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020-1448-28-000
ƒ J # o \ i d co CD ( / ( / \ ƒ 0 2 ® o /� S . % 7 § 7 � k 3 F \ } � / 00 >6 > $ / & &@& g ;s\e�0 0-4 2 = � \ : =.CO 0)0E(D 000ƒ 2§2ofk2\J %ƒ o no ,�o-� was 3 .9 �3m3 ME#E(Ermk2£ ; \ ® -2 =r a�0 c0 "CLk& §\ / = CL* — D) - ���� Ea2 @K \a736*CD S. _ , _ ,< 00 §7§k »G --0 m CD 0 @CD a y% 4 � ) « ° a k E 0 : § ; ƒ f 2 4 0 �' k i k A 4 § .. g o (.n I w 8 § ± S % { � OD \ \ k 8 U O D � a & © g 0 Eo � M; $Ej ) k 0 § o c r!, Er E g rr 000 0 � CA CO) ■ k' po ¥ OD - � > / 0 § @ a $ a $ J § E 2 i « 2 CL § A ■ M 7 N) N) CD M CL co 0 : \ ■ \ -n % I $ , t a � i I $ � / � § % . � 2 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GEAI L 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 M'an er, Stian I Hudson, Town of CST BM Elev: TsFBM Elev: I BM Description: TANK INFORMATION P/L TYPE MANUFACTURER CAPACITY Septic Septic Friction Loss Dosing TDH Ft Forcemain Aeration Dosing Dist. to Well Holding LEACHING CHAMBER OR UNIT Manufacturer. TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic Friction Loss System Head TDH Ft Forcemain Length Dosing Dist. to Well LAKE /STREAM LEACHING CHAMBER OR UNIT Manufacturer. Type Of System: Aeration Model Number: Holding County: St. Croix Sanitary Permit No: 515223 0 State Plan ID No: Parcel Tax No: 020 - 1448 -28 -000 Section/Town /Range /Map No: 32.29.19.2861 ELEVATION DATA BS I HI I FS I ELEV. St/Ht Inlet St/Ht Outlet Dt Inlet Dt Bottom Pipe System PUMPISIPHON INFORMATION Manufacturer Width Demand GPM Model Number Vent to Air Intake TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well Cover gn11 ARS(1RPTInN %YRTFM BED/TRENCH DIMENSIONS Width Length No. Of Trenches Vent to Air Intake PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING CHAMBER OR UNIT Manufacturer. Type Of System: Model Number: nISTRIRLITlf)M SVSTFM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Bed/Trench Center Pipe(s) Topsoil Yes ❑ No T T Yes No Length Dia Length Dia Spacing Coll / /1 \ /FR - ¢..ers.,,e f%nly vv Mnnnrl Or Af.r�rarla - Rvsfams Only Depth Over Depth Over xx Depth of Seeded /Sodded Bed/Trench Center Bed/Trench Edges Topsoil Yes ❑ No T T Yes No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 648 Cobblestone Court Hudson, WI 54016 (NE 1/4 SW 1/4 32 T29N R1 9W) Windsor Heights 1st Add Lot 28 Parcel No: 32.29.19.2861 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? ❑ Yes 7 No Use other side for additional information. 11�= F Date Insepctor's Signature Cert. No. SBD -6710 (R.3/97) 9 PA _ D commerce.wi.gov Safety and Buil mgs rvlsion County 201 W. Washington Ave., P.O. Box 7162 St. Croix W i sco n s i n toepartment Madison, WI 53707 -7162 Sanitary Permit Number (to be filled in by Co.) of Commerce 5 1 5 2. 2 -3 Sanitary Permit Application Nta Transaction Number In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Applic POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information ou prRE r sec ndary p urposes in accordance with the Privacy Law, s. 15.04(l)( m , Stats. Same I. Application Informati — P riot All Information Property Owner's Name / f �� � O n f L U Parcel # - Stian M' an er p Property Owner's Mailing Address ST. CROIX COUNTY Property Location /. 2 $ 6'\ 648 Cobblestone Crt. PLANNING 8 ZONING OFFICE ( J) Govt. Lot NE ' / /,SW' /,, Section 32 City, State Zip Code Phone Number Hudson, WI 54016 (612) 280 -3060 (circle one) T N; R 19 W II. Type of Building (check all that apply) `�,y�,`,n Lot # b Name ®1 or 2 Family Dwelling — Number of Bedroot ► i. vSubdivision D4'� \a•� 28 st Windsor Heights 1 Addition oc # ❑ Public /Commercial — Describe Use Na City of ❑ State Owned — Describe Use CSM ❑ Village of Number J!. 4" lea Na ® Town of Hudson III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A ' New System Replacement ❑ Treatment/Holding Tank Replacement Only Other Modification to Existing System (explain) System Abandonment & replacement of portion of dispersal cell, moving pum tank B. ❑ Permit Permit Revision Change of T O Permit Transfer to List Previous Permit Number and Date Issued Renewal Before Plumber New Owner 506309 8/29/07 Expiration IV. Type of POWTS System/Component/Device: Check all that appl Non - Pressurized In -Ground ❑ Pressurized In- Ground 0 At -Grade ❑ Mound ? 24 in. of suitable soil Mound < 24 in. of suitable soil ❑ Holding Tank the, Dispersal Component (explain) 0 Pretreatment Device (explain) V. Disp ersal/Treatment Area Information: Design Flow (gpd) 600.00 ft. Design Soil Application Rate(gp f) Dispersal Area Required (s Dispersal Area Prop ed (sf) System Elevation S 160 —6. as &X/ sq. Q �� /, S� 1 S5 VI. Tank Info Capacity in Total # of Manufacturer w Q Gallons Gallons Units ra Q U o H U U New Tanks Existing Tanks /., f u� w a a 0 U. Septic or Holding Tank 125 1250 1 Wie er Concrete Dosing Chamber 50 750 1 Wieser Concrete VII. Responsibility Statement- I, the un crsigned, a nine responsibility installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plum is Sign MP/MPRS Number Business Phone Number James K. Thompson 30021 (715) 248 -7767 Plumber's Address (Street, City, State, Zip Cod 340 Paulson Lake Lane, Osceola, WI 54020 -5413 VIII. Coun /De se Onl Approved _Disapproved Permit Fee Date Issued Issui gent Signature _ Owner Gi eason o ial $ q75. 75 � 2 2 /D L IX Condit* .$- €* "�teasons for Disapproval /I _ `/� ^�� f — 1 1. Septic tank, effluent filter and dispersal cell must all be services / maintained as per management plan provided by plumber, � 2: Atl setback tequiremente must be maintained "� �✓ n pet applicable Code / ordinma. (./ /� 0 Attach to complete plans for the system and submit to the Con n only on paper not 1 than 1/2 x II inches in size +b 2rQ. - ^J - - u!' mac, � l Lo�e1�f ✓c�-�� e/` SBD -6398 (R. 01/07) Valid thru 01/09 Atil�-a 11,Q On .0 J Q - r*� c%o. 6e.s -6. 6e added .g—la&* ehcs. TwenI f. {� 6c ¢rdded ;�•Epf.� -� 6 � z "sc�• vo 0 \ 4-ece rla;q, I �\ / e t MW(�I• I \ \ 3•r. T �c�nart. � \ . use i/ ,5F .' d-r Ne- u J0. y Cc66 /Q S•bone ",- &- / E / X � s � i KLL�4.i n net 40, // (/ Pro ostd 6a /o,v ale poo x4101 'cv, /Cco -646+? 77�' �Pe,O /ace.+, S -, e �La a ;naP So, a ✓a /aa-� o, �q, E 6,v Tttorn�o5on 8 /�y /oy, • 50 :/ eJaJua b'o� p•E by • ,[oca.•E.td propsrEy s�('i EX:S &hg ���c elegy (05/8 Ca , 66 166one Cei— d .+�• f, ury. �f 1B, cJ.� ' 9466 aEyfes& sec-. 31, r z4H ; .P , o{141alsc , SE• mix fie w/. ,oc/. 14 0.2-0 - IVYS ,28 - cb6 �. 6.,w: To or /710 hok Comer. E/cc.* = 9S. 9's- CXiS2�in9 �t3� «•3�Cc / /Cc�3,J'ES C.1�a.w6.crS C � u:t 5eut� Evld of• 6r'enckas b•e 1^eincu(cv eta %/fO�i G4 tt� �t"CQ.!/a'EiD7YJ 50.7. fn btre.nouedficp,ac u Dose Conventional POWTS Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD- 10567 -P (R.6/99). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Septic Tank The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. If the septic tank is fitted with an effluent filter, it shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Pump Tank The pump (dosing) tank shall be inspected at least once eve two ears. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent filter is installed at the p discharge, it shall be inspected and serviced as necessary. Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is not recommended. Soil compaction may hinder aeration of the infiltrative surface within the system and will promote frost penetration during cold weather months. Cold weather installations (October - February) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not, exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by removing biologically clogged adsorption and dispersal media and replacing said components as deemed necessary or by installing a new soil absorption cell to bring the system into proper operating condition. Questions on the operation or maintenance of the system should be directed to Jim Thompson at (715) 248 -7767 or your County Zoning inspector. Dose Tank Information Electrical as per NEC 300 and Comm 16.28 WAC Disconnect Tank component is properly vented Wieser Concrete Capacityl 750.36 Volume 1 20.28 Manufacturer Gallons gal /inch A B C _t D Dimension Inches Gallons A 19.90 403.60 B 2.00 40.56 C 3.35 67.91 D 11.75 238.29 Total 1 37.001 750.36 3" er tank. Alarm Manuafacturer JSJ Rhombus Tank Alert Alarm Model Number JSJH 1011421 Pump Manufacturer IGoulds _ Pump Model Number I EPO4 1. Force Main Pump Chamber Calculations Locking cover with warning label and locking device and sealed watertight i 4 in. min. f Alternate outlet location Forcemain diameter 2 in. Weep hole or anti - siphon device P ump off elevation (ft) 89.98 Dose tank elevation (ft) 89.00 Diameter: 2" Length: 60' Flow rate: 45.0 gal. /min. Friction loss: 2.47' (60' forcemain)(4.11ft)I00ft.) 2. Total dynamic head: 8.47' Min. supply pressure: 0.00' Vertical lift: 5.50' Forcemain friction loss: 2.47' Effluent filter friction loss: 0.50' (Sim/Tech STF 100A) 3. Pump selection: Manufacturer: Goulds Model number: 3871 EPO4 Pump will discharge approx. 47.0 gpm @ 8.47' TDH (4.80 ft. /second) 4. Dose chamber: Wieser WLP 750 — MR - 37.50" @ 20.28 al. /inch ( 760.36 gal. actual) Sizing: A),One day holding capacity: 19.90" 19.90" = 403.60 gal. B) Alarm setting: 2.00" =2.00" = 40.56�al. C) Dose volume: 3.35" =3.35" = 67.91 (600gal.)(20 1 /o) + (.164)(60') = 129.84 max. dose D) Reserve storage: 11.75" 11.75" = 238.29 gal. TOTAL 37.50" 37.50" = 760.36 MIGOULDS PUMPS APPLICATIONS Specifically designed for the following uses: • Effluent systems • Homes • Farms • Heavy duty sump • Water transfer • Dewatering SPECIFICATIONS • Solids handling capability: 3 /4" maximum. • Capacities: up to 60 GPM. • Total heads: up to 31 feet. • Discharge size: 1 1 /2 " NPT. • Mechanical seal: carbon- rotary/ceramic-stationary, BUNA -N elastomers. • Temperature: 104 °F (40 °C) continuous 140 °F (60 °C) intermittent. • Fasteners: 300 series stainless steel. • Capable of running dry without damage to components. Motor: • EPO4 Single phase: 0.4 HP, 115 or 230 V, 60 Hz, 1550 RPM, built in overload with automatic reset. • EP05 Single phase: 0.5 HP, 115 V or 230V, 60 Hz, 1550 RPM, built in overload with automatic reset. • Power cord: 10 foot standard length, 16/3 SJTOW with three prong grounding plug. Optional 20 foot length, 16/3 SJTW with three prong grounding plug (standard on EP05). • Fully submer in high grade turbine oil for lubrication and efficient heat transfer. Available for automatic and manual operation. Auto- matic models include Mechanical Float Switch assembled and preset at the factory. FEATURES ■ EPO4 Impeller: Thermoplas- tic Semi -open design with pump out vanes for mechanical seal protection. METERS FEET 10 9 30 s Submersible Effluent Pump " EPO4 3871 EP05 ■ EP05 Impeller: Thermoplas- tic enclosed design for improved performance. ■ Casing and Base: Rugged thermoplastic design provides superior strength and corrosion resistance. ■ Motor Housing: Cast iron for efficient heat transfer, strength, and durability. ■ Motor Cover: Thermoplastic cover with integral handle and float switch attachment points. ■ Power Cable: Severe duty rated oil and water resistant. i I rai ■ Bearings: Upper and lower heavy duty ball bearing construction. AGENCY LISTING $A' Canadian Standards Association Goulds Pumps is ISO 9001 Registered. i —► =-4-5 GPM � JSFT - ------------ + - -- — EP0 -. ----- ----- __--' S - _. 0 7 W s U 6 20 } 5 0 15 _ 4 TQ#3r 10 2 1 0 EPO -- -_ - ___ -.- - - -- -� S ^r_ ' - -- - -- - - -� - -- - - 00 10 20 30 40 50 GPM 4/74 ,p t4. -1% 0 2 4 6 8 10 12 m' /h CAPACITY Goulds Pumps © 2002 Goulds Pumps Effective September, 2002 83871 W" ITT Industries Q o H ~ v a h 0 0 N d 4 'O O N . N � N �r �V O r � r E 0 O z v N H a Q L m . O N a C co N �a a B • :i N J U C7 O' W �i MCI CC C� te n+ O O C (D N N H co � C 7 O O) N p N a O M 2 �.I _a CL 3 _ y . 0 C IL) a G a Z Z rn � c O - N a > N 7 V N O � O a m z z R E O Q to �•ooa` a a a o o O (J N N m C N O C) y O N s a 0 m O H N N C c m O c CO (O (O LO O AJ w E A d a L a 0 u U (D ° O O N O g 0 (D vi _ m cc a) m a� : 2 m Q N r> O U O T y mQO 3 3 Cc rn= O a) n' o . w am��N C c Vl O C O O� m 0 N p O a a y O N p N _0 N N= N ." O U O ao f > �pp o m N U� w t6 m N is N 0 E ° C N c: -5 C O ( N �• ° E w d EE� a cc �� - O N O O L U O O f 6 2 a.) 2 0. .. a- E C ^ C O N E .> c p •- O N C a E O m cn o M N > =a a m Q N O N 3 m Q N z E N N _ Lel E Y f6 E E a in a (D u) D O z p a � O Q A Cn C C O O N C C l4 l4 N N C c w � a C 7 LL a N :It z y E N O z CN Z a m c') H E 0 O z v N H a Q L m . O N a C co N �a a B • :i N J U C7 O' W �i MCI CC C� te n+ O O C (D N N H co � C 7 O O) N p N a O M 2 �.I _a CL 3 _ y . 0 C IL) a G a Z Z rn � c O - N a > N 7 V N O � O a m z z R E O Q to �•ooa` a a a o o O (J N N m C N O C) y O N s a 0 m O H N N C c m O c CO (O (O LO O AJ w E A d a L a 0 u U (D ° O O N O g 0 (D vi _ m cc a) m a� : 2 m Q N r> O U O T y mQO 3 3 Cc rn= O a) n' o . w am��N C c Vl O C O O� m 0 N p O a a y O N p N _0 N N= N ." O U O ao f > �pp o m N U� w t6 m N is N 0 E ° C N c: -5 C O ( N �• ° E w d EE� a cc �� - O N O O L U O O f 6 2 a.) 2 0. .. a- E C ^ C O N E .> c p •- O N C a E O m cn o M N > =a a m Q N O N 3 m Q N z E N N _ Lel E Y f6 E E a in a (D u) D O z p a � O Q A Cn C C O O N C C l4 l4 N N C c w � ccrosin ce.)artrrTent of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM 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 M'an er, Stian Hudson, Town of SST BM Elev. Insp. BM Elev: EBMDescriptio - 14 zo 3 GS 1 TANK IN FORMATION n TYPE MANUFACTURER �� CAPACITY Septic r� Q �Z�•a Septic '514 i 5 . 7 J Forcemain P . L ia" G 1::: � Holding O ZZ TANK TRACK INFORMATION O P!L �f3C WELL 25 BLDG. Vent to Air Intake ROAD Septic '514 i 5 . 7 J Forcemain _ Dosing IDist.toWell O ZZ Z _ Aeration 19 St /Ht Inlet LEAC HING Manufacturer: .LA G Holding q3 7 St/Ht Outlet / l + Z PUMP /SIPHON INFORMATION I I k t -to •L: __� Manufacturer ov� 5 emand C_PM Mod'u'N Number /�� r ' �,, TDH Lift � � Fricti � System Head TDH Forcemain Leng�h Dia. #I IDist.toWell SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. Croix Sanitary Permit No: FS ELEV. 506309 0 State Plan ID No: , Parcel Tax No: 9,y c;c> . M 020 - 1448 -28 -000 Section/Town /Range /Map No: 32.29.19.2861 STATION BS HI FS ELEV. Benchmark 5• , DIMENSIONS 9,y c;c> . M Length Dia � 4 /- ' Bldg. S wer SYSTEM TO P/L ` 19 St /Ht Inlet LEAC HING Manufacturer: .LA G 5 . � q3 7 St/Ht Outlet / l + Z 9 -3 Y Dt Inlet IS 93. Dt Bottom �� Header /Man. o ^je� o 4 J • Z Dist. Pipe tr But. System •S��s ��• � Final Grade _ � . (.01 9 St Cover p f 1 S cK �' IZ �• 9 � T 1 4 BEDITRENCH Width 1 Length o. Of Trenches ' 7 6 � x Hole Spacing PIT DIME` SIONo. Off its Inside ia. Liquid Depth DIMENSIONS 0 fft> ( 0 C ' # f reAC Length Dia � SETBACK SYSTEM TO P/L ` BLDG WELL LEAC HING Manufacturer: .LA G INFORMATION CHAMBER OR Type Of System: / l (.D �g �� UNIT Model N mber: + o ^je� o tr nISTRIRUTION SYSTEM Al_rLt <_ Z'S — Header /Manifold Distribution x Hole Size x Hole Spacing V n to Air ke N Pipe(s) \ \ Spacing \ Topsoil �ed es ] No 0 Length Dia Length Dia SOIL COVER Y Praccnra SVC}arnc ()nly YY Mound Or At -Grade Svstems Only Depth Over r Depth Over xx Depth of xx Seeded/ xx Mulched Bed /Trench Center / r Bed /Trench Edges \ Topsoil �ed es ] No Yes [ -1 No d� W COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #" 1 �stAdd Inspection #2: WI 401 N 4 T29N R19W drf s& H�i is Lot 28 Parcel No: 32.29.19.2 61 Location 648 CobblestoRe�Court Hud�pn, 6 S 1/4 32 ( F �/�� ,) Wi ,, , ' ,1 g / 1.) Alt BM Description = � ' , G am, _ + Y, � J uc 2.) Bldg sewer length - amount of cover Plan revision Required? % Yes )<No Use other side for additional information. Date Insepct 's Signa a Can. No. SBD -6710 (R.3/97) commerce.wi.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 sco n s i n Madison, W1 53707- -7162 Sanitary Permit Number (to be tilled in by a of Corri nerce :%' Sanitary Permit Application x t# action Number _ In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate g ntal unit is required prior to obtaining a sanitary permit. Note: Application forms fa' state -owned POWT eel Address (if different thanmailing address) submitted w the Department of Commerce. Personal information you provide may be used for secotuiary r unwses in accordance with the Privacy Law, s. 15.04(l)(m), 5tats. 1. Applicati I •- Please Print All Information Property Owner's Name , Parcel p { Property Owner's Mailing Address (f�� - 1�� c.o 2 City, State Zip Code Phu 11. Type of Building (check all that apply) Lot oCIAu - l 8 0 n y Location 1: Lot y., 51►J /,, Section (circle one N; R __ _ yy � IV{Slo Name A I or• 2 Familv Dwelling - Number of Bedrooms _ ff \ 1�1�SOR ❑ Public /Commercial - Describe Use _ /- ❑ City of _ i CSM Number Cl Village of ❑ State. Owned - Desc ibc Use 7 Town of Vt e� SOP�I ill. Type of Permit; (Check only onq'box on line A. Complete l in e B if applicabl A. It New System p g ❑ Re lacement System Treatment/Holding Tank Replacement Only ❑Other Moditicatioo to Existing System (explain) List Previous Permit Number and Date Issued R. ❑ Permit Renewal 0 Permit Revision ❑ Change of Plumber C1 Permit Transfer to New ' Before Expiration Oi°'ner I V. T e of PO System /Component/D Check all that apply) Non-Pressurized In- Ground ❑ Pressurized In- Ground D M -Grade C) Mound >_ 24 in. ofsuitable sail D Mound < 24 in of suitable soil ❑ I'ank ❑ Other Dispersal Component (explain) �._ ; D Pretreatment Device (explain)__— _ ioi�ong _ V. Dispersal/Treatment Area Information: _ Design Flow (gpd) Design Soil Application Rate(gpdsq Dispersal Area Required (st), Disper Area ProposT,94s!► System Elev�at 45 VI. Tank Info • Capacity in Total # of Manufacturer B c y F U u i, Gallons Gallons Units ra _ I ` Ncw Tanks Exiating Tanks N it0 a Septic or Holding Tank Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS s wn on the attached plaits. Plumber's Name (Print) Plumber's Signature P PRS Number Business Phone Number I % mar ra' w" td Plumber "s Address (Street, City, State, Zip Code) VIII. Coun ty/ e artment Use onl Permit Fee Date Isauod issuing Agent$tgnature f' Q,Approved ❑ Disapproved S Q OwaerG Reason forN IX. ConditjpWt*pyMlppEWeasona for Disap).roval 1. Septic tank,-effluent fitter r and 3 , y _ ti dispersal cell must all be services / maintained as per management plan provided by plumber. 2. All setback requirements mutt be rnaitttained L t111t Pk r code / jtlt]at1L•'� - -- — - Attach to complete plaus to.- the systeut and submit to die County only on paper not lcu t>tan 8 112 s 11 Inches in size SBD -6398 (R. 01107) Valid thru 01/09 Pro Go e Number ST. CROIX COUNTY T oCIAu - l 8 0 n y Location 1: Lot y., 51►J /,, Section (circle one N; R __ _ yy � IV{Slo Name A I or• 2 Familv Dwelling - Number of Bedrooms _ ff \ 1�1�SOR ❑ Public /Commercial - Describe Use _ /- ❑ City of _ i CSM Number Cl Village of ❑ State. Owned - Desc ibc Use 7 Town of Vt e� SOP�I ill. Type of Permit; (Check only onq'box on line A. Complete l in e B if applicabl A. It New System p g ❑ Re lacement System Treatment/Holding Tank Replacement Only ❑Other Moditicatioo to Existing System (explain) List Previous Permit Number and Date Issued R. ❑ Permit Renewal 0 Permit Revision ❑ Change of Plumber C1 Permit Transfer to New ' Before Expiration Oi°'ner I V. T e of PO System /Component/D Check all that apply) Non-Pressurized In- Ground ❑ Pressurized In- Ground D M -Grade C) Mound >_ 24 in. ofsuitable sail D Mound < 24 in of suitable soil ❑ I'ank ❑ Other Dispersal Component (explain) �._ ; D Pretreatment Device (explain)__— _ ioi�ong _ V. Dispersal/Treatment Area Information: _ Design Flow (gpd) Design Soil Application Rate(gpdsq Dispersal Area Required (st), Disper Area ProposT,94s!► System Elev�at 45 VI. Tank Info • Capacity in Total # of Manufacturer B c y F U u i, Gallons Gallons Units ra _ I ` Ncw Tanks Exiating Tanks N it0 a Septic or Holding Tank Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS s wn on the attached plaits. Plumber's Name (Print) Plumber's Signature P PRS Number Business Phone Number I % mar ra' w" td Plumber "s Address (Street, City, State, Zip Code) VIII. Coun ty/ e artment Use onl Permit Fee Date Isauod issuing Agent$tgnature f' Q,Approved ❑ Disapproved S Q OwaerG Reason forN IX. ConditjpWt*pyMlppEWeasona for Disap).roval 1. Septic tank,-effluent fitter r and 3 , y _ ti dispersal cell must all be services / maintained as per management plan provided by plumber. 2. All setback requirements mutt be rnaitttained L t111t Pk r code / jtlt]at1L•'� - -- — - Attach to complete plaus to.- the systeut and submit to die County only on paper not lcu t>tan 8 112 s 11 Inches in size SBD -6398 (R. 01107) Valid thru 01/09 C, 4, / -ce e w4 � � << �G l � 'f D 06/17/2009 10:57 FAX ST. CROIX CO. CLERK IM001 ' s * *ssssssssssssssssss ass TX REPORT ass sssssssssssssssssssss TRANSMISSION OK TX /RX NO 4845 CONNECTION TEL 917152487764 CONNECTION ID ST. TIME 06/17 10:56 USAGE T 00'32 PGS, SENT 3 RESULT OK s Viacom - n Dslmdmentof Commerce SOIL EVALUATION REPORT page of _3 Division of Wdy and BuNngs in accordance with Comm 95, Wis. Ad-- Coda � . County Attach complete site plan on paper not less than B V2 x 11 inches in s¢e_ Plan must include, but not limited to: vertical and hori'Lontat reference point (W), direction and Farms! I.D. percentslope, scale or dimensions, north avow, and location and distance to neatest road_ (PAIA Please print all thronnarlon. Rovkluve fe Personal Inflxmaliw+ r. preride mar be used Jouewndapr.GuWVAJFAIy. 6A (1) (ml)• !�C c �j Proportyawnsr r q E : a:.: �," ALP P opemwmdon G, Lot N 11451)114 S3ZT 2 9N R I9 E(0 1+ Pro tJwners Mallin Addres t 'r Ldt # Block # Subd. Name or CSM# Property 3, g 03 i ! L 2 5 T sT -(. oY vV City State Zip Gods Phone Number i ;• m City ❑ Village r; &4 Nearest vg Consh'uction Use: ja- Resideni'ml / Number of bedrooms 3 — c f Code derived design flow rate �iLQQ�. _ _ GPD Q Reptapemerrt ❑ Public or commercial - Describe: -- Parent material _ r � �___ Flood Plain elevation I applicable AJ ft. General cornm(ints and rewrnmendations: � f>7 e evea ' q 3 • - ' W W dQ" a �- ��`,, - �� ra . ll Boring it ❑ Boring I .�1.7v h I 9.Pit Ground surface elev. i 5' R Depth to limiting Factor „ In. Sna annl:�rnn R�rP Horizon Depth iii_ Dominant Color Munsell Redox Description Qu. Sz. Cunt Color Texture $Uv4aure Gr. Sa- Sh_ Consistence Boundary Roots GPDIICr Boundary 'Eff#1 1 - 092 1 o-`� to,, 3/7 `- , 51 Ez;; b „f -.-fi 0-:5 /C S 2 -2lo I I {_ 1�.7�". Sr'C) 2msb m fr c5 I v S s r)I I y in,,nitn r Kea 4 1 /r n'z e S O NA rvP Fz� Boring it ❑ Boring r). a.,\ [ - pit Ground surface elev. L_1 JLJ ft. Depth to limiting factor in. Sall Ileation Rata Hartaon Depth in. Dominant Color Munsep RedoxDesciplion Qu. sz. Cont. Color Texture Structure Gr, $Z. Sh. Consistence Boundary Roots GPDfle 'Elfin 'Efl:#2 I -Io z- --. s << 0_5 I Ca • {_ 1�.7�". 191 f II.1 �' .t n l7 � Lt� • � l nn i .1 / / I Wisconsn Department of Commerce SOIL EVALUATION REPORT Page I of _ Division of Safety and Buildings in accord with Comm ub, wis. AGM. 1,000 County 0--? Attach complete site plan on paper not less than 6 1/2 x 11 inches in size. Plan must Include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. (A percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 2 Reviewed b y r "� to 7, f I 0 Please print all inforrnatlon G £��,! /, , f Personal intonnation ou provide maybe used /oc.aecondagtpurpRaBA IPdYarJ(- •V 9 t' ' J Property Owner 7 77 , P party Location GOvt Lot N 114 _ 3k)114 S 3 ZT 2 R 19 E (o W Property Owner's Mailing Address i LCt # Block # Subd. Name or CSM# Sr t i Phone Number City State ZJ ED City ❑ Village ER-Town Nearest Road Code New Construction Use: - Residential 1 Number of bedrooms _ - _L— Code derived design flow rate —� 2� � Q— GPD ❑ Replacement ! / ❑ Public or commercial - Describe: — - - -- TI l Flood Plain elevation if applicable Parent material _— , - - - -- — General comments 0 l� �m e,'��QUn I Q� s 5 / . 2 and recommendations: ` 5K � �,/ 3 a� � a� Pt 2 _ — Zag FF1 Boring nn nh7�� 6l�fi - 7 v •(1VU L1 X- w wvi vw ,.._. — 5 - . •- Boring # � 5 • W ft. Depth to limiting factor _ �,Q -- in. Pit Ground surface elev. _ Soil Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDJft? in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. 'Ef1#1 I 'Eff#2 I 0--? lu 312 Z s t y 2 C S I C 2 -2( ID, 5i cl 2m5b , -Cr cs I v I„ r e 3 s rn I — — / . 2 S 76n e- — — /up )VP Aip 1 pip Effluent #1= BOD > 30 220 mg1L and TSS >30 150 mg/L ' Effluent OZ.= tSUU < Ju mgrL.arra 100 1 ou rrrgrr. CST Name (Please Print) nature - nature - CST Number Address Date Evaluation Conducted Telephone Number 21 \ ' `� - 7 - 2, ° -i 7 �.,02��. Al ( PEI Boring # I] Boring (� Pit Ground surface elev.) ft. Depth to limiting factor - in. Sol Application Rate Horizon Depth. Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW In. Mtmseil Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 I 0 - 10 b Z s t y 2 C S I C .$ z 16 -z5 ►D 5«I cs I„ r S 0-Sq mit Aip 1 pip r . Property Owner " 5 + La k � Parcel ID # Page _ of Boring # U Boring (� / ' ®- Pit Ground surface elev. � ft. Depth to limiting factor VS in. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary in. MunseN Qu. Sz. Cant. Color Gr. Sz Sh. I 0- Z , Si 2 m Nor C Z 0,55 , :5 i c 1 rrr�r cS (05 I S 40 1 Frac I rr, S +on — Roots Sol Applicatiori Rate GPDAF 'Eff#1 'Eff #2 v _` /V 11ijo F-1 Boring # U Boring 11 pit Ground.surface elev. ft. Depth to limiting facbr in. Soy A Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD1fF in. Munsell Qu. Sz. Coact Color Gr. Sz. Sh. 'Eff#1 'Eff#2 F-1 Boring # ❑ Boring Ground surface elev. ft Depth to limiting factor in. ❑ Pit Soy 82&atlon Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/tF in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Efl#1 'Eff#2 Effluent #1 = BOD > 3() 220 m91L and TSS >30:S 150 mgiL . Effluent #2 = B0D 30 m91L 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- 2648777. SBD•9330(R.07/00) F-1 Boring # ❑ Boring Ground surface elev. ft Depth to limiting factor in. ❑ Pit Soy 82&atlon Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/tF in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Efl#1 'Eff#2 Effluent #1 = BOD > 3() 220 m91L and TSS >30:S 150 mgiL . Effluent #2 = B0D 30 m91L 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- 2648777. SBD•9330(R.07/00) Effluent #1 = BOD > 3() 220 m91L and TSS >30:S 150 mgiL . Effluent #2 = B0D 30 m91L 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- 2648777. SBD•9330(R.07/00) Property Owner �! 5� Parcel ID # Page _ L of C a Boring # Boring G T Depth ib limiting factor in. pit Ground surface elev. �� eP g Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsed Qu. Sz. Cont Color Gr. Sz. Sh. '01#1 - Eff#2 Z "---. _ — s i e 1 2r aS < `mfr C's �- 3 l0 I , +110 4 - F-Cac 1 F-I Boring # U Boring ❑ pit iGround.surface elev. ft. Depth to limiting factor )n• Sob Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDf(P In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring F-I Boring # Ground surface elev. ft. Depth to limiting factor in. 1:1 pit Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDNP in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Efl#1 'Eff#2 ' Effluent #1 = BOD > 30:S 220 mg1L and TSS >30 S 150 mgiL ` Effluent #2 = BOD < 30 mglL and TSS < 30 mglL The Department of Commerce is an equal opportunity service provider and employer. if you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608 - 2648777. M- 833MAIMO) Boring F-I Boring # Ground surface elev. ft. Depth to limiting factor in. 1:1 pit Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDNP in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Efl#1 'Eff#2 ' Effluent #1 = BOD > 30:S 220 mg1L and TSS >30 S 150 mgiL ` Effluent #2 = BOD < 30 mglL and TSS < 30 mglL The Department of Commerce is an equal opportunity service provider and employer. if you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608 - 2648777. M- 833MAIMO) ' Effluent #1 = BOD > 30:S 220 mg1L and TSS >30 S 150 mgiL ` Effluent #2 = BOD < 30 mglL and TSS < 30 mglL The Department of Commerce is an equal opportunity service provider and employer. if you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608 - 2648777. M- 833MAIMO) 4 PAGE 3 OF 3 NAME: Wt La .Q,-- LOT# ( LEGAL DESCRIPTION: X1 /4 t J 1 /4,S;�? F,4 — E(or)O LO LLi v-x 1 � r s fi� 4 SIGNATURE: � -- --- DATE: 7 Z 0 3 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer - t (I 1, o Y Mailing Address _._ 2S�( - 7 / /y e . 4A 0 "4f Properly Address _ Y q loan p 0aw -A (Verification required from Planning Department for new City /State Aly-A Ssrn ,,. -c/ i Parcel Identification Number Property Location '/4, ' Sec. , T_N -R \V, Toivn of ©'-1 Subdivision 4> kA5,py- ei l -�s /S c���� - -_, Lot # Certified Survey Map t# , Volume Page !# Warranty Deed # _„ s 3 q 0 , Volume . Page # Spec h ouse ❑ yes 2 no .Lot lines identifiable t: yes ❑ no SYSTEM MAINIMANCE 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, journey nian plumber, restricted plumber or a licensed pumper verifying that (1) the on - site waste%vaterdisposal system is in proper operating condition andor (2) after inspection and pumping (if necessary), the septic tank is less than 113 full of sludge, Ilwe, the undersigned have read the above requirements and agree to maintain, the private sewage disposal system with the standards set fortly, 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 trust be completed and returned to the St. Croix County Zoning Office within 30 da the three year expiration date. I 'It1RE OF.Ap DATE 0NNNFR CERTIF I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) an (arc) the owner of the er dd�osetibed above, by virtue of a %varranty decd rccor led it, Register of Deeds Office. SIGNATURE 6.r LICANT DATA * *'"* Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. • "'s •" Include with this application: a stamped warranty deed frou: the Register of Deeds off a copy of the certified survey map if reference is made in lice warranty deed V Q Q LL O r- N I, C. a_ a. c� CD I c� N / o N i L S 01 °07' 53" E i C14 o ti `s 132.48' 7 Z h�� �.�° �., Ln 3: . _ h / o0 IQ o O N O 00 Ln \\ L L: \ / 00 (/j QU I 00 Ld (XD C 00 d- ih o M \ \ I Ln o N \\ \ \ 1 Q O I O N I co rn N ' O I d- N Og •23'S - S "WJ _ Cf) Ln 8 14 00, C) I w \ = INS ` ,�� � Ln � � Q4 �' 42 ' U O o0 I� N Z � 'I C3 \ / Q 00 4 co Lo Ln i U� 0 0 C\2 n c:) 00i cli CD i i z� I N 00 0. s2 I � i Lo 93.31' 305.73' N 00 0 50'4 W N 01 °1012" W 399.0 WEST LINE OF THE NE � 77' 1/4 OF THE SW 1/4 FiLE IXF L er � . �it ## DESIGN PARAMETERS POWTS OWNER +$ MANUAL & MANAGEMENT PLAN Pace of atla L S YSTEM SPECIFICATIONS Nu of Bedroo C7 al NA Number of Public Facility Units 5�. IVA Estimated fines (avage) _____t_ er � Eff luent Filter Mod �, . - r_ ;a NA 00 gal g Q l7 Design flow (peak), (E x 1.5} _ O ali/ al Soil Application Rate Pump Manufacturer ! T ~ � d monthis) ❑ NA lft Standard Influent /Effluent Quality Monthly average Fats, Oil & Grease (FOG) s30 mg /L a NA Biochemical Oxygen Demand (800 x220 mg /L Q NA _Y Total Suspended Soli (TSS) 5150 mg /L _ ❑ NA Pretreated Effluent Quality Monthly average 12 month( ' - ` O mont) Biochemical Oxygen Demand (800.) 530 mg /L 0 NA Total Suspended Solids ITSS) s30 mg /L Q NA Fe cal Coliforrtt (ge me an) 510" cfu /100ml ❑ NA Maximum Effluent Particle Size ! in dia. Q NA Other: � Q NA "iAlues typical for dornestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE Septic Tank Capacity C7 al O NA $optic Ta Man u f acturer 5�. ❑ NA Effivoril Filter Manufacturer . to t c 4NA Eff luent Filter Mod �, . - r_ ;a NA Pump Tank Capa g Q l7 O NA Dump Tank Manufacturer U3 %e- IS Q- V, ❑ NA Pump Manufacturer ! T ~ � d monthis) ❑ NA Pump Modal i7 NA Pretreatment Unit _ a NA Q Sand /Gravel Filter D Peat Filter Flush laterals and pressure test Q Mophonicei Aeration 0 Watland _ ❑ NA O Risinfecti 0 O ther: 12 month( ' - ` O mont) Qiapersal Collis) 0thor; 0 NA Q in- Ground (gravity) t7 In- Ground (pressurized) Q At -Grade 0 Mound ❑ NA ❑ Drip -Line 0 Other: �ithor:.: "" ❑ NA flier( ❑ NA Other; Q NA Service Evom Service Frequency Inspect condition of tank(s) At least once e ver y mon #h s} Q ye arlsl (Maximum 3 years) C3 NA Pump out contents of tank(s) When eorrbine slu and scum equals one -third I Y 3 ) of tank volume NA inspect dispersal cells) -- - - At least once lever ; _ _ , ❑ month Td years) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: ! T ~ � d monthis) C7 NA JiCyearis) _ inspect pump, pump controls & alarm At least gnce every; ,.__, Q month(s) © year(s) 0 NA Flush laterals and pressure test At least once every; _ �,,, © month(s) ❑ year(s) _ ❑ NA Other:_ At least Dance every; 12 month( ' - ` O mont) 0 NA 0thor; ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be mach by an Individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS )n$R$Ctor; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(e} to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface, The dispersal cell( shall be visually inspected to chock 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 ruthority. When the combined accumulation of sludge and scum in any tank equals one -third (y,�) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Qper4tor and disposed of in accordance with criapter NR 113, Wisconsin, Administrative Code. All othei services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of S12 months, $hall be performed by a certified POWTS Maintainer. 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System start up shall not occur when soil conditions are frozen at the infiltrative surface, During Power outages pump tanks may fill above normal highwAter levels, When power is restored the excess wastewater will be discharged to the dispersal cell(*) in one large dose, dv' Grioadirio the 0611(4) an d may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the puma tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWNTS Msint>Iitier to assist in manually operating the pump cerjtrols to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal coils. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil ebsorbtion area. Reduction or elimination of the following from the Wtt$tewatifr streorn may improve the performance and prolong the life of the POWTS: antibiotics; baby u wipes; cigarette butts; goridOMS, cottprl sW>aba; degreasers; dental floss; diapers; disintprr rants; fat; foundation drain (SUtT A Amp) water; fruit and vegetable , 4011ngf;; ga ebline3; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins, tampons; and waste sditerle�r ktrine, ABANDONMENT When the POWTS fails and /or is permanently taken out of servida the following steps shall be taken to insure that the system is Properly and safely abandoned in compliance with chapter Comm $ 3,33, 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 exciavatepd and removed or their covers removed and the void space filled with soil, gravel or another inert solid material, CONTINGENCY PLAN It the POWTS falls and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: E3 A suitable replacement area has been evaluated And may be utilized for the location of a replacement soil absorption systern. The replacement area should be protected from disturbetntlo and compaction and should not be infringed upon by required setbacks from existing and proposed structure, IOt result in the need for a new soil and site evaluation to rstabllph a su t ble area, Replacem systems mush 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 lest resort 00 * tlplacP the failed POWTS. �a The site snot an evaluated to identify a suitable repiaigee evaluation ent area. Upon failure of the POWTS a sail and site t`1 ation be performed to locate a suitable rspllaCerhont Ares. If no replacement area is available a holding tank ma y b s a last resort to replace the failed POWTS, E3 Mound and at - grade soil absorption systems mey be rA.0Ongt in place following removal of the biomat infiltrative surface. Reconstructions of such systems inu$t bortie(y with the rules in effect at that time. at the < < WARNING > > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAX CONTAIN I.ETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TA,jVK UNDOR ANY CI IGti MS TANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE OOFIMAT'00 IMPQg$IlitE. 4 DOITlONAL _COMMENTS POWTS INSTALLER l rip 8 j TAINER Name i Nom Phone ? / 155 ..� 3 ,9 �, a / Ph SEPTAGE SERVICING OPERATOR (PUMPER) 10M fiiILATORY AUTHORITY Name I Phone ..�� �•, a' :; Phtfne This document was dratted in compliance with chapter Comm 83.22121(b)tUldli&(fl and 93.54(1), (2) & (3), Wisconsin Administrative Code, i ' SEPTIC TANK E FUMIP CHAMBLR CROSS S&CTION AND SPECIFICATIONS 4" Cl VENT PIPE 12" MIN. ABO C;RAI)E WEATHERPROOF ?"25' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE WITH CONDUIT MANHOLE COVER FINISHED GRADE r/ PADLOCK & 4" CI RISER WARNING LABEL 4 " MIN. 18" IN. 6" MAX. •�l NLET rl ` WATER TIGHT SEALS GAS- A TIGHT + t� SEAL ► APPROVED JOINTS APPROVED ---- ; ALM APPROVED 'IPE 3' B ' ON 3' ONTO )NTO SOLID '" 1 SOLID SOIL SOIL i PUMP OFF ELEV. F OFF RISER EXIT PERMITTED ONLY IF TANK MANUFACTURER HAS APPROVAL: 3" APPROVED BEARING UNDER TANK CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE T ."ANK MANUFACTURER: NUMBER DOSES PER DAY: TANK SIZES SEPTIC I'k, 0 GAL. DOS& VO LUME INCLUDING DOSE GAL. FLOWBACK: 19 GAL. ALARM MANUFACTURER: ���S t� CAPACITIES: INCHES s g62L GAL. MODEL NUMBER: p SWITCH TYPE: TVN&0.& B = 2 INCHES - GAL. PUMP MANUFACTURER: G C = INCHES = GAL. MODEL NU14BER : � d SWITCH TYPE: D - INCHES = _j_k GAL. REAL "IRED DISCHARGE RATE y� GPM PUMA' & ALARM WIRING AS PER ILHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE . Ioz. FEET } MINIMUM NETWORK SUPPLY PRESSURE 2.5 FEET + FEET F ORCEMAIN X A.66 /1010 Fi. FRICTION FACTOR . FEET / T.OTAL DYNA MIC HEAD = FEET IN T ERNAL DIMENSIONS OF PUMP TANK: LENGTH .✓ ; WIDTH �--�' DIAMETER ---� LIQUID =FTH - 3 B "" Q I Cr p rz ! IGNED. _ ''�-- LICENSE NUMBER' a, 2 qq la LATE 1./88 '-dge _L or C�� z 2 ,- �� C T Lc ( N R /! E Nearest Road Now Construction use: ® Residendd 1 Number of bedrooms 0 Replacement Public or conxriercial -Describe; Code derived design now rate ` (y _ GPD ( ❑ Parent material _ (�U -h �•.J tis 1� / I 1 Road General Cortxne Plain elevation if applicable !� - — i - - -- � P.ti. recommendations: 0 Boring L - t * ® Pit Ground surface elov . !? fi. d7antFf to fimiHrav fnNv r`� �.. Horizon RECEIVED Dominant Color Munson Division ofSa sty a d Buildings r . S9�(9 t"TION REPORT a in a Attach complete site Plan an paper not less than a i indude, but not limited to: vertical and horizontal with Comm 85, Wis. Adm. Cod x i i�PI�rYust County ref nce Percent slope, scale or dimensions, north arrow, and location ISt to Pace! 1 .p. area d. PJ"S6 PI/Al 8/1 IffAm l e6c... Reviewed by PsnonN ink motion you provide may be used for seoondsry purposes (Priv —' / S 7rt roperly Location Z6 - & HMaWV " " P ress Govt, Lot 4/ F 114 1/4 S ?j Lot # 81&4* # Su bd. Name or State ro Cnde r O City 0M lope ® Town '-dge _L or C�� z 2 ,- �� C T Lc ( N R /! E Nearest Road Now Construction use: ® Residendd 1 Number of bedrooms 0 Replacement Public or conxriercial -Describe; Code derived design now rate ` (y _ GPD ( ❑ Parent material _ (�U -h �•.J tis 1� / I 1 Road General Cortxne Plain elevation if applicable !� - — i - - -- � P.ti. recommendations: 0 Boring L - t * ® Pit Ground surface elov . !? fi. d7antFf to fimiHrav fnNv r`� �.. Horizon Depth in. Dominant Color Munson Redox Description Qu. Sz. Cont. Color Texture Structure Consistence Botxdary Roots Gr. Sz. Sh. Ication Rate Gppfft' 'Eff#i I 'Eff#2 0 - 1z- Z6 - & u , 3 • CA6.er JlA .. nra... Soft # u Ong ® Pit Ground surface elev- 77 t D ft r% .Jk 4,. R...:. __ Horizon Depth in. Dominant Color Muned Redox Desctipfion Qu. Sz. Cont. Color Texture Structure Consistence Boundary Roots Gr. Sz. Sh. Soil icsdott Rate GPDIft= `Efti *Sff#2 0 - 1z- Z6 - & u , 3 • CA6.er JlA .. nra... -QU Z I rnan. - emuers rR = BW < 30 mgR and TSS < 30 rrrglL CST Name (Pisses print), .4 130 CST Number Addrm 833a9 Date Evaluation Conducted Telephone Number 11-5 - -o 7 7�S 7100 -oz 9 l Property Owner �cl { S /a l Parcel 4D # / y ❑ Boring ® Pit Giround surface elev. l ?r Page Z d 3 w.. F SMng # 0 BO& - I M # (D Bonng ' Effluent #1 a BOD, > 30 1220 nigh. and TSS 40 1150 nigh.. . Eftw t #2 a BOD, 130 nV& and TSS ! 30 ffV& 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. 38oat30 (L6w) /' �.�1� AMY+ In. C) wVlr7W Niy „ -_ r�� � �.t �” Munseq 1 313 p��� ^_ IWWX YcS n Gu. S7- Cont. Color Texture >, l xe Stnrcp Consistence Boundary Roots Gr. Sz. 5h. m k t vlr k c i C � p� fWte GPD/!!t t:tT#1 Eft#2 , S, (- , 5 M 7 5— .Z F SMng # 0 BO& - I M # (D Bonng ' Effluent #1 a BOD, > 30 1220 nigh. and TSS 40 1150 nigh.. . Eftw t #2 a BOD, 130 nV& and TSS ! 30 ffV& 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. 38oat30 (L6w) ' N. w -es� /a t -e F AGS E �� i �roNc� /�Sw� /s 'zTZq NR 9 SCALKS !" a _go � HM 1 KLKVAYION 7 am ! DESCRIPTION 0 � !- ;�Jnr�ck �•� BM 2 RLKVAYiON BM 2 DESCRIPTION SYSTEM 1RLEVAT'10 C L l 6o - ea✓ 4- �r SysTam TYPE O&A U� +..? �`..` �. -..�.. SI GNATURE DArE a: [4GOULDS PUMPS APPUCA71ONS Specifically designed for the fo"ing uses: • Effluent systems • Homes • Farms • Heavy duty sump • Water transfer • Dewatering SPECIFICATIONS • Solids handling capability: 1 /0 maximum. • Capacities: up to 60 GPM. • Total heads: up to 31 feet • Discharge size: V/2" NPT. • Mechanical seal: carbon - rotary /ceramic- stationary, BUNA -N elastomers. • Temperature: 104% (40'aCj continuous 1401(60°C) intermittent. • Fasteners: 300 series stainless steel. • Capable of running dry without damage to components. Motor: • EPO4 Sin phase: 0.4 HP, 115 or 230 V. 60 Hz, 1550 RPM, built in overload with automatic reset. • EP05 Single phase: 0.5 HP, 115 V, 60 hz,1550 RPM, built in overload with automatic reset. • Power tarp: 10 foot standard length, 16/3 SJTOW with three prong grounding plug. Optional 20 foot length, 16/3 SAW with three prong grounding plug (standard on EPOS). 0 2000 Goulds Pumps Eftestive Pebruary, 2000 63871 • Fully submerged in high grade turbine 09 for lubrication and efficient heat transfer, Available for sutamatic and awmi operation. Auto- mAk rnodlels include MedwicM Rw Switch assembled and Ixeset at the factohf. FEATURSS ■ EPO4 Impeller: Thermoplas- tic Semi -open design with pump out vanes for mechanical seal protection. a 5 4 3 2 1 Submersible Effluent Pump 3871 E�5 ® EKIS Impeller: Thermoplas- tic endosed design for improved performance. a>I Casing and Ease: Rugged thermoplastic design provides superior strength and corrosion resistance, ■ Motor Housing: Cast iron for efficient heat transfer, strength, and durability. ■ Motor Cover. Thermoplastk cover with integral handle and float switch attachment points. ■ Power Cable: Severe duty rated oil and water resistant. ■ Bearings: Upper and lower heavy duty ball Daring construction. AGENCY LISTING 9 . caneda stai"ds AMOdom (CSA listed model numbers end in "F" or "C ".) Goulds Pumps h ISO 901 hosand. " o 10 0 2 0 A GPM 6 8 10 12 "Wh cAwatlty Go ulds Pumps <& ITTfndustries 1 3q 40 5 v 4 State Bar of Wisconsin Form 1 -2003 WARRANTY DEED Document Number 11 Document Name THIS DEED, made between West Lake Builders, Inc., a Wisconsin Corporation ( "Grantor," whether one or more), and Stian R. Mianger and Michelle R. Semborski ( "Grantee," whether one or more). Grantor, for a valuable consideration, conveys to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ( "Property") (if more space is needed, please attach addendum): Lot 28, Plat of Windsor Heights I" Addition in the Town of Hudson, St. Croix County, Wisconsin 020 - 1448 -28-000 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except: Easements, restrictions and rights -of -way of record, if any. Dated November 17, 2006 West Lake Builders, Inc. (SEAL) - (SEAL) (SEAL) ,, , e k,�, (SEAL) AUTHENTICATION Signature(s) 1 1 authenticated on J TITLE: MEMBER STATE BAR OF WISCONSIN ACKNOWLEDGMENT STATE OF WISCONSIN ) ) ss. St. Croix COUNTY ) Personally came ore me on November 17 2006 the above- name A fn. (If not, authorized by Wis. Stat. § 706.06) THIS INSTRUMENT DRAFTED BY: 83<32t88 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., MI RECEIVED FOR RECORD 11/20/2006 10:15AN WARRANTY DEED EXEMPT # REC FEE: 11.00 TRANS FEE: 419.70 COPY FEE: CC FEE: PAGES: 1 Recording Area Name and Return Address River Valley Abstract & Title, Inc. 1200 Hosford Street, Suite 201 Hudson, WI 54016 File #: 2691941 s) who executed the foregoing the same. Attorney Doug Berg Notary Public, S t of Wisconsin 1200 Hosford Street Suite 201 Hudson W154016 My Commission is permanent) (expires: (Signatures may be authenticated or aclmowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED ® 2003 STATE BAR OF WISCONSIN FORM NO. 1 -2003 • Type name below signatures. 1of1 Y A WINDSOR HEIGHTS IST ADDITION LEGEND LOCAIEO IN PART OF THE SOUTHEAST 1/4 OF THE NORTHWEST 1/4 AND IN PART OF THE NORTHEAST 1/4 OF THE SCIITHWEST 1/4 OF SECIICN PTOPOUpOWWW1A � 32, TOWNSHIP 29 NORTH, RANGE 19 WEST, TOWN OF HUDSON, ST, CROIA ,aArroNs as COUNTY, INSCONSIN. — — — — pM11WIG kRAI%s DRAINAGE WEVENT Al �'', LOCATION P =No -_ - -__ IV V%ITf [AUNT (UNLESS OTHERW NOTED) port# 170995 1m E (NOT TO SCALE) � INw N 11 ' Al BEARINGS ARE REFERENCED TO THE —.. _ _ DaANAa EASENENrs Rf17R19low SECTION 3z f1WA R19W U 1944 , N g4Y W NORTH -SOUTH 1/4 LINE OF SECTON 31 T29N, R19W, StCROUCI WIL us xWRSrArt a k MIA — i °R o L4 1190 s Inr�' W ASSUMED AS S 0055'16' E mm ■w LBO • IOYFSt RUNS DPW i All BUILDINGS 10 BE CONSTRUCTED IN PROMIHn 99r i NR WTH DRAINAGE EASEMENTS SHALL HAVE A HNI FLOOR OR WINDOW WELL ELEVATION NOT LESS A HIRE • 0 WATER ELEVATOR F, %0 SETBACKS. TWD FEET ABOVE THE HIGH WATER ELEVAO SH O 1 PaNO hod FRUIT . 50' (WlfSS OTNRWSE NOTED) SIX . 12, REAR - :s D op GENERAL NOTICE STATEMENT ' ll' NOR PPE 9om SR SE I NU •=E POUND EACH PARCEL SHOWN ON T NAP (PLAT) 15 SUB.fCI TO \ 1 X0.18 7' 4UMNUY SwE, �UNIV, AND TOWNSHIP LAWS, RULES. AND FIAT LOCATION ETC.) ANY f0 N 1/1 CDR, SEC. 72 � COUNT WUWM[NI PARCEL, BEFORE MUN I OOR L AND CONTACT THE ST ' ROC Put I aFla AND APPROPRIATE TOWN BOARD FOR ADVICE. BURN ISEN CAP III 41n L�S,M I lr � 77' I 0 z 13 WNDSOR HEIGHTS 5 L SET OAT' BY If WON PIN 14 N 96'46'25" E 650.J0' 7 RA Ir WI 50 IBs./TT T . N 584.30' U I 0 AT ILL OTHER LOT CDR" U, 0 R A= RECORD(D AS 7.07' £RJR WINDSOR HF SH 28 /! "0 16 - -" -— 6 ym DRAINAGE EASEMENT NOTE: J, PG 8 °. 29 48699 SF. 44631 S 6 1 12 Ac 0 -W N 89'1105" E 672.89 WNPoPm nog WP " �' �{ �' NO OWNER OR RESIDENT SHALL DO ANYINNG WIN OR CHANCE THE 102 Ac m 613.56 WHICH WOULD INTERFERE L AWE 62 I TIVi ON OF 'HE APPROVED COMPREN OPERAB ENSK WATER OauNAfd AND SOIL ER09OV PLAN FOR �. = � L 34 .I •Nn la 35 u WVln Nl�, Z - THIS PLAT. THIS INCLUDES BUT Is NOT LIMITED TO BGILDRIG UPON, OBSTRUCTING, z _ _ ,� N 155 W 1567 'a $ 50621 S.F. 77„ 5 SF 1' �, A ALTERING, FILLPICi, OR EXCAVANIC DR T p , I COBB S S TONE � � � -� .Y +' A �; PLANNNG N ANY POND EASEMENTS. WATER IT z - � 1.16 Ac. i COURT 5 1,33 AC. 0 z �' — — — DRAINAGE OITCHES, WATER RUNWAYS, WATER 0 30 P� ` '� BO = 64 U - 3 9 a CULVERTS' BERMS OR GRASS SEECNIGS. I° ;; aSaaT s F \ _ — 11r — L — -- — 710.A7' -- — 6e' ° UTILITY EASEMENT: Y g•k' 1.05 Ac. --- nzx - -- - -- -wan— LAUD u o A c ,' / ' j \ PP•; Y H sOOI'w' 32 `4. z 554.0 -- 5. = N : °, NO POLE OR 6UNIED CABLES ARE 10 BE PLACED SUCH THAT THE INSTALLATION WOULD V) ; . W 1 9' a 3 64880 S.F. 1 ' 1 � \ 33 38 oa u ? , , q TII u c ON DISTURB ANY SURVEY STAKE, OR OBSTRUCT ^,0 ,(/ 3I g \ 50526 S.F. Lag Ac 45927 S.F g 4 m It nAON A4DAC ANY LOT L OR STREET LANE, m � F $ . . 5° 45708 $.. S, 6 Ac. • y ' .c. d77I 6 ' DS A ls' a �� THE DISTURBANCE OF A SURVEY S1AK. BY ANYONE CS A VIOLATION OF SECTION 236.32 a -; CS Ac. W ^. LIM a' Ill E1' Of MSCCHSLN STATE STATUTES. EASEMENTS AS HEREIN SET FORTH ARE FOR 7BS.SA 1278 15 , THE USE OF PUBLIC BODIES AND U PRIVAIE/PUBUC JNUIIES HAVING A RIGHT 10 S 88'580 W 1322.0 CITY OF HUDSON c SERVE THE AREA UNPIAiTED LANDS RA =s 89'40'10" w 1313.80' N lYllerdjsW�Y 9Y IPWIwM CS � sa ix B, T741A 174A r lwl D) r (lt WI kE. 17 POUND I' STEEL SHEET 1 OF 2 ct l 8ERNtSE8 CAP DRAFTED BY, HEWN SAMUEL HUNMREY ENGINEERING