce (~8) 61546 ~ ~ 9 Sanitary Permit AppHcat ~Qti c,,, . state. Plan `.°.N" m b~r ' / ~,( ~ In accord with Comm 83.21, Wis. Adm. Code, personal information you p ~~ '-4' ~ '' / V / 1 maybe used for socondary purposes Privacy Law, s 15.04(1 j(m) ' r Project Address (if diffueot rhea mailing address} N• . I. Applicadon Information -Please Print All Information <~ Q~~ // ~ ~. Pro Owner's Name ~ 2 ~J ~ Parcel N t p Block N .~L~.n^~v~ e,~n• ~ 3 ~ Property Ownu't Mailing Addreu op u P r ry Loca '' D / ~~ / - ~ ~ " ' Ciry State i /•, SLt'4~Y., Suction 1 r "~ , Z p Code Phone Numbe r !~ ~~ / // 7~S' ~(o ^(~~9 a 9 /C~(circleone) / T N 6 ( IL Type of Bttlldine (check aU that apply) y ~~ qS 'SJIp rk ~ !~- ; R E of Y~ `. ~ ~JC ~`1 or 2 F il D lli N b / Subdivision Name M Number am y we ng - um ~~ Q,,ti_ u of Bedrooms ( ~ f~~~ a ^ PublicJCommeroial -Describe U:e ^ state owned -Describe use ? ~ ~~ GeL~ I-tJi 22~Z3 ~rw .('~ OCi pvitla ~1'ownship of III, T ype of Permit: (Check only one box oa lIse A. Complete lIae B if applicable) ~1e~ f ~`' New S em ~- yst ^ Replacement System ^ Treatment/Holding Tank Replacement Only ^ Othu Modification to Existing System B• ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Pumit Numbu and Date [slued Before Expiration Plumber Owner IV. T e of POWTS S stem: Check all that a I /~! Non -Pressurized [n-Ground ^ Mound > 24 in. of suitable soil ^ Moun m. o sut AI-Grade ^ Single Pass Sand Filter ^ Corutructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filtu ^ Aerobic Treatment Uait ^ Rxirculating Sand Filter ^ Rxiralatia S thetic Media Filter ,~Leachin Chamber ^ Dri Line ^ Gravel-less Pi ^ Other (explain) ~ ~o V. Dis enalll'reatment Area Information: 1 ~,~, Design Flow (Bpd) Design Soil Application Rate(gpds() Disper©sal Area Required (s() Dispersal Area Proposed (s() System Elevation 9~/ l ' ~~ i 0~ ~ S ~ " 7 / ~7 / gs ~ T , U VI. Tank Info Capacity in Total Numbu Manufacture Prefab Site Steel Fibu Plastic Gallons Gallons of Units Conerote Constructed Glass Ncw Existing Tanks Tutu Septic a HoklinQ Tank o2.~t', - ~ S U f (C.A.~t.s2.~~. Aerobic Trcauncu Unit Dosing Charnbcr VII. Responsibility Statement- I, the undersigned, assume respoasibllity for in allatloo of the POWTS shown on the attached plans. Plumbu's Name (Print) Plum 's Si azure PRS Numbu Business Phone Number ~ ~~ d asp ~s ~ ~~s- a~ s ~ 9y Plumber's Address (Street, Ciry, State, Zip C e) / ~ a r~ ~~ / ~U /~ u-~ s ~~ VIII. nun /De artment Use Onl pproved ^ Sanitary Permit Fee (includes Gro dwater Date sued Issuin gent SignaNr o S psj Ownu Giv eason for Denial Surcharge Fee) nn 3t.J(J ~ ~~ q ~ { ~5 IX.. Conditions of Approval/Reasons for Disapproval ((~~ II ~I SYSTEM OWNER: ~ ~J~~,dcJS.~.. Mr~j~' CJtn~ e,,~~ //N,pallirepq, 1. Septic tack, effluent filter and ~ ~v ne Irk iltl~~~_ dispersal ceN must all be vertices / me~ttakrad Pa Cl as per management plan provided by plurrtbtK. n wu _~-__~.. 7~~ J .6~ QU~ w.. .vy~n cn ni o~ an nwr~)ww w0 ~~~~ .~ 11 ;1 11 ~'~• -r-~-• ~ ~ W .~, y O ~~~ q ~ ~ ~ ,y • ~~ ~' ~ ~ ~~ .y ~ ~ • ~ t ~ ,~ ~ ~ ~` ~, ~, =~~ ~ ~~ o ~~ e ~ H ~ . v ~~ r O ~, •p. '~ ~ ~'1 ~~ o ~Z ~ `~ q ~ ~ ~ ,~ ~, ~' ~~ ~ ~ ~~~ ~ ,~ ~ ~ ~ ~ ~~ ~ ~~ ~' o~ ~• Q ~ ~ - ~. RECE V~ p-~_._ t7ivisionoFSa~yand ~ SEC 2.9 200;~_SOI,L EVALUATION REPORT ~ / ~ 3 ...•.•...a. •,,.....,•.•.o sr. R Attac~r site plan paper ~ ' ~Wl~~r 11 it~res in size. Pier must Cour>ty 5 T COQ of ~. irrr~ude. but not J&riited !o: (t3tuj, dkr~tion and perrrafr!<slope, scraeor~, norttr arrow. di~oebo nearestroad_ Paroel t.D. ~~ ~ ` 6!l Please print all /nficumatlFon. Reviewed ~ t~ 9 9 d you aowae m.,- a ueea rossm~as~y a.poses ter r.aw. a. tsa (t) t+~>• ,v p s£ S1 °:GT• L Properryt~wner k'~~e~vo,v 1.3~s T ~ /9 Z 9 s~ s~ GvK. Ld T ,-a ,~a N ~ ~•c~ w Property Owrter's Address ~y GA • ~rtR G-'~ ~~ ' t:ot # ~.3 &Odc ~ Srbd. Pfame or CSkw `~ co }~o rte' E.v !N ~f~a:E •, ffUO.So ~ tv/• s y ~ ~ •-1?? ~ ~' ^ I?~S Toym t@eamst lead ~~+" ~ llse:J~ a6 t I~kr>ber of bedroom 3 " Code derived design ttow rate ySa - O'r? GPD D ~ ^ PrrbGc a oorrNrrercial - t~xibe: _5,~}~uDy Oytw.tS~i ~lood~;f `N ~. :General oorrenerrts and ._ ____ ' !Q'~r;~' 7~'S7'~P ~ $ StJ/7'~-6~E" F'+0/C /!yV /iil~~POUivQ cow vt,,ti, •f-t~ewh L t'~. D• w .T= 5. S ySt.~. - T3.; o,r0: t~w.t~-~ ~~ ~ .ii~WM oN•ipW ~. •L 6I~A~ ~ ~•INI~( Itl4KJ• ~I• ~{~ •1~i tloriztxr fepttr a-ainfirant Fasdooc Osaoaipkiorr Terc~xe Struclue Cor~enoe ea,rxlsry Boob ~r. [iMrrrseD na. sz. t?au. odor Gr. Sz Sh. 'i~1 'Eft ~ o- y ~o y ~~ - GS /,-~,,, s w 3~ ~ Z z • ~o is y ~-S / c . Z n tt11: Pit (3raxrd surface Nen. ~ !• ~~ ft. ~ > ~~ b- ~ sa Rake tlorfxon Depth Danbyant lZedurc Desaipilan Textrse 8tnrtsr~e Cone Botarde~y Roots C,P OA'E tn. Qu. Sz. Cont. Color CY Sz Sh. '~1 'EtNl7 o•>'Z ~a yR SL ~ ~ 3f . y • ~ z ~a ~ goy _------ ~ />~s ~~ ~,~- . Z . 3 6 • o ~o y~P ----- S~- cs /~ . y . ~ ya•So ~ s y y --- ~S /~ .~ c ~ z. ~ o ---; ,~. S D, s ~ Z... 5 qtv EMtrent #1 ~ eoo > 30 < 2~ man. and TSS ~o a 1 50 moll ` E1Rusnt ~2 = BpD < 3o mall and TSS <_ 3o melt. ~~t~I3~~T` 7~{tbl?i C(~ j ~ a2C~3 S Addn~ Oede C-vak~eA'iat Carducbd Telepirons Wrrrirer rnvate Sewage Consultants 2812 10th Ave. ~/N •S Foil TOT,9.G O/c 80 J~ Spring Valley, WI 54767 ,Z p . to ~..7 . Z. v • D-~a o • /0.x.'7. 30 • a~a z.o • io~7 . yo • o~ ~t ~~ K~R~va,v T3~9~s ~ Paroei In tt L 0 7`' Z ?7 ps~ Z~ 3 a ~~# ~ P, Groundsurfaoeelev.~ ~. Z ~ to~~~ ~~ Rate Florizon Depltt Domirsar# Redoa Destxiptia~t Texdxe Struckre Cor~tenoe t3oundary Roofs OPOVIP ~. Munsed t]u. Sz Corrt. Color Gr. Sz Sh. 'Et(#1 'Eff#2 ~ ~o~~ 3 ---- ~ s~ s w . y ~ io ~L / ~ c / z • .3 ~o "~- L ~ tivt G s -- . ~ -S o nr~~ . S D , S ~.,~ . 7 !. Z. i Fiaiaai Depth .... - --- - --~-. .._„ .-..~... .. Dominant Redox Descxiption Terre Strudarte Consistence Boundary Roots Soil Rate GPD~ in, t1Atu~sed th+. Sz Cont. Color Gr. Sz Sh. 'E~1 'Eff~2 O Pit Gnwrtd surface elev. R Oeplh to ~ factor h. ~~ Sod Rate F1ori7Art Depth Oarrrnant Redox Desaiptlon. Textire Cansistenoe Botrdary Roots GP DIIf~ irt. (Nun®ed Qu. Sz Cont. Color . Sz. Sh. 'E!f#f '~tt#2 Efduer~t #1 = BODs > 30 _< 2Z0 mgll_ TSS >30 _< 150 rngll ~ Eitiuent #2 = BC+D < 30 mgA. and TSS = 30 ntpiL s- The Department of Commerce is an 1 opportunity service provider and employe. If you need assistantx to access cervices or tied material in an al fotrnat, please t~rttact the depamrter-t at 608.2t~1i-3151 or TTY 608-264-8777. u ~/ ~ER~a,v ~,4-s r- L ~j v o~ Parcel to ~ L 4 t" ^ 3 3 ~°'`'~ # ~ Plt GrourM surface elev. , Z 4 tom, t~, e.,,rtr.,~. ts.,e,..> yo -~~ ~- 3 Page of Florlton pepd- Dorr~r~aret Redox Desaiptlon Texture . - Struchse Car-oe --- Boundary Roots soy - t3P lxe~ 0V1! in. ~~~ Munse~ io~l~3 Qu. Sz. Corti. Color -- ~ Gr. Sz Sh. s,~ ~ w 'Etf111 ,y 'Etf#2 • ~ ~o ~L / ~ c / . Z.. . o nr-~~ . S O A S ~,~ . 7 !. Z t 1 I e:. Gn~t,nd wxfa,~.do„ a i,....w:..: n_.n:__ ~~_ Horimn .Depth Dominant Redox Oesaiption --~- -- .- --a -- •• Texture Strucane Consistsnoe Boundary Roots SoB Rate GPDIf'~ in. Munsep Qu. Sz. Cont. Cdor Gr. Sz. Sh. ~ 'E~1 'Eifll1 a3odn9 # u ~9 ^ Pit Ground surface elev. R to ~ tacbor in. Sod Rate tiorizcn Depth Dormant Redoor DesatpSott. Texhxe Cara~tenee Boundary Rods GPDR~ M. Mur>se~ Glu. Sz Cont. Color . Sz. Sh. 'Efi19 'Eff#2 ESBtarnd #1 = BODs > 30 _ 220.tnglL TSS >30 <_ 150 rnglL • Eta #2 = BODs < 30 mglt. and TSS: 30 mgll. The Department of Commerce is an 1 opportunity service provider and employer. If you need assistance to access services or need material in an alternaf format, please contact the department at 608-266-31SI or T1Y 608-264-8777. s~ot~an ~. k w a A C Si ~~ \\~)^\ -..~ o ~~ ~ ~ ~ ~` ~ ow -.a cn ~ ~ to ,n .. J ~ N ~' ~ l/s ~ j ~ ~ m '~~',- C w~ ~~c~ ~.{ a-a ~ ~ N ~ ~ ~ ? p CT ~ Q° ~ .p ~ ~ ~ ~ ~ ~- Q ~~ b D, 4 C'a 4 ~o a c N N . ~ ~ ~" ~ ~ ~ ~ .. t`1i• ~ 1 '`1 ~ ~ ~ ~ ~ ~ ~ # ~~~ ~ ~ ~ ~ ~~ ~ `~ ~-.~ n i\~ {{` '1` i v O _ ~ ~ ~~ tsl ~ ~ .,~~ O .~ ~~ ~~ w • ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP C;~RTIFICATION FORM Owner/Buyer Mailing Address Property Address ,l (Verification requi"red "frd~n Planning Department foc new conswction) n ' ~ City/State /~ Wtt Parcel Identification Number ~er..dG~ ti LEGAL DESCRIPT~IO~iN Property Location /VOK %,, s~ y,, Sec. ,~ T~N-R~W, Town of Subdivision Lot # Certifed Survey Map-7# Volume .Page # Warranty Deed # / ~6~ y~ Volume ~~_~, Page # ~a~ Spec house ~( yes ^ no Lot lines identifiable ~ yes ^ no .s' Yp/ SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The propcrtyowner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, joutneymanplumber, resttictedplumber or a licensedpumperverifying that(1) the on-site wastewaterdisposal system is in proper operating condition and/or {2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above regninements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Departme~ of Commerce and the Department of Natural Resouuces, State of Wisconsin. Cettification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days o three exp' tioa date. /~ / ~/ v ' SI ATURE OF APPLICANT DATE OWNER CERTIFICATION I {we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the pr d " ed above, by virtue of a warranty deed recorded in Register of Deeds Office. ~, • ~j ~ ~~ SI ATURE OF APPLICANT 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 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATIOti'V Owner Permii # DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units .,~.~- ^ NA Estimated flow (average) al/day Design flow (peak), (Estimated x 1.5) al/day Soil Application Rate al/day/ft2 Standard Influent/Effluent Quality Monthly average" Fats, Oil & Grease (FOG) <_30 mg/L Biochemical Oxygen Demand lBOD51 <_220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand IBOD5) 530 mg/L Total Suspended Solids (TSS( 530 mg/L ^ NA Fecal Coliform (geometric mean) 510° cfu/100m1 Maximum Effluent Particle Size Ys in dia. ^ NA Other: ^ NA *Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE SYSTEM SPEGIFICATIONS Septic Tank Capacity ~ al ^ NA Septic Tank Manufacturer ~ ^ NA Effluent Filter Manufacturer ^ NA Effluent Filter Model ~d~ ^ NA Pump Tank Capacity al ^ NA Pump Tank Manufacturer ^ NA Pump Manufacturer ^ NA Pump Model ^ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: ^ NA Dispersal Cell(s) In-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA other: ^ NA Other: ^ NA Service Event Service Frequency Inspect condition of tank(s) At least once every: ^ ear( -1s) (Maximum 3 years) ^ NA Pump out contents of tankls) When combined sludge and scum equ s one-third IY31 of tank volume ^ NA Inspect dispersal cellls) At least once every: ^ month(s) (Maximum 3 years) yearls) ^ NA Clean effluent fiher At least once every: ^ monthls) year(s) ^ NA o Inspect pump, pump controls & alarm At least once every: ~ yea~(s)Is) ^ NA Flush laterals and pressure test At least once eve ry~ ^monthls) ^yearls) ^ NA Other: At least once every: ^monthls) ^yearls- ^ NA Other. ^ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tankls) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cellls) 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 tank equa{s one-third (Y,) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator 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 10 days of completion of any service event. GMW (4/01) Page bf START UP AND OPERATION ' For new construction, prior to use of the POWTS check treatment tankls) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal celllsl. If high concentrations are detected have the contents of the tankls) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cellls) in one large dose, overloading the celllsl and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. 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 and prolong the life 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; herbicides; 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 tie 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 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 replacement system: ^ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot tines and welts. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time... ^ 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 OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name G , Phone ~ .. G O., POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name ~ ~its~:• Phone ~/Jr"~ 3 G ... ~~ S(~ This document was drafted in compliance wkh chapter Comm 83.221211b11111d1&If) and 83.5411), 121 & 131, Wisconsin Administrative Code. ~~ V~~}8~ ~P. IZ.a STATE BAR OF WISCONSIN FORM 2- 2000 Document Number WARRANTY DEED THIS DEED, made between Kernon !. Bast, a married person, Grantor, and Kernon J. Bast and Donalda J. Speer-Bast, husband and wife, as Survivorship Marital Property, Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin: SEE ATTACHED EXHIBIT A Recording Area 75m940 KATHLEEN H. MtALSH REGISTER OF DEEDS 5T. CROIX GO.~ MI RECEIVED FOR RECORD 01/07/2004 12:35P~ IiARRANTY DEED EXEMPT # 8M REC FEE: 13.00 TRANS FEE: COPY FEE: CC FEE: PAGES: 2 Name and Return Address: Edina Realty Title, Inc. 400 S. 2'~ St. -Suite 115 Exceptions to warranties: Hudson, W154016 Easements, restrictions and rights-of--way of record, if any. 412540 20-1027-40-000 & 30-400 &20-00 Pazcel Identification Number (PIN) This is not homestead property. Dated this 6th day of January, 2004. * ernon J. Bast AUTHENTICATIQNa,(0~(~IC~ Signature(s) G~eC~ V1p~1C authenticated this 6th day of Jag ' TITLE; MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Edina Realty Title -Doug Berg 400 South Second Street #115, Hudson, WI 54016 (Signatures may be authenticated or acknowledged. Both are not necessary.) •Names of persons signing in any capacity must be typed or printed below their signature * ACKNOWLEDGMENT STATE OF WISCONSIN ) ST. CROIX COUNTY. ) ss. Personally came before me this January 6, 2004 the above named Ketnon J. Bast, a married person to me Irnown to be the person(s) who executed the foregoing instrument and aclcnowled the same. ~ ~J~ *Cheri Brown Notary Public, State of Wisconsin My commission is permanent. (If not, state expiration date: 3/11/2007 ~3 WARRANTY DEED STATE BAR OF WISCONSIN FORM No.Z-2000 -, ,. U Z'i87P lZ~ EXHIBIT A The NE '/. of the SE '/, and the N W '/, of the SE '/., all in Section 15, Township 29 North, Range 13 West, St. Croix County, Wisconsin, EXCEPT a parcel described as: Beginning at the E'/, comer of said Section 15; thence South 00 degrees 47 minutes 33 seconds East, along the east line of the SE '/, of said Section, 407.27 feet; thence South 89 degrees 08 minutes 15 seconds West 535.46 feet; thence South 14 degrees 10 minutes 34 seconds West 93.31 feet to a point on a 80.00 radius curve, concave southwesterly, whose central angle measures 25 degrees 34 minutes 33 seconds, whose chord bears North 54 degrees 32 minutes 33.5 seconds West and measures 35.41 feet; thence northwesterly along the arc of said curve, 35.71 feet; thence North 14 degrees 10 minutes 34 seconds East 76.12 feet; thence North O 1 degrees 07 minutes 26 seconds West 400.07 feet to the monumented south line of Certified Survey Map recorded in Volume 1, page 217 at the St. Croix County Register of Deeds Office; thence North 88 degrees 51 minutes 13 seconds East, along said south line, 570.78 feet to the point of beginning. Sep Oi 05 10:32a Team Speer Hast 7153868660 p.3 are ACRES ® LOT 10 ~,.,~ LOT ~ e42058~ FT. ~ 2.00 ACRE6 ~ ® 2.01 ACRES . ~ ~ ~ ~~ ® ® ~ 1~~ ea72e ea Fr. = ~'J ~ ~~ J ~ ~ a A 1' ~ a x $ ~ A+aRes ~ ~ g 1000180-l=T, 61 t' t~ 1! ® , - _... , .7 L.eA 006.6 Lea . eea.en ~ n. . J~,__. .. .. , - ~N~- • -• _ ... - . ! fir, ` ti ~. 220AC(~e ~ ,~ sat ncRE:s ~ , t ~ ~. . s~ o/a7s Rn 1=r. >i2aa6 EiO. Fr. ;~, ~ ~ ~t,~s ~~ 64T.~ NOTpta•E 01pffi 1 ~,f " 8 ~~. LI a i_ _~ . ~ LOT ZO ,. ® G9 .' Lao ul PI 2.Q1 ACp6A ® ~ ~ ' ~ L071T LB.O. ~ sol.eo ~ aaoAC:r~e ut ~ - ~ ~' ~ . Pd . Z,1! At~B 1ueze eO. Fl' ~ - •~,;E~;K , ~ ,; (s _ ' g ~ LO ~..~.... r ~ ` , ~ 6ezeo T 22 4..72 ACRq .+~~ IY ~ ~ "~ '~ . Q'OK/YEIIRN ; % .. / .-...-.._ ~ ........ _.._ ` ~+r>„~ / _ , ~ r J ~~ `x~ ~ ~-` ~! l j LQT SZlf ~ te J R03 ACR~B ~ a ® t ~ ~ ,~ 200 ACHES ~' ~ ~ ' 11210 BQ FT. ® ~ r ~ ~' eoT zai ~ ~ tt '. ee~ee s4. ~r. ~ R a 2tsACRES ~ ~ ~ ®~ RA177ErM~ i -u aa s1c ~ s ~oa ea Rr. ~ . ~ ,a6.6. ! `~.1 c ` ~ 1 J ~ ~ 1a a y ~ aa~tm 1 M.~rdlr+~R~ ....+r+t_ _ _~1"YV ~ 2 ~ -~.y ! 81!!. 9otmlLadEOF :NeNOnnlbzOctNr6Elc ~~~y~-~ ~~q~ /~ /~ gyp ~p~ry;~,7~ ~+ /~y~~ /:~~. lYJ/7CMI'LaWY J~Fa4J l'aVJI~I.'Y't) ~~W~1Lti/ l9U \:~l'LY~ILS:~S~!~ ONNN47EEh7B1FMf talE71ltE T/W. ~~ I+u+6EA tOpE+~tON _ d6rrwo5. Nt11+6Er oul~ccxrl o9t Lt FM~'Ualbly 3I0 T1 L71 IyM1yR/,~( , ~ 67 a u ~ w~ia~w ...-. genes .•~• y ty~ ^ ~. aoltir.se 11e, W A 8a'6174W M~ IQ CS7 +~ _,_. _ /e67-~f~M ~ ~ ~107 IA LS iq'6YlfW Me'at7Y_W~~ .•.._••• Y26A6 111!2iM 1.01 L011 BeP!'e'~IYW NC'7Y16W 17.7, N.7 L6 ~l1~TPItVM CJ~E! LI! 14M14N1 1J ~ ^- u 6oarr.~c ~"~' ztt s't L0t ^~~ _ aesos~.w y Lea.a ID e0e^~fOOW ~6.at La 661'6Te6E 10 6; u Noo'.ISat+r _ _rna u +_ ~ _ Iaa lta ~~ ~` NU'7i76E 36!•AT__ Ltl_ ~` Nflf7a.T1 -' 00 u, j ~ ` 1 L1? Nq'6ty~ wStiial'E eo+s a d OQ L.t L4 1 tet'~r1rw HN9tgw~~ LV7e 1 X1 _ lU_ SY'067SF _ _ 2771P ~ _ .,+ LO .____..,._____a_ ~Mlt'?CAW 4 r._ Il.ii Lµ ~ $06'C'R141N 4' ip 7+ ~ LM !O~ $~a'W ~ ~k L18 SOa'eeesw _ i><e L6 rasvzisw~ bay L16 IpY563l71f 116.60 L6 1164'teePV! 1e0.1 ltt tlea'Oe1~t? iW.76 Ut NOD+a6xW~ 180.: lb M7'a/Ya14 6YAS lY NBrWOtW ~pA! e .,....lam e.~~ Safety and Buildings Division 2 County t ` ~ ~ 01 W. Washington Ave., P.O. Box 7162 ~scons~n Madison, WI 53707 - 7162 Sanitary Permit Number (to be fill by Co.) r Department of Commerce (608) 266-3 I L ~ ` Sanitary P ~~ State Plan I.D. Nutt}ber - In accord with Comm 83.21, Wi h ~ /~ may be used for seconc' "~._ < Project Address (i different than mailing address) I. Application Information -Please Pr ~ d ~~ Q ~ ' Property Owner's Name l ~ L ~ 2005 ~~ Parcel # Block # ~DD- Proptirry Owner's Mailing Address IX COUNTY Property Locatio ~7 ~ ~ ~`` _ ~G OFFICE , `~ ~ j~ ~ Section ~ ~ City, State ? ~ ~ / ~~f:~ I/v -E~ Zip CodUe ~ ! ~~~ Phone Number p f r~ 7~.~- a6 77"~G / . , G T ~N; R<~E or W e) , ~O S~ II. Type of Building (check all that apply) or 2 Family Dwelling - Number of Bedrooms t ~ Subdivision Nam S Number ^ PubliclCommercial -Describe Use ^ State Owned -Describe Use ^City_ Vil ag Township of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) $-d S" A. New System ^ Replacement System g p ^ TreatmendHoldin Tank Re lacement ^ Other Modification to Existin S stem g y 13. ^ Permit Renewa Before Expiration Permit Revision ^ Change of Plumber ^ Permit Transfer to New List Previous ermtt umber and Date Issu/~ed / ~ [~/ / ~ /'(l D~ _ ~ ~ `~ ! ((O t0 IV. T e of POWTS S stem: eck all that a I - S (~JOn -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ nd < 24 in. ~ able soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand ^ Recirculating Synthetic Media Filter ~I,eaching Chamber rip Li ^ Gra I-less Pi Other (explain) V. Dis ersaUl'reatmentAeea Information: ~ Design Flow (gpd) Design Soil Appl' lion Rate(gpdsf) Dispersal Area Required (sfj Dispersal Area Proposed (sf) System Elevation ~, ~Do ~` ~ o .$"? `" s y=es= /.~ -3= VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank c~Q J ~ ~p / ! t , , ,~ I - - t~C•G.Sad~-rte Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume responsibility for i Ilation of the POWTS shown on the attached plans. Plumber's Name (Print) ~ f~,0 G1 TG~i~1~ Plum r Sign re MP PRS Number X357 Business Phone Number 7iS- ~S-6~s PIu1n~~s Address (Street, City, State, Zi C e) ] ~~ / ~//bQ VIII ount /De artment Use Onl Approved ^ Disapproved Sanitary Permit Fee (includes routtdwater Surcharge Fee) -q~ ~ V ~ O Date Issued l V lssu' g Agent gnat ( at ps) ^ Owner Given Reason for Denial 'T : -/ ~ b IX. C~ nsA ~ Approval/R~ns for Disapproval ~ ~/f ~~j~ ~~j r~e~~~ U((// dD ~ 0 S ~ U IKX ~~ / ~ ~ 6tir `yQ~C.4(/~/ ~~r~ C~t.a~~-~ vH. saw- o ,~- h.a~c.d sty"-~ ~ ~ r , (/ Afhch complete plaro (to the County only) for the system on paper ant less than SIR x 11 inches in siu _a3 O t3G r/Jl /z ~'l_ SBD-6398 (R. 01/03) y- i~~ ~~ ~ ~'~ q y 3 - ~s ~r~ '' ~6-e ,~ sa.~ ~-~ sy ~zs '~ g~a ~.~- a3 '~~. ~ 1' N l~~ y°~ ~sY sr ` s ~aa o3s ~ Safety and Buildings Division County ~ 201 W. Washington Ave., P.O. Box 7162 1SC0~~,~ Madison, WI 53707 - 7162 Sanitary Permit Number (to be fi{I by Co.) r Department of Commerce (608) 266-3 I G ~ ~~ - Sanitary Permit Applic 'o State Plan LD. Nurgber t 1 In accord with Comm 83.21, Wis. Adm. Code, pets fo n you pr N may be used for secondary purposes Privac 5.04 1 Project Address (i different than mailing address) I. Application Information -Please Print All Information ~ J~ Property Owner's Name 0 C t 1 ~ 2005 Parcel # Block # ~DD- Property Owner's Mailing Address ~[~ ~ ~ ~~ ST. CF201X COUNTY ZONING OFFICE Property Locatio , !~• C ~ ~ J Section ~ ~ City, State ~ ~ ~., ] ' ` C~~ ~ _ _ !/t-~ ~~ Zip Co~def ~ 7 d~~ Phone Numb^e~r ~j r~ 7~/~ Gyd Z7" 6 / '• j ~ ~j T ~N; RI~E or W e) , 20 S~ II. Type of Building (check aN that apply) ~ ~ ~I or 2 Family Dwelling - Number of Bedrooms Subdivision Nam S Number ^ Public/Commercial -Describe Use ^ State Owned -Describe Use ^City_ Vil ag Township of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) ,.$_a S" `~' New S stem y ^ Replacement System ^ TreatmenUHolding Tank Replacement ^ Other Modification to Existing System B• ^ Permit Renewa Before Expiration Permit Revision ^ Change of Plumber ^ Permit Transfer to Ne~v List Previous ertnrt umber and Date Issu/~ed / t' wit / / ~/-/~Q~ ~ ~ `1 _ ( (O (O ~• IV. T of POWTS S stem: eck all that a 1 - S (~lon -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ nd < 24 in. ~ able soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand ~ ^ Recirculating Synthetic Media Filter ~.eaching Chamber rip Li ^ Gra 1-less Pi Other (explain) V. Dis ersal/TreatmentAtea Information: ~ Design Flow (gpd) Design Soil Appli ation Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation ~. a Vl. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank c~O J ~ ~Q / C f , , „ . ,- tiC~.t:3~0-r` Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for i Ilation of the POWTS shown on the attached plans. Plumber's Name (Print) ~ ~Q ~T~~~~ Plum r Sign re MP PRS Number n3s7 Business Phone Number ?~s-a~g-6~s- Plulmber's Address (Street, Ci State, Zi C de) }~ 7 ~~ 1 VIII ount /De artment Use Onl Approved ^ Disapproved Sanitary Permit Fee (includes roundwater Surcharge Fee) / V U ~ Date Issued ~ U Issu' g Agent gnat ( t ps) ^ Owner Given Reason for Denial {,Q O : / ~ b IX. C~ ns~ ~ Approval/Reasons for Disapproval ~ Q~ ~~j Gr~e~ ~ ( / Q y ~ ~ • ~ C?~~~. ~~/~7~0 ~ .~K.C ~r'~/1 ` ~ ~l~ yTr ihe. G~t.a~~,~ vH: saw- ~ • ~ h-a~tc-d. S~d.J s~ ~e~~ (~ Attach complete plant (to the County only) for the system on paper not less than 81/Z x 11 inches io sitt _a3 - ~ GC r ~~ /off" ~- SBD-6398 (R. Ol/03) ~- /~~ /vcr c,~~ ~S q y 3 - ~s ,,~ Faso ~~ ,~ sa.~ 7-/ Sy x,7,5 r~ ~~- a3 ~=~ ~y~~,~sf ~7~~3 ~Y ~f ~ ~• N I~~ y°( S~ ~aao3s~