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HomeMy WebLinkAbout012-1017-70-001Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT `GENERAL INFORMATION (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 Steel, John & Roberta Erin Prairie, Town of CST BM Elev: Insp. BM Elev: 1 ~ BM Description: ~/h I G5 TANK INFORMATION /~ TYPE MANUFACTURER J3 CAPACITY Septic / Gh'+ t5'~': ~ JAb O ~'- ~ ~ Zto ~ ~:1 1 1~. 7i Holding TANK SETBACK INFORMATION TANK TO P/L WELL LD Vent to Air Intake ROAD ~'~ ~o Z7 3S~ - Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Num TDH Lift Friction Loss System TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM DIMENSIONS V v ~~ ELEVATION DATA county: St. Croix Sanitary Permit No: 515270 0 State Plan ID No: Parcel Tax No: 012-1017-70-000 SectioNTown/Range/Map No: 7'66,30.17.870 STATION BS HI FS ELEV. Benchmark 3. SS ~~• f~ Alt. BM 3,Zg ~~c.z7 Bldg. Sewer ~ .~~t SUHt Inle~~a SUHt Outlet !~ !j„ 3~j °f $, 'Z... ~L,..~t-a.~k.. S.9 ~ g7, (o Dt . t, ~"~. O . ~ °~ `7' 3 5 Header/Man. ~ • 9'sj/ .'"7? Dist. Pipe ~ Q . ~$ St. 7y Bot. System 9 3 4*~. Z 3 • c.1 Final Grade '-/ '~P • ~~ + d 8 St Cover F; I ~-.-~~C„ 3 . z ~ .Z ~ '~~ ac 1 or~a.~ J T J 1 CIVI I V F'/L [3LUb VVtLL LHr~C/J 1 RCHIVI ~cr~a.nmv mai wiauu~ci. 1 INFORMATION CHAMBER OR ~i^ ~~a'7'Q,~- Type Of System: ~ +~ UNIT Model Number: Gc,~ve.•.~? 0 3~t S`I' y ~o Q~ .'~ sl-C~J DISTRIBUTION SYSTEM ~ ZZ ~- Z Z .= y pl- Header/Manifol~ /~ Distribution x Hole Size x Hole Spacing Vent to Air Inta~e /~ Pipe(s) \„ Length W Dia Length ~ Dia Spacing`" V' SOIL COVER x Pressure Svstems Onlv xx Mound Or At-Grade Svstems Onlv Z w v~ Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched BedlTrench Center ~ ~• g' Bed/Trench Edges ~ Topsoil ~ ~es ~ No Yes ~ No d~ I COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 1699 150th Street New ichm nd, WI 546017 (SW 1/4 SW 1/4 6 T30N R17W) N~A;Lot 1 ~,~ ~ VL ~'~'~" ~'S" "`+( ~''aw~~. Parcel No: 0G6.30.17.8,70~J ~a ~jN U`Qv (~t~ 4 1.) Alt BM Description = God+»~ 2.) Bldg sewer length =G -~ ' ~- 't ~ ~~'" ~~"` / ,J ~ ~ ~ ~~~~ . f ~ ) ~ / CG~ K- ~ / - amount of cover = ~j ' Plan revision Required? ~ Yes No ,(_ ~ ~ I~ ` Use other side for additional information. 6 SBD-6710 (R.3/97) Date Insepctor's Signa Cert. No. ~ Safety and Buildings Division 201 W Washin to A P B O 7 62 County ~~ r ~ ~ . g ve., n . . ox 1 M di WI / ~~ seons~n a son, 53707 - 7162 Sanitary Permit Number (to be filled in by Co ) Department of Commerce (608) 266-3151 ~/~~ 7~ V nitary Permit Application State Plan I.D Nu tuber In accord with Comm 8321, Wis. Adm. Code, personal information you provide ae used f d A / /~/~ or secon ary purposes Privacy La Project Address (if different th n mai~ing address) a I. Application Information -Please Print All Infor ion C ,/) r~ ?F' ~Y / y ' ~ ~ /~' St~ Property O~n'Her s Name ` JtJI~ ('1 p ~,Q~o ~d U Parcel # Lot # t Block # O 6-f r ~ -f ~. x,12-~6 n 70-000 /1 !~- Property Owner s Mailing Address ~~ ~~ ~~,,, IyLANNINQ & ZONINQ OFFICE Property Location ~'~ t/ ~ ,~ // / ~ ~~ Ctty rate Zi V y Section ~ , p Code Phone Number , • ~ ~ II. T e of Buildin YP g (check all tha apply) T~ N; R E or or 2 Family Dwelling-Number of Bedrooms t4l~ ~~~ Subdivision Name CSM Number ^ PublicJCotnmercial -Describe Use ~lj( I')~ f'f~I3 ~ ~ ~Z ^ State Owtred -Describe Use /~ ~ ^City_^Village Township of /`j 'r~ III. Type of Permit: (Check only one box on line A. Complete line B if ap licable) er A. ^ New System Replacement System ^ Treaunent/I-folding Tank Replacement Only ^ Other Modification to Existing System B• ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Ovwier 1 IV. T e of POWTS S stem: Check all that a 1 Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ~ At-Grade ^ Single Pass Sand Filter ^ ~' \~ - Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ trcu ng Sand Filter ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain 1 ~ ~r, V. Dis ersaUTreatment Area Information: ~ Design Flow (gpd~ Design Soil Application Rat gpdsf) Dispersal Area Required (~ Dispersal Area / i Proposed (sf) Syste~t Elevation tTV ~ 7 ~5~ / ~t 3 ~/,,~ G r4 . VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units ,, ~`~ ~~ („~f /~ Concrete Constructed Gfass T New Existin J Lam? - g Tanks Tanks Septic or Holding Tank h / ~~C~ ' 1 Aerobic Treaanert Unit Dosing Chamber - VII. Responsibility Statement- I, the uodersi ed, assume responsibility for installation of the POWTS shown on the attached plans ' Plumber s Name (Print) Plumbe 'nature h4P/MPRS Number . Business Phone Nwnber ' umber s ddress treet, City, State, Zi ode) ` ~' V ~ , ~1 Z c~ ~,LCC ~ ~ ~" VI ~. ©c~S II. Count ~/De artment Use Onl proved ~ Sanitary Permit Fee (includes Groundwater Date sue Issuing nt Sign ure o Stamps) Surcharge Fee Lj ~~ ~ ~ ^ O tven Reason for Denial 'J ~ /b IX. Conditions of Approval/Reasons for Disapproval °SY51'EIy1 OWNER?` . 1: Septic tank, effluEttt t~tar anti dispersal cell must aU be selvk•.es / maintained as per management plan provided by pluxnbef. 2., AA selbat:krequiCementts must be,maintained ~ P~ aPPl~~e code / ordinalrces. Attach cnmol.ro nle....... B._ ~_.__... __._., ~__ .~ _ _ + ---v. -_...._..~,,..... .... ~.a~.~....,. .Un ...... ouc x u .ncnes m sou SBD-6398 (R. 01/03) STEEL'S SOIL SERVICE 3of3 David J. Steel John And Roberta Steel 1699 150th St. CST-POWTSM NW1J4,NW1/4,S7,T30N,R17W New Richmond, WI 54017 Lic. #248956 Town of Erin Prairie, St Croix Co. Direct 715-760-0347 Lot 1 CSM Fax 715-246-0318 3 Legend N 1"=40' • -Benchmark Ele. 100.00 ft I Top of Septic Tank Cover ;~ 1~ i ~ ~ ~ ~- ~ • =Alt Benchmark El 103.10 ft ----~---- Top of Retaining wall corner ^ =Borings _ Boring Elevations ~, B 1 = 97.00 ft B2 = 97.00 ft 'j~'~~L B3 = 94.20 ft c~' ~/z~h S k ~~/ B4 = 0.00 ft ! ~~ ~`~ ~Z, 1 ~, ~,<< / ~ ~~~ ~ ~ ~~~ '~ 7or z~ ~ ~,~ ~ ®~ - t~k ~° r ar r ~Q`~ ~k ~ ~~ ~kr~n w ~ '~ ~ ~'~ ~~` ~'"`~ r 3?.~- ~ - ~- JCS {~/~~-~~ ..~ ~'S~~ Q~ ~~ ~'~~ OIL EVALUATION REPORT #2129 ' Department of Commer ~ ~ ~ accordance with Comm 85, Wis. Adm. Code Page 1 of 4 Division of Safety and B gs Steel's Soil Service Attach complete site plan on paper not less than 8/2 x 11 inches in size. Plan must include but not limited to: v rti l d h i t l f i t BM di ti d County St. Croix , e ca an or zon erence po a re n ( ), rec on an percent slope, scale or dimensions, north arrow, and location and dis a to nearest road. Parcel I.D. - - ` 012-1017-70- 00 Please prin all in~~~ ~~ R i D ev ew y ate Personal information you provide may be us d for secondary purposes (Privacy L , s. 15.04 (1) (m)). /_ G /D (v O Property Owner ~~N ~ ~ 4~+~ I roperty Location John And Roberta Steel ovt. Lot na W1/4, N 1/4, S7, T30N, R17W Property Owner's Mailing Address ST. CROIX COUNTY t # Block # Subd. Name o CSM# 1699 150th St PLANNING 8~ ZONING OFFIC 1 na CSM Vol 13 Pg 612 City State Zip ode Phone Number City Village I Town Nearest Road New Richmond WI 54017 715-246-4102 Erin Prairie 150Th St ;New Construction Use: ~ Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD i j Replacement '~ Public orcommercial -Describe: na Parent material outwash Flood plain elevation, if applicable na ft. General comments Conventional system, system elevation 94.OOft. Trenches spaced and depth to code 3.OOft below grade or to be determined at the and recommendations: time of installation due to depth of sand in the system area. ~ Boring 1 Boring # ~ - Pit Ground surface elev. _ 97.00 ft. Depth to limiting factor 100 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistenc Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ~ 'Eff#1 'Eff#2 1 0-9 10yr 3/2 none sil 2msbk mfr cs 2c 0.6 0.8 2 9-22 10yr4/4 none sicl 2msbk mfr cs na 0.4 0.6 3 22-32 5yr4/6 none Is osg mvfr cs na .7 1.6 4 32-100 7.5yr4/6 none ms osg ml na na .7 1.6 t It ~~ 2 ;Boring ~ Boring # ~L _ Pit Ground surface elev. 97.00 ft. Depth to limiting factor 100 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistenc Boundary Roots GPD/ftZ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#t 'Eff#2 1 0-9 l0yr 3/2 none sil 2msbk mfr cs 2c 0.6 0.8 2 9-19 10yr4/4 none sicl 2msbk mfr cs na 0.4 0.6 3 19-100 7.5yr4/6 none ms osg ml na na .7 1.6 1 C/~ ~ t r ' Z 'Effluent #1 = BODS> 30 < 220 mg/L S >30 < 150 m / "Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) ~ natu CST Number ~! David J. Steel 248956 Address Steel's Soil Service Date Evaluation Conducted Telephone Number 1699 150th St New Richmond, WI 54017 6/4/2010 715-760-0347 SBD-8330 (R.07/00) Property Owner John And Roberta Steel Parcel ID # 012-1017-70-000 Page 2 of 4 L Boring 3 Boring # : ', Pit Ground surface elev. 94.20 ft. Depth to limiting factor 100 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 1 0-14 10yr 3/2 none sil 2msbk mfr cs 2c 0.6 0.8 2 14-22 10yr4/4 none sicl 2msbk mfr cs na 0.4 0.6 3 22-32 5yr4/6 none Is osg mvfr cs na .7 1.6 4 32-100 7.5yr4/6 none ms osg ml na na .7 1.6 ~~ r 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 I •Eff#2 I ~ 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 I *Eff#2 Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mg/L "Effluent #2 = BODS < 30 mg/Land 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) Steel'S Soil Service STEEL'S SOIL SERVICE David J. Steel John And Roberta Steel 1699 150th St. CST-POWTSM NW1/4,NW1/4,S7,T30N,R17W New Richmond, WI 54017 Lic. #248956 Town of Erin Prairie, St Croix Co. Direct 715-760-0347 Lot 1 CSM Fax 715-246-0318 i ,~ y!a ~~'" Legend 1"=40' • =Benchmark Ele. 100.00 ft Top of Septic Tank Cover • =Alt Benchmark El 103.10 ft Top of Retaining wall corner ^ =Borings \ goring Elevations B 1 = 97.00 ft B2 = 97.00 ft B3 = 94.20 ft B4 = 0.00 ft ~-- ~ 3of3 CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: ~~~ ~~ .~ Owner's Name: ~ y h n ~.~ ~ d ~ E, ; , ~-~- ~~- Owner's Address: C/ ~ f~ ~-~ s , f.. Legal Description: ~y (qf /~~c ~~ ~~ 6 ~ •-~"'~ Zj ~I~ ~ ~~ Township: C( ~ i ,~ ~~,~ ~ ~.~ •~ r County: ~ ~. ~` /~o ~' yc_ Subdivision Name: --y) ~ Lot Number: Parcel ID Number: Q /~ l0 /"7- 7d ~4~ 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 _ Mana ement 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: ,~, = License Number: /j'~ r~~cst,~ ~ ~+r~'~ Date: ~ -- Cj Phone Number '~~,5'_ Z(, 3 _ ~ ~~ Signature ~. Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 v~ STEEL'S SOIL SERVICE David J. Steel John And Roberta Steel 1699 150th St. CST-POWTSM NWl/4,NW1/4,S7,T30N,R17W New Richmond, WI 54017 Lic. #248956 Town of Erin Prairie, St Croix Co. Direct 715-760-0347 Lot 1 CSM Fax 715-246-0318 f `~ 0 . c; e ~Zf r ~~ - -- ~ ~ k ~II~G~ ~~ l iI ~- ~ - S ~~ Te Legend 1"=40' • =Benchmark Ele. 100.00 ft Top of Septic Tank Cover • =Alt Benchmark E] 103.10 ft Top of Retaining wall corner ^ =Borings \ Boring Elevations \\ B 1 = 97.00 ft B2 = 97.00 ft B3 = 94.20 ft B4 = 0.00 ft ^4--- ~o' ,I"fie ~~`~ ~ n~~ Z~~~~ o' - t,9>n k ~ Q :,~ "f ~ ~l' ~/~ ~~~~~~'S ~ ~~ 3 of 3 Soll Absorption System Cross S®ction Sao ft 4" Schedule 40 Final Grade PVC Vent Pipe p With Vent Cap ~_ ( ~~jj ft Leaching -i- Chamber 9i-~ ft ~~ ~- Sy/stem Elevation 3, 0 ft G ft 3oi1 Absorption System Plan View ft 3• ~~ ft ~~ ~ 0 . ft Trench 2 4" Dia. Header Leaching Ghamber Saecificati®ns Manufacturer And Model _ (3„ „ /; C~`_ EISA Rating ~ Q_ Sq ft per chamber Soil A rya pp tion Rate ~_ gpd/sq ft ~~~~ gpd Design Flow z Soil A lication Rafe ~'~-~- pp ~ ~ EISA = ~3 Chambers 2 rows of ~_ chambers each. ~ Page ~ of < 6 - ~ '- ~C5 ~~~~ ~ Inc ~°~°~° ai ~'~arPOy,~,~~ -PL-525, PL-625 Effluent Filters & Crease Traps ~W 1/16" Filtration Slots I III '1 525 Linear Ft. of 1/16" Filtration Slots Accepts 4" & 6' SCHD 40 pipe 1/32" Filtration Slots 1 111 ' 1 Alarm Accessibility Accepts PVC 1" Extension Handle 1/32" Filtration Slots Rated for over 10,000 GPD Accepts 4" & 6" SCHD. 40 Pipe Accepts PVC 1" Extension Handle e~wwA p~b""p~ ,4~ w ~ `,~~ , x i Gas Deflector Automatic Shut-Off Ball when filter is Removed Gas Deflector Automatic Shut-off Ball When Filter is Removed ,; ~ ,. -,.; PL-625 Outdoor Smart Filter Alarm All Polylok/Zabel filters accept the SmartFilter® switch and alarm. Alarm Accessibility www.polylok.com 8 1-877-765-9565 ~' ., ~~ PL-525 P1~L ~~ Inc. 6uaratiors in Proust Drainage Zabel• & wastaweter Products A cAvisom of Pdybk inc. PL-525 Filter - The PL-525 Filter is rated for over 10,000 GPD (gallons per day) making it one of the largest filters in its class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok PL-122, the Polylok PL-525 has an automatic shut off ball installed with every filter. When the filter is removed for cleaning, the ball will float up and temporarily shut off the system so the effluent won't leave the tank. Features: • Rated for 10,000 GPD (Gallons Per Day) • 525 linear feet of 1/16" filtration • Accepts 4" and 6" SCHD. 40 pipe • Built in Gas Deflector • Automatic shut-off ball when filter is removed • Alarm accessibility • Accepts PVC extension handle • Lightweight PL-525 & PL-625 Installation: Ideal for residential and commercial waste flows up to 10,000 Gallons Per Day (GPD-. 1. Locate the outlet of the septic tank. 2. Remove the tank cover and pump tank if necessary. 3. Glue the filter housing to the 4" or 6" outlet pipe. If the filter is not centered under the access opening use a Polylok Extend & Lok or piece of pipe to center filter. 4. Insert the PL-525 or PL-625 filter into its housing. 5. Replace and secure the septic tank cover. PL-525 & PL-625 Maintenance - PL-625 Effluent Filter The PL-625 filter is ideal for grease trap applica- tions. The 1/32" filtration has been shown to reduce fats, oils, and grease (FOGI by as much as 60% to 98%! The filter may be used in onsite wastewater systems that require a finer level of TSS removal. Whatever the application, Polylok has the filter for you! Ideal for: • Grease Traps • Laundromats • Dog Kennels PL-525 & PL-625 Maintenance: The PL-525 & PL-625 Effluent Filters will operate efficiently for several years under normal conditions before requiring cleaning. It is recommended that the filter be cleaned every time the tank is pumped or at 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 done by a certified septic tank pumper or installer. 1. Locate the outlet of the septic tank. 2. Remove tank cover and pump tank if necessary. 3. Do not use plumbing when filter is removed. 4. Pull PL-525 or PL-625 out of the housing. 5. Hose off filter over the septic tank. Make sure all solids fall back into septic tank. 6. Insert the filter cartridge back into the housing making sure the filter is properly aligned and completely inserted. 7. Replace and secure septic tank cover. www. polylok.com 1-877-765-9565 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION Owner ~ rl~ °-E 0 PI"~'~ ~~-Q-~ Permit # DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units ~ NA Estimated flow (average) tp~a gal/day Design flow Ipeakl, (Estimated x 1.5) ~d~ gal/day Soil Application Rate ~, ~' gal/day/ft2 Standard Influent/Effluent Quality Monthly average" Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODS) 5220 mg/L ~NA Total. Suspended Solids (TSS- 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BOD5) <_30 mg/L Total Suspended Solids (TSS) 530 mg/L CIA Fecal Coliform (geometric mean) 5104 cfu/10 0m1 Maximum Effluent Particle Size YB in dia. NA Other: ^ NA *Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity ~~IX' ~ Z ~ ~ gal ^ NA Septic Tank Manufacturer L[,~,?.2 ~S ^ NA Effluent Filter Manufacturer D ~ ^ NA Effluent Filter Model 2 ^ NA Pump Tank Capacity gal ,71~ NA Pump Tank Manufacturer Gl~ NA Pump Manufacturer f~NA Pump Model ~NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: ~NA Dispersal Cell(s) ~In-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tankls) At least once every: ~ ^ monthls- (Maximum 3 years) ear(s) ^ NA Pump out contents of tankls) When combined sludge and scum equals one-third (Y31 of tank volume ^ NA Inspect dispersal cellls) At least once every: ~ ^~yearl )Is) (Maximum 3 years) ^ NA Clean effluent filter At least once every: ~ .~ 3 ^ month(s) yearls) ^ NA Inspect pump, pump controls & alarm At least once every: ^ month(s) ^yearls) NA Flush laterals and pressure test At least once every: ^ month(s) ^ year(s) ,~NA Other: At least once every: ^monthls) ^yearls- ^ NA Other: ^ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tankls) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cellls) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third IY31 or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to,the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of <_12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (41011 Page of 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(s1. 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 cellls) in one large dose, overloading the cellls) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall 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 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 reconstrugted in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name .f Phone ~ ~~ ~ -. 2/ POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name ~ Z ~ Phone ~ _ 1~6 This document was drafted in compliance with chapter Comm 83.2212)(b111)(d)&(f) and 83.54111, 121 & (31, Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNEERSHIP CERTIFICATION FORM Owner/Buyer ~ ~ yl Cd.-~o p~P rl~c ~`f '-Q~'~-- Mailing Address 110 ~ ~ <Cjl~~j ~f ~,Q,~c~ ~~jvt.~~~, (,~,~/ ~O/ ~ Property Address s f ~"~ (Verification required from Planning & Zoning Department for new construction.) City/State LEGAL DESCRIPTION Parcel Identification Number ~~~ -~O/7-7d-6dd Property Location ~'/, , ~/Gt~ '/, ,Sec. ~_-, T :~c'3 N R ~' W, Town of ~je%°t ~F`a-iYt ~ Subdivision Plat: Certified Survey Map # ~ ~ ~ 1` Lot # Volume 3 ,Page # ~ / Z Warranty Deed # S ~ S 7~ ~ (before 2007)Volume ~ ,Page # ~! Z Spec house'~~yes~no Lot lines identifiable yes I no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman phunber, restricted plumber or a licensed pumper verifying that (I) 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. 1/we, 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 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 warranty deed recorded in Register of Deeds Office. Number of bedrooms __~_ ~ SIGNATURE OF APPLICANT(S) iZ/ i~ 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. 08/05) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) /~,~~ /~p.~y, 5~-- l~a.~.J~~rn~,(~.~1 located at: /'ups i/4, x,1'/4, Section _~_, Town ~y N, Range~~`W, Town of ~i: ,~ pct; ~; ~ , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service ~-/ -- /U Did flow back occur from absorption system? Yeses No (if no, skip next line.) Approximate volume or length of time: ~ gallons 2 z~ minutes Tank Capacity: / ~p ~ Construction: Prefab Concrete ~ Steel Other Manufacturer (if known): (..t~,e ~ ~ S Age of Tank (if known): __~Z. Permit number (if known) t~ Licensed lumber Signature) l-~ (Title) ~ ~ ~~ 1y (Date) (Prin Name) F3 ~ s-~ (License Number)1bIP/MPRS Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and. s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9J2008 STATE BAR OF WISCONSIN FORM 1 - 2000 WARRANTY DEED Document Number This Deed, made between John E. Steel and Roberta A. Steel, husband and wife, Grantor, and JOHN E. STEEL and ROBERTA A. STEEL. Trustees or their successors in trust. under the JOHN E. AND ROBERTA A. STEEL LIVING TRUST, dated November 13, 2007, and anv amendments thereto, Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (the "Property") (if more space is needed, please attach addendum): See attached. liilll VIII IIlII 1111! VIII lilll lilt IIIEI! illl lil * 8 7 5 7 0 9 2$ ~7~~as KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CD., WI RECEIVED FOR RECORD 05/29/2D08~ 10:50AM WARRANTY DEfrD EXEMPT t 16 REC FEE: 13.00 PaGES: z Area Name and Return Address Joseph P, Eazley Earley Law OfTices 539 South Knowles Avenue Together with all appurtenant rights, title and interests. 012-1017-70-000.012-1019-80-100 Parcel identification Number (PIN) This is homestead property. Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except easements and other encumbrances of record. Dated this l ith day of January, 2008. *John E. Steel f~, ,9~~G~ G *Roberta A. Steel ~L~LQfL~tt_.~ > AISTHENTICATION Signature(s) John E. Steel and Roberta A. Steel, husband and wife, authenticat this t 5th day of anu , 2008. *Jose h rle TITLE: BER STATE BAR OF SCONSIN (If not, authorized by § 706.06, Wis. Stats.) ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. County ) Personally came before me this day of the above named to me known to be the person who executed the foregoing instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY Joseph P. Earley. Attorney_at Law {Signatures may he authenticated or acknowledged. Both are not necessary.) Notary Public, State of Wisconsin My Commission is permanent. (If not, state expiration date: .) 'Names of persons signing in any capacity must be typed or printed below their signature. V1':iRR,1NT1' DEED STATE BAR OF WISCONSIN FORM No. 1 -?000 1 of 2 ADDENDUM Part of the SW %4 of the SW '/4 of Section 6, and part of the NW 1/e of the NW '/4 of Section 7, Township 30 North, Range 17 West, Town of Erin Prairie, described as: Lot in the Certified Survey Map recorded June 16, i 978, in Volume " 3" of Certified Survey Maps on Page 612, as Document No. 349469. Together with: A parcel of land located in the Fractional SW ~4 of the SW'/, of Section 6 and the Fractional NW'/4 of the NW'/4 of Section 7, T30N, RI7W, Town of Erin Prairie, St. Croix County, Wisconsin further described as follows; Commencing at the SW corner of said Section 6 (also being the NW corner of said Section 7); thence N00°54'43"W along the West line of the Fractional Section 6, 462.53' to the Southerly right-of--way line of County Trunk Highway "GG"; thence S65°57'41"E, 329.30' along said Southerly right- of-way line to the point of beginning; thence continuing along said Southerly right-of- way line S65°57'41" E 674.14'; thence continuing along said Southerly right-of--way line Southeasterly 6.74' along the azc of a 851.51' radius curve concave to the Northeast whose chord bears S66° 11'18"E 6.74'; thence continuing along said Southerly right-of- way line S02°20'34"E 13.55'; thence continuing along said Southerly right-of--way line N87°39'26"B 29.26'; thence continuing along said Southerly right-af--way line Southeasterly 177.83' along the arc of a 851.51' radius curve concave to the Northeast whose chord bears S74°34'03"E 177.51 to the East line of the Fractional NW% of the NW'/4 of said Section 1; thence S00°3'06"E 295.25' along said East line; thence S89°00'38"W 814.46' to the computed Southeast corner of that Certified Survey Map filed in Volume 3, Page 612 in the St. Croix County Register of Deeds; thence N00°59'22"W 645.30' along the East line of said Certified Survey Map to the point of beginning, containing 372,917 squaze feet (8.561 acres) more or less. Subject to easements and restrictions of record, if any. 2of2 . /""`~. 34s~ss ~' \\ ~m ~ti~ ~' ~ GG~ ~ ti6 r~ FILED 06 1978 ~~a~ ~~.°'"~ \ ` `~U \ ~~ . ~~ \ ~~ ~G , W ~_ v ~~ ~~Z ~` ac ~WW ~~O ~~W ~ ~ h ~3Q N ~ !Op ZOO SCI-LF l" = /00~ O = / ~~ /.PON P/PE [vT. /. /3 L B~[ F. CERTIFIED SURVEY ART OF THE Sw'/w of THE Sw'/y SECTJON (o, RNO PJ?RT of THE Nw'/4 OF THE NI,U'/4 OF SECTfON 7, Tao N , Qi7w , TowN OF ERIN PRAIRIE, ST. CRaIK COVNTY, wJSCONSIN. r ~ r~•. 34~46J DESCRIPTIGfv Fart of tt?e SW4 of the SVJ4 of Section ~, and part of the fvW~ of the i~W4 of Section 7, Towns}zip 30 Tt'orth, Range 17 West, Town of Erin Prairie, St. Croix County Wisconsin described as followse Commencing at the Northwest corner o.f said Section 7; Thence S 1° 03' E 32.?. 08 feet to a point; Thence IC 88° 57' E 33.00 feet to a paint and this being tho poini• of beginning of this survey; Thence continuing tv 880 ~7' E 267.00 feet to a oirit; ThencN N 1 G3 W ~~49.5~ feet to a. po:irl-h; Thence ~ 66~ ii' '~r' 294.37 feet to a point; Thence S 10 03' E 773.33 feet to the poir:t of be- gir~r~ing. This parcel contains 139,9?_1.6 square feet or 4.36 ~.cres of land more c,r less excltzdirl~; lard released far hig}~way r:i.ght-of-vra~~ purposes. SURVEYOR'S CERTIFICATE I, Richard D. Eooth, being a duly qualified surveyor, so hereby certify that by order of ar,d tinder the directiar, of John Steel , I have surveyed and mapped t:~ie pr•cperty described. The plat shown on t}~te sheet is a true and correct representation of the exterior bour;daries of the land surveyed and that I have complied wit'r: the ~~rovisions of Chal,ter 236.34 of i;he Vdiscor.sin Statutes to ~;'r~e be:s-I; off' my knowledge and belief. ~~~r~ Richard D. Booth Registered Land Surveyor Clear Lake, Wiscar~sin r4~ay 15. 1978 Appnoved .in Comp.~.ianee ~a Sec.~.ion 5.1.4 a ~ the ST. CROIX COUNTY ZONING ORaINANCF ab an Agn.icu.~~una.~ Pa ce.~. ~. A RR L~$A 8LR Zoning Admtin.iexica~on June 16, 197k ~' RICHARD D. 800Ti-1 ~ S-1413 i i CLEAR LAKE, W1S. I t ~ E ,. ~~i d d~ su RJR=4~®~ ~ ny01 3~n l~ I O p~ ~ C w ~ C ~ O 7 ~ ~p r- I ~ ~ 3 ~ ~'~ ~ ~ .. 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Gt ~ 3' ~ ~ N !D ~ _ ' ~. ~ ~ v O 'S 1 C ~ ~ ~ G O N a a O tD ' ~ ~ ~~ O ~ "~ 1 !~ N H J ~ ~ I ~ v v>za ~ ~ ~, ',, „a~ °, m co D ~' a ~ ~ I ~ ~ ~ a c ~ o o ~ ~ I Z o co ~ ~ c~rw ~~ ~~o~j NO Q I n ~; ro rN+ ~ ~ ~ Q I O O O R ~~ 0 ~ ~ ~ Q g ~ y ~ ~ c ~ D I ~ ~ I ~ ~ (,~ ~ ~ ~ e'o w ~' ~ ~ ~ ~ w ~ I ~ ~ ~ ~ ~ I ~ ~ ~ ~ 3 y I rn N Ia ~ ~ N IZ N o c O D D ~ ~ ~ ~ N N ~ ~ N~ ~/J~[~~ - ~f C ' ~ i w ~ a I Z j cb '' -~ N I ~ O ! A? I ~ ~ C I ~ J T ~ ryZ . I ~ ~~ I to -~ rn W ~ ~ o I Q,~ ~z B j ~ ~ '•' ~ ~ ~ y Z ~ ~ I ~ O a I c ~ D' I a ~ a ~ i I x ~ I o a v ~ i ~ o I ~ o- o a ~ ~ N "' O Vl I ~ ~ (p I 4 J I O A y (D ~ ~ ~ O O a N w O ti tv ~ Oq I Fn O t0 ~ ,A b I ~ Parcel #: 012-1017-70-000 ozi22i2oos 10:40 AM PAGE 1 OF 1 Alt. Parcel #: 06.30.17.870 012 -TOWN OF ERIN PRAIRIE Current ,X''. ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: JOHN E & ROBERTA A STEEL Owner(s)' v = Current Vwner, L = current c;o-owner O -STEEL, JOHN E & ROBERTA A 1699 150TH ST p ~' I'~~\ ~ / t; NEW RICHMOND WI 54017 ""'" _ ~ ~/~G~ ,C .V - ) ••II `w "~~ Districts: SC =School SP =Special Property Addr ss(es): ' =Primary Type Dist # SC 3962 Description NEW RICHMOND " 1699 150TH T I~ SP 8020 UPPER WILLOW REHAB DIST ~~ ~ ~ ~U co ~~nn ~nnTr~ ~ Legal Description: Acres: 4.330 Plat: N/A-NOT AVAI BLE SEC 06 T30N R17W 4.33 AC IN SW SW & IN Block/Condo Bldg: NW NW OF SEC 7 DESCRIBED AS CERT SURVEY MAP IN VOL III P 612 EXCEPT PART TO HWY Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) .03 ACRES AS DESCRIBED IN 837/128 06-30N-17W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 998/328 MD 07/23/1997 837/128 07/23/1997 579/49 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 104638 172, 300 Valuations: Last Changed: 11/07/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 4.330 50,300 127,800 178,100 NO Totals for 2005: General Property 4.330 50,300 127,800 178,100 Woodland 0.000 0 0 Totals for 2004: General Property 4.330 10,300 112,900 123,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 115 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel #: 012-1017-7U-~~~ 03/31/2006 12:39 PM PAGE 1 OF 1 Alt. Parcel #: 06.30.17.870 012 -TOWN OF ERIN PRAIRIE Current XJ ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O =Current Owner, C =Current Co-owner JOHN E & ROBERTA A STEEL O -STEEL, JOHN E & ROBERTA A 1699 150TH ST NEW RICHMOND WI 54017 Districts: SC =School SP =Special Property Address(es): ' =Primary Type Dist # Description ' 1699 150TH ST SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 4.330 Plat: N/A-NOT AVAILABLE SEC 06 T30N R17W 4.33 AC IN SW SW & IN Block/Condo Bldg: NW NW OF SEC 7 DESCRIBED AS CERT SURVEY MAP IN VOL III P 612 EXCEPT PART TO HWY Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) .03 ACRES AS DESCRIBED IN 837/128 06-30N-17W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 998/328 MD 07/23/1997 837/128 07/23/1997 579/49 7nn~ CI IMMARY Bill #: Fair Market Value: Assessed with: Valuations: Description Class RESIDENTIAL G1 Totals for 2005: General Property Woodland Totals for 2004: General Property Woodland 104638 172, 300 Last Changed: 11/07/2005 Acres Land Improve Total State Reason 4.330 50,300 127,800 178,100 NO 4.330 50,300 127,800 178,100 0.000 0 0 4.330 10, 300 112, 900 123, 200 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 115 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 . • D 349469 o~ FILED ~. ~ ~ \ JUN 1 g ?978 ao it v ~,~ ~~ . 6 ~ c Tti~ '~ ~.°'"" s, ~ ~ °cfl_ 296%~ ~ y3~ ' \ ~ \ 'F'/ i n ~ \~ \ ~ ~ .~ ~/w -:~o °~ ~~~ v~ ~~W W ~ v ~~ ~' W h ~3Q N o ,ao zao SCgLE /" = /00 o = / " /.PoN P/PE ~vT. /. /3 1 B~L F. GERTI FLED SURVEY PART OF THE SS.~ Yy of THE S w'/y SECTION !o, RNO PART of THE Nw'/~ OF THE NW'/4 OF SECTION .7, Tao. N , QITw , TowN OF ERIN PIZgI21E', ST. CROIJf COUNTY, ~aaaa+aa awava~a v'ER / ~ ~ °`-S~ , TOt~)NSHIB'~ ~~i1''' , _ SEC. T~<~ N, R ~ W ,0.; DRESS, / , ST. CROIX COUNTY, WISCONSIN. ~- °3DIVISION LOT LOT SIZE-_`~~/~+ /:<<~_, . , . PLAN VIEW •Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM -__ i TIC TANK(S)~~ MFGR. _~S ,CONCRETE ~~STEEL N0. of rings on cover ~~ Depth ~ " DRY WELL :'NCH~S N0. of width length area. .~ na. of lines --~ width ~~• length,~<~ ~ area~~fT' ,. r dapth ~ o top of pipe ~ p " u~C RATE ~ , S" AREA REQUIRED r,'~ / ~; " ~ AREA AS BUILT {~ .~ `!~'~ ,~ ;claimer: The inspection of this system by St. Croix County does not imply complete % .pliance with State*Administrative Codes. There are other areas that it is not possible inspect at this point of construction. St. Croix County assumes no liability for ~ :tem operation. However, if failure is noted the County wilt. make every effort to .ermine cause of failure. ~ .f~~ BASES AND OZLS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. • ~ .. a. ' • ~ ~ ~'INSPEC~.0~ .~ ~ ~/ D~TED__ ~ , ~`) f ~~ ~~ PLUMBER ON JOB ~ .~ LICENSE NUMBER t ~ ~ .~ .. _ _ _. _ -~ RF$ORT br ItiSPLCTIO'.1--I~lDIVIDiJAL SEZ•IACE llISPOSAI, SYSTEI~1 • ." SnniL-ary Pernit ~ .~ • • r State Septic ~~ •,~`~ c~ ~' ~ ~ TOt•INS1iIP ~ J • r ~ a " ~ t. roi~ County aFPTIC TA'?T: M 11.W h c~ ~ ~ ~ . . Sx2e _ gallons . `lumber oi' Conpartfients ..~~ -~~' Distance Front: 'dell ~o~_ft, 127, or greater slope ~ ft. Building ` ft. Wetlands f: • highc,~~•cter ft. ' DISFOSAT, SYSTL.~ Tile Field or '~~Seepage Pit(s) Distance From: tell. ft. 12%_or greater slone~ ft Building S~ f t . Wetla-~ds " ~ f FIB I~i~;hwater ~ ft. ~~. . Total length of lines ~~~ft. i3uraber of lines Z Length of each line ~~ft, Distance between lines ft. Width of file i , ~reneh ~ ' ft. Total absorPti,on area - Z. - s ft _ ~ De q t'~ P of ~ roGk U_ elo~7 file / ~-- in. Depth of rock over file Z in.. Cover 2 ..aver .rock,, Depth of tide below grade ~_in. SloPe of . - - trench min ner ln~) ft. Depth to Bedrock ft. Depth to ' round water PITS ~ _ ~3umber of pits .Outside dia t ft. Depth below inlet ____,___ft. Gravel around ;zit : e o. .Total absorption .area ,. _____-----s q . f t . . .Square feet of seePape trench bottom area required ::quar~ feet of epa~:e nit re required - . ~ ; Inspected y. ~ ~t,~Title':. Approved ~~..~'~~ ,~: Date .f 197 . ~. Rejected Date 197 __.. EH 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH - ' P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION: ~'/,J~'~ '/4, Section ~, T~~'' N, R ~~(or) W, Township o~y ~r~ A-' ~~~^ ~ Lot No. ,Block No. County ~ /hr ~ X r.S bdivisign Name . Owner's Name: Mailing Address: ~~ - ^) ~ j ~-~ TYPE OF OCCUPANCY: Residence `~ No. of Bedrooms `"~ Other EFFLUENT DISPOSAL SYSTEM: NEW ~~_ ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS ~~ '~' 7~ PERCO TION TEST ~- ~'~- SOIL MAP SHEET ~-~~~ SOIL TYPE PERCOLATION TESTS TEST DEPTH HOURS WATER IN TEST TIME DROP tN WATER LEVEL, INCHES RATE CHARACTER OF SOIL HOLE AFTER INTERVAL NUM- INCHES THICKNESS IN INCHES SINCE HOLE 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN BER _ P~ ~~,, i ~ /~ ~l ~ IvC~ .~ ~ ~ ,~ SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) q 7'7Z+ ~ ° ~ v ~, ,/ ~/ 7~ZN ., _- ~ 3 ~ ~ ~ ~ 7 Z ,, ~-, .. ., ~ ~ ~ ~, PLAN VIEW (Locate percolationtests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy. ~~/ 5 `a ~ 1300 4 ~A./~tb/E Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. t P~. B 6 7 State and County Permit Application for Private Domestic Sewage Systems *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # State Permit # ~~°2 County Permit - ~ County A. OWNER AF PROPERTY Mailing Address: B. LO N: '/4 '/, Section ~, T~~N, R~~ (or) Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family (,/Duplex No. of Bedrooms _ ~ No. of Persons ~~ D. TYPE OF APPLIANCES: Dishwasher L~ff~ NO Food Waste Grinder Automatic Washer ~ _ NO Other (specify) E. SEPTIC TANK CAPACITY /,~~-r) Total gallons No. of tanks _~ *Holding tank capacity Total gallons No. of tanks New Installation ~/ Addition Replacement _ Prefab Concrete ~ *Poured in Place Steel Other (specify- F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) , S 2) .<~ 3) _; ~; Total Absorb Area /,~ ,<; sq. ft. Newer/Addition Replacement *Fill System Seepage Trench: No. Lin . Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length ~5 7 • Width ~7 Depth , ~~ Tile Depth z ~-'~ No. of Lines ~ Seepage Pit: Inside diameter Liquid Depth Tile Size '~ ~~ Percent slope of land ~ ~~_ Distance from critical slope '"- I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certi 'ed Soil Tester, NAME r+ - ~ C.S.T. # ~ 7 C~ and other information obtained from a.r ``" wner/ uilder-. Plumber's Signature J MP/MpRSW#p / L~ S ~ Phone #~-y~ - s y 2q Plumber's Address 4 uc ,~ ~ PLAN VIEW: Provide' sketch .below of svstem (include direction of slope and all distances in accord with _y~ ./~ _ r' ~~~-------t YES [,PFe~" # of Bathrooms-~ ~y~~ ~~~ ~~