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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Divis ii if INSPECTION REPORT Sanitary Permit No:
479275 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:
Matacz nski, Jeff I Pleasant Valley, Town of 024 - 1029 -10 -200
CST BM Elev: Insp. BM Elev: BM Description: Section ( fown /Range /Map No:
f Q 6 m I C - 21.28.17.1778
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
1 9 R- S.(`S
Septic Z06 Benchmark j trio
Dosing Alt. BM G 3 94 G �
7
AeFet[on Bldg. Sewer 15 S dS
Holding St/Ht Inlet go, ! ,
oe
St1Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Seas /� t / / Dt Bottom /9-7
Dosing S / 7 Header /Man.
Aeration Dist. Pipe
S Z Y
Holding Bot. System I
PUMP /SIPHON INFORMATION e" r> t �" G rade
Manufacturer Demand St Cover
GPM �rK �'s�u -✓ r�.y 3•J
Model Number
TDH Lift Friction Loss Systerr�„�ie TDH Ft
Forcemain Length t Dia. I Dist. to well
8a .., S`d
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside D' Liquid Depth
DIMENSIONS ). v7 �d 1
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEA Manufacturer:
INFORMATION CHA ER OR
Type Of System: J i -f' ` -15' 0 ( Model Number:
M.0V.b -� :2 - F *! 9T' � UNIT
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size o Air Intake
x Hole Spacing Vent t
ci Pipe(s)
Length Dia Length NEE •T Dia Spacing
SOIL. COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over Ixx Depth of T /Sodded� xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil F Yes No T; §J Yes [ .'! No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / Z_$ 6 5 Inspection #2: r' /
,/ �' o f _ P Parcel No: 21.2 RM
i Location: 1787 30th Avenue Hammond, WI 54015 (NE 1/4 NE 1/4 21 T28N R1 7W) NA Lot 2 8.17.177B
1.) Alt BM Description = � S ; & ` ` c.^ ` � " � 4-y
2.) Bldg sewer length =
- 'amount of cover
5
�
-i Required? - — - - -- - - - - -
l I Yes [ ^ No I
for additional information. r -__ -- ------ -. -. --
3197), Date I sepctor's Signature Cart. No.
l plc e.,1 P`^"''' a n`" r J-z j Nlo�v�
201 W. W Avon P-0-
7162
St /;?o I •V
Oe artinent oi' COMMO as IN /G.
Cw2S
Sanitary Permit App C -
fa acooed wft CO M a.21. Wk Adm. Ctips. PN 1 p 0 Add„ ,
am be and Pot'MORMYPwP Maw ` tIS:M(� m) � 1.70, Zn T1�6•
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1 Septic tank, effluent filter and � e�,, � Mk �+� 1� 0 V
dispersal cell must all t e serylced / maintained (pc f t�C eo+
as per management plan provided by plumber.
2. All setback requirements must be maintained
as per applicable code /ordinances. 2
A11eeMee�iett *L1n(NM �)1Yriea/�M1a�SMt aUiseMwisM
SBD -6398 (R. 01/03)
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Safety and Buildings
cor�rnerce.wi. OV 4003 N KINNEY COULEE RD
g LA CROSSE WI 54601 -1831
TDD #: (608) 264 -8777
isconsin www.w
w ww.coe.wi.gov/s
sin.go /
iscosin.gov
Department of Commerce
Jim Doyle, Governor
Mary P. Burke, Secretary
June 17, 2005
CUST ID No.223475 ATTN: POWTS Inspector
JOE STANG ZONING OFFICE
STANG PLUMBING & ELECTRIC ST CROIX COUNTY SPIA
PO BOX 263 1101 CARMICHAEL RD
WOODVILLE WI 54028 HUDSON WI 54016
CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 06/17/2007 Identification Numbers
Transaction ID No. 1148204
SITE: Site ID No. 700250
Jeff Mataczynski Please refer to both identification numbers,
30th Street above, in all correspondence with the agency. t
Town of Pleasant Valley
St Croix County
NE1 /4, NE1/4, S21, T28N, R17W
FOR:
Description: Proposed Four Bedroom Mound System
Object Type: POWTS Component Manual Regulated Object ID No.: 1024074
Maintenance required; 600 GPD Flow rate; 15 in Soil minimum depth to limiting factor from original grade
System(s): Mound Component Manual - Version 2.0, SBD- 10691 -P (N.01 /O1), Pressure Distribution Component
Manual - Version 2.0, SBD - 10706 -P (N.01 /01); Biofilter
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.
No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s. 145.06,
stats.
The following conditions shall be met during construction or installation and prior to occupancy or use:
• This system is to be constructed and located in accordance with the approved plans, and the "Mound Component
Manual for Private Onsite Wastewater Systems Version 2.0" SBD- 10691- P(N.01 /01).
• The pressure network is to be constructed in accordance with publications SBD- 10706- P(N01 /O1) "Pressure
Distribution Component Manual for Private Onsite Wastewater Treatment Systems - Version 2.0" and /or the
sizing methods of publication "SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST -SAS
(01/8 1)".
• 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.
• The area within 15 feet horizontally below the system shall remain undisturbed. Vehicular traffic or soil
compaction in this area is prohibited.
• A state approved effluent filter is required. Maintenance information must be given to the owner of the tank
explaining that periodic cleaning of the filter is required. Access to the filter for cleaning must be provided
per Comm 84 product approval conditions.
DFPAL)
M
JOE STANG Page 2 6/17/2005
• 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:
The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating
to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and
maintenance manual and/or owner's manual for the POWTS described in this approval.
• 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 with the approved management plan or as
required under s. Comm 83.54(4) shall be considered a human health hazard. In the event this soil absorption
system or any of its component parts malfunctions so as to create a health hazard, the property owner must
follow the contingency plan as described in the approved plans.
The owner is responsible for submitting a maintenance verification report acceptable to the county for
maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized
in the POWTS.
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
r
MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: Jeff Mataczynski 4 bedrrom mound
Owner's Name: Jeff Mataczynski
Owner's Address: 2414 Oak Ridge Circle
Hudson, Wise. 54016
1- 175- 497 -6889
Legal Description: NE 1/4 NE 1/4 S 21 T 28 N R 17 W
Township: Pleasant Valley
County: St. Criox
Subd Name: 7 Acres Pending
Lot Number: # 2 pending Block Number:
Parcel I.D. Number
Plan Transaction No.:
Page 1 Index and title
Page 2 Data entry
Page 3 Mound drawings
Page 4 Lateral and dose tank
Page 5 System maintenance specifications
,FIVE Page 6 Management and contingency plan
14 2 005 Page 7 Pump curve and specifications
JUN Page 8 Plot Plan
SAFE' & B U J LD1t1G S Page 9 Soil Evauation Report
Designer. Joe Stang License Number 223475
Date: 06/1 05 Phone Number. (715) 6845166
Signature: e�
DesWad Pursuat to the
Mound Component Manual for POWTS Version 2.0 SDB- 10691 -P (N. 01/01), and
SSWMP Publication 9.6 Design of Pressure Ditgtl E n Networks for ST-SAS (01/81)
UIVISbUN OF SAFETY AND BUILDINGS
Version 4.01 (R. 09/04) Page 1 of 9
SEE ORRE ONDENCE
Mound and Pressure Distribution Component Design
Design Worksheet
site Information
(r or c) R Residential or commercial Design Nom: Sand fi ll ( 0) caWukiOoM wwrae e
400.00 Estimated wastewater Flow (gpd) "able 83 kl du soil to&nerd for bad
1.50 Peaking Factor (e.g. 1.5 = ISO%) cafocm of <= 36 OWM.
600.00 Design Flow (gpd)
8.00 Site Slope ( °!o)
100.25 Contour Line Elevation (ft)
15.00 Depth to Limiting Factor (in)
0.40 in -situ Soil Application Rate (gpd/ft)
Distribution Cell Information
90.00 Dispersal Cell Length Along Contour (ft) = 6.87 Cell Width (ft)
1.00 Dispersal Cell Design Loading Rate (gpd/fl?)
1 Influent Wastewater Quality (1 or 2) Are the laterals the highest point
in the distribution Y
Pressure Distribution Information network ?. Enter Y or N
(c or e) c Center or End Manifold
3.34 Lateral Spacing (ft) If N above, enter the elevation ft
4 Number of Laterals of the highest point.
0A38 Orifice Diameter (in) (e.g. 0.25)
3.25 Estimated Orifice Spacing (ft) = 10.7Z ft /orifice
2.00 Forcemain Diameter (in)
90.00 Foraemain Length (ft) Does the forcemain drain back? Y
85.00 Pump Tank Elevation (ft) Enter Y or N
3.25 System Head ft x 1.3 14,68 Forcemain Drainback (gal)
16.50 Vertical Lift (ft) 56.43 5x Void Volume (gal)
2.53 Friction Loss (ft) 71.11 Minimum Dose Volume (gal)
22.28 Total Dynamic Head (it) 36.70 System Demand (gpm)
Lateral I a meter S I� on Manifold Diameter Selection
in. dia.' opt ions choice in. dia. a ions choice
0.75 1.25 x
1.00 1.50 x x
1.25 x x 2,00
1.50 x 3.00
2.00 x
Gallonslinch Calculator (optional)
'treatment T a nk I 800500 Total Tank Capacity (gal)
1200,001 Sept Tank Capacity (gal) 1 36.001 Total Working Liquid Depth (in)
Wieser Manufacturer 22.22 gal/in (enter result In cell 649)
Dose Tank Information Effluent Filter Intonnation
800.00 1 Dose Tank Capacity (gal) lZabel Fitter Manufacturer
22.22 Dose Tank Volume (gal /in) A100 Filter Model Number
Wieser Manufacturer
Project: Jeff Matacxynskl 4 bedrrom mound Rage 2 of 0
Z0d -QI ZE:ET SO -LT -90
Mound plan View
�t
4 i g Observation Pipe
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r..•.� *? .�.� «a:r «r ».'•x " ":. ".'r' " «•rxr r «. «r ».t.r rx:+ r A
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� 1. +� «x. «.«y«•. "- « «'Ir +ti «4 «'{.YYY« '11.1: •� •1. 1i «• «- y- .- w•'L•y'M•. -'� y" �"
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.....,.._ .._... -. _..—�� L
Mound Component Dimensions
A A21.00 ft E E 10.50 in H 1.00 ft K 11.36 ft
B ft F in I 94.03 ft L 112.73 ft
D in G ft J 7.31 ft W 28.01 ft
600.30 (fl?) Dispersal Cell Area 1863.06 (ft Basal Area Available
6.87 (gpd/ft) Linear Loading Rate 9.00 (ft)1/10 B Obs. Pipe Placement
Mound Cross Section View
Aggregate Dispersal Area
Finished Grade 103.77 (fl) --�-- - -r►
rri s .. Ff
1 rirrrrrr 2 �rrrrsr G _.._ T
ir�rrr r {s {i
I F [Dispersal Cell 102.50 (ft Lateral
102.00 (ft) ~"► Invert
Dispersal Cell D
A.
Elevation E
4
4
- 100.25 (ft) Contour Elevation
8.0 % Site Slope G eote4le Fabric Cover
Shading Key '$ y Dispersal Cell See lateral details on
[1] Topsoil Cap 1.5 ft Page 4 for numb size,
rirrr Subsoil Cap �► "' ti;; • 'rtir�r and spacing of laterals.
AST M C33 Sand "' f - " ` • f.
r^ .�, :. � .ti �;, �ti �y ; • r � , f F Laterals are equally
• rued Layer ® 0.5 ft a "• lypfcaf ldteraf r f.;." spaced from the
YyYLYq, :`Mr�'n�� 'ti �. ti:'L "•L distribution cell's
5 r r r• Agg regate «a C r:r.r.x,'r.�.x.x.r.: ".rr"••
cent fine in the
A " distribution cell (AXS).
Project: Jeff Mataczynski 4 bedrrom mound page 3 of 9
r;0d =QI E>;:9T SO —LT -90
Center Connection Lateral Layout Daigram
Force main eonneotion Oa tae a gross to manifold at ang Pam. Laterals an hdemic al
P
• w Turn -up Waif ball valve or (+ X— ••+112 x02 ->1 Laterals & fora main of PVC Soh 40
cleenodPlug pet COIAM TaNt8+4.30.5
Holes drilled an the bottom of the lateral,
Number of Laterals 4 Orifice Diameter 0.188 in
Lateral Diameter 1.25 in Orifice Spacing (X) 328 ft
Lateral Length (p) 44.28 ft Orifices per Lateral 14
Lateral Spacing (S) 3.34 ft Orifice Density 10.72 ft /orifice
Lateral Flow Rate 9.18 gpm Manifold Length 3.34 ft
System Flaw Rate 38.70 gpm Manifold Diameter 1.50 in
Total Dynamic Head 22.28 ft Foroemain Velocity 3.75 ft/sec
Dose Tanis information Locwv cover war, vll
label and locking device and
sealed water6lght'
EkX*ical a5 per NEC 300 and or a In. min,
Comm is.28 WAC
Tank Component is Properly vented < -- AlOW7111 outlet
ICCation
Forcemabt diameter
Wieser Manufacturer 2 In.
Ca a 800.00 Gallons
Volume 22.22 gal/inch A
Weep hole or atrU-
Dimension Ind Gallons 8 siphon device
A 18.80 417.81 C
a 2.00 44.44 Puny of _s w4abon (ft)
C 3.20 71.11 1 86-
D 12.00 Me.84 D
Total wooi 800.00
, Wale talk elevatiort
3" Bedding 6naer tank. 85
Alarm Manuffacuurer SJE- Rhombus Controls
Alarm Model Number ITank Alert 1
Pump Manufacturer Goulds
Pump Model Number 13887 EPOSF
Pump Must Deliver 38.70 gpm at 22.28 ft TDH
Project: Jeff Matac4nski 4 bedfforn mound rage 4 of 9
170d
M21jnd§vstem Maintenance and Operation Specifications
Service Provider's Name Joe Sta r Phone 715 -684 -5166
POWTS Regulator's Name St. Criox County Zoning Phone 715- 386 -4680
System Flow and Load Parameters
Design Flow - Peak 600 gpd Maximum Influent Particle Size 1/8 in
Estimated Flow - Average 400 gpd Maximum BOD5 220 mg/L
Septic Tank Capacity 1200 gal Maximum TSS 150 mg/L
Soil Absorption Component Size 600.3 ft Maximum FOG 30 mg/L
Type of Wastewaterl Domestic Maximum Fecal Coliforml >10E4 cfu/100 mL
Service Freguency
Septic and Pump Tank Inspect and /or service once every 3 years
Effluent Filter Should inspect and clean at least once every 3 years
Pump and Controls Test once every 3 years
Alarm Should test month)
Pressure System Laterals should be flushed and pressure tested every 1.5 years
Mound Inspect for ponding and seepage once every 3 years
Other
Miscellaneous Construction and Materials Standards
1. Observation pipes are slotted and materials conform to Table Comm 84.30 -1, have a watertight cap,
and are secured in as shown in the mound component manual.
2. Dispersal cell aggregate conforms to Comm 84.30 (6)(i), Wis. Adm. Code.
3. All gravity and pressure piping materials conform to the requirements in Comm 84, Wis. Adm. Code.
4. Tillage of the basal area Is accomplished with a mold board or chisel plow.
5. The mound structure and other disturbed areas will be seeded and mulched to prevent soil erosion
and help reduce frost penetration.
Lateral Tum-up Detail
Finished ...............
Grade `
6-8" Diameter Lawn pop Threaded Cleanout
Sprinkler Valve Box Plug or Ball Valve
.
Distribution
Lateral
Long Sweep 90 or Two
45 Degree Bends Same
Diameter as Lateral
Project: Jeff Mataczynski 4 bedrrom mound Page 5 of 9
Mound System Management Plan
Pursuant to Comm 83.54, Wis. Adm. Code
Gaw al
This system Shall be operated in accordance with Comm 82-84 Wis. Adm. Code, and shall maintained in accordance with its' component
manuals (SBD- 10691 -1 (N.01101) and SSWMP Publication 9.6 (01/81)) and local or state rules pertaining to system maintenance and
maintenance reporting.
No one should ever order a 9WW or pump tank since dangerous gases may be present that could cause death.
Septic and pump tank abandonment snap be in accordance with Comm 83.33, Wis. Adm. Code when the tanks are no longer used as
POWTS components.
Septic or pump tank manhole 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. F_ngosW access openings great than 84nches in diameter shall be secured by an effective locking device to
prevent accidental or unauthorized entry into a tank or component.
SerAjc Tank
The septic tank shall be maintained by an indiMuel certified to service septic tanks under s. 281.48, State. The contents of the septic tank
shall be disposed of in accordance with NR 113, Wis. Adm. Code. The operating condition of the septic tank and outlet filer shall be assessed at
load once every 3 years by inspection.
The outlet filer 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
shell be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm.
The septic tank shall have Its contents removed when the volume of sludge arid scum in the tank exceeds 113 the digcdd volume of the tank. If
the contents of the tank are not removed at the time of a triennial assessment, maintenance personnel shall advise the owner of when the next
service needs to be performed to nrakdalt less than modmu m scum and sludge accumulation in the tank.
The addition of biological or chemical additives to enhance septic tank performance is generally not reined. However, if such products are
used they stall be approved for septic tank use by the Department of Commerce.
E" Tank
The pump ( dosing) tank shall be inspected at least once every 3 years. Ali svvitches, alarms, and pumps shall be tested to verify proper
operation. If an effluent filter is Installed within the tank it shall be inspected and serviced as necessary.
Mound and Pressive Distribution System
No trees or shrubs should be planted on the mound. Plantings may be made around the mound's perimeter, and the mound shall be seeded
and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic (other than for vegetative
maintenance) on the mound is not recommended since sot compaction may hider aeration of the infiltrative surface wffl* the mound and snow
compaction in the winter will promote frost penetration. Cold weather installations ( October - February) dictate that the mound be heavily mulched
as protection from freezing.
Influent quality Into the mound system may not oweed 220 mg/L SOD 150 mg/L TSS, and 30 mg/L FOG for septic tank effluent or 30 m91L
BOD5, 30 mg/L TSS,10 mglL FOG, and 10' cfW100 mL for highIy treded effluent. Influent flow may not mooed mmilmum design flow specified
In the permit for this installation.
The pressure distribution system is provided with a flushing point at the end of each lateral, and It Is recommended that each lateral be flushed
of accumulated solids at least once every 18 months. When a pressure testa performed it should be compared to the initial test when the
system was installed to determine if orifice clogging has occurred and if orifice cleaning is required to maintain equal distribution within the
dispersal cell.
Observation pipes within the dispersal cell shall be checked for efflux ponding. Pondirg levels shall be reported to the owner, and arty levels
above 6 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring.
C n ffi= cv Plan
If the septic tank or any of its components become defective the tank or component shah be repaired or replaced to keep the system in proper
operating condition.
If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective oomponerd(s) shah be imrneoletely repaired
or replaced with a component of the same or equal performance.
If the mound component falls to accept wastewater or begins to discharge wastewater to the ground surface, lt will be repaired or replaced In
its' present location by increasing basal area N toe leakage occurs or by removing biobgicahy clogged absorption and dispersal media, and related
piping, and replacing said components as deemed necessary to brig the system into proper operating condition.
See Page 5 of this plan for the name and telephone number of your local POWTS regulator and service provider.
Project: Jeff Mataczynski 4 bedrrom mound Page 6 of 9
16d 6T9VT9Q9TL :xOHA :OZ 66 :LT 56 -OZ-Ve
NG O ULDS PUMPS Subawsibl
Effluent Pun*
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APPUCATIQNS • Fully submerged in high ■ ON tom: Thermo- • B~ Upper aW lower
Specifically designed for the grade turbine oil for plastic encluod design fir heavy duly WAap
followliv uses: lubrication and e#ficir►t improved petimmanm c:orstructiom
Effluent item heat transfer: • fig aid ttaw Rugged
• Homes Atr WkW tortbaatic and design p vMes AGENCY LONG
'fig rNgl operatim- Caw�odsaas
• Newry duty sump models Include Medumigt
Water trenWer Fho $wlkb wed a Melor goes* CM iron (CSA listed model numbers
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• Qewate N grad art the Mg for ~ t" trier, and in "F" or *C*.)
and "
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Solids handling capalilliiy_ IN M tmpeger: ltarmo- flon wAO afthm
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• capacities: up to 00 GPM.
wlih out as for
• Total twads: up to 31 feet. md�nimp v�an
cal' seat pivaction, 0 1 0 6M Cable Severe duty
• Discharge Sbw I'm NPT. rated on and waver resistant
• MWenical seat Carbon -
BUNA -M e18610ffers_
• Temperature:
104OF (40°C) continuous
140OF (60co irdermitimc PETERS, PUr . —
• Fasteners: 3W series 10 ��
stainless steal.
• Capabu►+ of runner$
dry without daa W to
compcnierds, e } ( � 39 Pr
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.— MAY- 2 2 - -04 07:59 AM P. 02
Wisconsin Uepa or Commove SOIL EVALUATION REPORT Pape of 3
Oivision or Safery and Buildings
in accordance wM Comm 85, WIO. Adm. Code
C-
ANach camplets alie plan on paper not lets than 8 112 x 11 Inches In Otte. Plan must
include. but not Hated to; vertical and horizontal reference point (9M), direction and Parosf I.D.
percent elope, sale or dimensions, north arrow, and location and distance to nearest road.
Please print all Information. Reviewed by D t.
v.rsanhi Wom eow you provide msy M used for acardsry ptirmso ("my Law, a. 16-04 (1) (NO).
Prq» Owner Properly oCa
a4 Oovt, Lot �, 114 f, 114 S .' ( T' �8 N R E ( w
Prolwrly Owner's Me nii Add ts L01 * Blau k tit or CS
C4 tale zip code phone Nuniber pry ❑ 111190e own Nearest Rood
43 'New Construction Use; ❑ Rsakiential / Number of 0"moms .... Code derived design Now rate _ OPD
Cl Roplacernant Q Publle or cane e►dall - Describe: •
Parent material _ „r�� r' r~ Flood Plain elevation N eprritaWa a 4 R
General corrrmenIn /on a'D
E f ec o "a some. - ----
9arir•p N C) Boding
t"5 PII Ground surface elev. rt. Depth to )kn*q factor In.
Hodson Depth Dar dmrd Color Radox Description Texture Stntebre Consistence Boundaryjftwo in. Munset Qu. Sz. Cont. Odor
it Qrouna surface etsv. 91UL 1L . Oepdt to N n tg (ador,,..,� ,, In.
Horizon Depth Oomkwo Color Redox Description Texnrre 9tructWe Consletonce Boundary Roob. + •E
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The Department of Commcrcc 1: an equal opportunity aarvlce provider and employer. if you need assistance to $oases oar Flo" or
need material In an alternate format, please contact the department at 6011- 266 -3151 or TTY 606 - 264.0777.
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of 3
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code County
Attach complete site plan on paper not less than 8 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. 7i 1
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. ?1 �� I
Please print all information.
�Re' ed b Date
Personal information you provide may be sed for w, S. 15.04 (1) (m)). 5 Oq
Prop e Owner Property Location i - 7 - 1
i � ' ciS2 Govt. Lot 1/4 �1/4 S ( T �g N R
Property Owner's Mailing Add ss Lot # Block # Subd. Name or y M# lZ 9 O b f h -e
City State Zip a zPi( ,i_ E] city ❑ 7il own Nearest Road
I �as U •e j 3D v
New Construction Use: ❑ Residential / Number of bedrooms -T— Code derived design flow rate GPD
❑ Replacement ❑ Public or commercial - Describ X fL
Parent material �� ` Flood Plain elevation if applicable //
General comments V � o Cp Q� C 001 r0(ki- /0 0,0 5--
a d recomme aeons: f %�QZ e Gc�'j' d'�
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Pit Ground surface elev. ' /r � P g -- --�- -- in ' Soil ADDlication Rate
.% Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD
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In YR s a •
Boring # Boring
it Ground surface elev. ft. Depth to limiting factor In. Soil lr�t(On Rete
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft'
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Effluent #1 = BOD > 30 _< 220 mg/L and TSS >30 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS 5 30 mg/L
CST pne (Please Pr1nQI I Signature CST C Number
Address r . e E4aluation Conducted Telephone Number
i y7�
� - 1
Property Owner & � S e Parcel ID # Page of _
n Boring # El Bo' a n -�J J Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate
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Boring # Boring Ground surface elev. Depth to limiting factor 1SZ_ in.
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Effluent #1 = BOD > 30 _< 220 mg/L and TSS >30 _< 150 mgA- ' Effluent #2 = BOD _< 30 mg/L and TSS 5 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.
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGRBEMBNT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer e-q M r" 4 sV
Mailing Address
Property Address
(verification required from (V zCq Planning Deparrment for new construction)
City/State �� s� �✓ Parcel Identification Number OZ 0 - 10 " Z
LEGAL DESCRIPTION ( . PHIS
Property Location ,UL '/4, N ' ' /,, Sec. T LL N -R-L2-W, Town of
Subdivision
Lot #_
Certified Survey Map # �- 7� Z" , Volume — # Y^
Warranty Deed # 2 9 l 3 v j , Volume Page # 3 q
Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑ no
N CE
SYSTEM MAINTE AN
Tr
use and maintensnceof your septic system could result in its premature failure to handle wastes• Proper mamt== consists of punvping out the septic tank every three years or
sooner, if needed by a licensed pumper: What YY011 put into the system
the function of the tic tank as a treatment in the waste disposal stage system.
can affect septic g
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
waswphumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on situ waatewaterdisposal system
is is pmper operating condition and/or (2) after inspection and pumping (if necOSSUA the septic less than 1/3 full of rtre tank sludge•
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with tine 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
ZA 30F expiration te.
AP ANT DATE
QWNER CERTIFICATIQN
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of
4 theZ n ve, by virtue of a warranty dad recorded in Register of Deeds Office.
*W AtM OF APPLI DATE
00***s Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Departs
• 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
I
•. 511!2005 11 38 AM FROM Fas: Whispering Pines LLC TO 15184940870 PAGE. 001 OF 001
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779134
�, ' p
L) y U j KATHLEEN H. WALSH
y 6 A ' ' DAVIT' OF REGISTER OF DEEDS
CORRECTION ST. CROIX CO. WI
Document Number RECEIVED FOR RECORD
(TYPE OR PRINT CLEARLY IN BLACK OR RCD INK) 11/05/2004 01:40PH
AFFIANT, Tanya Y— Seeg hereby CORREE TIIV�E AFFIDAVIT
swears or affirms that a certain document recorded on .the 16th day of
September 1 2004 (year) in volume 2657 1 REC FEE: 13.00
Page 461 , as document number 774532 which was recorded TRAITS FEE:
in g C t croix County C
, State of Wisconsin, contained the following C F FEE:
C FEE:
error (if more space is needed, please attach addendum): PAGES:- 2
Typographical Error
Grantee's Names read as:
Jeffrey Mataczynski and Corrin V on Wold, both
sinle persons as joint tenants
Recording Area
AFFIANT makes this Affidavit for the purpose of correcting the above document Name and Rea
as follows (if more space is needed, please attach addendum): Return to:
Title One Premier Group, Inc.
Correct Grantees Names should be Hudson, WI 54016
Jeffrey Mataczynski and Corrin Von Wal d, both
both single persons as joint tenants part of 1029- 10 - 00'
Parcel Identification Number (PIN)
AFFIANT is the (check one):
❑ Drafter of the document being corrected. '
❑ Owner of the property described in the document being corrected.
Xft Other (explain: Title Company ) ,
The original document (in part or whole) X1 is ❑ is not attached to this Affidavit (if origins utnent is not attached, please attach legal
description and names of grantors and grantees).
Signed:
//)�M, 74
+ a a eeger
hate of Wisconsin )
ss.
-ounty of St. Croix )
>ubscribed and sworn to (or affirmed) before me this
4th day of November , 2004 �(
p UQ�� '
C
Jotary Public, State of Wtsco sin [U\Y`/. k
4y Commission (expires) (is): 12 _ i a -G PALM
'HIS INSTRUMENT WAS DRA"6 BY:
Tanya Seeger, Title One Premier Group Or 1iJlS s
706 19th Street South, hu dson, 16 " >��
This inslrumen0gos p is not (clieck one) a conveyance of real properly as per s. 77.21(1) Wisconsin Statutes.
(A Wisconsin Real Estate Transfer Return is required for instnlments that do convey real property. ) _
Names of persons signing in any capaciry nmst be typed or printed helow their signature.
7Co`1��5
U 2690 P 347 774532
rtl 5 1 i7 P u 1 6 STATE BAR OF WISCONSIN FORM 1 - 2000 KATHLEEN H. WALSH
WARRANTY DEED REGISTER OF DEEDS
Document Number ST. CROIX Co.. W1
This Deed, made between Kurt Christensen and RECEIVED FOR RECORD
Elizabeth Christensen, husband and wife 09/16/2004 10:06AN
Grantor, WARRANTY DEED
and Jeffrey Mataczynski and Corrin Von Wold, both EXEMPT #
single persons as joint tenants REC FEE: 11.80
TRANS FEE: 227.70
Grantee. COPY FEE:
CC FEE:
Grantor, for a valuable consideration, conveys to Grantee the following PAGES: 1
described real estate in St. Croix County, State of
Wisconsin (the "Property ") (if more space is needed, please attach addendum):
Lot 2 of Certified Survey Map recorded in Volume 18
on page 4822 as Document No. 772742 being a part of
the Northeast Quarter of the Northeast Quarter (NE'a Recording Area
of NE's), Section 21, Township 28 North, Range 17 P
West, Town of Pleasant Valley
RETURN TO:
For Reference Only: Tax Key No.: part of Title One Premier Group
024 - 1029 -10 -000
XXX 30th Ave. Hudson, WI 54016
Hammond, W1 54015
part of 024 - 1029 -10 -00
Parcel Identification Number (PIN)
Together with all appurtenant rights, title and interests. 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
Roadways, Easements, and Restrictions of Record.
Dated this 13th day of September 2004
*Kurt Christensen 1' abeth Christensen
* *
AUTHENTICATION ACKNOWLEDGMENT
STATE OF WISCONSIN )
Signature(s) ) ss.
St. Croix County. )
authenticated this day of Personally came before me this 13th day of
Kay V- Pl "ny September 2004 the above named
.._....... PUbUC Kurt Christensen and
*
%Aflgainnal Elizabeth Christensen
TITLE: MEMBER STATE BAR OF
(If not, to me known to be the person s who executed
authorized by §706.06, Wis. Slats.) the fore ' 'ns n d I the same.
THIS INSTRUMENT WAS DRAFTED BY
* Ka
Michael H. Forecki, Attorney NotK Pub tc, State of Wisconsin
Eau Claire, Wisconsin My Commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.) December 12 2004 .
"Names of persons signing in any capacity must be typed or printed below their signature.
WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 1-2000
Attorney Michael H Forecki 3452 Oakwood Hills Pkwy Ste 1, Eau Claire WI 54701 -7928
Phone: (715) 835 -3029 Fax: (715) 8354112 Title One Premier Group T4895283.ZFX
Produced with ZipFormTM by RE FormsNet, LLC 18025 Fifteen Mile Road, Clinton Township, Michigan 48035, (800) 383 -9805 www.ziuform.com
\ i
VOL 18 PAGE 4822
KATKLZM H. ALSH
REGISTER OF DEEDS
CERTI FI E[I SURVEY MAP RECEI hECORD
LOCATED IN PART OF THE NE 1/4 OF THE NE 1/4 08/26/2004 041 15P
OF SECTION 21 T28N R17W TOWN OF CERTIFIED SURVEY MAP
PLEASANT VALLEY, ST. CROIX COUNTY COPY FEE: 3.90
WISCONSIN PAGES-. 2
N 1/4 SECTION CORNER FIELD DRIVE LOCATED ON LOT 1
POSITIONED FROM ST. TO BE REMOVED AT TIME OF
N 114 CORNER CROIX COUNTY GPS DRIVE CONSTRUCTION
SECTION 21 COORDINATES SECTION 21 PRIVATE
N89 °38
U- ENTRANCE NE CORNER
'14 " E - - MM - ' - - --
1310.92' 3 .59' 36.46' �
rn t - 4 "E 131 93' NORTH LINE OF THE NE 1/4
a?., 492.30' N8935'42 E 1277.94' 649 . 74 Q�K �V
6.00'+ 1 2.89 - 500.24' - 608.81' T ca
168. ' 1 36.93'
z x -V -' PROPOSED N FIELD ........�
..�.. ..� ..- ................ �N�fIVCE ..................
m � � �EN�f-IMA�iF< a�IVE
ELEV. = 1138.79 i '� O
O m m o OD S00 °07'29 E BENCHMARK 7 O
Z i m < O i 148.23' ELEV. = 1125.84 Z LOT 3 I
m m m + mm � �3 �: A
n o ° i m o �a LOT 8.01 ACRES INC. R/W / I: rn
m g 348,992 SO. FT. i ^ O
0 7.00 AC INC. R/W Qa 1z I
BENCHMARK s'„ 304,921 SQ. FT. 7.10 ACRES EXC. R/W
ELEV. = 1122.06 n
a i m a 309,254 SO. FT.
m� LOT 7 ` 6.59 ACRES EXC. RAN -s +
T+ a 5.18 ACRES INC. RNV 286,918 SQ. FT. / /i 4 �33 33'
I +�
j Z �j y 225,727 SO. FT. �� _ �� 3 +
(�
a O �cn' 5.04 ACRES EXC. RNV
O m i 219,559 SO. FT.
V m NOTE:
mITHE THE SEPTIC SYSTEM FOR LOT 1
o MAY NOT BE INSTALLED WITHIN A.09 °4 326
0 66' WIDE ACCESS EASEMENT. N�5 °4 ' E 3a $�� m o
6.0 '+ 455.05' Tc O
O N89 °38'14 "E 521.05' 12 �
m mI
W BENCHMARK + m I
c7t ELEV. = 1119.08
CO A
Q I I
LOT 4 c O
,� = j a ,G�Jn_o VO_MFG
m 8.62 ACRES / tiw¢�� c G3L---- - -DC-D m
O cn A 375,477 SO. FT.
m NOTE: NO OWNER OR RESIDENT SHALL
m DO ANYTHING WHICH WOULD
Z
Q
INTERFERE WITH OR CHANGE THE E 1/4 CORNER
m i j V OPERATION OF THE WATER DRAINAGE SECTION 21
A �/
O AREA LOCATED ON THIS C.S.M.. THIS
T� 0 60' WIDE DRAINAGE ARI?Ari - INCLUDES BUT IS NOT LIMITED TO
m 30' FROTHS E CENTER OF r l ,� BUILDING UPON, OBSTRUCTING,
/ ALTERING, FILLING, OR EXCAVATING OR
PLANTING IN THE DRAINAGE AREA. Pi
a SOUTH LINE OF THE NE 114 OF THE NE 1/4 cn ca
S89 °36'33" W 645.05' 7-1 T
�apn arc o �aa�� 0 y
-- - - - - --
NOTE: LEGEND o
a m
THE LOTS SHOWN ON THIS MAP ARE LOCATED IN AN � m
AGRICULTURAL AREA. OWNERS OF THE LOTS SHOWN MAY ALUMINUM COUNTY SECTION T
EXPERIENCE EXTENDED HOURS OF FARM EQUIPMENT CORNER MONUMENT FOUND v m
OPERATION DURING VARIOUS TIMES OF THE YEAR OR Z z
I MAY EXPERIENCE ODORS ASSOCIATED WITH LIVESTOCK. 0 3 /a" X 18" IRON REBAR SET WEIGHING M
1.50 LBS. PER LINEAR FOOT
O O0
.. - - - - - - - - - .100' ROADWAY SETBACK LINE _
m
OWNER SURVEYOR — — X EXISTING FENCELINE
KURT AND ELIZABETH EDWIN C FLANUM
CHRISTENSEN NORTHLAND SURVEYING, INC. A SOIL TEST
877 BENDY DRIVE P.O. BOX 14 SCALE IN FEET I " o 200'
HUDSON, WI 54076 ROBERTS, WI 54023
THIS INSTRUMENT DRAFTED BY SAM ADAMS
JOB NO. 04 -72 DATE 7 -20 -04 SHEET 1 OF 2 SHEETS 200 O 200
Vol 18 Page 4822