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HomeMy WebLinkAbout022-1020-70-020 Wisconsin Department of Commerce ; County: ' safety and Building Division PRIVATE SEWAGE SYSTEM St. Croix • 4 INSPECTION REPORT Sanitary Permit No: 405142 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) Permit Holder's Name: City Village X Township Parcel Tax No: Jotblad, John & Jana Kinnickinnic Township 022 - 1020 -70 -020 CST BM Elev: Insp. BM Elev: BM Description: l / 01-/_ q Q /► d� TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic OD a Benchmark � (O Dosing Alt. M Aeration .�l _ Bldg. Sewer `0 S Holding S t Inlet S �� St/Ht Outlet TANK SETBACK INFORMATION r TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic > Dt o r m e I ZS Zr Dosing J Z }/^ Hea r /Man 0 0 Aeration Dist. Pipe Holding Bot. System 2 - 7 Fin I G rade PUMP /SIPHON INFORMATION � r „ �,� ;r,� , l n--A t S le Manufacturer Demand - 7/ t Cover LLD S GPM �• / 6S U Model Number Ea � H 3 '� I 2 . 3 (0 1 . TDH Lif� Friction Lo System Held TDH I Ft Forcemain j Lenqtb,./ Dia. �/ Dist. to W ll N6, SOIL ABSORPTION SYSTEM BEDIT SIONS Width Length No. 0 Trenches PIT DIMENSIONS No. Of Inside Dia. DIM Liquid Depth ENSIONS & SETBACK SYSTEM TO P/L BLDG IWE LL / LAKE /STREAM L C G Manufacturer: INFORMATION Type Of System: CHA R OR ,- ^ j f , Model Number: DISTRIBUTION_ Header /Manifold I D istribution x Hole Size x Hole Spacing to Air In ke Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center I ' ngA/ Bed/Trench Edges Topsoil Yes No [*] Yes >i No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: " 1 / / 0 y Inspection #2: — 7/_ // 0 2 - - Location: 459 County Road SS River Falls, WI 54022 (SW 1/4 NW 1/4 8 T28N R11 8W) NA Lot 1 Parcel No: 08.28.18.119A20 1.) Alt BM Description = S r 2.) Bldg sewer length = Z. l - amount of cover = a 3.) Contour= ' O 2 Plan revision Required? � Yes o a r Use other side for additional information. 1 G�N'L� �//✓!!l�Yt _ __ Date Insepctor•s ignature Cert. No. SBD -6710 (R.3/97) f Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 ST. CROIX I��O�S,n Madison, WI 53707 - 7162 Site Address Department of Commerce G-iv — ��`�� �" • K SS Sanitary Permit Application"" P �s�1z In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ❑ Check if Revision may be used for secondary purpos s P riv acy I. Application Information -Please Print All orma State Plan LD. Number SIT E# 644844` TRAN ID I 644884 �SZ Property Owner's Name MAY 2 4 2002 Parcel Number 1 9. Z13- 18 (( k-2 JOHN & JANA JOTBLAD o22 I ZO- - o;w Property Owner's Mailing Address T. IX 9 2Subdiv Nion Property Location ZONING OFFICE 7318 157TH STREET W SW w NW !i•S 8 T 28 N R18W City, State Zip Code Phone NumbeLot her BlockNttmber APPLE VALLEY MN 55124 651/645 me Na CSMNW W CSM 647126 v, tS� 4ibZ II. Type of Building (check all that apply) �S �ya! �..,, h�t°e s. ❑City 1 or 2 Family Dwelling - Number of Bedrooms 3 ❑Village ❑ Public /Commerci - Describe Use [Township KINNICKINNIC ❑ State Owned f 102 Si) Nearest Road Y_ fo S , COULEE TRAIL M. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B 1f applicable) A For County use 1 ❑ New 2 ❑ Replacement System 3 11 Replacement of FExisdng ddition System Tank Only Syste B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date lssued ]v. Type of Permit: (Check all that apply) (numbering scheme is for internal rise) � - ' t� 44 11 Non - Pressurized In- Ground 2113 Mound 47 ❑ Sand Filter SO ❑ Constructed Wetland 22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line 45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other V. Dispersal/Treatment Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate r104.25 ystem Elevation 4 � Final Grade Required Proposed6. }, \ Rate (Gals. /Days/Sq.Ft.) (Min./Inch) Elevation 450 430 450 J �l.o� N/A 106.05:..; VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber I Pb$dc Gallons Gallons of Tanks Concrete Constructed Glatst New Existing Tanks Tanks Septic or Holding Tank 1000 . 1000 1 W E CONCRETE X Dosing Chamber 600 1 600 1 1 IWIESER CONCRETE X VII. Resp onsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached Plumber's Name (Print) Plumber's SIgnature MP/MPRS Number Buslaess Phone Number BENNIE HELGESON 20292 715/772 -3278 Plumber's Address (Street, City, State, tp Code) W1229 770TH AVENUE, SPRING VALLEY WI 54767 VIII. County /De artment Use Onl Sanitay Permit Fee (includes Groundwater Date Issued Issuing Agent Sigoa0lrtt (NO Pproved ❑ Disapproved y Surcharge) coo ❑ Owner Given Initial Adverse • 3ZS o} ?1)D ` Determination IX. Conditions of Approval/Reasons for Disapproval Attu complete Plana (to the County only) for the :stem on paper not less than 81/1 =11 !aches In she eRn -61 (R. 05101) _ t o d 0 n I A eri I• 4 O IL r jV C 4 � _ 3 CC fi A ,-W ° F �� k V" Oki rh G n c yt 3 , 3 b 1 0 G n y Safety and Buildings 4003 N KINNEY COULEE RD LA CROSSE WI 54601 -1831 TDD #: (608) 264 -8777 �se www.w onsin w ww.commerce.state.wi.us/sb isconin.gov Department of Commerce Scott McCallum, Governor Philip Edw. Albert, Secretary May 20, 2002 CUST ID No.220292 A777V: POW7S Inspector BENNIE W HELGESON ZONING OFFICE HELGESON EXCAVATING ST CROIX COUNTY SPIA W1229 770TH AVE 1101 CARMICHAEL RD SPRING VALLEY WI 54767 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 05/20/2004 Identification bets Transaction ID N<1 5211 SITE• Site ID No. 644884 John & Jana Jotblad Please refer to both identification numbers, Coulee Trail above, in all correspondence with the agency. Town of Kinnickinnic St Croix County SW 1/4, NW1A, S8, T28N, R18W FOR: Description: Proposed Three Bedroom Mound System Object Type: POWT System Regulated Object ID No.: 852251 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: General Approval Conditions: • This system is to be constructed and located in accordance with the enclosed approved plans and with the "Mound Component Manual for Septic Tank Effluent for Private Onsite Wastewater Systems" SBD- 10572 -P (R 6/99) and the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems SBD - 10573 -P (R 6/99). • 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. Stats. • 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(1)(a) - 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 witfteo19rtanagement plan or as required under s. Comm 83.54(4) shall be considered a human h ovally APPROVED 3 DEPARTMENT OF Cnuueare BENNIE W HELGESON Page 2 5/20/02 Owner Responsibilities Continued: • The owner is responsible for submitting a maintenance verification report per Comm 83.55, that is acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. 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 Gerard M. Swim POWTS Plan Reviewer - Integrated Services (608)- 789 -7892, Mon. - Fri. 7:30 am to 4:15 pm WiSMART code: 7633 jswim@commerce.state.wi.us cc: Leroy G Jansky , Wastewater Specialist, (715) 726 -2544 INDEX SHEET � PROPERTY OWNER: JOHN & JANA JOTBLAD 7318 157TH STREET W APPLE VALLEY, MN 55124 a �y PROJECT NAME: JOHN & JANA JOTBLAD PROJECT LOCATION: SW 1/4, NW 1/4, S 8, T 28 N, R 18 W MUNICIPALITY: TOWN OF KINNICKINNIC COUNTY: ST CROIX DESIGN: PRESSURE DISTRIBUTION MANUAL SBD- 10573- P(R/99) MOUND COMPONENT MANUAL SBD- 10572 -P (R 6/99) CONTENTS: Page 1: Plot Plan Page 2: Cross Section and Plan View of Mound Page 3: Distribution Pipe Layout Page 4: Septic Tank & Pump Chamber Cross Section & Specifications Page 5 WLP 1000/600 - MR ZABLE Tank Specifications Page 6 Pump Specifications Page 7 POWTS Owner's Manual & Management Plan - Pg. 1 Page 8 POWTS Owner's Manual & Management Plan - Pg. 2 Name: Bennie Helgeson Signed Address: W1229 770th Avenue Spring Valley, WI 54767 Credential Number: 220292 Date: May 16, 2002 U VISWN Of SAE 7Y A D DINGS SE CORRESPO NGE 9' — m � LL �► r QQk d r / � Q o d Cr � t �- e- a O 4 C l d ��t (, r! Q N ^ ^Q 4 + �1 0 f Page — -- Synthetic Covering r Distribut P ASTA C 33 Sand Topsoil -- H G 'ev, / P � o 3 E . „ E ke, low, Slope ----� CELL Of 2�_ 2 I Main Plowed Aggregate Layer 0 7SFt. E a Cross Section Of A Mound F _ Ft. G Ft. A 7 Ft. H -- Ft. Signed: g Ft. License Number: K . _ Ft. L R7• z Ft. Date: Ft. Position I a_ Ft. of W ��. Ft. Force Main Observation Pipe K F F O - -------- - - - - -- --------------- - -- o r- --------- ____ -- -- ..---- .- - - -- ----- - - --.� Distribution ELL Of '-,"-2 2 Pipe Aggregate I „ Observation Pipe TuFm - Plan View Of Mound A ct�5`✓ Perfor0ted Pipe 081011 C If1k,4ell) .c ! End Vlew Perloroled o``o PVC Pipe e �eAh 0�-+ -� a Holes Located on Bottom >'• are Equally Spaced Q PVC Force •Mole From Pump e rr � P PVC ✓ / Manifold Pipe e fE'G��CKJJ -"a Oitlrlbutlon..• Pipe Distribution Pipe Lay P R S — L L X .a Y Hole Diameter Inch Signed: •' •• Lateral Inch (es) License Number: Manifold Inches Date: �� Force Main Inches j vU LIE 9,* f5i�eo. /oy �10 t 'Pet- � q / c •c. � = � I ! / X 1 74 Page 4 Of SEPTIC TANK !; PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS 4" CI VENT PIPE 12" MIN. ABOVE GRADE E WEATHERPROOF JUNCTION BOX APPROVED 25' FROM DOOR, WINDOW OR WITH CONDUIT MANHOLE COVER FRESH AIR INTAKE W/ PADLOCK E WARNING LABEL FINISHED GRADE 4" MIN. „ 2 y y "c.-L. Qe6ePVA S.D. u �� IN. ��� 18 WHIN• 18 PIPE ' INLET GAS - WATER TIGHT SEALS TIGHT s /APPROVED A SEAL JOINTS WITH F1�7ER _I � ALM APPROVED PIPE APPROVED 2A $1E 1- B ON 3' ONTO PIPE 3' p Ox►6" — F — ' , SOLID SOIL ONTO SOLID C I ' FT. -- OFF SOIL PUMP OFF ELEV . 91,� D 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS L / i r T � l dl •C 1rtt� ' SEPTIC / DOSE , ? X TANK MANUFACTURER: U)1CST" . TANK SIZES: SEPTIC p0� GAL. DOS ��OLUME FLO BACK y GAL. DOSE e)0 � Se I TI ES : A =_ INCHES = - Dl. 6K GAL. ALARM MANUFACTURER: <• r. �� t MODEL NUMBER: B = 2 INCHES = 33,5 - GAL. SWITCH TYPE: � ,.Q C = _� INCHES = PUMP MANUFACTURER GOs "� D MODEL NUMBER • �Ib D _ Z12 INCHES = 1� . GAL SWITCH TYPE: RED DISCHARGE RATE' a PM PUMP & ALARM WIRING AS PER ILHR 23 W AC�� REQUIRED � 2 ` FEET r VERTICAL DIFFERENCE BETWEEN PUMP OFF AND •DISTRIBUTION PIPE • / F EET + MINIMUM NETWORK SUPPLY PRESSURE FEET -7,41 + ia�' FEET FORCEMAIN X 3.3 FT /100 FT OTALIDYNAMICAHEAD - ET • WIDTH DIAM R INTERNAL DIMENSIONS OF PUMP TANK: /LIQ �1?e Src UID 5rPTIT '3C- _ A / / x� IA t S c- , /min �C �e C • �� 7 �o 6 SIGNED : LICENSE NUMBER: DATE: 1/88 o 56" N 39" p 84" m � L 4I •I , z< I / • ' f� I -- 1 ( , I • � 1 � I 1 I � t N n ,rmr G is i i a u m 3.. 48 5" I 'I , I w ' z p ` 42" m z o z Z O c m l Z ^ ot:> OmO- �I�DOODfn N y rnOp �O Q 2 ZC =I�G r — pp' p Z� m � m r? rte.. cn Z 7 m ngm � x D I D -I v or z a o v J my I�mm -�+ (o L4 cn m I ti �� mm D$ ��p o. v 4 mI� 00 C/) Z p p m ' N N V:2 O � U — U 1 D �- C -1 r0 p o m O UuU zz D m� 0 En � z� O cn vv mrn Z � A W Z � � r Crn 0 co N Z m p C 1 � z � i NONE No NONE ENE EMOMME M 0 No ONE MEN NNE No NNE ONE MEN MEN ME mom an mom N No ME -No ENO BRENNEN ON MENOMINEE ONE �\m���������� No ■ONES \������■ NOON No MEN mom No ME NONE No MEN MEN mom mom ONE mmm=m= OMEN mom El o ��mommom MINME POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 7 of 8 FILE INFORMATION SYSTEM SPECIFICATIONS [4 owner JOHN & JANA JOTBLAD Septic Tank Capacity 1000 al ❑ NA it# Septic Tank Manufacturer WIESER CONCRETE ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ZABEL ❑ NA Number of Bedrooms 3 ❑ NA Effluent Filter Model A -100 12" X169 ❑ NA Number of Commercial Units 112 NA Pump Tank Capacity 600 a l ❑ NA Estimated flow (average) 300 gal/day Pump Tank Manufacturer WIESER CONCRETE ❑ NA Design flow (peak), (Estimated x 1.5) 450 gal/day . Pump Manufacturer GOULDS PUMPS IN® NA Soli Application Rate aVda /ftz Pump Model 3885 ❑ NA Influent/Effluent Quality Monthly average* Pretreatment Unit ® NA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑Peat Filter Biochemical Oxygen Demand (BODJ 5220 mg/L ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L [3 Disinfection ❑Other. Manufacturer Pretreated Effluent Quality ❑ NA Monthly average" Dispersal Cell(s) Biochemical Oxygen Demand (BOD 530 mg/L ❑ In -ground (gravity) ❑ In -ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ At -grade ® Mound' Fecal Coliform (geometric mean) 510 cfu /100m1 ❑ Drip-line ❑ Other Maximum Effluent Particle Size Y. Inch diameter • Values typical for domestic (non- commerclal) wastewater and septic tank effluent. *+ Values typical for pretreated wastewater. MAINTENANCE SCHEDULE 1 Service Event. Service Frequency Inspect condition of tank(s) At least once every 2 ❑ months 12 year(s) (Maximum 3 yrs.) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y) of tank volume Inspect dispersal ceil(s) At least once every 2 ❑ months Q year(s) (Maximum 3 yrs.) Clean effluent filter At least once every 1 ❑ months IR year(s) Inspect•pump, pump controls & alarm At least once every 1 ❑ months ER year(s) ❑ NA Flush laterals and pr essure te st At least once every 3 ❑ months Qtyear(s) ❑ NA other: At least once every ❑ months ❑ year(s) ❑ NA other: At least once every ❑ months ❑ year(s) ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer, Septage Servicing Operator. Tank inspections must Include a visual inspection of the tank(s) to identify any missing or broken hardware, Identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels In the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When tie combined accumulation of sludge and scum in any tank equals one -third (Y) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatipment components; and any other maintenance or monitoring at intervals of 12 months or less 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. START UP AND OPERATION. For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may Impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. OWNERS: JOHN & JANA JOTBLAD Page of _ System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power Is restored the excess wastewater will be discharged to the dispersal cell(s) In one. large dose, overloading the cell(s) and may result In the backup or surface discharge of effluent To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. • " Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts, condoms; cotton swabs; degreasers; dental floss ;'diapers; disinfectants; fat; foundation drain (sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMMENT When the POWTS falls 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 ch. 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" b a removed and properly disposed of by a Septage Servicing Operator. • Alter 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. IN Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. « WARNING>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name HELGESON EXCAVATION INC Name Phone 715/772 -3278 -Phone 715/273 -5811 SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY- Name JOHNSON SANITATION Agency ST CROIX COUNT ZONING Phone 715/273 -5811 Phone 715/386 -4680 This document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies. This document meets the minimum requirements of ch. Comm 83.22(2)(b)(1)(d) &(n and 83.54(1), (2) & (3), Wisconsin Administrative Code. Use of this document does not guarantee the performance of the POWTS. GMW (2/01) I 9d s /OLii o t Wiscon,n Department of Commerce SOIL EVALUATION REPORT Page � of WNW f Safety and Buildings r in accordance with Comm 85, Wis. Adm. Code County l , el Attach complete site plan on paper notjess than 8 1/2 x 11 inches in size. Plan must � �X include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. 'PQVD)iU G percent slope, scale or dimensions, north arrow, and location and distance to nearest road. f print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location GG" - LQL S LJ 1/4 MW 1/4 S 8 T ZF$ N R E (or W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# City State Zip Code Phone Number ❑ City [] Village 2] Town Nearest Road ST. -?i'cUL I F I S - 13 1 (6i.Z) - 7 Z3 -)08? x—"11 M1Ct- !KJIV I 2 �)U L 'MAIL ®, New Construction Use: ® Residential / Number of bedrooms L 4 Code derived design flow rate %'" GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material _ G LPrC_ 1, PrL - Tt UL Flood Plain elevation if applica 6 General comments and recommendations: w'lUV K.N�) 'X N I A.l U r 0E- SArP� FILL Boring IT] Boring # . ® pit Ground surface elev. 1 p , 0 ft. Depth to limiting factor L i Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD 1ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 IQ't 2 - b 1 z - s i I z+% 6 r Z '1 -tS 10K2 3Ib s1 + Z `�Sb 1 Z Wt �r �°� — 5 43 3 �S �q-�.SK �t.cu z•s gl� L O � m�i. - . . Boring # ❑ Boring ® pit Ground surface elev. fL Depth to limiting factor 1 _7 L in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 �l z _ S i I 2-4-s S )` I Z- sb 3 3 - 1.5 -1fL L/2 s L • 5 r- • Effluent #1 = SOD > 30 < 220 mg/L and TSS >30 _< 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Si natu CST Number Arthur L:. tJegerer t O�`59 ^ C 220254 Address iJ e g e r e r Soil T e s t i n & Design Service ate Evaluation Conducted Telephone Number 421 N. 1-iain St. River Falls, WI 54022 715 -425 -0165 1 Property Owner L —� Z ar I I -P � 11U �- � -� P ce D# G Z 3 Page of Boring # ❑ Boring ® Pit Ground surface elev. 103 • ft. Depth to limiting factor Z� in. • " Soil Application Rate I orizon ' Depth Dofnihanf Colot edox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •E ff#1 Eff#2 D_7 1 u VL. 31Z S! I Z3 , SY23 /1 'FlF – ) -Sc-i2 S /£1 1; owl i Boring # ❑ Boring ® Pit Ground surface elev. �•9 ft. Depth to limiting factor ! g in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 1 -g \oLt rZ 3 t Z si l Z`P blc, vn - FI C-5 L -S .5 g -1 �u�t li �! 6 - s i J 2`P 3 b►� »i `Pl`F7•S'-225 /Z 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 GPD/ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 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. sso.9330 (RUB) ' PLOT PLAN Page 3 of 3 , , Scale 1'= r Cyv�o v2 EZ, t u Zs N 0 0 1g,• I / I 01 /! t OT Qi Z)VsTU\z-3 s � V) OM 3Z �s 0 • �o 3 a r $�C L L Ud, (7� C 1 1" lRU�1 PIPE -- bF pN CUU T1Z.Pr L - 715- 425 -0165 220254 CST Signature Date Telephone Ilo. CST No. Job NO. EROSION CONTROL PLAN COMMENTS: For Lot 1, County Rd. SS, Kinnickinnic Twp. Plan submitted by Rock Creek Excavating Use of sediment barriers, such as silt fence is indicated along the north, east and a portion of the south property lines. The main source for construction site runoff will be the house foundation excavation and any soil stockpiles until final grading and stabilization is completed. Contain or divert runoff away from adjacent properties by installing either silt fence or a temporary earthen berm ALONG CONTOURS on the east and north side of construction activity, but doesn't appear necessary on the south side. Maintain existing vegetation between house excavation and County Rd. SS drainage ditch, which is >150 ft. from construction work. Have construction equipment and vehicles use only one stabilized driveway access that is designed for heavy equipment; this will avoid muddy, rutted conditions that allow contaminated runoff into the road ditch. If excavator grades the site to create berms as recommended to contain sediment and adequate distance /vegetation between work area and road ditch, installation of silt fence MAY not be necessary, especially if drainage is on relatively flat slopes. Please feel free to contact me with questions or ask for assistance with erosion & sediment 2 tion. , oil Erosion Inspector #665054 I • iii■■ ■�■ ■�■■■■�■ ■r, � ■►�,�,��� ■t ■■■■■ ■ ■■■ NONE won ONE 0. MENEM MEMMEME !■■1■■r.iro �Wall M ■w■ ■i�■ ■ ■■■■■■��■■■■■■■■ MIN ■■ G? 46*41M �!J�■�■EIrDI`� ■■�1M■■■■■■ ■■■■ll■■■ 1�CI / P!W■■U■■ ■■SWE i:,.�.! ■ ■ ■ ■■ ■■■■■■ ■ ■ ■ .. • . . ■rME®■■■ ■� ■■■■■■W'�'� ■■■■ ■ ■ ■■■■■ ■ ■ ■■■■M1 ■■ ■Y■SI■t ■■■■■M■■ ■■ ■■■■■■�■ ■Il■■■N911AR■Il■■ ■■■■■■■■■■■■ ■■■■■■ ■■■ • - ■IA■■■ INS ■■■ ■■■■■■■■■■! no■■■■■■ •. - . I mmomommm m 0 ONFI ■■■■■■■■ ;.:ii■■■■■■ NOINUMMUREM ■ ■■■■ ■II ■■■■■■■■ FRIFT Y■■■■ ■I■ ■ ■ ■ ■ ■ ■ ■ ■■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■I ■Ti�� ■■I ■■■■ o ■■!■■■■■ ■� ■� ■ ■� ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■I ■IalMlr� ■■■■ • MEMNON ■■■■■■■Ml!lto ■ ■■ ■ ■ ■ ■ ■■■ ■ ■ ■■■I ■ ■! ■��■ ■ ■■ NINE MENNEN � ■V ■rl ■ ■ ■ ■r�l ■ ■��■■ ■■■■ ■■■■■ I■■ ■■■■■■ � � A .. . ■■■I1�■■■■YNI■■■■■■ ■■■■■■■ ■1■■■■■■■■■ ■ ■■ ■r� ■ ■■■ ■ ■ ■■ ■ ■ ■�I�I�a ■wwlr ■III■■■■■■■■■ .•::•. . ■■■■■■■■■ ■i�■■■■■■ mmngammul•.......m • J Mx� EROSION CONTROL PLAN CHECKLIST M Check (✓) appropriate boxes below, and complete the site diagram a with necessary information. � O z Site Characteristics North arrow, scale, and site boundary. Indicate and name adjacent streets or roadways. Location of e xisting drainagewa s, streams, rivers, lakes, wetlands or wells.7y�c /u, & dc�uc�e Location of storm sewer inlets. Location of existing and proposed buildings and paved areas. The disturbed area on the lot. Approximate gradient and direction of slopes before grading operations. Approximate gradient and direction of slopes after grading operations. Overland runoff (sheet flow) coming onto the site from adjacent areas. Erosion Control Practices ❑ Location of temporary soil storage piles. Note: Soil storage piles should be placed behind a sediment fence, a 10 foot wide vegetative strip, or should be covered with a tarp or more than 25 feet from any downslope road or drainageway. Location of access drive(s). Note: Access drive should have 2 to 3 inch aggregate stone laid at least 7 feet wide and 6 inches thick. Drives should extend from the roadway 50 feet or to the house foundation (whichever is less). ❑ Location of sediment controls (filter fabric fence, straw bale fence or 10- foot -wide vegetative strip) that will prevent eroded soil from leaving the site. ❑ Location of sediment barriers around on -site storm sewer inlets. ❑' Location of diversions. im Note: Although not specifically required by code, it is recommended that concen- trated flow (drainageways) be diverted (re- directed) around disturbed areas. Overland runoff (sheet flow)from adjacent areas greater than 10,000 sq. ft. should also be diverted around disturbed areas. 7' Location of practices that will be applied to control erosion on steep slopes (greater than 12% grade). Note: Such practices include maintaining existing vegetation, placement of additional sediment fences, diversions, and re- vegetation by sodding or seeding with use of erosion control mats. ❑ Location of practices that will control erosion on areas of concentrated runoff flow. Note: Unstabilized drainageways, ditches, diversions, and inlets should be protected from erosion through use of such practices as in- channel fabric or straw bale barriers, erosion control mats, staked sod, and rock rip -rap. When used, a given in- channel barrier should not receive drainage from more than two acres of unpaved area, or one acre of paved area. In- channel practices should not be installed in perennial streams (streams with year round flow). ❑ Location of other planned practices not already noted. J CQ V Indicate management strategy by checking (✓) the appropriate box. Z Management Strategies ❑' Temporary stabilization of disturbed areas. Note: It is recommended that disturbed areas and soil piles left inactive for extended periods of time be stabilized by seeding (between April 1 and September 15), or by other cover, such as tarping or mulching. Permanent stabilization of site by re- vegetation or other means as soon as possible (lawn establishment). • Indicate re- vegetation method: Seed ❑ Sod ❑ Other • Expected date of permanent re- vegetation: Poo b *!Z i • Re- vegetation responsibility of: ❑ Builder Owner /Buyer • Is temporary seeding or mulching planned if site is not seeded by Sept. 15 or sodded by Nov. 15? 71 Yes XV No Use of downspout and /or sump pump outlet extensions. Note: It is recommended that flow from downspouts and sump pump outlets be routed through plastic drainage pipe to stable areas such as established sod or pavement. Trapping sediment during de- watering operations. Note: Sediment -laden discharge water from pumping operations should be ponded behind a sediment barrier until most of the sediment settles out. Proper disposal of building material waste so that pollutants and debris are not carried f off -site by wind or water. Maintenance of erosion control practices. • Sediment will be removed from behind sediment fences and barriers before it reaches a depth that is equal to half the height o f the barrier. • Breaks and gaps in sediment fences and barriers will be repaired imme- diately. Decomposing straw bales will be replaced (typical bale life is three months). • All sediment that moves off -site due to construction activity will be cleaned up before the end of the same workday. All sediment that moves off -site due to storm events will be cleaned up before the end of the next workday. • Access drives will be maintained throughout construction. • All installed erosion control practices will be maintained until the disturbed areas they protect are stabilized. For more assistance on plan preparation, refer to the Wisconsin Uniform Dwelling Code, the DNR Wisconsin Construction Site Best Management Handbook, and UW— Extension publication Erosion Control for Home Builders. j The Wisconsin Uniform Dwelling Code and the Wisconsin Construction Site Best Management Handbook are available through the State of Wisconsin Document Sales, (608) 266 -3558. Erosion Control for Home Builders (GWQ001) can be ordered through Extension Publications, (608) 262 -3346 of the Department of Commerce, (608) 267 -4405. EROSION CONTROL REGULATIONS Erosion control and stormwater regulations can be complex. Local, state and, in some cases, federal regulations may apply. Before construction make sure you have the appropriate permits. LOCAL ©RDINANCES Check with your county, city, village, or town for any local erosion control ordinances including shoreland zoning require- ments. Except for new 1- & 2- family dwellings, local ordinances may be more strict than state regulations. They may also require erosion control on construction projects not affected by state or federal regulations. UNWORM dWELLING CODE (QEPT. OF COMMERCE) CONTROLS REQUIRED FOR MORE INFORMATION, CONTACT: • Silt fences, straw bales, or other approved perimeter • Local building inspector measures along downslope sides and side slopes. . Department of Commerce, Safety and Buildings Division, • Access drive. P.O. Box 7969, Madison, Wis. 53707, (608) 266 -2128. • Straw bales, filter fabric fences or other barriers to protect on -site sewer inlets. • Additional controls if needed for steep slopes or other special conditions. STQRMWATER PERMIT (DEPT. OF NATURAL RESOURCES) I CONTROLS REQUIRED FOR MORE INFORMATION, CONTACT • Erosion control measures specified in the Wisconsin Department of Natural Resources, Storm Water Permits, Construction Site Best Management Practice Handbook. P.O. 7921, Madison, WI 53707 -7921, (608) 266 -7078. • Measures to control storm water after construction. This publication is available from county UW- Extension offices or from Extension Publications, 45 N. Charter St., Madison, WI 53715. (608) 262 -3346 or toll -free (877) 947 -7827. A publication of the University of t ^. ,,,, Wisconsin — Extension in cooperation with the Wisconsin Department of Natural Resources. Ens %On 01999 by the Board of Regents of the University of Wisconsin System. Send inquiries about copyright permission to: Director, Cooperative Extension Publications, 201 Hiram Smith Hall, 1545 Observatory Dr., Madison, WI 53706. University of Wisconsin- Extension is an EEO /Affirmative Action employer and provides equal opportunities in employment and programming, including Title IX and ADA requirements. GWQ001A Standard Erosion Control Plan for 1 bt 2 Family Dwelling Construction Sites �t �` Printed on DN R WT-458-96 R- 02-02-2M-1 0 — S Editing and design by the Environmental Resources Center, University of Wisconsin — Extension. O- recycled paper ST CROIX COUNTY ` SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer - C){ t v\ 4 r eX n C� ,� y `f a d Mailing Address 73/ s�,5 ] ��' �' W ��� ✓i�jl�� �/� S / Property Address tr9 ( SS (Verification required from Planning Department for new construction) City/State Parcel Identification Number e4 o Z- a /o a6 7 o a av LEGAL DESCRIPTION Property Location 5 i,c.' y,, ri w ' /., Sec. _ , T--ZS�_N - R i j� W, Town of K /,7 Subdivision Lot # � . Certified Survey Map # t4y 71 aA i� Volume / . Page # y / 0 Warranty Deed # _ `-' �` " �- Volume Page # Spec house ❑ yes 29 no Lot lines identifiable ® yes�no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property -owner agrees to submit to St. Croix Zoning Department a certification force, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and um in if necessary), se P P tic tank is less than 1/3 . g ( ary), p full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. Q 'L'2'7V'- ( �r )PI le'd o 5 / 0 SIG ATURE APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. SI ATURE Of APPLICANT DATE tRS*** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * ** •� Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed U 1906P 182 STATE BAR OF WISCONSIN FORM 1 - 1998 WARRANTY DEED CORRECTIVE Document Number KATHLEEN H. WAALSH This Deed, made between Fred Lenertz, Inc., a Wisconsin REGISTER OF DEEDS corporation ST. CROIX CO,, MI Grantor, RECEIVED FOR RECORD and John M. Jotblad and Jana L. Jotblad, husband and 06-06 -2002 12 :30 PM wife � R�iEAWTY DEED d Grantee. REC FEE: Grantor, for a valuable consideration, conveys to Grantee the following 11.00 described real estate in St. Croix Coun State of Wisconsin TRANS FEE: ty, COPY FEE (the "Property"): Recording AMRT Name and Re s This Corrective Warranty Deed is given to correct the Joh M. otblad legal description on the Warranty Deed filed as Jana otblad r , - - Document No. 676943, in Volume 1876;x: Page 364 on April 23 x Lot s & Cou10� Nn I N 2002. The correct legal description is reilected below. xudso w 54016 Jj� q Parcel Ide ficafion Number (PIN) 1J � This is Not homestead property. Lot 1 in Certified Survey Map filed in Vol. 15, P age 410 2, as '156cttmenV No. 647126 located in part of the SW 1/4 of the NW Section 8, Township 28 N, Range 18 W, Town of Kinnickinnic, St. Croix County, Wisconsin. Together will all appurtenant rights, title and interests. None Grantor warrants that the title to the Property is good, indefeasable in simple fee and free and clear of encumbrances except Dated this day of (SEAL) (SEAL) * * Fred Lenertz WLen arms, nc. (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGEMENT Signaturc(s) gWgT�IM�► State Of Wisconsin, . , } ss. gal Ic NO-TAR ISCQN51N �,��� \X Coon authenticated this Personally came before me this day of 2002 , the above named ed Lenertz Inc. a Wisconsin co or ti n * Q/J TITLE: MEMBER STATE AR OF WISCONSIN to (If not, me known to be the person who executed the foregoing authorized by §706.06, is. Stats.) instrument and ac owledge the same. THIS INSTRUMENT DRAFTED BY Coldwell Banker B rnet 02 -04759 1301 Coulee * v ` - � Notary Public, State of (Wisconsin Hudson, WI 54016 My commission is permanent. (�f ot, state expira�o date: ( Signatures may be authentica ed or acknowledged. Both are .•) not necessary.) Names of versons signing in an v caDaci must be typed or printed below their signature. 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