HomeMy WebLinkAbout020-1363-16-000 Wisconsin Department of ComaVrce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT sanitary Permit No:
430476 0
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)). 9 2 e0 ! 56_ _
Permit Holder's Name: City Village X Township Parcel Tax No:
Stevens, Blake I Hudson Township 020 - 1363 -16 -000
CST BM Elev: Insp. BM Elev: BM Description: Sectionlfown /Range/Map No:
/0- U G6-t 27.29.19.2153
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic `7 DO Benchmark
Dosing Alt. BM 2. Z 0
Aeration Bldg. Sewer
ek 4- Z- 97
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
p lP � � / �
Dosing H�r /Man. S --
�•S
Aeration Dist. Piper
Holding Bot. System
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer Demand St Cover
GPM - 2
Model Number
TDH Lift Friction Lo stem Head TDH Ft TT
Forcemain Length I Dia. Dist. to Wel
SOIL ABSORPTION SYSTEM
BEDITRENCH
DIMENSIONS Width / Lengt S No. Of Trenches IT DI NSIONS o. Of Pits Inside Dia. Liquid Depth
llPP �— �i
SETBACK SYSTEM TO P/L BLDG IWELL LAKE /STREAM Manufacg1 r:
INFORMATION CHAMBER OR
Typ Of System: / UNIT ._Nuuumbber:: Y J
Model
DI BUTTON SYSTEM
Header/ nifpld Distribution ! x Hole Size x Hole Spacing Vent to Air Intake
Lengt Dia 'p Length L 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
Bed/Trench Center Bed /Trench Edges Topsoil Yes No Yes No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1:_/Z 2 Inspection #2:
Location: 636 Commerce Drive Hudson, WI 54016 (SE 1/4 SW 1/4 27 T29N R1 9W) Exit 4 Business Park Lot 16 ,Pa_rlcel No: 27.29.19.2153
1.) Alt BM Description = �h't /�rj 33f"_ � 1 {2� cf 61 �p
2.) Bldg sewer length
- amount o f cover =� 3 � T / ��� •. �� /�,
Plan revision Required? [] Yes r; o I ;L- 2 03 T ( /
Use other side for additional information. (!
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SBD -6710 (R.3/97)
Date Insepctor's Cart
Safety and Buildings Division County
` 201 W. Washington Ave., P.O. Box 7162 (� �!!
iseons W Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.)
(608) 266-3151 V
Department of Commerce
State Plan I.D. Number � �7 o POS�
Sanitary Permit Application -v 6 03 G
In accord with Comm 83.21, Wis. Aden Code, personal information you provide � Address rr Brent than mail' n address)
may be used for secondary purposes Privacy Law, s 15.04(1 xm) oo r4&
1. Application Information - Please Print All Information
Pr ny Owner's N• me Parcel t H Block N
N '�� S ego -1,3o lb -oco C- 215
Property er C s "�
y OOw''ss Mailing Address Property Location
7 7f Section a � 7 M�f
City State
ry / may/ // ZZiip C^o7der Phon Nu1mbPer �j
11[ / /lit AIL ✓ l J �✓ '�lJJ �� � � / N; R /� E
ircle or W e)
11. Type of Building (check all that apply) Subdivision N
❑ I or 2 Family Dwelling - Number of Bedrooms
r r
&PublidCommercial - Describe Use
C1 State Owned - Describe Use
? j r x { Z`f • ",�f L ❑City _❑Village,I'ownship of S!J'I
Ill. Type of Permit: (Che ck only one box on line A. Cle)
A ' New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only - 0 Other Modification to Existing System
4
B. ❑ Permit Renewal ❑ Permit Revision - ❑ Change of ❑ Permit Transfer to New
List Previous Permit Number and Date Issued
Before Expiration Plumber O`vne
1V. Type of POWTS System: Check all that appl
Non - Pressurized la-Ground ❑ Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑Single Pass Sand Filter 11
Constructed
Wetland ❑ Pressurized ln- Ground C1 Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit C3 Rximulating Sand Filter ❑
Recirculating S thetic Media Filter ❑ Leaching Chamber ❑ D[iP line ❑ Gmvel-k% Pi ❑ Other (ex
V. Dis ersalrl'reatme t Area information: em Eleva
Design Flow (gpd) ign Soil Application Rate(gpdsf) ispersal Areauired (5-f) ispersal Area Proposed (5-f) ystti h / Sr
301 S -a fJ
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Stee G stic
Gallons Gallons of Units Concrete ConstrictGlass
Ncw I Exix[ing
Tanks TarJ4v
Aerobic Treatmcru Unit
Du Chamber
VII. Responsibility Statement - 1Aunder usibili for installation of the POWTS shown on the attached lans.
Plumber' Name (Print) MP/MPRS Number Business Phone Number
Plumber's Address (Street, City, State, L - �S �t�7 /� (.� J /
Vlll. Count /Department Use Onl
Sanitary Pennit Fee (includes Groundwater Date Issued 1 u' Agent Signature o Stamps)
}Approved ❑ Disapproved Surcharge Fee)
[I Owner Given Reason for Denial 2 l 0 / �3 0
Conditions of
1X. Approval/Reasons for Disapproval
SYSTEM OWNER:
1 Septic tank, effluent filter and O,-�t �i • S"
dispersal cell must all be serviced J maintained
as per management plan provided by plumber. t
2. All setback requirements must be maintained p-l;` . nn. -�Q A0Je_ - y�cr
as per applicable code /ordinances. e 59 ( �` 1
- — o S t✓% - 5 ��
Attach complete plans (to the County Duly) for the system on paper not ku thin al/2 x It laeh size r�
SBD -6398 (R. 01/03)
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Safety and Buildings
4003 N KINNEY COULEE RD
LACROSSE WI 54601 -1831
TDD #: (608) 264 -8777
1\*isconsin www.commerce.state.wi.us /sb
Department of Commerce www•wisconsin.gov
Jim Doyle, Governor
Cory L. Nettles, Secretary
October 15, 2003
CUST ID No. 139462 ATTN: POWTS Inspector
TODD L SINZ ZONING OFFICE
T L SINZ PLUMBING INC ST CROIX COUNTY SPIA
E5609 708TH AVE 1101 CARMICHAEL RD
MENOMONIE WI 54751 -5520 HUDSON WI 54016
CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 10/15/2005 Identific ers
Transaction ID N .928055
SITE: Site ID No. 666398
Cedar Falls Building Systems Please refer to both identification numbers,
Commerce above, in all correspondence with the agency.
Town of Hudson
St Croix County
NE1 /4, SW1 /4, S27, T29N, R19W
Lot: 16,
FOR:
Description: Commercial (office /storage) Non - pressurized In- Ground System
Object Type: POWT System Regulated Object ID No.: 924740
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes
Corti
a DITIONALLY APPROVED. The owner, as defined in
and Wisconsin Statutes. The submittal has been CON
chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. APP
The following conditions shall be met during construction or installation and prior to occupancy or use: DER RTM
NQF:
General Approval Requirements: SEE COF
• This system is to be constructed and located in accordance with the enclosed approved plans and with the "In-
ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems VERSION 2.0"
SBD- 10705 -P (N.01 101).
• The leaching chambers must be installed in accordance with the manufacturer's printed instructions, the plan
approval and Comm 83, Wis. Adm. Code system sizing criteria. If there is a conflict between the
manufacturer's instructions and the plan approval, the plan approval and code requirements will take
precedence.
• Access to the filter for cleaning must be provided per Comm 84 product approval conditions. Maintenance
information must be given to the owner of the tank explaining that periodic cleaning of the filter is required
• The plumbing for this project discharges to a private sewage system. The approval covers only
domestic /sanitary wastes directed into this system. The Department of Natural Resources must be contacted
regarding the treatment and disposal of all industrial wastes.
• State and federal regulations prohibit the discharge of hazardous wastes to a private sewage system. Accidental
discharge of any hazardous substance to a private sewage system must be reported to the Department of Natural
Resources or the Wisconsin Division of Emergency Government.
TODD L SINZ Page 2 10115103
• 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
• 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 private sewage system installation is required. Arrangements for inspection shall be made with the
designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stat
• Comm 83.22(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:
• Comm 83.52 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.
Comm 83.54(1).
• Comm 83.52(2) A POWTS that is not maintained in accordance with the approved management plan or as
required under s. Comm 83.54(4) shall be considered a human health hazard.
• Comm 83.55 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 Safety & Buildings 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 to the owner and any others who are responsible
for the installation, operation or maintenance of the POWTS.
Sincerely, Fee Required $ 175.00
Fee Received $ 175.00
Balance Due $ 0.00
Charles L Bratz
POWTS Reviewer II, Integrated Services WiSMART code: 7633
(608)789 -7893 , 7:45 am - 4:30 pm Monday - Friday
cbratz @commerce. state. wi.us
cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544
Henry F Grote , Certified Soil Testing
FCC
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Cedar Falls Building Systems - Conventional System 4j
Construction Materials and Techniques •
All materials must comply with Comm 84 and be installed in accordance with manufacturer's
specifications. Construction methods must comply with the following Component Manual:
In- ground Absorption (v. 2.0) — SBD- 10705 -P
Location: Lot 16, Exit Four Business Park
NE 1 /4, SW 1 / 4, Sec. 27, T 29 N, R 19 W
Town: Hudson
County: St. Croix
Date: October 12, 2003
Owner: Cedar Falls Building Systems
Address: 5455 Freitag Drive
Menomon' , WI 54751
Plumber: Todd Si
Signature: IfM717y
License # MP 139 6 OVED
Y � A 1MERCE
U NG3
Attachments: 6748 Plan Approval Application
SBD -8330 SPONDENC
Page 1: cover
2: design criteria and sizing
3: plot plan
4: system cross section/plan view
5: maintenance
Page 1 of 5
Design Criteria
I-M Wastewater Contaminant Load: 30 mg/L < BOD < 220 mg/L
Anticipated septic tank effluent 30 mg/L < TSS < 150mg/L
Fecal Coliform > 10,000 cfu/100 mL
Estimated design load = 3 ° gallons /day hydraulic load
Design Calculations
In situ designed loading rate �• 4�Z� gallons /sq. ft. per day
Depth to estimated high ground water in.
Depth to bedrock ti z in.
Cross slope at system z • Z %
System Elevation
Final Grade Elevation �' b
Septic tank `��'� ��-' `' gallons
Effluent filter C-9 F o zt -14 ►b A
Estimated Daily Load
10 FTE x 13 gpd = 130 gallons /day
3 floor drains x 25 " = 75 " "
Daily Load = 205 gallons /day
Design flow = 1.5 x 205 gpd = 308 gallons /day
Septic Tank Sizing
Spreadsheet calculator gives 643 gallons as minimum tank sizing for 308 gallons /day with a three year
service frequency. Use Huffcutt 800 gallon septic tank.
Adsorption Cell Sizing
Design flow of 308 gallons /day requires a minimum of 616 square feet of effective area at 0.5 gallons per
day per square foot loading. Use 20 leaching chamber shells, Standard Infiltrator with an EISA of 31.1
square foot per shell.
20 shells x 31.1 sq. ft. /shell = 622 square feet
Specs.calcs.gravity Page L Of
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Management
Management of this system is critical. As a condition of approval of these plans this system management section
must be reviewed with the owner, and the owner must be provided with a complete set of plans including this management
section. If problems develop with the adsorption system or any other system components, the installing plumber, T. L. Sinz
Plumbing, 715- 235 -2644, or the St. Croix County Zoning Office should be contacted at 715- 386 -4680 for their assistance.
General
Proper functioning of an on -site disposal system, "septic system," is significantly dependent on the volume of water
which flows into the system and the level of contaminants in that volume. The lower the volume of water and the lower the
level of contaminants, the better and longer the system will function. Typical system components include a septic tank or
compartment to settle out solids and contain greases and oils, a filter on the outlet of the septic tank to retain small particles
of the same density as water, a pump tank or compartment to allow a dose to be accumulated, a pump and controls, and
finally some type of soil adsorption cell to recycle the water in a manner to protect ground water quality and public health.
1. If the septic tank is installed prior to sheet -rock and /or painting, pump the septic tank before normal use begins to ensure
adherence to contaminant load design criteria.
2 Install water - saving appliances whenever and wherever possible.
3. Repair even small water leaks as soon as possible.
4. Never pour grease or oil down any drain or stool.
5. Garbage disposals are not recommended; if you must have one, use it sparingly.
6. No paper products other than tissue should go into the system.
7. No chemicals should go into the system.
8. Avoid surge flows of water; try to spread laundry throughout the week.
9. Septic tank effluent must be less than or equal to the design criteria specified in page 2 of these plans.
10. If septic or pump tanks are no longer used, they must be properly abandoned.
11. If construction timing and weather could create a frozen infiltration system, weather - proofing with plastic sheeting
and heavy mulching may be required to maintain a functional system at start-up.
Maintenance
1. The septic tank must be inspected every three years by a properly licensed person.
2. If necessary, the septic tank must be pumped to remove solids and scum; pumping is required if the
combined scum and solids volume equals one third of the tank volume.
3. Periodic observation pipe inspections should be made by the owner to examine the state of the in -situ soil
adsorption cell. Quarterly inspections are recommended, and a licensed plumber should be notified if effluent is
consistently ponded in the adsorption cell. _
4. If this system contains specific treatment components other than those mentioned here, maintenance
requirements will accompany their specifications.
5. Avoid compaction such as vehicle traffic within 15' down -slope of the adsorption system.
6. Avoid disturbing the system itself such that might encourage erosion or disturb the required seeding of the system.
7. Particularly avoid winter traffic such as sliding or snowmobiling which might compact snow and lead to
increased frost depth.
8. Surface drainage must be diverted around the system; avoid landscape changes which might send surface run -off into
the system area.
9. Warning: Do not enter septic, pump or other treatment tanks; death may result because they may contain lethal gases or
insufficient oxygen,
Contingency Plan
Wastewater monitoring of volume and quality is not a normal requirement for regular strength wastewater systems;
such monitoring may become necessary if problems develop. Any necessary monitoring shall be done in accord with the
requirements of Comm 83.54 (2). Pumping and hauling of wastewater may be necessary while analysis and repairs are
implemented. Additional testing, designing, and /or installation of additional treatment components or conversion to a
holding tank may be necessary.
Page 5 of 5
.50114 lot olfrQ A 4�1 r
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page t of 3
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Certified Soil Testing
Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County St. Croix
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. wed By Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
Cedar Falls Building Systems Govt. Lot NE 114 SW 1/4 S 27 T 29 N R 19 W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
5455 Freitag Drive 16 Exit Four Business Park
City State Zip Code Phone Number City A Village je Town Nearest Road
Menomonie WI 1 54751 1 715 - 235 -3541 Hudson I Commerce
New Construction Use: _- Residential / Number of bedrooms Code derived design flow rate 308 GPD
>' Replacement Public or commercial - Describe /warehouse
Parent material sandy /loamy outwash Flood plain elevation, if applicable NA
General comments
and recommendations: install trench system w/ 0.5 gpd /sq ft loading @ system elevation of 94.0
FT1 Boring # Boring
l "t Pit Ground Surface elev. 98.8 ft. Depth to limiting factor > 96 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDItt
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 'Eff#2
1 0 -6 10YR 2/1 - sil 3 m gr mvfr cs 1f /m .5 .8
2 6 -28 10YR 3/3 - sil 1 m sbk dsh gs 1 m .2 .3
3 28 -40 10YR 3/3 - Is 1 m sbk dsh gs 1 m .7 1.2
/ 4 40 -76 7.5YR 4/4 Is 1 f -m sbk ds cs 1 m .7 1.2
-
5 76 -96 7.5YR 4/6 fsl 0 m mvfr .3 .5
Bor
Boring #
Pit Ground Surface elev. 97.6 ft. Depth to limiting factor 85 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDtft'
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 0 -7 10YR 2/1 - sil 3 m gr mvfr cs 1f /m .5 .8
2 7 -14 10YR 2/1 - sil 2 f sbk mvfr gs 1m .5 .8
3 14 -30 10YR 3/2 - sil 1 m sbk dh cs 1 m .2 .3
4 30 -44 10YR 3/3 - Is 1 f -m sbk dsh cs 1 m .7 I 1.2
r
5 44 -56 7.5YR 4/6 - Ifs 1 f sbk mvfr cs
�. , �, 2 6 56 -65 10YR 4/6 - s 0 sg ml cs - .7 1.2
7 65 -85 7.5YR 4/6 - fsl 0 m mvfr - - .3 .5
Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg /L ` Effluent #2 = BOD 130 mg /L and TSS < 30 mgr
rAddress Name (Please Print) Signatu 1 ►� CST Number
�. �ry F. Grote ° � 1 `�� 222774
" Certified Soil Testing Date Evaluation Conducted Telephone Number
E. 4366 353rd Ave., Menomonie, WI 54751 9/22/2003 715 233 - 0398
Property Owner Cedar Falls Building Systems Parcel ID # Page 2 of 3
3 ] Boring # Boring
Id Pit Ground Surface elev. 99.7 ft. Depth to limiting factor > 112 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 0 -9 10YR 2/1 - sil 3 m gr mvfr cs 1 f/m .5 .8
2 9 -17 10YR 2/1 - sil 2 f sbk mvfr gs 1 m .5 .8
3 17 -35 10YR 4/6 - sl 1 m sbk mfr cs IM .4 .6
4 35 -54 10YR 3/3 - Is 1 m sbk dsh gs IM .7 1.2
5 54 -112 10YR 4/6 s 0 sg ml 1M .7 1.2
I
1 m roots to 62; irregular, stratified 7.5YR 4/6 fsl (0, m, mvfr) @ 48 -51, 71 -74, & 81 -83"
f�
F-1 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
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
I
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
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
i
I
i
I
' Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg /L ' Effluent #2 = BOD < 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 -9330 (R.07 /00) Certified Soil Testing
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10/17/03 FRI 16:11 FAX 7152359190 CEDAR FALLS BUILDING SYS Z001
10/ 17/2003 13:.12 fA; 7152352592 T L SIN PLLiP,ING INC
16003
ST CROIX COUNT
SSPTIC TAJgK MAWTF-WANCE AGRBEM33NT
AND
OWNL'RSWP CBRT7iCAT10N FORM J
C?WnerBuycc' LA� S [ L J/ S
Mu ing Address N a7 3`7 ? — fir e G � __PewAuk-G tE �l s.3o 7a
Proporty Address � Q1�„1� ELP E L) 11 t; t. n� l� l
(Vc6rtcatioo iequlrcd ftom Planning Depvtmeta( for new aaastrneeioa)____ �—
civslerc Parcel Identification Number
na L�C� 3 - l -tom
LEGAL DE CRIPx" Ol!,T _ /p
pfnperty LotJativn �S . � /a. }.. Sec. _2L T , � 2 9 N .K�..W, Town of 1' ®� Ca�
Svbdi,viSivn %Df�K_ �C�,�[�t3t:<SS _► Lot #
Cettifled Survey Map # �'a•'e #-
VG171ffi8 �
Warranty Deed # c� 7 94 'VOltt c _� Pa,;e #
Spec house D yes birrco I,ot tines identifiable kyeS D no
5 LtNTENANCE
Improp aruseandmaintena your septic Mta mcouldresultin jig ptematmfanutetob =dtcwastes.Proper eaance
coasism of pampi7ng antt the septic muk every tbres ye3r5 or mc=, if needed by tt brewed pamper. Wbat you put iota the sy stcas
east affect tha funcdoa of tbo soptie tuck se a treettnent CM59 ist the waste diaP'osal aysttctn.
The propeM OW= agrt:=t= to aubnnk to St. Croix Za cing Depaftet r-= a cer�tloa fates tdg W by the owner aad by it
ca+ cpitrmbor.i Pi p� �a ° edptm>pet}u
;09 42 tbt System
is in proper aperatitg cvndiden and/or (7) aflsr LmgwG"d= and primping (if ummaryl the septic Y"* is less than IM full of sludge.
r1wc, the uvrlct;signed ht ve read tl* above rsquin moots and agree to utsiWAR this pzi AW sOVAge disposal system with the sta &r6
fmt fotlh. harem, Asset by the Dcpart um of Ca==me and the Dt:(lt f mo:%t Of Notm+a 1 Xc% other., S=te cf WLScan9la. C=tW' -* loa
statiZtg that your sortie systear has been miaintaiacd mtat be completed atui relt rarA to the St, -CMis Cv=ty ZoniAg office es KWA 30
da C the cWW YW expiration date.
..c.d. , c. ! �J �l U •
SMNATUSRE Of APPLICANT/ DATE
DYN9 a zCATION
I (wc) crnit'y that aft smt=zow an this form art true to the best of MY (,our} 1:aawledg;c. I (care) am (ere} 1>3 own ai
Lb e opetty drfvn`bGd above, by vuatc of a warrnary steed recer&d in Register orMeds Offer.
hI J03
FtG ArME OF A i c 1CANT DA't'0
Any intormatsou that is ,min- teytrsauiciirnay trtsutt iti th sanitafypcu4►it batng �Yeked by rfx TionLrg Depnnuicnt ••• -•-
• I vAth this Y a stamped wi inty deed from sac 9,09 ister of Drtds 0 f 5 c 0
a copy of tha cord aed survey »p if et:fe== is made in d"' WattenO deed
Bureau of Integrated Services C in ac I-age of
9 a c c ordance with s. D�J; yfYis. Adm. Code
t'.
Attach complete site plan on paper not less than 8 112 x 11 inches in s e. o must Co h
include, but not limited to: vertical and horizontal reference point (B ction , „ p �
percent slope, scale or dimensions, north arrow, and location and di to neat�tr_`
Parcel t _D. 4
t! fVN
APPLICANT INFORMATION - Please print all infor n. Re;,;e, by oats
,,
Personal infonnation " "" - 3,11 �Rcgx
You Provide may used for secondary purposes (Privac LavG,�s. 15.04 (��..�, > ;
Property Owner � � .f��
t-7r°1 S . Wa il Lot lG ,.t /4 3110 1/4,8 ?- T V1 .N,R I W
Property Owner's Madi Add res # .i Subd. Name or CS y
I 4 ott ca e s tF tz h
City State zi p Code Phone Number
>.� � � � � �� � FL- � � � � � $ � El city ❑ Village i own Nearest Road (to( ) 4130 1 5UO
u New Construction Use; ❑ Residential / Number of bedrooms Addition to existing building
❑ Replacement Public or commercial - Describe:
Code derived daily flow n gpd Recommended design loading rate _bed, gpd /ft ` trench, gpdff?
Absorption area required bed, ft ( _trench, it 2 Maximum design loading rate r bed, gpd/ft r trench, gpdHt
Recommended infiltration surface elevation(s) "t �o
ft (as referred to site plan benchmark)
Additional design /site considerations g
Parent material _ b F,5 9 y a e � i3 t,+ C *,)tom � a. Flood plain elevation, if applicable
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U Unsuitable for system tJ s p u rA S❑ u Y S El u Ir
s❑ U ❑ s r9 ❑ s U
SOIL DESCRIPTION REPORT Ne ( 7M
Boring # Horizon i Depth Dominant Color Mottles Texture Structure Consistence Boundary Dots GPD/ft2
in. Munsell Ou. Sz. Cont. Color Gr. Sz_ Sh. Bed :Trench
rVNfr CLJ 2� 5
Ground 7 5°
''r AIL
elev.
Depth to
limiting
factor
12) in.
Remarks:
Boring #
Ground t - i'�. ,j S t1s,
elev. 19,3 7ft.
Depth to
limiting
factor
1 11 in. Remarks:
CST Name (Please Print) Signature Telephone No. a.(
f Q r-" C s
Address Date CST Number
�'. 37
PROPERTY OWNER SOIL DESCRIPTION REPORT
Page of
PARCEL 1.0.#
Boring # Horizon Depth Dominant Color Mottles Texture
-„ in. Munsell Qu. Sz. Cont. Color Gr Sh. Consistence Boundary Roots z
Bed , Trench
sli ' 0 1
44 rf t 4 Sep �:ca i # r5
Ground ft �$ ''r S'
elev. ft.
Depth to
limiting
factor
Remarks:
Boring # t
Z.-f .5 `.
�'=
Is 4,015 rgV C� �
Ground q ;• tjq - 1 ld$ t. _ ,• � �
elev. f
Depth to
limiting
factor
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munseli Qu. Sz Cont. Color Gr. Sz. Sh. Bed Trench
Boring # t o f 3(l Y $ r wt-� r r✓ w irk 5
`g n y (e
i.�}4 P J��b � S .d- ��e. .S a "ie a 93��
k r
Ground
`] 3�US- - ft.
Depth to
limiting
factor
k in ' Remarks:
Boring #
Ground
elev.
ft. .
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R. 07/96)
-
t MV1P QM tAtMTA L
1432 120' STREET, NEW RICH1tQOND, WISCONSIN
715 -246 -2454
Ton Nelson-
Certified Sail Testes' 227387 -- Registered Sanitarian SR00713
as
SCALE I" _ a
BM 1.
-c p �, - Tom Nelson
BM 2
10/17/03 FRI 16 :11 FAX 9152359190 CEDAR FALLS BUILDING SYS 0002
10117/03 FRI "14:20 FAX 715 386 4687 REGISTER of DEEDS 1 00 2
seA SA& OF W1SC 0MJN PPM 2 - 1 ftM liiA7'HLRpy H. WA1SH
WARkAAT�'*t DEED RI C R CIF DEEDS
AocameatNutiibaz ST_ GROX7i CU.. V
This Deed. =ads betwomte .T., LL a"bemvfm wed REGEIVRD FOR RECORD
Liabititry CutaPa4YG�r, and SuzmTIM XLC Grantee, lAi 89:3
Cf!fttor, for a valwblt cond&rBdcm. =ts+ceys and wamats to Grime, Ehe WARRANTY DUD
following described teal estate in SL Croix County, State of �Jlr w jn (ifmme
space is nectlad, Plea= dttach add,;ndi=): rtEC FEE: 11.66
TRAXS FEE; 5;a2, 90
Lc+i 1 ,fiat of E xit Fou $u p%* fn the ?owa of iiwdaaat, St Croix COPY FEE:
y2+, Wiscw tt. PAGESS; 1
f'atccptious to watsanties- B st m m . WMftcthus and sight ,&, vay a
rccord. if any. Anx
NHme BRA RcWm Address
AUN 0 3 7 10, f-.
02P--j30-1fi
tatetl identificatio muwt a CPR
This is not bcneswAd pro)Serty,
Dated this �. J4 1 day of
— --
� f
A(MN01i LIM 4! NT
AUTIDINMCATIO N STATE OF NDMSOT A )
Signamte{S) _ aut6ltticated this Bay arr� co unt y ) ss
of )
IPMO SI I cwt: beforc n Le this day of Hftvir cr
2003, file above named C—P.x_, LLC, a Wiscageip Usuitead
TITLE. bONMER STATE BAR OF WISCONSIN �IlaWiiey Cqssspany = me knoom u be the Perron wb9 executed the
fore9=8
7 adgrd the .
Qf bl auzborixed by wo E 7%.06 Wis. ^s2ats.j 1Ni<a�
a
tits IRMUM0a WAS VaJUTEP By I+Totsry c, e a o
C.P.T'., I,.LC Donna M,. CB�rwood 1809 Nostiswest My Cwmmissioa !t& eat.
Ave. Ssi,ilWatgr. MN 55082 FCC (If M staac close:
(Si -mn* mqy be m!dlchGcu( o aClulaul9d Bob dR not
*X1,11% of Fc-8 4947ng in ut a4m.;v mmat ba wped - pli-W brio- their sigpeume.
W ARX NY7Y AETsa STATE PAR OF WASCOIMSTN FORM No. 2 — 2000
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