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HomeMy WebLinkAbout020-1398-11-000.,, " "' • ".,,`.... ` " ." P"'KliTltC-1 L ~~Y1THti7-C J T~~f Safety and Budam; t vision ,r ~ INSPECTION REPORT GENERAL INFOf~tVIATION (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 Townshi CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~~ / ~/ ~ / _ I, t~ (~ Dosing ~ ~ A ~~ Aeration Holding ,= TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic > ~ r ~ ~ // --i V l ~ i ~ 0'h r. Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer and GP Model Number TDH Lift riction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well " 420459 0 State Plan ID No: Parcel Tax No: 020-1398-11-000 ELEVATION DATA STATION BS HI FS ELEV. Benchmark~~~/ r ~~ /D~t ~! / 0 v.~ Alt. BM s~~/ 98".3 Bldg. Sewer 3.(,~ ~7 SUHt Inlet ~ ~ ~ d A G. SUHt Outlet ~- G . Z Dt Inlet ~- Dt Bottom / ,~.- Header/Man. ~~- L O 9'S 7~' Dist. Pipe ~~ a /" ~ d- ~ u~ G/~ 7~ Bot. System ~~ t Final Grade 3 .a - 7~ 97 St Cover ~-0~ pp qaJ 7U i SOIL ABSORPTION SYSTEM /~!ik~nb.P/1i~// ~ ~~,,,~,~ BED/TRENCH Width ~ ~ Len th ~ ~ No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ ~ !_ SETBACK INFORMATION SYSTEM TO P/L~ BLDG WE L LAKE/STREAM LEACHING CHAMBER OR an cty~recr-- Ltd '~'YGi "'E~S ~ci. Typ Of System: ~ ~ ~I ~- ~ Yd~n UNIT , ~- Model Number: ~1 ~ U on d ~ 30 C DISTRIBUTION SYSTEM ~~~ entto Airln ke ~ 3~ ~ ~. !'r~~..,, ~~. ~I.:c Header/Manifold Distribution / ~~ Ix Hole Size ~x Hole- S~cfa~- N ~r Pipe(s) ~ / -_~~/" ~ ,~~ Length Dia Length ~ Dia pacing '~- SOIL COVER x Pressure Systems Onlv xx Mound Or At-Grade Svstems Onlv Depth Over ~ .~- Depth Over / xx Depth of xx Seeded/Sodded xx Mulched ' Bedlfrench Edges Bed/Trench Center 3 Topsoil ~ ~ ;~ Yes _ No ~ g ~' Yes ~` ! No _ ~ COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: /~/,6-v Inspection #2: / /__ Location: 832 Ross Road Hudson, WI 54016 (NW 1/4 SE 1/4 2 T29NLR~19W) Pheasant Run Lot 11 ~ Parcel No: 22.29.19.2471 1:) Alt BM Description = ~Ar}'i'p O~ODi/s/ << ~~S~Ql ~~ ~~`,~~(i~..-,..yC ~uf '~7'~-~C- ~ld - ~-~'~' 2.) Bldg sewer length = ~~~ /-ttll~c~~ X22- li~,yt,/iy~G~,fGL ,~o ,~,(~ O~'1~~~"/ - amount of cover = ~ ,,p~j ~ ~~~~~ Plan revision Required? Yes ~ /~~ /_ _ ~~- ~ - _ i II` / ~ ~ ~ Use other side for additional information. l~ ~"~ ~y (ptF~ ~ ____ SBD-6710 (R.3/07) Date Insepctor's ignature Cert. No. ' Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. s See reverse side for instructions for completing this application PO Box 7302 iscon in Personal information you provide may be used for secondary purposes Madison, WI 53707-7302 Department of Commerce [Privacy Law, s. 15.04(1)(m)] (Submit Completed form to County if not r _~ ~ '~ ~ ~ YU 30 S state owned. ) Attach complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x 11 inches in size. County State Sanitary Permit Number heck if revision to previous application State Plan I. D. Number • C ~ I. Application Information -Please Print all Information Location: 3 ~ S Property Owner Name Property Location , a ~~ Property Owner's Mailing Address ~~ ~ Lot umber Block Number P / d .~ y7~ / ter' City, State Zip Code Ph ne Nurnb4r, ;_ - ~ Subdivision Name or CSM Number ff`' II. Type of Buil ing: (check one) _ ~ ^ city `"`°"~ ~ 1 or 2 Family Dwelling - No. of Bedrooms :~ ^ Village ^ Public/Commercia j describe use):_ ~ ~~~ ~t~,~ /~ Town of / i " r ~ ~ ~ ^ State-Owne Z ~~ LGS ,~ d'7J Gl / ~B • Nearest Road ~ v s'S Parcel Tau Number(s)ZO .. 4 D III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) A) 1. ew 2. ^ Replacement 3. ^ Replacement of 4. 5. 6. ^ Addition to System System Tank Only Existing System B) Sanitary Permit was previously issued Permit Number ,j" ~ Date Issued Q - -•O Z IV. Type of POWT System: (Check all that apply) .. l8'fVon-pressurized In-ground ^ Mound - ^ Sand Filter ^ Constructed Wetland ^ Pressurized In-ground ^ Holding Tank ^ Single Pass . ^ Drip Line ^ At-grade ^ Aerobic Treatment Unit ^ Recirculating ^ Other: V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate ' 6. System Elevation ~[S ~ 7. Final Grade Required Propo sed Rate (Gals./day/sq. ft.) (Min./inch) i ~?j~j~- ~j Elevation ~~ 7 ~ v y ~Q ~ y~ / . 0 . • • .O VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing Crete structed Tanks Tanks m/ ^ ^ ^ ^ ,z~ -- ~ ~ c~~s ^ ^ ^ ^ ^ VIII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POW shown on the attached plans. Plumber's Name (print) Plumber's Signature (no stamps : rA4I?1MPRS No. Business Phone Number ur ~ ~ z.t lima 7/~ 63.s---l'6 Plumber's ddress (Street, City, State, Z p Code) Zd' fllc/~'rvt~'P /?c~ r-r,Gi~ S ~'s Gi=GG 6,~'/-Y~1- Z/°'G IX. County/Department Use Only ^ Disapproved Sanitary Pern-it Fee (Includes Groundwater Date Issued Issui Agent Signatur (No sta~~ips) `RLApproved ^ Owner Given Initial Adverse Surchazge Fe ~~/ Determination S"O r / ~. /~o L X. Conditions of Approval /Reasons for Disapproval: ..~ ~ ..~ a~t~ ~ "~ hoc . - SBD-6398 (R. 07/00) .- ~ Ls-T #'A' sct~,E /R" Y~ ~ l d r~ 2 =.fp - J~'+', 1a~ D/~ ~A4s Aao/~ SQL Fogerty Plumbinij I « - '~B~'~~ #221180 I ( ~ = ~,d3 lam- ~~V~~cl 28288 McKenzie Rd. I 0 = /~s~ utC_ s T u/~`~~ ='~~G Spooner, WI 54802 I~ ©= w~6L~ > s-~ ` ~Rorr, Sysrie~n (715) 635-960~i 3 ~ ~~ S~STE~ ~ L tiE'lGS .F ?'X Pis' ~ ~~ ~ u ~ ~-v ~ Py 6 ~ .tom ~/ ~ ~ t X0.8' ~C,ved f `,~ l9' b ~jn~ E j c ~ ~ ~ .~ ~ ~'' ~~ ~~ ~ ~. ,~ / ~ /' r ~ ~ ~ ~'jv ~~. ,~ S.-1 ~ ~ \ _ ~ .. . ` ~ ~ ~ ~ .\ ~ . ~ ~ ~` . ~ ~ ~ \ ~ Zoe ~' ~ ..- -- ~ \ ~~ \ \ "// /~ _ IAw /~~ _... _ ~ l tc~-,E ~~ ~ Yo ~ l ~ l QAE/ 6JNj 7+~ O~.2Xi~ /00.0 r l p9,3 • ~ . ~ ~ ~ ~. ~~~ Fogerty Plumbing #221180 l ~ ~ . ~i,v~ Lei- fq~uv~'~s 28288 McKenzie Rd. O ^ /2~ ~_ s ~, ~,,,~,¢~~ r~~G Spooner, WI 54801 ~~ ©= w~6L~ > sue' ~,tcw. sysr-,eirr (715) 635-96~ ~ 3~ sir srE~, ~ /~ ~ Z c~E'l.GS .F ?',r pTs ~ ti ~ ~-v = Py 6 ~ ~ ~ qt ~O,p'Locv ~~r- < < i~ iy...~,Z 1 1 1 ; ~~ ,` ~ /pip '~ ,,.. - -~ ~ -_ ze ~ s--~ .~ ~~ ~ ~ ~ ~ ~` \ ~ ~ ~ ~ ~ ~-z _ ~ r~ L~ /~ ~ . , t ~ ~xo _ ~~ ~ . ` \ wain Departinent of Commerce SOIL EVALUATION REPORT . f)i~llaion of Safety and Build'u~gs in acxorr~rrce wish Cormr 8S, VWs. Adrrt Code Attach cpmpM9fe ~ P~ On paper nd less plan 8 1/2 x 11 infies in sae. PIar1 traV5t l1 irdude. but not tirrrted Eo: verdtal and t~arizontat telasndQ port fa>iAJ. draclion and Rar~oel !.t). petoe:tt slope. sCB~ a ~. rrorlh arrow. and location erd distarroe b nearest road. ~ / _ r F - v Z Please pry»t aI! ~fo~»~stiva. ,~ S~ J 3 OS b!- iatonreeart,rou,na„be 'fiu~posKl~+~r .a,5:osl4)f~. • r a~ ~ n- Location . . ism- ~ ~ w ~= Owner's B /tddress - Lot d 8locic ~ Subd. Name a ~/~ E `~ A' c~ir , , state ~ _ __ O~ D tB'i'awn ~c ~~'"a .~~~.-777 u ~~~~ ... .,. vy ... '~~ owe <~/oZ. r T ~~N R E ~ ~ . Nearest ~- Constnraion Use: ~, Number of bedroorrrs Code ddiMed design lbw rate ~d c7o D ~ ^ herdic or oorrnerr~l - t)esenbe . Paront a ~}1tcl/~.r,~ - Flood Pfaire ateratiore iF applicable .//„~ .. >t. r~tG ~Z ~4~ 6 ~~c ov~laa ty.~~ .. # ^ 8arir-D ~~eS~ItT/E+/J C°~ ~~"'r f ~ Ground serrtaoe eeleer. ~, r~ R Depdr to factor /~ D in. Sol Rde x Horiaore lfe Oe Owreiteant CoGOr Redox Desaiption Texture Strercture Cor>sisterece 8oerndatl- Rods GP Olll m in. fYbxeeN Qu. Sz Cord. Cobr (~ Sz Sb. 'E1tit1 'Etf01 ,., ~_ ~ ..__ 2 .~ L ..- _ ,f- 9'~ ~ 0 ^ ~ * ^ B«~ ~- Q pqt Groud serface eta+r_ _,, R Qeph b ~ factor 7 ,~22 tre. Sal Rtde r ffortaon Oemtle Oon Redwc Oesaipdon Texture Strur~xe Cansi~taa 8ar+d~rY ROds GP OAt in. (lu. Sz. Cant. Cola Gr. Sz Sb. 'Elfdt 'E~2 ~ ~ ~- .~ ~ L (~ ~ ...._ .~- ~ . 2 ~ ERtrsa t ~ = 8t)Q, > 30 < ~ ~ and TSS X30 ~ 15 011e~1 ~ ~ #2= ...." s c 3p apll. aexl TSS < 3ll nglL - ~Q~ ~ ~ 2 f`4 s F+i'ger't~t Plgmbiag & Perk Testipg 'Ere~irratiare ~oadnGed 7!,$`7~.~* 7~7~ t~/e~rren~a tad ~~ ~7y"`~Z ~~"'~~rS.1 ~-- Proper owner 13~s'T'" Panne! iD ax ~ D --. ~3 ~~~-- / / -Di~ page _~_ of Boring ~ ~ goring - ~pit Ground surface elev. ,~~ ft. Depth a limiting factor ~ !jp M. ~ ~ ~e 3 Horizon Depth Dominant Cotar Redox Description Texture Structure Consistence Boundary Rants GPWfl' in, Mansell C?u. Sz. Cont. Cokx Gr. Sz. Sh. ~ ~ •EfflK1 •Effp2 Z Q~ -- ".-..- ~ ...-- • ~+ )) G ~'2- ~~ ~~ ^ BOfing # ~ Boring LET'. - T ^ pit GrounQ surface elev.. ft. Depth to pndlhg factor M. Sop Apppwtipt Rate Florizon ~M Donm~anl Color Redox Descxiption Texture Structure Consistence Boundary Roots GPDVR' in. Mansell Ou. Sz. Cont. CoMr Gr. Sz. Sh. •Eff#'1 •EfiwF2 ^ Borh~g # ^ Botlf-9 ^ Pit Groand surge elev. R ffeplh b pmiting factor In. Sop Rate Horizon Depth Dominant Color Redox Description Texture SUucture Conststenoe Botlrtdary Roots GPWft' in. Mansep tatr. Sz. Garrt. Color Gr. Sz, Sh. •Etf#1 'EIfa~2 • Effluent #1 = BOD, > 30 < 220 mglL and TSS >30 < 150 mg/L • Effluent #2 = BODs < 30 mpll. and TSS < 30 mgJL 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 G08-26G-3151 or TTY 608-264-8777. SBD~t7~0(A.N00) LdT ~',~ Q#/ 1Slttj 7+~ Ol°R?[ir /O~ r P~-3 r ._-- ~ = B.orrs~ve ~ = ~rrl~ LdT ~N~'RS ~ ~ z~c°c~w t ~~' ~ ~ ~ b ~~ \ ~ 7~ ~~ ~ ~ / +~ S.~ ~ ~ ~~~ ~~ ~ . ~ ~ ~ \ ~~ ~ ~ ~ - ~ ~ ~ 8-a \ f ____ ~'' ~ X-/S ~ ~ ~ ~ ~ \ J~~~M ~ / , _ ~~~ \~ ~ ~ moo, ~/ . e ' ,,,,_~ /~ ~ ~ ~ \ \97 Fogerty Plumbing ~ #221180 28288 McKenzie Rd. Spooner, WI 54801 (715) 635-9609 ~~~ / ~~ ~~~~ Z tmr iii e ~ ~ -. O ~ ~ o a' ~ n- ~ . ~ '~' ,p ~ ~ ~ a ~~ ii u n ~ ~ -; ~ ~ .~- ... ~ .~ ~ ~ ~ VJ ~ a„~ * ~ 0 ~ _• . ti. ' •y ~~ . ~~~ .~..~ CD ~~ \~ 1\ / \ •' . ~ ~ ~ \ //~~ ~•: Y . , ~.~ .; q.. ~• ``ter a i` • - --_ w ~ ..~ ~ i,•.^Yt~. b o ~. . • ~..~. ,'s• 1" ~• .- ~ ~ .~ i'~ ~~. r+ ~ ~~ ~ m ~-- ~ o ' p `-' b ~. ni•"~ ~J' .... O ~ ii +-~ ~ C1 w~ (D O ~ ~ ~ ~ .. °~ a. ~ .. i co vii cc b O ~- (D a a c~ ii .: -~ ~ . N -~i~ ~. C .~~..' ' p y. a f~D li "`9 V n 0 CD n -~+ V• •/ ~ ~.~r V u (~ ~ ~ ~ J • • l /• O o~ ~' ~ ~ ~--+ ~ ~ .-r ~ ~ _ ~ y fy ~ O ~' CD a 0 d ' O N r. °p N O (D . ~ ~ ~ ~ e~-h O (3i-~ dp~A .. cv -S' N G~:-4 N n Wcxti+Zl ~ti7 '~ ~ h+ ... ~ o~m o~ tflp ~ S~tary P~ A ~k.$32 QDS~S . ~a~o~a~c~.aa-a3.2i, arm tia.. p sa rerase side Rr iastroclioa~s ~ ao®apiding his $~$~11 Pbsoaat iatbraeeAiaa y~oa provide ~!- 6e aand ~ soooaaary paapoaas oepsrtn~eac as ou~ameoae (ptiva~y Lahr, s.15.01(ixajj~ ~0/3S aoi w. was~~oa Ave ro eoa 73a Ma~sos, w[ 53707-T3o Wed tbraba~aay- ifaK stale aiwaed. C~ d ~Yle Q L Ia#e~rasdtae - Please Pew alt Iatioa~aatisn - Iwealiaa: . .~ 7 GT 0 2 2002 = w,S x ' ..w. ~ -~-w-- -___- - - - ~. t .~ Q~ 1 ar 2 FinaOj- D -No. of Bodrooaas ;,~. B"ibae~ of 1 ~L Con O (desaibeasek?s~d~'G ~f-~ S•T ~~- :t tELG:C 3~X ~.5'~ l~karmtnod jn,. ~' (QICCtt OIIC tlOi[ Ua liuC A. t~eCk boe[ p1 liaa B A) 1. 2 ~ 4. b ~ O A ~ Pa+rait rr~ peeriosstjt leased 1V. Yyrpe •f P'OWT (C'heci~ alt 0ac apply) ~~ t] Aloand - - [] Smd 1'~1er D Ceaamodod w~ D PresAmriaod ta-graved [7 Iioi~gg Tat 0 ~q6k Pas . t] Drip Lice p A! grade D Aa+obic Tiertmeet i~it O Rer?aabtinS t7 ()tha: v Atli td - • y ~ Z qqo .o • VII. Taat t~padey is Tatd i of 1'rrSb S71e l~ Ptestic L~atisa tia0oas Tads Coa- Caa- t«~ T~v arse sauceod Taaics Tats ~ O t] ~ O a59YOle rCSpO f0[ lagli~i0a Of NIC PO~ S~ OO We ~Approv~ed o tm'~dAa,-ase ~ ~~ c;Q-. o~7,ca ` . a~1~_ ~ c~ ~~~~eA~~~p-~24J 5~ s ~d~. ~e~r~an H~~v-; ra.e o.~ ~,, ~k~. ~. ~~ ~ Y ~ ~ '~ t1~MeAt,J~1'l~w~u,~' c ~na~„ ~Ma~,-1.,v`w.v~ ~.vOA4`C '~6-~,~ .~e.~:~ ~d-* ~~Fc.- ae- ~/le,, ~,,,~ct~S SPeu~`cax~e~S , r--~ J, i. mfg Eo ~~°~ ~ o 3~Y~~[! dN V ~ C ~/~ +~#ap ~^ 0 ~ V N N Q ~~~ a a' t ~'d ® n1 b~ \ `1 Q. ~~ y ~I, 4 "~ K ~~ ~ t ,, / ~~ a r h V ~ ~~ ~~ ~ ~~ ~ ~ 1 ~ ~1 ~ v ~ ~t ~ nl x ~ ~ ~- ~ K ~~ o ~- ~_ ~ ~o ~ ~ ~ ~ ` ~ ~ N( ' ~ ` U M ,~ II r~ 1 ~ . Q~ t~~l - ~? I I .. 1 ~~ ~. 1 i a ~~~ c m d~ .~#~ ~~ ~ ~ ~ ~ ° .-, ~-~~ N ~ Q I ~' v d~_ ~ `,~. ~ }"`~ 2 b1d ° ~^~ :~ ~ ~ ~` ti ~ ~: "'mot ~ ~ 'o v h Z ~ ~ ~ ~~ ~ ~~ ~ ~~ ~ v ~ V i~ ~t ' ~ o a ~ S ~ ~ ~ Q ~~ ~ ~ ~ ~ O q~, Q rL 3 ~ M `~ N( d u e .j it q ~ ' ~ O n ~_ h N V~sconaila.Depariment of Commerce Dwrision of Safety and Buildings SOIL EVALUATION REPORT Page ,~ of • m aa~roancx vnu~ unrnn w, •~ws. run lete sib plan on paper not less than 8 112 x 11 inches in size. Plan Attach com R E p include, but not lirroted to: vertical and horizontal reference point (BM), direction nd Parcel LD. percent slope, scale or dimensions, north arrow, and Location and distance to t road. JUN b D t Please print all information. y a e Personal information you Provide may be used for secondary Pis (Privacy Law, s. 1 .04 (1 ~rr)~ R X C ~ • ~ D~ property Owner pro G OFFICE Govt Lot ~j(,v G' 1/4~'~ 1/4 SZZ T Z7 N R ~~ E (or)fW Property Owner's ~-1! ~ d ~ _ B `n-1 LQt~ 1111 Block # . Name or CSM# tate Zip Code one-Number .City S ^ City ^ ~Nage ~3own Nearest Road h l .. I ( ) ~~775 j~} New Construction t1se: [~ Residential /Number of bedrooms Code derived design flow rate ~Sa ~~ d d GPD ^ Repfaoerrrent ^ Public or cmnmenciaL -Describe: Parent material ) Q s ~ ~ Hood Plain elevation Lf applicable ft. Cer~rai comments S~S~Prrt e% v ~ ~° P 9/ • t?o how ~~ q-3 PO and recemmendations: I Boring # ~ B~"~ V0~' Ground surface elev. ~ ~ • 3~ ft Depth to limiting factor ~~ in. Soil Application Rate l-loriz~ Depth Dominant Color Redox Desription Texture Structure Consistence Boundary Roots GPD/ft2 in. Munseti Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 -io ~b z --, s ~ I 2 ~s ~ . 5 . ~ Z ~0- ~- - si ~ ~ ~ - it L ~ S _ ~._- 33.(a fO4.~a © ~~ # ~ Boring n ~, ptt Ground surface elev. -(~ • liJ ft. Depth to limiting factor~_ in. Sa'1 Appliption Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDfft2 in. Munsell Qu. Sz. ConL Cola Gr. Sz. Sh. 'Eff#'i 'Eff#2 1 ~-I~ LO . 2 5' m r I v -~ 1 - ~ ~ -- -1 Z ~~ _ . 5 - 'Effluent #1 = 80D5 > 30 < 220 mglL and TSS >30 < 150 mglL ' Effluent #2 = BODS < 3D mg/t and T55 < 3v mgn. CST ame (Please Print~)) lure CST Number ` Date Evaluation Conducted Telephone rvumoer ~. 5~~~~4, X25___ ~-io~~2 --~-5^Z~~--~dc~~ ~2 Property Owner "`--' - `S~ Parcel ID # ,~0 ~" // ~~ ~ ~ 3 Boring # ^ Boring ~. Pit Ground surface elev. ~ ' ~ ~ ft DeP~ m 9 ~~ ~ I ~ in- Sal Applicatuxr Rate th D ~r-t-Color u D Redox Description Texture Stnrc4ue Consistence Boundary Roots GPDIftz Horizon ep in. ar r MunseU Qu. Sz. Cori Color Gr. Sz. Sh. *Eff#t 'Etf#Zr -13 I C7 r 2 -- S,1 Zn^p~hk rn-~r c 5 ( ~ Z 3-~2 ~ ~ 41~+ ~ 2 ~_ ~ - 3 yZ-~ ~$ ~D ~ -- ~S - - 1.2 Boring # ^ Boring ^ Pit Ground surface elev. R Depth to limiting factor in. Soil cation Rate Horizon Depth Dominant Color Redox Description Texdue Structure Consistence Boundary Roots GPD/ft~ in. Munsell Qu. Sz Cunt Color Gr. Sz. Sh. 'Eff#'I 'Eff#2 ^ Boring # ^ Boris ^ Pit Ground surface elev. ft Depth ~ limiting factor in. Sa'I Applicatron Rate Hor¢on Depth Dominant Caor Redox Desxxiptwn Texture Stnrcture Consistence Boundary Roots GPD/ftz in. Munseq t'lu. Sz. Copt Color Gr. Sz. Sh. 'Eff#1 'Eff#2 • Effluent #1 = BODS > 30 < 220 mg/l_ and TSS >30 < 150 mglL 'Effluent #2 = BODS < 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 deparhnent at 608-266-3151 or TTY 608-264-8777. SBr3~8330 (R07/OD) L , PAGE~OF~ NAME Q ~t S ~ LOT# /~ LEGAL DESCRIPTION ~/c.~ 1 ~S T t4 ,S T Z R ,NCR, I ~ ElorY~ ~%SCALE:I"= yQ BM 1 ELEVATION /Ck"). C~ BM 1 DESCRIPTION-~Qo-~ YG/ ~~~Qc ( l~oc~. (J I~.'~ H BM 2 ELEVATION S 6~ BM 2 DESCRIPTION o o ~ ~{ee ( ~~ (~ ~~ `~ ~ SYSTEM ELEVATION ;k~~ 9~ 6 O LG we r 9~, o Q ALTERNATE ELEVATION fop9ZOyLaw ~ ~ 9/~Oy CONTOUR ELEVATION gSUO a- ~ ~ U O SIGNATURE DATE ~ _ Z o zJ C PAGE~OF~ NAME ~ a S ~ LOT# /~ LEGAL DESCRIPTION /flt.~ 1 ~S~ to ,S Z~ T Z `I ,N,$„ I Q E(or~ SCALE: 1'" _ ~~ BM 1 ELEVATION /G~~. d BM 1 DESCRIPTION ~Qa-~ y~/ ~S-~¢c ~ ~oc~ ~ ~~: ~ ~, BM 2 ELEVATION q ~ ~5U ,p BM 2 DESCRIPTION -~p o~y.S~ee ~ F.oc~ (~ ~~'~i L. SYSTEM ELEVATION !v~ 9`/. Q ~ LG w e e 9~, o a ALTERNATE ELEVATION ~o~9LOyLaw ~ ~ 9/~O~ CONTOUR ELEVATION ~/5. ~O ~- q ~ U O N Sic . Z Z d -t- DATE ~ - Z U -~ z ~- O .d c~ \° O II n' a CD / ~ I " ~~K/ ~\ `~ i .~,~ ~ ~. C ~ ' - - ,__, e ~ .. o - 11 .~ ' TJ A~ M N O ~ 'CS ~ O ~• ~ ~ . ~ CD ~ . , _ II If C • -- ~ H ,- "~ ~ ~ . ~ t . y~ O I. _ ~~ v .~ ;~ ~\ . yj. • • b~ ~` a w` ~~• . ~ a•. ,• ~ ---... ... ~ . .• CD r '.. -. - . CD'-~ ~ ~ a ~ - ~ .. . • ..~ ~ :. ' - .~ . .~ ~ ~ ~'. : ~ ~ . .' •. ~ b i ~, a t ` ` \ ~ r ~ ~: O 'tt V1 ~ ~ ~~ N ~ ,~ ~ ~ ~~ Q ~ ~~ Q+ C ~ ' N {{ {I II sv ~ ` . +~. ~ ._. - _ _.. ~. 1 ._~~~ '~. .... (~~ o ca , ~ ~ --- r p. r"'f. G~ a c~ ~_ O~ g acs' N ~ C~3 ~ OOQ uy °~ 00 ~ A ~~ wcx~-+'a tn_m ~"'C ~'~N o3 o~m ~' ~ ° a f'a l 1 M V] ^~ l I N (~ ~ O i ry ~ o ~• n ~ ~+ ~"~'~ ~ ~ ~~ O V `~ a 0 e-~ ~ ~ a t -~. ~~ FILE MIFORMA'f10N Owner Permit ~ ~ pES1~iN PARAMETERS Number of Bedrooms ^ NA Number of Public Facil'tty Units ~NA Estimated flow (average) al/d Design flow (peak!, (Estimated x 1.5) aUda Sots Application Rate ~ S ~ aUdaylft~ Standard Inftuent/Effluent Quality Monthly average* Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BOD5) 5220 mglL ^ NA Total Suspended Solids ITSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand IBODS) 530 mg/L Total Suspended Solids (TSS) 530 mglL O NA Fatal Coliform (geometric mean) 510` cfu/100m1 Maximum Effluent Particle Size Y8 in dia. DNA Other: O NA 'Valdes typical for domestic wastewater aril septic tank effluerrt. POWTS OWNER'S MANUAL & MANAGEMENT PLAN s~~,~. caFClacaTloNs Fags ~ of ~""'~ Septic Tank Capacihr .11~ ~ O NA Septic Tank Manufacturer ~. ^ NA Effk~tt Ftter Manufa ~L ^ NA Effktent Rlter Model ^ NA Pump Tank Capacity al ~? NA Pump Tank Manufacturer Q NA Pump Manufacturer ,~ ~NA Pump Model ~ 17~ Pretreatment Unit ^ SandlGravel Filter D Mechanical Aeration O Disinfection ~ Peat Filter O Wetland ^ Other: Q NA Dispersal CeU(s) In-Ground (gravity) O At-Grade ^ Drip-Line ^ NA ~ In-Ground (pressurized) ^ Mound D Other: Other: [] NA Other. p NA Other. ^ NA MAIM 1 ~MAM(:t SI:HCIJUI.C Service Event ~~~ Freque~l4Y Inspect condition of tank(s) At least once every: ^ month(s) (Maxlmuro 3 years} ~ ear(s) DNA Pump out contents of tank(s) When combined sludge and scum equals one-thins (Y3) of tank volume. ^ NA Inspect dispersal cell(s) At least once every: ~ y~.(y.) s) (MaxUlttun 3 years} 3 ^ NA Clean effluent filter At least once every: 1 _ Z o month(s) earls) ^ NA O month(s) ~ ~A Inspect pump, pump controls & alamn At least once every: ^ y~$) ~ month(s) Q NA FlusFr laterals and Pressure test At least once every: ^ year(s) Other: At least once every: ^ month(s) ^ yearls) ~, NA Other. Q,NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the folbwing 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 w ponding of effluent an the ground surface. The dispersal ceU(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 aidicate 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 IY3) 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, pretreatmem units. and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shalt be provided to the local regulatory authority within 1 O days of completion of any service event. • Page Lof ~- ~II~~~UP AND OPERATION For new construction, •prior to use of the POWTS check treatment tanklsl for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentn~ilons 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 nornnal 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 t 5 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 be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • AI! 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 utifaed 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 wilt result in the need for a new soil and site evaluation to establish a suitable replacement area. Replac~nent 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. iL], 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 NUIPOSSIBLE. SEPTAGE SERVICING OPERATOR !PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name ~ 1 G~ (K ~~ / Phone ~'(~' ~ ' gD This document was drafted in compliance with chapter Comm 83.22(2)(bllt)(d)&(f) and 83.54(1), 121 & (31, Wisconsin Administrative Code. S ner4 WI 2 POWTS INSTALLER POWTS MAINTAINER (715) 635-9fi09 ~ Name 1 ~~~ ~ Name Phone S'-r- - ~~ Phone ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer t1~i/0~ l.~S7~ Mailing Address Property Address (Verification required from Planning Department for new CityJState I~~.r/, ~.~/-~- ~'y ye parcel Identification Number X20 -- /~P ~ //-GIJd LEGAL DESCRIPTION Property Location it'/G/ '/,, ~ '/., Sec. Z2 , T~N-R~~«~, Town of ~C/DSD/~ Subdivision ~/~iVT /LdrA/ l Sfi ,Lot # 1,,~. Certified Survey Map # ~- ,Volume 7 ,Page # /~'p/ Warranty Deed # ~ 2 7 ~l o ,Volume ~~~~/ ,Page # x/33 Spec house ^ yes (~o Lot lines identifiable (Oyes ^ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The _property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site 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 requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. '~""~ - ~~ SIGNA OF LICANT 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(). Mfr; the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. ~.;~~ ~' /~~ / oz SIGN TURF OF APP ICANT DATE ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ****** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed 1531 P-5~ x(33 ~ 627510 _ STATEDAR~\v, nATHLEEN H. WALSN Daumeat Number WARRANTY DEED REGISTER OF DEEDS CROIX CO. WI ST . , This Deed, made between Made A. Shimon, a single persoa, RECEIVED FOR RECORD . Od-02-P000 3:00 Ptl .~____ __. _.__ INI~tITY DEED Grantor, and Keraoa J. Bast and [iowhia J. Speer-Bast, 6usbaBd EXE10'I A tTRT COPY FEE: and wife, COPT FEE: _ TRIII~ER FEE: 8{6.00 R'CORDI)B FEE 00 1ti : . PAGES: 3 Grantee, Grantor, fw a valuable consirleratian,cenveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if moce space is needed, please attach addendum): Recording Area (see Attached Exhibit "A") NmeaadR~~A OGLAND Zilz, Estreen 8C Ogland P.O. Box 359 Iiudson, WI 54016 OZO-1059-g0-000 Pared ldanCificmion Nisber (P(N) This is aot iraaestead property. 01) (is not) Exceptions to warranties: Easements, restrictions and rights-of-way of record, if any. Gated this _ ~ d 4~''' day of Joiy ,?.0110 • • M A.SYiaoa • AUTHENTICATION ACKNOWLEDGMENT Signature(s) Marie A. Shimoa, a siagk person, STATE OF WISCONS(N ) ____~ ) ss. --~ - Coanty ) i 1 auth +L Kq ~i day of July x~ personally cams before me this day of o?•~ ~ f the above named TI~•• a v ~ ~fiATE 8AR OF WISCONSIN +•• to me known to be the person(s) who executed the foregoing - - instrument and acknowledged the same. auth '~§ 706.06, Wis. Stars.) THIS INSTRUMENT WAS DRAFTED BY • Attoroey Kristlaa Ogland Notary Public, State of Wisconsin H_udsaa, 1 16 __ My Commission is permanrnt. (If not, state expiration date: (Signatures may be authealicated or acknowledged. Both ~e not necsswyJ ') • Nantes of persons signing in any capacity must be typed or printed blow their sigrratute. Nonnrion vrdiaruns tomo.n. r9na m i aS ra STATE BAR OF WISCOWSIN eoDe66101t WARRANTY DEED FORMNa2-If99 ~Y ~o~• 1531P~~~ 434 EXHIBIT "A" A PARCEL OF LAND LOCATSD'IN THS NORTHW85T QUARTER OP THS SOUTHEAST QUARTER (NW 1/4 OF 5S 1/4) OF SECTION TFTBNTY TWO (22), TOWNSHIP TWENTY NINE (29) NORTH. BANGS NINETEEN (19l WEST, MORE FULLY D$SCRIBED AS FOLLOWS: Commencing at the East Quarter corner of said Section 22; thence•North 0 degrees 02 minutes 57 seconds East along the Salt line of the Northeast Quarter of said section a distance of 40,00 feet) thence North 89 degrees 57 miautes•16 seconds west 750.00 feet; thence Neaterly 450.4T feet along the ~ of a 405.17 foot xadius curve concave Southerly whose long chord bears South 75 degrees 47 minutes 19 seconds West 445.83 feet; thence South 61 degrees 31.iainutes 54 seconds West 135.86 feat to the point of beginningr thence continuing South 61 degrees 31 minutes 54 seconds Weat 150,12 .feet; thence Southwesterly 297.89 feet alonq~the arc of a 740.00 foot radius curve concave Southerly whose long chord bears South 49 degrees 59 minutes 5B seconds Went 295.88 feet;. thence South 53 degrees 22 minutes 28 seconds Sast 409.87 feet; thence South 0 degrees 15 minutes 46 seconds Sant 687.10 feet to a point•on the South line of the Northwest Quarter of the Southeast Quarter of said Section 22; thence North 89 degrees 57 minutes 16 seconds West 1269.89 feet along said line to the Southwest corner of said Northwest Quarter of the Southeast Quarterr thence North 0 degrees 16 minutes 35 seconds West along the North-South Quarter Section line a~diatance of 1x96.23 feet; thence North 89 degrees SO ninutea 17 seconds Bast 6S1.01 feet] tha~ce North 0 degrees 11 minutes 41 seconds Weat 12.40 feet to the Southwest corner of the Certified Survey Map recorded in Volume 7 of Certified survey Malta, page_1891; thence North 89 degrees 50 minutes 17 seconds Sast along the South line o£ said Certified Survey a distance of 651.09 feet to the Northeast comer of the Northwest Quarter of Southeast Quarter;~thence South 0 degrees 35 minutes 46 seconds Weak along the Bast line of said Northwest Qnarter of t'he Southeast Quarter a distance of 129.94 feet to khe point of beginning. ALSO subject to that part of a 66 foot aide easement reserved for Future township road included in the above described parcel, said easement being 33 feet equidistant and at right angles to the following described reference lines: REFSRF.NCE LINE NUNBBR 1 Commencing at the Sast Quarter corner of said Section T2; thence North 0 degrees 02 minutes 57 seconds East along the 8aat line of the Northeast Quarter of said section a distance of 40.00 feet to the point of beginning of the following described reference line: Thence North 89 degrees 57 minute's 16 seconds West 750.00 feet; thence Westerly 450.87 feet along the arc of a • 905.17 foot radius curve concave Southerly whose long chord bears South 75 degrees 47 minutes 19 seconds West 445,83 Eeet; thence South 61 degrees 31 minutes 54 seconds West 285.98 feat; thence Southwesterly 297,89 feet along the arc of a 740.00 foot radius curve concave Southerly whose long chord bears South 44 flegrees 59 niinutea 58 seconds West 295,88 feet; thence South 38 degrees 28 minutes 07 seconds Weat 100,D0 feet; thence_9outhwestsrly 381.99 Yoe 1531PpGE435 Exhibit "A" - Page 2 ' feet along the arc of a 427.00 foot radius curve concave Northerly whose long chord bears South 64 degrees 05 minutes 43 seconds West 369.38 feet; thence South 89 degrees 43 minutes 25 seconds fleet 546.65 feet to the end of said reference line. REFSRfiNCE LTNB NUMBER 2 Commencing at the East Quarter corner of said Section 22; thence North 0 degrees 02 minutes 57 seconds Bast along the,.East line of the Northeast Quarter a distance of 40.00 feet= thence NorCtt 89 degrees 57 minf~tes 16 seconds West 750.00 fasts thence Westerly 136.81 feet along the arc of a 872.17 foot radius curve concave Southerly whose long chord bears Sptith 85 degrees 42 minutes S7 seconds Weet 136..67 feet to the point of beginning Of the following described reference lime: Thence North. 269.97 feet; thence Northwesterly 350.77 feet along a 500.00 foot radius curve concave Southwesterly whose long chard bears North 20 degrees 05 minutes 50 seconds West 343.62 feetp thence North 40 degrees 11 minu0es 41 seconds West 70.00 feet; thence Northwesterly 158.48 feet along a 227.00 foot radius curve concave Northeasterly wttoss long chord bears North 20 degrees 21 minutes 38 seconds West 155.28 fsetr thence North 0 degrees 11 minutes 41 seconds Weat 500.06 feet to the end of said reference line. ' Ail in St. Croix County, Wisconsin. L.5 Lw) ~, ({.., I!"" 1 o; ~' ~~ t~ ~' e~' ~, 3' ~; w ~y . , ~.~. !~3 ~j O' 1`!f'"Z ~- 1 2.05 ACRES ~ ~. ~• ~ 89,221 SQ. FT. i ~' '~ ; ~i ~ • ~- 1 ~ N •. ~ ~, ~ ` E ............... ........................:i fi ~ ~ ~ ~ ~ ~' ~~ ~. - ~-- --~---- N88'S3'19'E288.9 DEDICATED TO THE PUBIJC ~ ~ ~ i . ~-- -ROBERT'S LANE --- ~ -, ~-- 6'~ ~ ~ ~ ~ i ~ N88°53'1f N88~19~'E 977.58' C] - --~--~--~--~--.__.__.---------i _ _----1 ~$ ~ ~ ................................I........ ~ ~'~' Z 1 -~ ~' 1 1 ' I 1 l H.1f~.L = •'' ~, ~v _~`"c s 925 f ~ ~ 2.03 ACRES ~1 ~ m ~ 88.571 SQ. Ff. ': ~ ~ ~ ~ '. M `~ EI `~ ~ ~' ~ ?~. ~ MINIMUM BUILDING •, ~ •~ Cs ~~ • . ` ~~ ~ ELEVATION =927.5 ~ ~ ~ ~ H,~ILL ~ 386°59'19"W 492x1' \ ~ ~'.. ~~ 30' DRAINAGE ~~~~ ~'. `~ ~ ~ EASEMENT -'~,~ ~ Q~ 2.33 ACRES ~ ~~ ~ ~ . '~1.YI~5 101,590 SQ. FT. \~~~ ~~~,, ~ MINIMUM BUtt~tNG ~ ~~ ~ ELEVATION =927.5 ~~~ s ~. SBg'1245'W 649.48 JYOIJLD DISTUF63 ~ ' ~ . Tt•~ t't OF WISCONSIN LIC 30D1ES AND -ov~i.x;,, _=,WS, ~ 3.80 ACRES ~N~eEFOF~ ~ 16.5,319 S4. FT. ~ MINIMUM BUILDING ~, ELEVATION =925.5 cxn.-~~ F 131.8'+/- ` . E/1gT AND Q4'+~ NORTH OF LOT CORD ~ 688.61' Y_ Y X ~.x~~ - __ __ _. __ I - Q~ _~ ~ ° ~ z O~n1GD ~ ~'l 04~1[~G°3~ ~ S1/4 CORr<ER SECTION 22 $89°12'4 sourH ~ of Tl~ NW1/4 OFTiiE SE~/a Vt1Cl ~ A ~~ L'a4°Jt11-~ a