HomeMy WebLinkAbout024-1022-90-000 Wisconsin Department of Commerce SYSTEM
Safety and Buildings Division PRIVATE SEWAGE Coun�i Croix
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanit�YIISTfftNo.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 11
Et Holder's Name: ❑ City ❑ Vi t _ p of p tate Plan ID No.:
rth, Helene Pleasan Vale Towns i .Z.l = 0/6 M Elev.; Insp. BM Elev.: BM Description: _ rceL jb_22- 90000
6D -b 6U •O � U 1V
TANK INFORMATION b ELE ATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ICMD 16 CD Benchmark 1 04 0
Dosing Alt. BM
Aeration Bldg. Sewer 25� -i p 9f •ZO
Holding t Ht Inlet - p f j— p 43• If
TANK SETBACK INFORMATION St/ Ht Outlet r---
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
Air I ---�
Septic -O' NA t rc� Z�� • ��
Dosing " } p NA Header /
D
Aeration NA Dist. Pipe
Holding Bot. System s ZC> ,
PUMP/ SIPHON INFORMATION Final Grade al..
Manufacturer Demand St cover (5�' �f ( L70, Z_Z
Model Number �� oZ GPM 5/tt J—
TDH Lift?-K Friction `. � System�•S TDH k?
H ead
Forcemain Length l�_ Dia. " Dist.ToWell 9p`
SOIL ABSORPTION SYSTEM
BED/TRENCH Width / / Length i No f renches PIT No. O Inside Dia. quid Depth
DIMENSIONS 4 9 l DIMENSION
SYSTEM TO P/L BLDG I WELL LAKE /STREAM LEACHING acturer:
SETBACK CHAM
INFORMATION Type Of i i Model Nu r:
System: $Q > ID - -- NIT
DISTRIBUTION YSTEM
Header / Man f I Distribution Pipe(s) u x Hole Size x Hole Spacing Vent To Air Intake
Length Dia- Length _� Dia. -2 Spacing �� - �C f 4 PC)
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil []Yes E] No E] Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc. Inspection #1: 08 / !a oo section
Location: 316 170th Street, Hamm nd, WI 54015 ( 17W) - 17.28.17.128A ,
1.) Alt BM Description = /�m+� 5 . a c,r Q . 1(7 A� - �D �l r• I
2.) Bldg sewer length = ( c)
- amount of cover = > 4Z`` S�,
3.) contour= G % 1 SIL-*-0A S40 cd ftt = it (•0 , )
PI n revision required? ❑ Yes No
�1 ethe side for additions infQi;p do t (( TD )X 1 1 - 4 Ta
6 S D -6710 (R.3"/97) % nn , W r� (� Date Inspector's Signature Cert . No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
Vi scons i n SANITARY PERMIT APPLICATION 201 W. Washington Avenue
P O Box 7302
Department of Commerce In accord with Comm 83.05, Wis Adm. Qode Madison, WI 53707 - 7302
_ r
• Attach complete plans (to the county copy only) for the s teal, on p er no" 1 County ,
than 8 1/2 x 11 inches in size. `: � � 1 )e
/r^ t � `
• See reverse side for instructions for completing this appficatlon S to Sanitary Permit Number
Personal information ou provide may be used for secondary
Y p Y ry +. z heck if revision to revious application
[Privacy Law, s. 15.04 (1) (m)). rr f . 1 r = : X
� 5T Gtr ,� to Plan I.D. Number
I. APPLICATION INF RMATION - PLEASE PRINT A INFOR - 31 V41
Property Own e ;, ;,, roperty L io
0j( ,e . .� _. r t /a1,51 T r N, R 7 E (or)
Property Owner' Mailing Address u t Block Number
Cit , State Zip Co e PK n Mir Subdivision Name or CSM Number
T YPE F BUILDING: (check one) ❑ State Owned H it� � ��✓ Nearest Roa
Public 1 or 2 Famil Dwellin - No. of bedrooms ❑ T own OF • 1_ /l 1r d .SE
III BUILDING USE (If building type is public, check all that app V) Parcel Tax /7-
1 ❑ Apartment/ Condo 1'dr ax+i S�:rtJ 6{ %L k
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel /Motel 9 ❑ Office / Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. ❑ New 2 Replacement 3. E] Replacement of 4_ El Reconnection of 5 E] Repair of an
_System ________ System Tank Only System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 Mound 30 ❑ Specify Type 41 E] Holding Tank
12 E] Seepage Trench 22 In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 9S 43 E] Vault Privy
14 E] System -In - Fill -�,�, f=
VI. ABSORPTION SYSTEM INFOR,I RATION:
1. Gallons Per Day 2. Absor�.. rea 3. Absorp. Area 4. Loa g Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
,/�� ✓ Re wired (sq. ft.) Prop ed (sq. ft.) (Gals/d�ylsq. ft.) (Min. /inch) q Elevation,
70 3 "— ! 7r / Feet IeO Feet
Cap acity
VII TANK Ca in gallons Total # of r Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con steel glass Plastic App
New Existing strutted
Tanks Tanks
e tIC T O �I Inlrlin9 Tan k/ ❑ ❑ ❑ ❑ ❑
�� impTan fiber ❑ ❑ ❑ ❑ ❑
PONSIBILITY STATEMENT
I, the undersigned, assume responsibility f installation f the onsite sewage system shown on the attached plans.
Plumber's e: (Print Plumb s ign tamps) MP /MPRSW No.: Business Phone Number:
Plumber' d ess(Street, City, State, Zi e _
7 g7 T IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps)
Approved E] Owner Given Initial !t Surcharge fee) /
Adverse Determination ao
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: 1:� oo rlse"
4- SV Sf+ — 4 4 1o1RGC,:P cLCM.ts C w- 4e /- GJ�eH� 4�e..��� S 3 4� y ----v 90re'%f 5 I'K u $ f 1` e
C , e es, m� �/ r l
SBD -6398 (R. 4199) DISTRIBUTION: Original tottounty, One copy To: Safety & Buildings Division, Owner, Plumber
Ik
INSTRUCTIONS
1. A sanitary permit is valid fortwo (2) years.
2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608- 266 -3151.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
11, Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. if building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
----------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
' Safety and Buildings
PO BOX 7162
MADISON WI 53707 -7162
TDD #: (608) 264 -8777
*Asconsin www.commerce.state.wi.us
Department of Commerce Tommy G. Thompson, Governor
Brenda J. Blanchard, Secretary
May 27, 2000
CUST ID No.139462 A7TN: POWTS INSPECTOR
ZONING OFFICE
TODD L SINZ ST CROIX COUNTY SPIA
E5609 708TH AVE 1101 CARMICHAEL RD
MENOMONIE WI 54751 -5520 HUDSON WI 54016
RE: CONDITIONAL APPROVAL Identificatio s
PLAN APPROVAL EXPIRES: 05/27/2002
Transaction ID N 31910
SITE• Site ID No. 193048
HELENE HAWORTH - RESIDENCE Please refer to both identification numbers,
ST CROIX County, Town of PLEASANT VALLEY; 170TH ST above, in all correspondence with the agency.
SETA, SE1 14, S17, T28N, R17W
FOR:
Description: MOUND SYSTEM
Object Type: POWT System Regulated Object ID No.: 665763
J YP Y g J
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.
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. All permits
required by the state or the local municipality shall be obtained prior to commencement of
construction /installation/operation.
CAUTION: Wis. Stats. 145.135(2)(b)., indicates that the approval of a sanitary permit is based on regulations
in force on the date of approval. The effective date of COMM 83 revisions is expected to be July 1, 2000.
Thus, depending on the type of system and your design, this plan approval may not be eligible for sanitary
permit approval if submitted to the issuing agency on or after July 1, 2000.
Note: There is a otP ential for a lawsuit that may delay the effective date of the code so this status may or may
not change.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhea
Sincerely, DATE RECEIVED 05/24/2000
/ FEE REQUIRED $ 180.00
iT, FEE RECEIVED $ 180.00
E , POW,- S PL REVIEWER II BALANCE DUE $ 0.00
Integrated Services l`
(608)266-2889, M - F; 745 - 1630 HRS
PEPAGEL @COMMERCE. STATE. WI.US WI'RT'1: 7633
cc: HELENE HAWORTH
Helene Haworth - Mound RE CEIVED
Transaction # Mq
Y 23
2000
SAFETY & BOGS, DIV.
Location: SE 1/4, SE 1/4, Sec. 17, T 28 N, R 17 W
Town: Pleasant Valley
County: St. Croix
Date: May 20, 2000
Owner: Helene Haworth
Address: 31617 St.
H d, WI 54015
Plumber: To Sinz q
Signature: c
License # MP 13946
Attachments: 6748 -Plan Review Application
SBD 8330
P 0
Copt ditiD1Z .W. T.S•
page 1: cover AP dl
2: calculations i y
3: plot plan DIVIDE p ENT � D
OM
4: system cross section SA AN RCE
5: plan view, lateral detail 1LDl
6: pump tank exit detail SE E CORR
7: pump curve NCE
page 1 of 7
System Calculations
One family residence _S bedrooms
Loading rate (5 2$ gallons /sq ft per day
Depth to ground water '- Z in
Depth to bedrock ? in
Cross slope z "� %
Force main length # ft o in
Manifold /header length ft of in
Drainback 2 3 gallons
Lateral length 1 @ ft of' Z in
Lateral elevation ft (bottom of pipe)
lateral hole siz t/¢ in @ b in spacing
holes /lateral, holes total
Lateral volume '��'� gallons
i
Total lateral discharge rate Z 1.11 gpm @ 'L'� ft head
Elevation difference ' bti ft
ion loss .� ft @ gpm
Total dynamic head Z 'g� ft
Pump /si 16 gpm @ ft of head
Manufacturer `" "O""'` Model # .
Dose volume ` gallons
Lift /siphon tank I �"`� c- T , L ` gallons
Septic tank , l gallons
Measurement pump on & off in
Height alarm from tank bottom in
Reserve capacity 3�5 gallons
calcs page Z of -4
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SEPTIC E SPEC,IFI'CATIOAIS
DOSE
TAIJr.S MANUFACTURER. " IJI.JMBER OF DOSES: PER DAB
TAWK SIZE: k �� - �'� GALLOWS DOSE VOLUME
ALARM MAUUFACTUKLjt: S `� do ta IAICLUDING BACKFLOW: , 1 GALLONS
M100CL IJuKbEK: , ° i 1 � ``' CAPACITIES: A = 22 '� IIJCHES OR ZZ� .l�� GALLOWS
SWITCH TUPL: `�b 8 c Z
IWC►IES OR GALL0Q5
PUMP MAIJUFACTURCR: ` 7 ° ' ^ t: a l �'� WCMES OR GAL101J5
MODEL MUMBER: S4*mr- D- INCHES OR GALLO►JS
SWITCH TYPE: �MQ.Ve..4v " NOTE: PUMP AWD ALARM ARE TO BE
MINIMUM DISCHARGE RATE Z � (,PIS INSTALLED OW 5EPARATE CIKCLIT6
VERTICAL DIFFERfAICC BETWECU PUMP OFF AAJD OISTRIBUTIOW PIPE.. 5?1 FEET
+ MIU IMUM NETWORK SUPPLY PRESSURE .. . . . .. 2',�/ FEET
T✓ /
+ , FEET OF FORCE MAIN X IF FACTOR. -1'�� FEET
TOTAL OtWAMIC HEAD _ FEET �
ILITEitWAL DIMEW61OWS OF TAWK: LENGTH ` ;WIDTH � ;LIQUID DEPTH
Engineerin Details - SHEF30
L $k
Pump Characteristics Performance Data
ft" /1111ove Ewt SOLI Able t x
Aet•ttM& Mtodds SNEF30A1
30
FW load Atop 0
iRaor Shoo Pab 14 1 i
R.PJd.
vemw n s I
Hall 60
o , o �,
lemperet.r ("W" 4l.4 a ,
NEIRA Dodge A 11eNSeao•d a 1 r
hsnlotioa tkss A �,.,,,.1 ,,,,J to w a
DicShltt She 1 ^) /2- NPT(3tppt� Total ROW feet 4 S 12 1` 10 24
Som Nay 3/4' (19rpp) 0'AI (II.S.1 44 3 29 Z$ 12 0
U?A 14 *kt 3011s"
P•wu Cord 1B/3, S)TW, 2iV srd. Dimensional Data
W. Materials of Construction �r�" ' Al (ROW a« let«eetitnel WIN le to
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Ietton Plpt• stk s••v4 5 `" 0
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Faison $I"%$ Suet -
C 1999 H drornotic% Pumps, Ashlond, Ohio. Ai! RtN Reserved.
Ir HYDRQMATIC -YourAuthorizedLocal
■ • 1 I T , I W"
1840 lorry Rwd AsWmd, 06 44805 V: 419.289.3042 Fax 419.711.4087
Web Site: www.pentairpunp.(om '
SALES OFFICES IN All 14AJOR CRIES AND COUNTRIES � ` �
item a: W- 02.6350 1208 6M
Wisconsin Department of Commerce . /� OIL AND SITE EV N Page I of 3
{ Division of Safety and Buildings VR'GINAL{vith Comm 83.0-, Code
\ Certified Soil Testing
Attach complete site plan on paper not less than 8'/2 x 11 inches in size. PAtr must Co t
include, but not limited to: vertical and horizontal reference point (BM), din9ction and! , Jr -,� y St. C r o i x
percent slope, scale or dimensions, north arrow, and location and dista tQr nearest roati.
ParcA I.D.# 024 - 1022 -90 -000
APPLICANT INFORMATION - Please print all information.
Re '
Personal information you provide may be used for secondary purposes (Privacy La� a 1 rt�
.5.04 (1) (rr Date
, " _% r Y
Property Owner Propert "?
Haworth Helene .> t ICSE 1� 1/4 S 17 T 28 N R 17 W
Property Owner's Mailing Address Lo t` • -f' Byte #: ame or CSM#
316 170th St. '' F t t
City State Zi Code PhoneNumber ❑ City ❑ Village ZTown Nearest Road
Hammond WI 54015 715- 796 -5371 Pleasant Valley 170Th St.
New Construction Use: Residential / Number of bedrooms 3 - ❑Addition to existing building
❑❑ Replacement ❑ Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate • bed, gpd /ft • trench, gpd /ft
Absorption area required 900 bed, ftz 750 trench, ft- Maximum design loading rate 5 bed, gpd /ft • t rench, gpd /ft
Recommended infiltration surface elevation(s) 97.1 ft (as referred to site plan benchmar
Additional design / site consideration install 4 'x 95' rock bed mound on 95.1 contour as upslope edge of rock w/ 2' sand fill
Parent material till Flood plain elevation, if applicable NA ft
S= Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U= Unsuitable for system ❑ ® U X S❑ U ❑ S ®U ❑ S® U ❑ S X U S X U
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Bounda Roots GPD /ft2
Boring# in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed I Trench
1 1 0-3. 7.5YR 3/2 - sl 2 m gr mvfr cs 2f1m .5 .6
2 3 -9 7.5YR 4/4 - sl 2 f sbk mvfr cw if .5 .6
Ground 3 9 -15 • 7.5YR 4/4 - sl 2 m sbk mvfr cs if .5 .6
elev
96.3 ft 4 15 -20 • 7.5YR 4/4 f2d 7.5YR 5/8 sl 2 m sbk mvfr cs - .5 .6
Depth to 5 20 -35 7.5YR 4/4 m lOYR 6/2 sl 1 c sbk mvfr - - .4 .5
limiting
factor
15•- a
2
Remarks:
2 1 0 -3 7.5YR 3/2 - sl 2 m gr mvfr cs IUrn .5 .6
2 3 -6 7.5YR 3/2 - sl 2 f sbk mvfr cs if .5 .6 /
Ground 3 6 -16 7.5YR 4/4 - sl 2 m sbk mvfr cs if .5 .6 ✓
elev t2f 7 4/6
95.7 ft 4 16 -22 7.5YR 4/4 1OYR 6/2 sl 2 m sbk mvfr cs - .5 .6
Depth to 5 22 -36 7.5YR 4/4 f2p 7.5YR 5/8 scl 0 m mfr - - NP .2
limiting
factor
16"
r 13"
Remarks:
CST Name (Please Print) Signature: Telephone No.
Henry F. Grote - 715- 665 -2681
Address C ertif ied of Testing Date CST Number Ref #
P.O Box 57, Knapp, WI 54749 3/16/2000 222774 1099
PROPERTY OWNER Haworth, Helene SOIL DESCRIPTION REPORT 2 v 3
«�. .� 1.4 Page ds
PARCEL 1 024 - 1022 -90 -000 r -, o- Certified Soil est
Depth Dominant Color Mottles Structure GPD /ft
Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. onsistence Boundary Roots
Bed Trench
3 1 0 -6 7.5YR 3/2 - sl 2 m gr mvfr cs I f/m .5 .6 /
2 6-12, 7.5YR 4/4 - sl 2 f sbk mvfr cs if 5 6
Ground
elev 3 12 -24 : 7.5YR 4/4 - sl 2 m sbk mvfr cs if .5 .6
f3d 7.5YR 5/8
95.7 ft 4 24-30. 7.5YR 4/4 10YR 6/2 sl 2 m sbk mvfr - - .5 .6
Depth to
limiting
factor
24 "_
Remarks:
4 1 0 -5 7.5YR 3/2 - sl 2 m gr mvfr cs 2flm .5 .6
�E
2 5 -8 7.5YR 4/4 - sl 2 f sbk mvfr cs if .5 .6
Ground
elev 3 8 -12 7.5YR 4/4 - sl 2 m sbk mvfr cs if .5 .6
95.1 ft 4 12 -31 . 7.5YR 4/4 f2f 7.5YR 5/8,5/3 scl 0 m mfr - - NP .2
Depth to
limiting
factor
12"
u
Remarks:
5 u 1 0 -4 . 7.5YR 3/2 - sl 2 m gr mvfr cs 2f1m .5 .6
2 4 -7 , 7.5YR 4/4 - sl 2 f sbk mvfr cs if .5 .6
Ground
elev 3 7-14. 7.5YR 4/4 - sl 2 m sbk mvfr cs if .5 .6
94.4 ft 4 14 -20. 7.5YR 4/4 - sl 2 m sbk mvfr cs lm .5 .6 ✓
Depth to 5 20 -29 7.5YR 4/4 f2d IOYR 6/2 scl 0 m mfr - - NP 2
limiting
factor
20"
Remarks:
Ground
elev
Depth to
limiting
factor
Remarks:
�r
1
r
M
0 3
g
Ilu
Cl
s
d
H
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06 FRI 10:11 F.4T 715 386 4686 ST CRl CO ZONING Z001
ST C RO IX COUNTY
SEPTIC TANK MAI P-NANCE AGREEMBW
AND
OWNERSHIP CERTIFICATION FORM
Owner % r l ZAdI1?
Mailing Address I la s -
C ,
Property Address
(Verification required from Planning Department for new construction)
City /State ._ik► ti�iAt+? W� Parcel Identification Number _l-- �(t (
LEGAL DFSCRI TJON � f
� o� � 0 - � ..Town of
Property Location <5 � . /., /�, Sec. / 7 . T N y
Subdivision Tot
X Certified Survey Map # . Volume Page #
}C Warranty Deed # _ ��o (y3 'Volume . Page ##
Spec house ❑ yes io Lot lines identifiable ❑ yes 11 no
SYSTEM MAnnTUNANCE
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 forte signed by the owner and by a
mastorplumber, journeyman plumber, testrietedplumber or a Iic wedpumper verifying that (1) the on -site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less 0=1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth., herein, as set by the Department of Commerce and the Departmcnt of Natural Resources, State of W isconsim 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 c year cxpizati date.
G / ,6 — >
x SIGNATl3R� OP A3'pLTCANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) Lnowledge. I (we) am (arc) the owners) of
rr
9M;;::r anty decd recorded in Register of Deeds Office. 6
DATE
Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. • *' *'
** Include with this application: a stamped warranty deed from the Register aad��the warranty deed
a copy of the certified survey trap if
u isconsin Department of Commerce ORIG%F&ND SITE EVALUATION Page I of 3
�. Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
Certified Soil Testing
Attach complete site plan on paper not less than 8 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and St. Cr
percent slope, scale or dimemsions, north arrow, and location and distance to nearest road.
Parcell.D.# 024 - 1022 -90 -000
APPLICANT INFORMATION - Please print all information.
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). R V ed By Date,
Property Owner Property Location
Haworth, Helene Govt, Lot SE 1/4 SE 1/4 S 17 T 28 N 17 W
e or CSM#
Property Owner's Mailing Address Lot # Block # Subd. Nam
316 170th St.
City State Zi Code PhoneNumber __ City [ Village 'Town Nearest Road
Hammond WI 54015 715- 796 -5371 Pleasant Valley 170Th St.
New Construction Use: Z Residential / Number of bedrooms 3 []Addition to existing building
Replacement Lj I Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate • bed, gpd /ft2 .6 trench, gpd /ft
Absorption area required 900 bed, ftZ 750 trench, ft' Maximum design loading rate • bed, gpd /ft _. t rench, gpd /ft
Recommended infiltration surface elevation(s) 97.1 ft (as referred to site plan benchmar
Additional design / site consideration install 4 ' x 95' rock bed mound on 95.1 contour as upslope edge of rock w/ 2' sand fill
Parent material till Flood plain elevation, if applicable NA ft
S= Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U= Unsuitable for system � Z U Z S C1 U ❑ S Z U u S Z U
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Bounda Roots GPD /ft2
Boring# in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 1X00- -3 7.5YR 3/2 - sl 2 m gr mvfr cs 2f1m .5 .6 S
2 3 -9 7.5YR 4/4 - sl 2 f sbk mvfr cw if .5 .6
Ground 3 9 -15 7.5YR 4/4 - sl 2 m sbk mvfr cs if .5 .6 S�
elev
_ 96.3 ft 4 _�5-20 7.5YR 4/4 f2d 7.5YR 5/8 sl 2 m sbk mvfr cs - .5 .6
Zp Depth to 5 20 - 7.5YR 4/4 nt 10YR 6/2 sl 1 c sbk mvfr - - .4 .5
limiting
factor
15"
Remarks: _
2 1 0 -3 7.5YR 3/2 - sl 2 m gr mvfr cs I f/m 5 6 ,5
2 3 -6 7.5YR 3/2 - sl 2 f sbk mvfr cs if .5 .6 •5
Ground 3 6 -16 7.5YR 4/4 - sl 2 m sbk mvfr cs
t 5_, .6
elev .� YR 4/6
_95 7 It 4 16 -22 7.5YR 4/4
l OYR 6/2 sl 2 m sbk mvfr 4 s\ �`' - y - :5: � i \� .6 b
Depth to 5 22 -36 7.5YR 4/4 {2p 7.5YR 5/8 scl 0 m mfr - Y =�'L, 'IP 2 0.0
limiting
factor e + x r n
ST C
Remarks: — ter, ors +CE
GRIP
CST Name (Please Print) Signature: \ Telephone No`. `
Henry F. Grote 715-665
Address C ertified of esting Date CST Number Ref #
P.0 Box 57, Knapp, WI 54749 3/16/2000 222774 1099
PROPERTY OWNER: Haworth Helene SOIL DESCRIPTION REPORT � Page 2 of 3
PARCEL I.D.# 024 - 1022 -90 -000 Certified Soil est,ng
Horizon I Depth Dominant Color Mottles Texture Structure onsistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
3 1 0 -6 7.5YR 3/2 - sl 2 m gr mvfr cs if /m .5 .6
2 6 -12 7.5YR 4/4 - sl 2fsbk mvfr cs if .5 .6 S
Ground
elev 3 12 -24 7.5YR 4/4 - sl 2 m sbk mvfr cs if .5 .6 5'
f3d 7.5YR 5/8
_ - _9 5.7 ft 4 24 - 7.5YR 4/4 1 OYR 6/2 sl 2 m sbk mvfr - - 5 .6 , s
Depth to — —
limiting _
factor
24"
Remarks:
4 1 0 -5 7.5YR 3/2 - si 2 m gr mvfr cs 2flm .5 .6
2 i 5 -8 7.5YR 4/4 - sl 2 f sbk mvfr cs 1 f .5 .6 • t
Gro und
elev 3 8-12 7.5YR 4/4 - sl 2 m sbk mvfr cs if .5 .6 ,S
95 4 12- 1 7.5YR 4/4 f2f 7.5YR 5/8,5/3 scl 0 m mfr - - NP 2 p D
Depth to
limiting
factor - --
12"
i
I
Remarks:
5 l 0 -4 7.5YR 3/2 - sl 2 m gr mvfr cs 2f1 m .5 .6 •�
2 4 -7 7.5YR 4/4 - sl 2 f sbk mvfr cs if .5 T .6 ,S
Ground
elev 3 7 -14 7.5YR 4/4 - sl 2 m sbk mvfr cs If 5 6 . ,r
944 ft 4 1 14 -20 7.5YR 4/4 - sl 2 m sbk mvfr cs IM .5 .6
Depth to 5 20 -29 7.5YR 4/4 f2d 1 OYR 6/2 scl O mfr - - NP 2
limiting .
factor 1
20"
Remarks:
6 1 0 -15 7.5YR 3/2 - sil
- -- �- -- -
2 15 -20 7.5YR 4/3 - sil
Ground -- -
elev 3 20 -28 7.5YR 4/4 - sil
90.0 Z§--36 7.5YR 4/4 c2d scl
10YR 6/2
Depth to
limiting
A�samsurface elevati n as failed dry ll an about 10 west; dry well s ste
factor -- — -
28" _ Y Y Y elev "
l estimated as about 8
I .0; Category 1 failure discharge tc zone of easonal aturat on
Remarks: hand boring
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'T RS OFFICE
C,f d .l ,.. H . s h . .......... ...... ..................._ ._.__ ......... ST. CT(uln CrN, WLSf
... _ . .............
Recd. ftyr RTor9_ '"
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19
quit tlttiras to .... lie . ..c3 1!:ar� Tth ... ................. . . .' ...- day oF __ ___�
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..._..... ........ -- - -
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----------- _.... ............... "" ----- - - - - -- - --
the following desczibed real estate in - - ..... 5 _ Croix _--- ...._... ..... County.
State of W" Sr niin: we* wN ro
Tax K• No....'- -- -- - -- - __ .................
A parcel of land situated in the East one -half 2f the Southeast one -- fourth
(Ek SE%) of Section, 17, Township 28 Nort t, Range; 17 West, more fully
described as follu -s: Cor ,,;z_n -iry at th. - corner of the SoutV east
quarter of the Sout..ea,;t qu - th . -:ce North 938 feet; thence West 4:4.39
feet; thence South 938 feet; thence East 464.39 feet to the place of
beginning.
Thio deed is executed pursuant to a divorcA decree entered in the Circu "t
Court of St. Croix County, Wisconsin on August 21, 1980.
a
FEE
This -..- ..-- -- 15------- - - -- -- homester..d property.
(is) (is not)
r Pr:fed this _. -- `' - day of ---- .....------- Au3ust -- ]9._80..
- - -- -- --- --- --- --- --- ------- - -._(SEAL) �{ L�=_��. -.� ! L.44' < -r:� � (SEAL)
' -- __.Qer, J.dA,_Nat .. th---------------------------
-•......... -- - •- -------- --•---- -------- ---•--- --- -- - --- ------ ( SEAL► -- ---- - --- " - •- -- -- -- - -- .- --- ------- ---- --•-- -- ---_- ----(SEAL)
' ----------- --------- --- -•----- ------- •-- --- --- --- ---- --- ---- - -- --------- ...... ------ -- -- -_----------------_---- .......
AUTHEN'TICAT10N A0Kri OWLEDGMENT
Signatures authenticated this ------------------ day of STATE OF `'rISCONSIN
--- ---- -- ---- - --- --- --- ---- -- ---- - ----- 19. - - -- -- as.
- -. -- ---- 1X--- -•--------•- -- ---- County.
-- -- ---- - - ----- -- ---- --- - - -- -- - -- ---- - -- - - ---- ----- - --- --- - - - - --- Personally came before me, this . - -- -- --- -- day of
' AUri(St -- - ----- the above named - - - -- - --- -
TITLE: STATE BAR OF WISCONSIN ... ..Gerald_. L ., . flaw r -- -- - --- - - -- - - " -
(If nnt, "- -- -----_- --- --- • - -_ -- ---------- - - ---- -- -- --• - ----- -- -- ------ -- ------
-----------------------------
authorized by § 105.06, Wis. State.) _.___
,•...., J - ----- ------
THIS INSTRUMENT WAS DRAF BY •, Cr - y , n to be the person ....... . who executed the
r? a� 4pstrumenf and ack ledge the same.
W1111a;; n t.
• o 44 ;� K .. /4 1 ZED- -- - - - - -- -
At.to:f�y -.at Law- - - - - -- - ----- - -- a " -
.
W_i. �corl� : n 54016 �a
( Signatures may be authenticated or a all - . otAy l t4i c .St...CroiX --------------------- iour.'.y, W.I.
(p�v, _, ' x6n t permanent. (If n- stage expiration
2 re not nec a y.) s r�`f ...a.• • f° ,.r �� 19 R1
The use of w:.n sts is uptional ''�. r ttr 1l. ...... .. .. --'- -..)
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