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042-1005-30-100
Wisconsin Department of Commbrce PRIVATE SEWAGE SYSTEM County. St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 578925 GENERAL INFORMATION (ATTACH TO PERMIT) OLD state Plan ID No: Personal information you provide may be used for secondary purposes (Privacy Law, x.15.04 (1)(m)i. , S Permit Holder's Name: city Village X Township Parcel Tax No: Warren Town of 042-1005-30-100 Bourn Thomas Geor a p No: CST BM Elev. Insp. BM Elev: BM Description: 03.29.18.42A 10 TANK INFORMATION I D A Sectionrrown/Range/Ma TYPE MANUFACTURER CAPACITY STATION S HI FS ELEV. O b t) Septic ` 1iE Benchmark g 3 f 0 `f • S3 a 91 i 14 - 6 66 Dosing At. BM P~ •--p ~ ao AeFatien o n..~oa Bldg. Sewer t= t Pa t b k SZ S Hoiding S 1 Inlet St/Ht Outlet `J TANK SETBACK INFORMATION TANK TO P! WELL 1 BLDG. Vent to Air Intake ROAD Dt Inlet Septic ► / Dt Bottom j cJ O Hea a /J 1 ~7.7 6 ist. Pipe 3 , Aeration D Holding Bot. System J I Final Grade r PUMPISIPHON INFORMATION Manufacturer 1 GPM Demand St Cover l Model Number ' ~ J~ Cpl ~1 ~ SI l.C ~ C" TDH Lift Friction Loss , System HeaduI C` TDJ,i„ t V w ~U Jam(„ Forcemain Length Dia. Dist. to Well I / 11n SOIL ABSORPTION SYSTEM BED/TRENCH Width / ~ j Len ) INo4M 0 1 PIT DIME S No. Of Pits Inside Dia. liquid Depth DIMENSIONS 1 fl SETBACK SYSTEM TO P/L BLDG WELL r LAKE/STREAM LEACHMtG Manufacturer: INFORMATION d q~ CHAMBER OR Type M H15 1W Model I NA- UNIT Number DISTRIBUTION SYSTEM Hea rMianifokf p ID istribution / Ix Hole Siz ► x Hole yS'ng Vent to Air Intake Pipe(s) I Win- (Q Length Dia Length Dia J• Spacing " ) SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only L*n $p er Depth Over xx Depth of tl xx Seeded/Sodded xx Mulched Bladlr. ch CeMer 0 Bedlrrench Edges / Topsoil I / Yes ®No Yes 0 No COMMENTS: (Include✓✓%ode discrepencies, persons present, etc.) Inspection #t:~/ ~ / Inspection #2:~ .+-~~r~! V ovl L r [ or~'~~`~arCel No: 03. ~.18.444 2A 10 Location: 1208 113th Ave Roberts, WI 54023 (NW 1/4 SW 114 3 T29N R18W) NA Lot 1 ~ ° ~s 222iif000 , -+a a+~'grud.e e1:s~c.I~if ve~u~;-td. ~u p? ~ouX -{e oadn~iA~ h ` g _ I , 1.) Aft BM Description= 2.) Bldg sewer length=l_ C~ j~~7IlS Pl,aYd;'~+'POtr ~OO+~ usPc~ - amount of cover = V , It c anJ 1 V 0,SC Qa~,sh~~ y2 on a~ J p Plan revision Required? ® Yes No ' Use other side for additional inform n• LO 7 Date Insepctor's Signature Cert. No. SBO-8710 (R.3197) Ar r6 ~ ~D 8 ~i ~b~~0/►S . KSte P of ~ ~ ,~r.C~~ h son ~ 2- .~~~d l5 A%4 Ic L 5 ~ u' ~]C O 1 40 (,t>a ~rcrf ~ lA lt-~ 6rl Fa ~afLto.~s , .t er ~bus~ Lc, U /31 ~ - 4 n-ad- ~ d ,n cO ifc] f J beloJ yrJLO- orCELVED County A f~' Safety and Buildin s Division St. Croix ~s Roo 1 201 W. Washington Av O. x 7 Sanitary Permit Number (to be filled in by Co.) Madison, WI 5 CROIX COUNTY UNITY D VE OPMF-N1 0 7309 GI ZS Sanitary Permit Application State Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit 2590633 is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04(l m Stats. 1208 113 Ave. L Application Information - Please Pjik All Information Property Owner's Name Parcel # u 042-1005-30-1004 Thomas and Judy Boum Property Owner's Mailing Address Property Location P.O. Box 113 Govt. Lot C YZ+►b City, State Zip Code Phone Number NW ~'/$W Section 3 Woodville Wi. 54008 (circle one) T29 N; R 18 E or vp H. Type of Building (check all that apply) Lot # 1 EX1 or 2 Family Dwelling - Number of Bedrooms 3 T Subdivision Name l Block # ❑ Public/Commercial - Describe Use Q Q° ❑ City of Number El village of ~ JJCSM ❑ State Owned -Describe Use y1 fA y 76 fda [kTown of warren III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System ❑ Replacement System Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal [](Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner 578925 4-28-15 IV. Type of POWTS System/Component/Device: Check all that apply) ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ((Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device(explain) V. Dis ersa eatment Area Informatio Design Flow ( ) Design Soil Applicati Ragpdsf) Dis real Area Rejpdred Dispersal Area Proposed (sf) System Elevation 450 1.0' 0 • "l 50 \Z 450 105.00 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units d 0 0 New Tanks Existing Tanks 525 Poylok o 2 Si A C7 a a. U rn on V. Septic or Holding Tank 1000 1000 Wieser x Dosing Chamber 1 600 600, combo x VII. Responsibility Statement- I, the undersigned, assu a responsibi ' nstallation the POWTS shown on the attached plans. Plumber's Name (Print) A ' Signa MP/MPRS Number Business Phone Number Keith Knudtson 648443 651-470-1737 Plumber's Address (Street, City, State, Zip Code) 927 150th St. Roberts Wi. 54023 V o u n /De artment Use On 154 pproved y ~ Permit Fee Qssued Issuing Signature en Reason for Dem $ r I IX. Condit0p ; 0Wasous for Disapproval a G 3 C 1 .Stank, ftiant Nw and' e es cell must all ~be ti L ~'F-c wl • l M t ~ss Par dement phut provi by, plumber. art, 2Itlt~ttNt OfdlfltAtlON. >M psr bow Attach to complete plans for the system and submit to the County only on paper not less than 8 In z I I inches in size SBD-6398 (R. 11/11) Page 8 of 8 • WELL Note: Nearest Northerly P2 - 204 ft. 0 25 50 Proposed Three Bedroom Home Note: WesstPJL is - 305ft. from Home Graphic Saab (Fast) 1 imh a 50 R Sanitary Site Plan Ha For:Thomas and Judy Bourn Lot 1 of+Csm Vol. 19 Pg. 4918 Proposed 4" Sch. 40 PVC Building Sewer NWl/4-SW1/4 See. 3 T29N-R18W ,--r P/L Town of Warren -St. Croix County -697.00' 3anan ectionpers ~ SEE CORRESPONDENCE 383.43(8)(4)c d insti insullate building sewer SPS 382.30(11)(c) 98.00' Proposed Wieser Concrete 10001600 WLP Combination Tank w/a Poly-Lok PL-525 Filter 100.00' 102.00' Proposed 2"Sch 40 PVC Force Main / 104.00' t/ 104.50' #1 106.00' 7.40 Acre Parcel - BM O B #z o 108.40' Proposed 6'x 75'Mound Dispersal Cell located along the 104.50' contour w/a System Elev. of 105.00' 8% #2 ABM i #z ari Elevation Data IB #3 B#1 = 103.70' P/L B#2 = 106.00' B#3 = 102.80' B# 1 Orig. = 101.80' BM#2 = Top of 2"PVC Pipe Elev. =100.00' A BM = Top of 2" PVC Pipe FN# 1208113th Ave. * HRP =Same --450.00' ASSUMED ELEV. = 100.00' CIL of 113th Ave. ~tienx7~.tp;y~ DIVISION OF INDUSTRY SERVICES 3824 N CREEKSIDE LA 1~ - o HOLMEN WI 54636 ® a Contact Through Relay P ` http://dsps.wi.gov/programs/industry-services ' `mow www,wisconsin.gov 1~ 0 ssIO'NScott Walker, Governor Dave Ross, Secretary August 24, 2015 CUST ID No. 648443 ATTN POWTS Inspector ZONING OFFICE KEITH E KNUDTSON ST CROIX COUNTY SPIA 927 150TH ST 1101 CARMICHAEL RD ROBERTS WI 54023 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 08/24/2017 Identification Nurribers Transaction ID No. 2590633 SITE: Site ID No. 816347 Thomas and Judy Bourn Please refer to both identification numbers, 1208 113 Ave above, in all correspondence with the agency. Town of Warren St Croix County NW1/4, SW1/4, S3, T29N, R18W Lot: 1, Subdivision: 19-4918 FOR: Description: Mound / Three Bedroom / Sloping Site Object Type: POWTS Component Manual Regulated Object ID No.: 1552107 - Maintenance required; 450 GPD Flow rate; 60 in Soil minimum depth to limiting factor from original grade; System: Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01101, 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. 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, CONDI stats. AQQ The following conditions shall be met during construction or installation and prior to occupancy or use: EQ-~ of D Reminders pP,ovessi ~ Of • This system is to be constructed and located in accordance with the enclosed approved plans and with the component manuals listed above. • The pipe materials for the sewer pipe between the house and the septic tank shall conform to SPS 384.30 Wis. 5EE Adm. Code. Required under plan submittal - SPS 383.22 (2)(a)4.b. Specification, including a description of the materials for the project (This includes size, material and ASTM number.) • Per manual cited above, limited activities are allowed in the area 15 feet down slope of the component area. Soil compaction, excavation, vehicular traffic and other similar activities that impact the treatment and dispersal are prohibited. • The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption area. chs. NR 811 & 812c KEITH E KNUDTSON Page 2 8/24/2015 • 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 POWTS 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. Stat • SPS 383.22(7) 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 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. 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, Charles L Bratz Please Include a Copy With Your POWTS Reviewer 2, Division of Industry Services Payment Submittal. (608)789-7893 , 7:45 am - 4:30 pm Monday - Friday WiSMART code: 7633 cherles.bratz@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm KEITH E KNUDTSON Pale 2 8/24/2015 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 POWTS installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(4), Wis. Stat • SPS 383 22(7) 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. 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. 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. 1 ~SU~ When You Receive That Invoice, Charles L Bratz Please Include a Copy With Your POWTS Reviewer 2, Division of Industry Services Payment Submittal. (608)789-7893 , 7:45 am - 4:30 pm Monday -Friday WiSMART code: 7633 charles.bratz@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm f t t MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Thomas and Judy Bourn Mound System Owner's Name: Thomas and Judy Bourn - Owner's Address: P.O. Box 113 Woodville WI 54008 Na Legal Description: Parcel in the NW1/4-SW1/4 Sec. 3 T29N-R18W Township: Warren County: St. Croix Subdivision Name: Csm Vol. 19 Pg. 4918 Lot Number: 1 Block Number: Na Parcel I.D. Number: 042-1005-30-1000 Plan Transaction No.: Page 1 Index and title Page 2 Data entry Page 3 Mound drawings Page 4 Lateral and dose tank Page 5 System maintenance specifications Page 6 Management and contingency plan Page 7 Pump curve and specifications ZONALLY Page 8 Plot Plan 40VED SAFETY AND )NAL SERVICES IDUSTRY SERVICES Designer: Keith Knudtson License Number: MPRS648443 Date: 08/06/1 Phone Number: 651-470-1737 Signature: )MSPO(dDE 7-7 'or / Designed Pursuant to the ~ Mound Component Manual for POWTS Version 2.0 SDB-10691-P (N. 01/0} an both SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST-SAS (01/81) and Pressure Distribution Component Manual Ver. 2.0 SBD-10706-P (N. 01/01)CIZ, I G/ /,Z) Version 7.0 (R. 03/2012) Page 1 of 8 Mound and Pressure Distribution Component Design Design Worksheet Site Information (R or C) R Residential or Commercial Design Note: Sand fill (0) calculations assume a 300.00 Estimated Wastewater Flow (gpd) Table 383-44-3 in-sftu soil treatment for 1.50 Peaking Factor (e.g. 1.5 = 150%) fecal coliform of 36 inches. 450.00 Design Flow (gpd) 8.00 Site Slope 104.50 Contour Line Elevation (ft) 60.00 Depth to Limiting Factor (in) 0.40 In-situ Soil Application Rate (gpd/ft2) Distribution Cell Information 75.00 Dispersal Cell Length Along Contour (ft) = 6.00 Cell Width (ft) 1.00 Dispersal Cell Design Loading Rate (gpd/ft2) 1 Influent Wastewater Quality (1 or 2) Are the laterals the highest point in the distribution Y Pressure Disribution Information network? Enter Y or N (C or E) E Center or End Manifold 3.00 Lateral Spacing (ft) If N above, enter the elevation (ft) 2 Number of Laterals of the highest point. 0.155 Orifice Diameter (in) 2.33 Estimated Orifice Spacing (ft) = 7.03 ft2/orifice 2.00 Forcemain Diameter (in) 110.00 Forcemain Length (ft) Does the forcemain drain back? Y 80.35 Pump Tank Elevation (ft) Enter Y or N 4.55 System Head (ft) x 1.3 17.94 Forcemain Drainback (gal) 14.40 Vertical Lift (ft) 67.41 5x Void Volume (gal) 2.76 Friction Loss (ft) 85.35 Minimum Dose Volume (gal) 0.00 In-line Filter Loss (ft) 34.46 System Demand (gpm) 21.71 Total Dynamic Head (ft) Lateral Diameter Selection Manifold Diameter Selection in. dia. options choice in. dia. options choice 0.75 1.25 x 1.00 1.50 x x 1.25 2.00 1.50 x x 3.00 2.00 x 3.00 x Gallons/Inch Calculator (optional) Treatment Tank Information Total Tank Capacity (gal) 1000.00 Septic Tank Capacity (gal) Total Working Liquid Depth (in) Wieser Concrete Manufacturer gal/in (enter result in cell 1349) Dose Tank Information Effluent Filter Information 603.36 Dose Tank Capacity (gal) Pot Lok Filter Manufacturer 16.76 Dose Tank Volume (gal/in) PL-525 Filter Model Number Weiser Concrete Manufacturer Project: Thomas and Judy Bourn Mound System Page 2 of 8 Mound Plan and Cross Section Views T J Observation Pipe ::A FKK 'J" •rM1"•~°• .•:lL ^L• °ti• :M1'd': :L :.°TL. •°4A."b8 ::~S pS L Mound Component Dimensions Down slope toe extension made. ft K 7.60 ft A 6.00 ft E 11.76 in H [Aft B 75.00 ft F 9.50 in z ft L 90.19 ft D 6.00 in G 0.50 ft J ft W 19.33 450.00 (ftz) Dispersal Cell Area 1125.00 (fe) Basal Area Available 6.00 (gpd/ft) Linear Loading Rate 7.50 (ft) 1/10 B Obs. Pipe Placement Mound Cross Section View Aggregate Dispersal Area Finished Grade 106.79 (ft) G l105.50 (ft) Lateral F ' Dispersal Cell" 105.00 (ft)--O Invert Dispersal Cell ' Elevation ? r~ ...t 7.:t`~ ,,.')'S, „Lr.`~: <.'S fit. •r. k- A, 104.50 (ft) Contour Elevation 8.0 % Site Slope Geotextile Fabric Cover Shading Key T Dispersal Cell See lateral details on Topsoil Cap = 1.5 ft L ~j ; ;in_•.S,LS; xaa;;;o er:p~ Page 4 for number, size, Subsoil Cap o j'" ' " r~ :•:4a.; and spacing of laterals. Laterals are equally ASTM C33 Sand • Tilled Layer 0. ft ra,: ,„Ty icaI Lateral Y F spaced from the ^ L~ ftl L L 't distribution cell's L L 5 1 1 1 ti L L © Aggregate o x.1,..:1.1:".ti centerline in the 0- A - distribution cell (AxB). Project: Thomas and Judy Bourn Mound System Page 3 of 8 End Connection Lateral Layout Diagram Lattrals oentered over the A tc dimension i a Turn-up wfball valvo or eloenoutplug P ,t All laterals art identical Holtz drilled on the. bottom of the lateral s equaillj spaced Farce main connection via tee of cross to manifold at art point.. Laterals Morcemain Sch 40 PVC per SPS Table 384.30-6 Number of Laterals 2 Orifice Diameter 0.156 in Lateral Diameter 1.50 in Orifice Spacing (X) 2.37 ft Lateral Length (P) 73.47 ft Orifices per Lateral 32 Lateral Spacing (S) 3.00 ft Orifice Density 7.03 fez/orifice Lateral Flow Rate 17.23 gpm Manifold Length 3.00 ft System Flow Rate 34.46 gpm Manifold Diameter 1.5Q in Total Dynamic Head 21.71 ft Forcemain Velocity 3.52 ft/sec Dose Tank Information Locking cover with warning label and locking device and sealed watertight Electrical as per NEC 300 and SPS 316.300 WAC 4 in. min. Disconnect Tank component is properly vented E--- Alternate outlet location Forcemain diameter Weiser Concrete Manufacturer_ 2 in. Capacityl 603.36 Gallons Volume 16.76 gal/inch A Weep hole or anti- Dimension Inches Gallons B siphon device A 19.91 333.65 B 2.00 33.52 C Pump off elevation ft C 5.09 85.35 91.10 D 9.00 150.84 D Total 36.00 603.36 Do♦ se tank elevation (ft 3" Bedding un er tank. 90.35 Alarm Manuafacturer SJE. Rhombus Note: Switches Alarm Model Number Tank Alert 1 containing mercury may not be used in Pump Manufacturer Goulds this system. Pump Model Number 3871 EP05 Pump Must Deliver 34.46 gpm at 21.71 ft TDH Project: Thomas and Judy Bourn Mound System Page 4 of 8 Mound System Maintenance and Operation Specifications Service Provider's Name Powers Sanitation Phone 715-246-5738 POWTS Regulator's Name St. Croix County Landuse Dept. Phone 715-386-4680 System Flow and Load Parameters Design Flow - Peak 450 gpd Maximum Influent Particle Size 1/8 in Estimated Flow - Average 300 gpd Maximum BOD5 220 mg/L Septic Tank Capacity 1000 gal Maximum TSS 150 mg/L Soil Absorption Component Size 450 ft2 Maximum FOG 30 mg/L Type of Wastewater Domestic Maximum Fecal Conform >10E4 cfu/100 mL Service Frequency Septic and Pump Tank Inspect and/or service once eve 3 ears Effluent Filter Should inspect and clean at least once eve 3 ears Pump and Controls Test once eve 3 ears Alarm Should test month) Pressure System Laterals should be flushed and pressure tested eve 1.5 ears Mound Ins ect for ondin and seepage once eve 3 ears Other Miscellaneous Construction and Materials Standards 1. Observation pipes are slotted and materials conform to Table SPS 384.30-1, have a watertight cap, and are secured in as shown in the mound component manual. 2. Dispersal cell aggregate conforms to SPS 384.30 (6)(i), Wis. Adm. Code. 3. All gravity and pressure piping materials conform to the requirements in SPS 384, Wis. Adm. Code. 4. Tillage of the basal area is accomplished with a mold board or chisel plow. 5. The mound structure and other disturbed areas will be seeded and mulched to prevent soil erosion and help reduce frost penetration. Lateral Turn-up Detail Finished , *40*0000*0*00*0 Grade v/ 6-8" Diameter Lawn ---Tf Threaded Cleanout Sprinkler Valve Box Plug or Ball Valve Distribution Long Sweep 90 or Two 45 Degree Bends Same Diameter as Lateral Project: Thomas and Judy Bourn Mound System Page 5 of 8 Mound System Management Plan Pursuant to SPS 383.54, Wis. Adm. Code General This system shall be operated in accordance with SPS 382-84 Wis. Adm. Code, and shall maintained in accordance with its' component manuals [SBD-10691-P (N.01/01), SSWMP Publication 9.6 (01/81), and Pressure Distribution Component Manual Ver. 2.0 SBD-10706-P (N. 01/01)] and local or state rules pertaining to system maintenance and maintenance reporting. No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with SPS 383.33, Wis. Adm. Code when the tanks are no longer used as POWTS components. Septic or pump tank manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be seated watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 84nches in diameter shalt be secured by an effective locking device to prevent accidental or unauthorized entry into a tank or component. Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113. Wis. Adm. Code. The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the fitter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittentfilter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of a triennial assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such product are used they shall be approved for septic tank use by the Department of Commerce. Pump Tank The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary. Mound and Pressure Distribution System No trees or shrubs should be planted on the mound. Plantings may be made around the mound's perimeter, and the mound shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic (other than for vegetative maintenance) on the mound is not recommended since soil compaction may hinder aeration of the infiltrative surface within the mound and snow compaction in the winter will promote frost penetration. Cold weather installations (October-February) dictate that the mound be heavily mulched as protection from freezing. Influent quality into the mound system may not exceed 220 mg/L BODE, 150 mg/L TSS, and 30 mg/L FOG for septic tank effluent or 30 mg/L BODS, 30 mg1L TSS,10 mg/l. FOG, and 104c(011100 mL for highly treated effluent. Influent flow may not exceed maximum design flow specified in the permit for this installation. The pressure distribution system is provided with a flushing point at the end of each lateral, and it is recommended that each lateral be flushed of accumulated solids at least ace every 18 months. When a pressure test is performed it should be compared to the initial test when the system was installed to determine if orifice dogging has occurred and if orifice cleaning is required to maintain equal distribution within the dispersal cell. Observation pipes within the dispersal cell shall be checked for effluent pahding. Ponding levels Shan be reported to the owner, and any levels above 6 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. Contirxtencv Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component(s) shall be immediately repaired or replaced with a component of the same or equal performance. If the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or replaced in its' present location by increasing basal area if toe leakage occurs or by removing biologically dogged absorption and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. See Page 5 of this plan for the name and telephone number of your local POWfS regulator and service provider. Pretreatment Units The information and schedule of mananagement and maintenance for pretreatment devices such as aerobic treatment units or disinfection units are attached as separate documents and are considered part of the overall management plan for this system. Project: Page 6 of 8 Page 7 of 8 NGOULDS PUMPS Submersible Effluent Pump EP04 3871 EPO5 N~. V 1W 1W APPLICATIONS • Fully submerged in high ■ EP05 Impeller: Thermoplas- ■ Bearings: Upper and lower grade turbine oil for tic enclosed design for heavy duty ball bearing Specifically designed for the lubrication and efficient improved performance. construction. following uses: heat transfer. ■ Casing and Base: Rugged • Effluent systems thermoplastic design provides AGENCY LISTING • Homes Available for automatic and superior strength and corrosion • Farms manual operation. Auto- resistance. G caWIan StwWards Association • Heavy duty sump matic models include • Water transfer Mechanical Float Switch ■ Motor Housing: Cast iron (CSA listed model numbers end • Dewatering assembled and preset at the for efficient heat transfer, in "C" or 7".) factory. strength, and durability. SPECIFICATIONS ■ Motor Cover: Thermoplastic Goulds f ffnps is ISO W WgsWW. FEATURES cover with integral handle and • Solids handling capability: float switch attachment points. maximum. ■ EP04 Impeller: Thermoplas- 5 Power Cable: Severe duty • Capacities: up to 60 GPM, tic Semi-open design with rated oil and water resistant. • Total heads: up to 31 feet, pump out vanes for mechanical • Discharge size: 1'12" NPT. seal protection. • Mechanical seal: carbon- rotary/ceramic-stationary, BUNA-N elastomers. • Temperature: 104`T (40`10) continuous 140OF (6090) intermittent. METERS FEET 10 • Fasteners: 300 series stainless steel. 9 30- - scPM • Capable of running dry without damage to 8- L 2 5 F components. 25 °a 7 Motor: x • EP04 Sin le phase: 0.4 HP, v_ 6 20 115 or 2Y0 V, 60 Hz, 15504 RPM, built in overload with Q 5- 15 automatic reset. a 4- • EP05 Single phase: 0.5 HP, o EPo 115 V or 230V, 60 Hz, 1550 10 3 10 RPM, built in overload with eroa automatic reset. 2 • Power cord: 10 foot s standard length, 16/3 SJTOW with three prong grounding plug. Optional 20 ° 00 10 20 30 1 ao so Gann foot length, 1613 SJTW with three prong grounding plug g o z a 6 0 12 m3/h (standard on EP05). CAPACITY Goulds Pumps 2)2°01 Goulds Pumps <& ITT Industries Effective May, 2001 83871 WELL Page 8 of 8 • Now Nearest Northerly PtL - 204 fi. 0 25 5o Proposed Three Bedroom Home Note: West P/L is - 305ft. from Home C.-PWe Saab (7-0 1 inch- 60 tt Sanitary Site Plan For:Thomas and Judy Bourn Garage Lot 1. oPCsm Vol. 19 Pg. 4918 Proposed 4"Sch. 40 PVC Building Sewer NW1/4-SW1/4 Sec. 3 T29N-R18W P2 Town of Warren -St. Croix County 697.110' Note: Provide frost protection per SPS 383.43(8)(4)candinsulatebuildingsewerper SEE CORRESPONDENCE SPS 382.30(11)(c) 98.00' Proposed Wieser Concrete 10001600 WLP Combination Tank w/a Poly-Lok PL-525 Filter 100.011' 102.00' Proposed 2"Sch 40 PVC Force Main / 104.00' /J 104.50' #1 106.00' 7.40 Acre Parcel - BM B #2 I o fJ 108.40' Proposed 6'x 75'Mound Dispersal Cell located along the 104.50' contour w/a System Elev. of 105.00' 8% #2 1 ABM 1 ttl Qrl Elevation Data ®B #3 13#1 = 103.70' \ P/L B#2 = 106.00' B#3 = 102.80' B# I Orig. =101.80' BM#2 = Top of 2"PVC Pipe Elev. =100.00' ABM = Top of 2" PVC Pipe FN# 1208113th Ave. * HRP =Same -450.00' / ASSUMED ELEV. = 100.00' C2 of 113th Ave. RECEIVED nn rr qq E~ / of 3 Wis. Dept. of Safety and Profes l*r ~ SQJ,7Z SOIL EVALUA-17011 RE-1-01 I Page J Division of Safety and Buildings ST. ~N D~~ps;e latith SPS 385, Wis. Adm. Code ty F'MEIV f Coun ~ J Attach complete site{e er not less than 8 1/2 x 11 inches in size. Plan must 44 include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). -2,416r -0AAMI A) 7- -(5- Property Owner Property Location Govt. Lot 1 /4 jl d 1 /4 S_3 T N R E (orLo Property Owner's Mailing Addr ss Lot # Block # Gaer C~ /,J p ❑ City Village Town Nearest Road IZc~ $ C'dy/State Zi Code Phone Number / ( 0 New Construction Use: Residential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement / ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable ft. General comments 1441,a -/-/01:: _ and recommendations: " &4w Boring # Boring l~I Ia.l Pit Ground surface elev. 143, 142,7 ft. Depth to limiting factor 77 _ in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 -$02 7 -r S _ lee, 'el-2 E Boring # Boring ® Pit Ground surface elev. 1114 ft. Depth to limiting factor /-//2_ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff t2 c 111-54 a .j 7-,3 e * Efflue #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L nt #2 = OD < 30 mg/L and TSS < 30 mg/L CST Name ( e Signatur _ CST Number Address Date Evaluation Conducted Telephone Number 7 SBD-8330 (R11/11) Property Owner Parcel ID# Page of Boring # ❑ Boring 101 M Pit Ground surface elev. ft. Depth to limiting factor ~77 in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. S/h. * ff#1 ff#2 b L? X r ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 102 F-1 Boring # E] 11 Boring Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 * ff#2 F-1 I * Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD 5 < 30 mg/L and TSS < 30 mg/L The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay. SBD-8330 (RI 1/11) Properly Owner 'S. a4' Parcel ID#~1'`~ Page of F-51 Boring # ❑ Boring Pit Ground surface elev. ft. Depth to limiting factor ~7 7- in. Soil Application Rate 2 Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * ff#2 .41 J ~ c 1- 7 ` r l 73 ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft z in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 ff#2 Boring F-1 Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * ff#2 * Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD 5 < 30 mg/L and TSS < 30 mg/L The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay. SM-8330 (1111/11) --'~'G~~%~+~-f~-~- ciCd.O ~QGf'~A1 ----1S.k~~'~,,~~~.JL(1-~1..~.5~~~=~~7-•[l''"11-.r.Q ~ ~i i I I I c~ ~aG ~J ; - - I I Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM county: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 578925 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [.Privacy Law, s.15.04 (1)(m)). Parcel Tax No: Permit Holder's Name: city Village X Township 042-1005-30-100 Bourn, Thomas Geor a Warren, Town of Section/Town/Range/Map No: CST BM Elev: Insp. BM Elev: EBMescription: 03.29.18.42A 10 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic S Benchmark $3 16q$3 /da e r Alt. BM Dosing P~ "~J dd o .n~~oa n D Sz Bldg. Sewer ~Ij,, ~a St/Ht Inlet Hoiding St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom ,1 5 ~g Header/Man. f Dosing Aeration Dist. Pipe Holding Bot. System Final Grade PUMPISIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number 17 TDH Lift Friction Loss System Head TDH Ft J Forcemain Length Dia. Dist. to well 7 r SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM CLEACHIR OR Manufacturer: INFORMATION Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bedirrench Center Bed/Trench Edges Topsoil 0 Yes Nok Yes No COMMENTS: (Include code discrepencies, persons present, etc.) inspection #1: Inspection #2:-77-/ / Ts Location: 1208 113th Ave Roberts, WI 54023 (NW 1/4 SW 1/4 3 T29N R1 8W) NA Lot 1 Parcel No: 03.29.18.42 10 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = ~J~ IW1.J4 0 1~~11 ~n Q~ _ - - Plan revision Required 0- Yes ~ No Use other side for additional information. Date Cert. No. is Signature Insepcto SBD-6710 (R.3197) l~. ivy/$w 96 -7 p`~bit 'Al lS P14uQ'i~5c,~ Z -711 ff~ ° ~~Iecff`nn A 64 r~/ Vic{' JlJtld ~^aA 1 :r1c p p Y X13 ~ ,ter County Safety and Buildings Division s D 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) S Madison, WI 53707-7162 Sanitary Permit Application State TransactionNum In accordance with SPS 38321(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, s. 15.04(l)(m), Slats. f 2 og J 2 t~ Ave L A lication Information - Please Print All Information I / V Property Owner's Name Parcel # T~iomas v awn 1_12- vvS 3() -160 Property Ownterr''s Mailing Address 2 Property Location T V )-6 bx ' J Govt. Lot City, State Zip Code Phone Number V N 1/, 5 VV 1/, Section 3 pUC~v ~k, IN 5 dU g 57 J~~ - 22 T ZC N, Rl circleE I VTo', e of Building (check all that apply) Lot # 2 Family Dwelling - Number of Bedrooms 3X_ Subdivision Name n lock # ❑ Public/Commercial -Describe Use (/L- t~ r ❑ City of hCU~~ ^l CSMNumber ❑ Village of ❑ State Owned -Describe Use J~/ I R / O 0 lS al m Cals.- 19 1 1. 1 4 ~ -1 ' CJ Town of N V VL ✓ l1 16. Type of mit: (Check only one b z online A. Complete, 11p U if applicable) A. New System ❑ Replacement System ❑ Tre en M hg Tank Replacement Only ❑ Other Modification to Existing System (ex ) 3I X-7(I B. ❑ Permit Ren 2--permit Revisi El on Change of Plumber 11 Permit Transfer to New Before Expir ion Owner IV. Type of POWTS System/Component/Device: Check all that a 1 Inn 1-TrAMP Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable s_oilJ - tJ j 41 ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) _ JN,/tLIA~ V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Ele ation y5o 9q I~2S q5 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units c O / i N cC cd New Tanks Existing Tanks 5 a U v rn w C7 P. F- ~Z U Septic or Holding Tank V !l _00 J O U /DG Dosing Chamber (Cob 1 ~J b 49 A112 VII. Responsibility Statement-I, the undersigned, assume sponsibiliWfor install 'on of the O S shown on the attached plans. Plumber's Name (Print) Plumb 's gnature MP/MPRS N\mber Business Phone Number Plumber's Address (Street, City, State, Zip Code) c ~SUf" J ®Z VIII. ount_ e artment Use Only Permit Fee Date ue Issuing Agent i e Approved rf7 Disapp $ d b er Given Reason o ial IX. Conditions of Approval/Reaso)otsapproval SYSTEM 0) 1. Septic tank, effluent filter and J 1~~ - e "erV dispersal cell must ) loo ided bytplumber. ,AAn tA J as per management Plan p 2. All setback requirements MU A c ete plans for the system and submit to the County only on paper not less than 8 in x 11 inches in size SBD-6398 (R 11/11) `1 tt 74- AV roA r 4mv~ loo Pof ~ o ,~r.Ut P6 LO D (,3 /J~ J Soli Ahsoralion System Cross Section ♦ 103.00 ft 102.45 ft V Schedule 40 Final Grade PVC Vent Pipe 100.45 ft Wfth Vent Cap Leaching Chamber 99.45 ft System ©ewation 3.00 ft 5.00 ft ft Soil AbsorDtlon System Plan View ft 3.00 ft 5.00 ft Leaching Trench 1 Chambers 4' Dia. Trench 2 Header Vent Or Observation Pipe Trench 3 Leaching Chamber Specifications Manufacturer And Model _ /7 ~i / f w ay EISA Rating 20.00 sq ft per chamber Soil Application Rate 0.40 gpd/sq ft 450.0 gpd Design Flow = 0.40 Soil Application Rate 20.00 EISA = 57.00 Chambers 3 rows of 19.00 chambers each. Page of Septic-Dose Tank Cross Section And Pump Performance Specifications E Tank Manufacturer Wieser Pump Manufacturer Goulds Tank Model Number 1000/600 Pump Model Number 3871 EP04 Total Tank Capacity 1,600.00 Alarm Manufacturer SJE Rhombus Max. Bury Depth 8.00 Alarm Model Number Tank Alert 1 FSwitch Type mechanical Filter Manufacturer Pol lok Total Dynamic Head (TDH) - Feet Filter Model Number 525 Elevation Head 19-Y.L Distal Pressure Network Loss Minimum Pump Performance Required Force Main Loss 1.50 GPM 0 Ft TDH Total 150 0, l~ ' a at Manhole Min. 4" Above Grade With Locking Device. Inlet Manhole Manhole Min. 4" Above Grade < 6" Below Grade Sealed Watertight Securely Mounted With Locking Device Weather-proof Junction Box Finished Grade 'r a Covher f Vent Min. 12" Disconnect Ft Above Grade Means With Vent Cap f < < < < <'<'< <'S'< < S <a< < <'< <'< < <'< < <'t < < t S r< Outlet Outlet Filter IInlet Baffle a< A :X: Switch Settings and Reserve Capacity V4" Tank Volume = GPI Weep Dimension Inches Volume Gal. B Hole (reserve) A 20 350.00 a; (alarm) B 2 33.52 Off Elevatio C (dose) C 5 86.64 <y< t (dead) D 9 150.84 Bottom a a D a Elevation as Total 36 603.00 a a Ft a s a a> a a a>> s>>> a a> a a s a>> s s a a t ><><>`><>`s<a`a<><a<><a<at><>`a<><a<>s><><>`a<a4 a4 a<>.9a<>4 a<><>ts<a's`y'a<as>4 asaRaja<>4 ><>'4 ><>.100<><><>` GENF_RAT, EVWALLATjON: The septic/dose tank is bedded and back filled in accordance with the manufacturer's product approval specifications. Maximum depth of bury as specified by the manufacturer may not be exceeded without prior approval. Manhole covers exposed to grade have an effective locking device (padlock) installed. Piping at the inlet and outlet is of approved material, connected to the tank with watertight fittings, and laid on stable soil to prevent settling or sagging. The force main is sleeved with 4" Sch. 40 PVC to bridge the tank excavation and the sleeve is sealed watertight. Electrical service complies with NEC 300 and Comm 16.28 WAC. 02105 LJ Page of f Page 7 of 8 'SU OLDS PUMPS ~r e Efflue* ft rit EM4 3871 EP05 ■ FP06 ThertiTOplas- ■ tipper ~ NTUCADONS • FrtYy st~mer9ed ~~grade hirbine Od for tic enCloaad desw for ~ ~+n9 Sped1~y designed for the lubrication and efficient following uses: heat transfer. ■ Cadng aid Basin Rugged systems tfaifebleforautonmticarttd dTertnopias-M design pmt ACiicir I.iSFING a • Farms mutual operation. Auto- ~ and aonrosion * cm eden3wWm LsA=d-* • li" duty sump matic modek kck de ■ Mawr Housirw can iron (CSA Famed model numbers end • Water transfer Medw" Float Swidt foreMdei t heat transfer, In •C• or •F• • wing asseirtMed and prate atttte factory- strength. and dinablity. ■Mnim Cojecibermoptar~c GadekRnipsTst~t3900lNeg+oleie8 S1 ECIEICATIONSS ~r watt integral handle and • St s hartd1m, cap~il'uy: FEATURES Nat 8 tent poirI. '1<° rna~an~m. SOW lmpe0er: TWMOPkr- 8 PPww Cdit Swere duly CaROTM. to fo GPM. de Sert*gm design with • T ~ to 31 feet. purrs out vene5 for medranie~ Tamed and water rest ttt Dt5dtarge siw.1111* NPf. seat p vtoction. • MedmnicA seaF carbon- -vrW cast G SZBZIw", K N" ekstornem : -ar, DeMw - !~C} sctrair~otts its iritBffrBttOFIt METERS FEET -per 300 series 14 = _ _ } - - steel " • - of Ong 30 _ 'E FJra2 to - . 23 R image 8 ; ry -z_ 25 - f u~ 7 - • F - = tease: 0.4 Hp -50 tk 1550 WV - aavdoad with i- S 4 115: L 2K4 - 50 H7-1 b50 3 10 RPK t _ -eTti>ad with SIT{)IM rT.- prong Dardffig gug. tptnowl 20 0 % 10 2f 30 40 50 GPM foot tengt=t.16a OW vAM amp" 0 2 a 6 8 14 12 myh Wandard on 13% CA,?AErtY Goulds Pumps 42001 ra ws fps ~ ITT Industries Effectidrwy. 2oo1 awl r! Water l BABIES. by Coppebne Suncare Products A 3 %®2 ~ /U f /gw (tea AV ar~~`~7L 0 od+,s . vv 4 /Ca q W 4b 7e A / loo' OR %.'r. / /~/eS+C f3 ~1- ~,9 / bD a f?'i ~-]C O P Y n 16 r 1 Safety and Buildings DiviVio S rd t 201 W. Washington Ave. P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) r ~1 P Madison, WI 53707-7162 g 9 25 s Sanitary Permit Application State Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit NJ N 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, s. 15.0 1 m , Stats. Z5 6) e- /ice L Application Information -Please Print All Information Property Owner's Name Parcel # Lt 1 D %A 310 - `ev Property Owner's Mailing Address Property Location y 2-A o 13 -Ib Govt. Lot City, State Zi Code Phone Number p l~, C ICJ/., Section wD de/ r / ircle one e E of H. Type of Building (check all that apply) t # Subdivision ~ N; Name or 2 Family Dwelling - Number of Bedrooms kl( S Block # ❑ Public/Commercial - Describe Use ❑ City of State Owned - Describe Use 1n1/ CSM Number ❑ Village of Town of l III. Ty Check only one box on line A. Complete line B if applicable) A. ew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) D j s7-46 brJ caj-S w I ON E" 3- J 7~0 B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner i -IV T of PO /Com onent/Device: Check all that app I Own-Pressuriz and ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suits le soi ` ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) J 1 (M f U `(JJ V. Dis ersal/Treatment Area Information: Design Flow (gpd)/ Design Soil Applicatiop Rate(gpdsf) Dispersal Area Required ( Dispersal Area Propo78 (sf) System Elevation / zl U J / Al~- 4 ✓ u~✓ VI. Tank Info Capacity in Total # of / Manufacturer Gallons Gallons Units pL 1p 2 o n New Tanks Existing Tanks a,3 Holdng Tank epo .L eo Se Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for' stallation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber' igna MP/MPRS Number Business Phone Number lei ~h Plumber's Address (Street, City, State, Zip Code) V . Coun /De artment Use On roved Disapprove Permit Fee Date Issued Issuin i e ' $ l_ 6 V ❑ er Given Reason for Dem l~ S• 5 H hD IX. Conditions of Approval/Reasons for Disapproval ` Dssor~ l~ v✓ P SYSTEM OWNER: C J 1. Septic tank, effluent filter and dispersal cell must 4?e_erv_iced. / maintained as per management plan provided by plumber. 2. All setback require ment. Ay Attach to complete plans for the system and** "Mce It y t t""KA than in z t inches in size SBD-6398 (R. 11/11) CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Bourn Sewer Owners Name: Thomas & Judy Bourn Owner's Address: P.O. Box 113 Woodville Wi. 54028 Legal Description: NW 1/4 SW 1/4 S3,T29N R 18W Township: Warren County: St. Croix Subdivision Name: Lot Number. 1 Parcel ID Number: 042-1005-30-100 Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber. Keith Knudtson License Number: 648443 Date: 04/15/2015 P ne Number (651) 470-1737 Signature el - Designed pursuant to the In-Grou Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01101). Page 1 4 1. _ ♦ ~ , 1 t•. S ~ it 4 j r > i 1 fl, ~ / ~ 1. ' c. F. • „ r 1~f ~ i~ 1 r 1 ~ ^ rv s. f to 17 pa-) A-F fV. / loo' ho•Rc t+~.. 7 ~bpoT o~",IgUe ~ies+e b,y e~D Q ~ D C2, 0 i §,oll Absorotion 8"tem Cross Section 103.00 ft 102.45 ft C Sdiedule 40 Final Grade PVC vent Pipe 100.45 With Vent Cap ft Chamber er b 99.45 ft System Elevation 3.00 it 5.00 ft ft I $U Abso n fWatem Plan An ft 3.00 ft 5.00 ft Leaching Trench 1 Chambers 4° Dia. Trench 2 Header Vent Or Observation Pipe Trench 3 Leaching Chamber Specifications Manufacturer And Model EISA Rating 20.00 sq ft per chamber Sal Application Rate 0.40 gpd/sy ft 450.0 gpd Design Flow x 0.40 Soil Application Rate 20.00 EISA = 57.00 Chambers 3 rows of 19.00 chambers each. Page of Filters -525 EFFLUENT FILTER Awe PL-525 Filter is rated for 0,000 GPD (gallons per day) 7116' Filtration Slots AWM Mac' 'rig it one of the largest filters Am Oft iih ; class. It has 525 linear feet S" filtration slots. Like the__ y AccoMM :l ok PL-122, the Polylok ExNwWnHwWb -ft--525 has an automatic shut aff ball installed with every filter. When the filter is removed for moaning, the bail will float up and Varnporarily shut off the system so he effluent won't leave the tank. ~afV1V x_ No other filter on the market can FftgonSlft make that claim. IORded fm MWD" wooo ceu PL-525 Maintenance: 40 V 0----- The PL-525 Effluent Filter should operate efficiently for several years -10 # under normal conditions before requiring cleaning. It is recom- s mended that the filter be cleaned every time the tank is pumped or a, least every three years. If the ' installed filter contains an optional alarm, the owner will be notified by an alarm when the filter needs servicing. Servicing should be t done by a certified septic tank --o pumper or installer. B@9 WIm F1W is 1. Locate the outlet of the : U.S. Patent No# 8,015,-088 -~-s 5971.640 PAMO"d septic tank. 2. Remove tank cover and pump tank if necessary. -525 Installation: 3. Glue the filter housing to 3. Do not use plumbing when the 4" or 6" outlet pipe. If filter its removed. Ideal for residential and com- the filter is not centered 4. Pull PL-525 out of the housing. mercial waste flows up to under the access opening 10,000 Gallons Per Day (GPD). use a Polylok Extend & 5. Hose off filter over the septic Lok or piece of pipe to tank. Make sure all solids fall 1. Locate the outlet of the center filter. See page back into septic tank. septic tank. 19-21 for Extend & Lok 6. Insert the filter cartridge back 2. Remove the tank cover and information. into the housing making sure pump tank if necessary. 4. Insert the PL-525 filter the filter is properly aligned into its housing. and completely inserted- 5. Replace and secure the septic tank cover. 7. Replace septic tank cover. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page FiLE INFORMATION SYSTEM SPECIFICATIONS Ov ner d~Ct~ Septic Tank Capacity gel ❑ NA . Permit # - , - - t Septic Tank Manufacturer v5-(- D NA DESIGN PARAMETERS Effluent Fitter Manufacturer ~o ❑ NA Number of Bedrooms ❑ NA Effluent Fitter Model ~JZ ❑ NA Number of Public Facility Units Pump Tank Capacity al *14A Estimated flow (average) al/day (Pump Tank Manufacturer 3k" Design flow (peak), (Estimated x 1.5) Sa al/day Pump Manufacturer X VA Soil Application Rate/day/ft2 Pump Model gal Standard inffuentlEffluent Quality Monthly averages Pretreatment Unit A Fats, Oil & Grease (FOG) S30 mg/L ❑ Sand/Gravel Fitter D Peat Fitter Biochemical Oxygen Demand (BODS) S220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average D' Cell(s) Qo:t.~ ❑ NA Blochemical Oxygen Demand (BODE) 530 mg/L ln-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) X104 cfu/1 OOmI ❑ Drip-Line ❑ Other: Maximum Effluent Particle Sae a in die ❑ NA Other: ❑ NA Other: ❑ NA Other. ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At feast once every: ❑ month(s) 3 year(s) (Maximurn 3 years} DNA Pump out contents of tank(s) When combined sludge and scum equals one-third (Y} of tank volume ❑ NA Q Yew(s) th(s) (Meidmum 3 years) ❑ NA Inspect dispersal cell(s) At least once every: 3 R' Clean effluent filter At least once every: A Pin y~th(sl ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ month(s) 0 Year(s) Q month(s) J<ONA Flush laterals and pressure test At least once every: ❑ year(s) other: At least once every: a Y onth(s) ❑ 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 tank(s) 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 cell(s) 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 equals 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 Admsiisvative Code. Ali 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. Page -7 of y START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when 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 cell(s) in one large dose, overloading the cell(s) 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. I ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits 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 lines and wells. 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 sit@-has not been evaltjnted to Hent r/ aluati a o ing ank be ' e a~ e FfZDql t`3 TF5t~. t~D/L AJ6~,J rVSTR(J~?Z 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 > > 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 POWTS MAINTAINER Name Y,e i+-Vx Kn U 0 Name Phone ~5 I y, d 1'73 7 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name o wd 24ti1l ~J Phone Phone (v fD This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ceq` '/v5_5-79_0-7)y ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer go /d g' S OL szL ey~l bGr Mailing Address lgww PD. o'r wve~ ytll e of - 5-Dog? Property Address D 1_1'?! LJ 1 l (Verification require from Planning & Zoning Department for new construction.) City/State %Bparcel Identification Number /d 0✓ , .~0- /moo LEGAL DESCRIPTION Property Location Sec. T N R_Z3 W, Town of Wg_^,_g n Subdivision Plat: , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # (before 2007)Volume , Page # Spec house ElyesE5no Lot lines identifiable 9/yesOno 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 §SPS. 383.52(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. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Safety And Professional Services 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 am/are the owner(s) of the property described above, by virtue of a w my deed recorded in Register of Deeds Office. Number of bedrooms SIGNATURE OF APPLICANT(S) DATE ***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. 04/12) 410 ,7 3 a ~oo S / roG " Mo 98" q~ 1 Property Owner Parcel ID # Page of ~L F Boring # ❑ Boring Pit Ground surface elev. ft. Depth to limiting factor> /asp in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 142~ 40A l q 9 • `t5 .I 2 ❑ Boring # ❑ 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/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 ❑ Boring ❑ Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.07/00) Wisconsin Department of Comm rce RECEIVE®s EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Co m 85, Wis. Adm. Code My s County Attach complete site plan on per n~'l~ss tharl UQ311 inc es in size. Plan must include, but not limited to: ve al and horizontal reference poi t (BM), direction and Parcel I.D. n ~1 percent slope, scale or dimen ions, brtQ8Fd W4 oditb ation d distance to nearest road. tJ o[ a~- ,30 ZONING pFFIC Revie by Date Ple atl'iRfof Personal information you provide maybe used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 3 7 Property Owner Property Location r. Govt. Lot I 1/4 r 1/4 T_ N R E (or) Property Owner's Mailing A dressLot # Block # Subd. Name SM# Mal _v/ City S Tj Zip Code Phone Number ❑ City / ❑ Village .Town Nearest Road r( ) ) Y-// New Construction User Residential / Number of bedrooms - Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable ft. General comments _ and recommendations: 9 91 41te (,k7 LLj F-/ I Boring 7!~ Boring # pit Ground surface elev. /2?, ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 -2 ~Vt~ Ic g'! 1A 5~ - < u.7 44 /4q- C1 Z Y i F I? kv Boring # ❑ 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/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 7 - ? * Efflu "f #1 = BOD5 > 30 < 220 mg/L and TSS > 0 < 150 mg/L * Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L CST Number CST Nam (P se Pri ~AA Signature / vc,~- P/ Address Date val ion Con ueted Telephone Number SBD-8330 (R07/00) i Y I 1 i i a~ 1 /00 9'8 RECEIVED 942), i -7 8s VOL 19 PAGE 4918 VAY 4 S REGISTER H. I REGISTER OF DEEDS ST. CROIX CO. MI RECEIVED FOR hECORD 01/26/2005 64:00PK 8T, CROIX COUNTY CERTIFIED SURVEY MAP 8URVEYOR'SRECORD eEr__Ery +a oo COPY FEE: PAGES: 3 CERTIFIED SURVEY MAP LOCATED IN PART OF THE NORTHWEST 1/4 OF THE SOUTHWEST 1/4 AND PART OF THE SOUTHWEST 1/4 OF THE SOUTHWEST 1/4 OF SECTION 3, TOWNSHIP 29 NORTH, RANGE 18 WEST. TOWN OF WARREN, ST. CROIX COUNTY, WISCONSIN. N 89'15'10" E 5282.28' / W 1 /4 COR. / SEC. 3 EAST-WEST 1/4 LINE / - T I 1318.84 - - - - - - - - T - - - - - - - C" P963.44' I I CIE 1/4 I ' UNPLATTED LANDS COR. N 89'31'44" E ± SEC. 3 W I I N 89'0431" E 247.90' 242.84' 1 I 4k~ S, !p IF~ 0 Val I I ry s8. I I 14 7;'7-79 .2.7 _ I n u, CL 9 44 ~cv LOT 2 o I 400515 S.F. _ ~i3 ( LOT 1 up p to 80' TEMPORARY w i 22253 CUL-DE-SAC 9.19 Ac. 3 7 4 c nQ z EASEMENT TO BE - N 6 REMOVED UPON W p EASTERLY EXTENSION _i'" n 1•:>z i OF ROADWAY. I'o - N 16_, v cy) o Io Ls ~;)J~ TAT 3 J 01 0 1 b c te. ® ® ® ±••w~•..ess.~,~ 363659 S.F. i~ t~iI Z I I L t1 ® s~.i8.35 Ac w S I I L2 _ i N -59'0 7" E - y- ' cc I I r o i 94.4 r'~p 7 ROGER LYHH HUhM1PHREY LOOT 4 S.2188 I I Q m I i 233843 S.F. wo /1z CL 5.37 Ac. ' W t 8" l - .86' i 738.38' 529.94' WI - 1268.32' - UNPtATTED LANDS LEGEND: S 89'27'23' W 1321.18' - - T ■ SET 3/4" BY 18" IRON 1 o PIN WT 1.50 LBS./FT. :o OWNER SET 1 1/4" BY 18" IRON °o SW COR. PIN WT. 4.172 LBS./FT. SEC. 3 SURVEY CONDUCTED AT THE Z REQUEST OF THE OWNER: FOUND 3" ALUMINUM MIDWEST EQUITIES, LLC COUNTY SECTION MONUMENT NOTE: SUITE 1110 EST STREET 100' BUILDING SETBACK BEARINGS ARE REFERENCED TO THE WEST BALDWIN. WI 54002 LINE 1 LINE OF THE SW 1/4 OF SECTION 3, ASSUMED TO BEAR N 00'49'01" E PROPOSED DRIVEWAY LOCATIONS E. NOTE: R.A. - RECORDED AS DEDICATION EAST OF TEMPORARY 12' UTILITY EASEMENT SCALE: -zoo' CUL-DE-SAC TO BE CONSTRUCTED BY 30' MIDWEST NATURAL GAS o so goo zoo PROPERTY OWNER TO THE EAST. EASEMENT (VOL. 1510, PG. 95) THIS INSTRUMENT DRAFTED BY KEVIN SAMUEL SHEET 1 OF 3 HUMPHREY ENGINEERING Vol 19 Page 4918 Go Parcel 042-1005-30-100 0/27/2007 10:29 AM PAGE 1 OF 1 Alt. Parcel 03.29.18.42A-10 042 - TOWN OF WARREN Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 01/26/2005 00 0 Tax Address: Owner(s)' O = Current Owner, C = Current Co-Owner O - HAWKINS, WILLIAM E WILLIAM E HAWKINS 976 170TH ST HAMMOND WI 54015 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 1208 113TH AVE SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 7.400 Plat: 4918-CSM 19-4918 042/05 SEC 3 T29N R18W PT NW SW BEING CSM Block/Condo Bldg: LOT 01 19-4918 LOT 1 (7.400AC) Tract(s): (Sec-Twn-Rng 401/4 1601/4) 03-29N-18W NW SW Notes: Parcel History: Date Doc # Vol/Page Type 10/11/2006 836415 QC 06/29/2006 828493 AGREE 11/30/2005 813236 2936/192 EZ-U 03/22/2005 790139 2768/580 QC more... 2007 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 05/31/2006 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 7.400 55,700 0 55,700 NO Totals for 2007: General Property 7.400 55,700 0 55,700 Woodland 0.000 0 0 Totals for 2006: General Property 7.400 55,700 0 55,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 f*1 Ie in ° § N O > (D r. Z m C) * a ~ m z ?N m a -04 Lon O .A m C) c moo N~ oNA OM Nr N rrl r D4 m\ C r*'1 -P M z0 O 74 - - - - - - - - - - O Y5. V y A 1 V ~ r„< I D _ m i D Q n X11 I I s k I m I-F i OKI