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024-1029-40-200
o f m c v1 7 1 c 7 7 3 ,r CD Co A M n o •^' CD m n !� 4 O St O y O 0 0 0 O 0 O co 0 (D — N `C v OD (D ,7.. a 0 (D 0 0 n (p O O N 0 � aD (D O ^ CD "' 3 m ° Qo I a Po 0° O y(A m U) m O O A o l (D a a D ai a a N l (o D y a N ? Ul CD W N m m N 1 3 a �� n �o N CD ° 00 ° w � �! 0 o °O a l 0 o a': N O C N N E I W "Rd• 0 - z g 0 g 0 0 3 I 0 0 0 3 CO y N a Q a o z �l 3 0 O O = m M O C do _ _ _ m I �0 CD fu CL 0 3 O a o O ? D o 7 7 O m a I I R n X X m I m c c C.) I z m I CD -f CA p > > p z N 0 rn 0 A C a. 0 M N M 00 03 83 z Z .. 3 .. m 2 N CD y n f I A CD y c $ m N ao n < 0 °c a n CD d 3 (D v a C m 7 fn 3 G7 (D x 3 O O . c 3 O .Z O G CD 0 O N 7 N N C 5f 'CD N C CL I °mvNc a I a a o rr ° o�i m m CD m O 7 N 0 y np 3 D0 I 0 a Do�3 ya y CA 0 (D N 0< I O 7 v, j 0 (y N a'1 N C 00 C'O I A Nqa) an= O N y C m I m 7 N z� m y 7 0 0 � n O o3 ce.CD N � n _.0 :3 O z0 nm A 7 O �• 0 0 ?j CD I CD Op 0p 0 0 o e N ° o n ° o o Parcel #: 024 - 1029 -40 -300 04/18/2007 11:52 AM PAGE 1 OF 1 Alt. Parcel #: 21.28.17.1806 -10 024 - TOWN OF PLEASANT VALLEY Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner O - HAUGE, DAVID G & CAROL J DAVID G & CAROL J HAUGE 252 CTY RD T HAMMOND WI 54015 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description " 252 CTY RD T SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 6.067 Plat: 4426 -CSM 16/4426 SEC 21 T28N R17W SE NE NE SE FORMERLY Block/Condo Bldg: LOT 3 LOT 1 CSM 15/4134 NKA LOT 3 CSM 16/4426 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 21- 28N -17W SE NE Notes: Parcel History: Date Doc # Vol /Page Type 03/31/2003 715178 2187/547 QC 03/01/2002 672459 1846/169 QC 2007 SUMMARY Bill #: Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 04/20/2006 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.000 21,900 186,700 208,600 NO AGRICULTURAL G4 5.070 400 0 400 NO Totals for 2007: General Property 6.070 22,300 186,700 209,000 Woodland 0.000 0 0 Totals for 2006: General Property 6.070 22,300 186,700 209,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 568 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 59 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)1. Permit Holder's Name: City Village X Township Parcel Tax No: Hau e, David & Carol I Pleasant Valley Township 024 - 1029 -40 -200 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 21.28.17.1806 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) 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 Bed/Trench Edges Topsoil Yes M No Yes [ _j No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 252 County Rd T Hammond, WI 54015 (SE 1/4 NE 1/4 21 T28N R17W) NA Lot 1 Parcel No: 21.28.17.1806 1.) Alt BM Description = 2.) Bldg sewer length - amount of cover = 3.) Contour = Plan revision Required? F _1 Yes (] No Use other side for additional information. SBD -6710 (R.3/97) Date Insepctor's Signature Cart. No. County Sanitary Permit Application ST CROIX COUNTY WISCONSIN In accord with 15.04 St. Croix County Sanitary Ordinance ZONING OFFICE Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER (Privacy Law. S. 15.04(1)(m)) 1101 Carmichael Road Hudson, WI 54016 -7710 (715)386 -4680 Fax (715)3864686 Attach complete plans for the system on paper not less than 8 -1/2 x 11 inches in size. County�nitary Permit # ❑ Check if revision to previous application f Cho 6 1. Application Information -Please Print all Information PLot n: Property Owner Name 1/4 1/4, Sec M AY 0 7 2003 N, R (or) Property Owners Mailing Address mb�r Block Nu be ST. CROIX COUNTY ZONING OFFICE City, te Zip Code Phone Numer Subdivision Name SM Number f. 11 Type of Building: (check one) / Ocity ❑ Village own of 0 1 or 2 Family Dwelling - No. of Bedrooms: �Cl s 7 /U(r- 2!�� ❑ Public/Commercial (describe use): ❑ State -owned Nearest Road 11. Type of Permit: (Check only one box on line A. Check box on line B if applicable) 001M CLzz Parcel Tax Number(s) A) 1 1.0 Repair 1 2.0 Reconnection 3. 01SIon - plumbing . ❑ Rejuvenation / a -tl Sanitation 8) Permit Number Date Issued State Sanitary Permit was previously issued Q 12— Q a-7 10 IV. Type of POWT System: (Check all that apply) ❑ Non- pressurized In- ground 14 Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other . DispersaUTreatment Area Information: S L _b 02. 1. Design Flow (gpd) 2. Dispersal Area 1. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. 9ystern Elevation 7. Final Grade Required Proposed (Gals. /day /sq.ft.) (Min. /in Elevation I. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks - ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ It. Responsibility Statement I, the undersigned, assume responsibility for repair/ reconn nction/rejuvenationMstallation of non - plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installati of non-plumbing sa itation system. Plu Nan Plumber' at s MP /MPRS No. Business Phone Number t _ Plumbers Address (Street, C' y, State, Code ep Ill. County Use Only Disapproved anitary rmit Fee Da Issued ssuing A t Signatur o stamps) CK / App roved Owner Given Initial Adver�e Determination ( /D IX. Conditions of Approval /Reasons for Disapproval: /1 FGr 7�i�2ooz� �� mQ,J:,, a rr► �e�d S�'� - lA4- we , ,P� ti-t' 4.1 c4 loon 6-Pn is 4 6�y J �IuJ�G �� 8Z. 3o �0 Le - cz-��Q ritr% a h(,-a6 A �s 414. i s 0 i Cf j i r � llJeusJG moo' Private interceptor Main Sewers 1 July 1, 2002, Comm Table 82.20 -2 1 4 inch diameter private interceptor main sewers no longer require department review 1 Counties should review designs 1 Code change pending regarding department 9 P 9 9 9 P reviews for 2 buildings served by one POwTS 1 Defined: Means a privately owned sewer serving 2 or more buildings and not directly controlled by a public authority lb chi h°- ✓t� Private Interceptor Main Sewers �o, s s-�"` p L .� r Comm 82.30 (12) Y44 - 4-y� Setbacks, pitch, • �Clcanout installation same as �s = a" PVC for building sewers Building Comm 82.30(11)(c), Sewer (d), and (e) 1 Frost protection same as for building Private Directional Fitting sewers Interceptor Frost Sleeve 1 Qw mq r uired at Main Sewer 4 the 2 CO in Direction point of the PIMS *< Holding of Flow See Comm 82.35 >;Y Tank 4- 1 Cleanouts <= 100 ft Access Road apart. Cleanouts require a frost sleeve I I --I -u 0 cn _ I � �A O c cn D z m y m z _ co x o O m 0 X O 'C 0 cl) m 0 —v m N n < o co X r tj m O C -n r n OW v c u 2 c D Z = c = —� C7 G)m 0 Z O m C m C/) z �1 Z D z o C CDO r- Fn co N p (n c Cn c o (/) zz < — --I I Z m o C7 Zz m z W I d m m ' mm E ° d3v m6 -,is m o c m f � �� m� c W D C n y �' C 7 0 ° O 7 p N (r 0 m m f 3? f d a f v v °- c Iv "� a a CD �nm m� mho °� ° o� c m 0 , o m n° 03 > CD ..L ` X X ... N 7 y N 7 0 C" 0 W n y n .Z _ d W< C �. ,z 7 r. W �� �� -' =0o 'a �� Ill p N o o a a o f N v D Hv, co m O a �? �_ ° a m ° m �, O m H `° y m O a m u ° �o °• 0 :i1 W < d o L O co y � o cc - D o z o w - m y 7 • m_ �' N v m z C z a, AD O d W� W 0 n�• y y n m m (D H I 0 o y H 1 -i -I H. 7 y O ,Q, z z !n z M C H d 7 W N N O 7 O O L 7 N 7 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division t Jill; INSPECTION REPORT Sanitary Permit No: 405012 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: Hau e, David & Carol I Pleasant Valley Township 024- 1029 -40 -200 CST BM Elev: Ins,. BM Elev: BM Description: L too •fl' Co • c7 l•+r vwwf.Q = �a1t`st 00114 M " TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic �t.S �_ t�� enchmar�C i r term . DSO 0%2 _ Dosing �l It. BM Aeration J Bldg. Sewer /0 4Q �� 42• 3 Holding SUHt Inlet lA t S� tIo -7S TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic ZO 39 t Dt Bottom tL 30 Dosing Header /Man. �r .., o 3.7- off_ Aeration Dist, Pipe 3.3o Holding Bot. System 3 • f j0 r o k - 20 Final Grade PUMP /SIPHON INFORMATION �;(( t'Z -- Manufacturer V. P ernand St Cover G p GPM � tS. 40 t k M odel Number ^ � r 1 / TDH Lift Frictio�L�� Syste Head T �` Ft Forcemain Length [ilia. Dist. SOIL ABSORPTI SYSTEM Sri f*RSWH Width r Length t No. Of Tm*"fies PIT DIMENSIONS No. Of Pits • Inside Dia. Liquid Depth DIMENSIONS� SETBACK SYSTEM TO P/L BLDG IWELL LAKE /STREAM LEACH G nufacturer: INFORMATION CHAMBER Type Of System: DISTRIBUTION SYSTEM / Header /Manifold Dl t ' x Hole Si e t ( x Hole Spacing Vent to Air Intake D '� , p Pipe(s) f p O ' Length 3 ' Dia Length ' a f Spacing 3' $ SOIL COVER Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded Mulched Edges ITopsoil Bed(rrench Center Bed/Trench Ed g lop Yes [] No xx Fn� Yes No " CO ME S: (Include code 'screpe i ersons present, etc.) Inspectio At { 710 � Inspection �/ 1 - l �,' � Lo on: 52 County R T Hammond, WI 54015 (SE 114 NE 1/4 21 T28N R17W) NA Lot 1 rrut arcel Np: ?,1.28 17.1 1.) Alt BM Description tAZZ S.0 . � ►�I'. �� "" � g i s 2.) Bldg sewer length = ^.( 0t amount o cover srtw�o� fo� 3.) Contour =(100 .SID Plan revision Required? ; Yes No y �� Use other side for additional information. t_ Date In j se - pctor'sSignature � Cert . SBD 6710 •�h A-� � .r¢slt�[ . OG+ts► 1 J } �~ r x� a �. 'w _, _ � �� 1 t - 1 ��. t �__ / � � ' � •� � , � �' .. ' !„ �. y � ' i �� '% . 11. 5 s r � .. .� � � �. ♦ 1 i e�r i4�t� - M• . _ - - - -- -�- c�tr i Sala d Suildinps Ilivision S��Yd ,' _--! washinaton Ave,, P.O. Sox 7162 --- ---- -- Madison, V.1 53707 7162 Site Address �sconsfi� pe artment of Commerce ----- SanitsuY Permit Number Sanitary PerWt Application yos ncZ informadon you provide heck if Revision In accord with Cotaax 83.21. Wis. Alta• Code, Per� w :13. 1 m My kLy for sec Stste Plan LD. NF L Iafor*Ww - Pis>sse Trott All Ildotmatloa RECE`� ED pF Numbe r 'a Nam 2002 —iox?Jrb g s Fropety Lo p Ownai a Marlin: MOM ST CRW, COUNT Y cgdoa MG QFFICE Std !f 5 ; I T N R ? B Y,ot Number 131ock Number Zip code um r l Chy. Staoa CSiK i~tunbec Su vision Name w, r � S . 4 03 4 t a, at StsildIN (cluck zu that apply) OCigr 1 or 2 Family Dvt *Uh* - Numbsa of Bedrooms QViiliBe ll D =O U n . Nall c C. t ``� "= o • s - u iP M. T7" of (Check Dray aloe box oa c A (ntmtberio9 seheaoe for lt><er� WO) . Contplet� line B it gpp� cable} A. 1 low 2 0 paplaeament System 9 0 of 6 Addition to For Cotaa4 use T onl S sdeat Date Issued 8. P fP* � if Sankary Permit Prevkmwy Is sued Permit Numbor (6 Zop rV. Type of P�eruttts (Checlt all that s►pply)(numberinR scheme h for Internal WGPIE O p In- Ground 2,V Mound 47 ❑ Sand Furor ' SO ❑ Const=ucaed wedsnd 4a 0 N ' 0 � � 4111 gam Tsai; 49 0 Siagle Pali S1 ❑ Drip Lae 22 a 0 At•arade 46 0 Mrobio Traaaaent Unit 49 0 Reclrcula' 3o 0 odd 4s V. fin' Percolation Rats big== Eiewtion Final tirade Dedp Flaw w At" nal Area So11 Application 13levatioa proposed Itxro(osis.lDayslSq•Ft) (Min.11ttch) d tACauer Prefab site Steel Ffbsr Plastic VI. Tank 1Lnto ltY iu . Toot Number Coa¢seta Constauted Glass Cialloai "am of Tanb NOW T Sepik or Iloidinti Teak - �d 1?tuioe c� x S Q U e- 2y , statement t, the moms res Rit for of the pOVVT3 *00% oa the attaehed s Plume Number V umber'I Naar MAW) Plumbor's Sienaan Number Busipes� Flumboc's Addou (Street. City. State, Zip Code) d s� VIII. Cotmt IDs Use O Sipaure (No Stamps) Sanitsay Permit Fee (includes i3rouadwater Date Issued Issoiss8 oat AS Approved 0 DWwwved SurcharSe Fee) [� owner Given mule! Adverse IX. Condtttoat at pFproraUAwsons for DiaaAFrova! A tMX.'Q"t– ts.�tls�`. � r ` A - 14 rw�'�ie.• i3 �" �"�'s`'c-��e� ,- ya tr►c S ea aoe lei : u iDrba Is rise SIB (R. 05!01) sPc u - `'`s l •• �"�'�. -.� "° f""' G« PLOT PLAN Scale 1 Page 3 of 7 1 / � Q i i i r O I_ L4 ev tz-m • : vM G Utz —� o • � 1 Ave i s e) I L., m,o' OQ N`�1CwU LOT LtQE I ? goo' I r o . �o ��r eo ►'�lPfl - �T o rc /i /� � $ _CU-1 DC frtiL I ,i i s O -� S . �PttUtJ � M Whip t v Zo6 10 0 NOTES; 1 . Elevations shown are existing w g ro u n d elevations unless otherwise noted. 3. Septic tank to be approved caps. ( 2. required). ZOp �f3op gallon capacity manufactured by 4. Bench mark _ EF�- PVB0 UL �. Divert surface water around system to prevent ponding at the uphill side. Wisconsin Department of Commerce SOIL EVALUATION REPORT Pa a of ty and EErildings g 3 Division of Sof in accordance with Comm 85, Wis. Adm. Code ST C�Z O —I Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County � include, but not limited to: vertical and horizontal reference point (BM), direction and Parc I I.D. ru1� percent slope, scale or dimensions, north arrow, and location and distance to nearest road' 'Lu ZoD Please print all information. 002 171 we by Date " `' Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). � Property Owner Property Location ST. G?ZO!�; COUNT _ ��w D — - - L L. I 6ovtLot �� 1/4 rl F .11 E o W c' Property Owner 1 Owner's Mailing Address Lot # Block # Subd. Name or CSM# CSM � 0 \S , L) Iay City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road New Construction Use: [R Residential / Number of bedrooms Code derived design now rate (1 d O GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material L b g O U E 1Z Flood Plain elevation if applicable ] A ft. General comments i " and recommendations: ►`1 U KJD w� l 0 o r - ZJ \S71ZLb V jl OYJ (2-QL _ Y''1 LM um 6" ot= SMA) F3� 1rt`�,t fv� 6 3uw ❑ Boring # r❑r Boring !C! pit Ground surface elev. ���- 3 ft. Depth to limiting factor 3 2 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 I 'Eff#2 1 -8 lrYlc7.3lz �QH [L 31� — S Z�sb�f 3 zo ZS �.S��z �fy - cS . 1 I t � 5 3z C) mfg ❑ Boring # ❑ Boring `— , Pit Ground surface elev. •cT ft. Depth to limiting factor qS in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture P Structure Consistence Boundary Roots GPD/ft z in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 I •Eff#2 o 1 0\j (-'3 L - e s i t - L - Fs b CS . S • 8 •Z R _31 lU`22316 si Z b cs l`F .S •$ 3 31 -LL kD4R VA - a S t- Z • Effluent #1 = BOD > 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 O 8Z CST Number Arthur- L. Wegerer 220254 Address �iegerer Soil T e s t i n g & Design Service Date Evaluation Conducted Telephone Number 421 if. Bain St. River Falls, RI 54022 '1 - -0 Z 715 -425 -0165 i p • Property Owner I IU G E Parcel ID # o Zy 10Z - 1 ` q C - ZO C) Page L of 3 F�]) Boring # [] Boring Pit Ground surface elev. 91 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 0- ) Oti 2 312 - SL Z `FI^ ' C. Z`F • S 6 - VA 3y-37 �.5��2 Ylb l � -S`�R S�� c p �f� - • v o ' ❑ 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 17 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 • Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L • Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777. SBD -6330 (R.6/00) PLOT PLAN Page � of Scale 1' =y0' I Q - i I� L4 Cl) �!om r y D ' A) Z) S ID � > C) �a 1►�'�6 - -. o 6-4 LOT LINE f goo rs.3 �I - SO PitVIJ� S13so�J_:.. 1�ERM1SS1_D.t�1 / \� 0� 18. �ml � Zoa 7-30-,OZ 715- 425 -0165 220254 0 2_ 18 CST Signature Date Telephone ITo. CST No. Job NO. Uw:1959P 426 I5 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX Co., MI Document No. i i RECEIVED FOR RECORD 0 8 - 26 -2002 4:20 PM EASOM EXEMPT i TRANS FEE: 15.00 COPY FEE: Y FEE: PAGES: 3 etum to: t4V la C. t wv-v f or-y. 5"y 01 024 - 1029 -40; 024- 1030 -50 Parcel Numbers DRAINFIELD EASEMENT Easement made this 9L2 *f "' day of August, 2002, between Clyde S. Jacobson and Joanne E. Jacobson, husband and wife, Hammond, Wisconsin (hereinafter referred to as GRANTOR) and David G. Hauge and Carol J. Hauge, husband and wife, Hammond, Wisconsin (hereinafter referred to as GRANTEE). 1. GRANTORS are the owners and occupants of a tract of land described as: The Northeast Quarter of the Southeast Quarter (NE ;i of SE k) of Section Twenty -one (21), Township Twenty -nine (29) North, Range Seventeen (17) West, EXCEPT the South Two (2) rods thereof. 2. GRANTEES are the owners and occupants of a tract of land described as: Part of the Southeast Quarter of the Northeast Quarter (SE k of NE k) of Section Twenty -one (21), Township Twenty -eight (28) North, Range Seventeen (17) West, Town of Pleasant Valley, St. Croix County, Wisconsin, more particularly described as follows: Lot One (1) of Certified Survey Map dated April 12, 2001, and recorded July 25, 2001, in Volume 15 of Certified Survey Maps, Page 4134, as Document No. 652128, office of the Register of Deeds for St. Croix County, Wisconsin. t U__19�9P 427 3. GRANTORS desire to convey, and GRANTEES desire to obtain, the right to establish a sewerage absorption unit (mounds system) and sewerage pumping pipe across the above described tract of land of GRANTORS. 4. Therefore, GRANTORS, in consideration of the sum of One and No /100 ($1.00) Dollars, receipt of which is hereby acknowledged, do hereby grant, sell and convey to GRANTEES the right to lay, construct, operate and maintain said unit and pipe in, on, and about the property of the GRANTOR, more particularly described as: Part of the Northeast Quarter of the Southeast Quarter (NE 1 -4 of SE 'i) of Section Twenty -one (21), Township Twenty -nine (29) North, Range Seventeen (17) West, commencing at the Southeast corner of Lot One (1) of Certified Survey Maps dated April 12, 2001, and recorded July 25, 2001, in Volume 15 of Certified Survey Maps, Page 4134, as Document No. 652128 being the point of beginning; thence South 89 ° 56'44 "W along the South line of said Certified Survey Map a distance of 150' thence SO °13 "W parallel to the west line of the above- described Certified Survey Map, as extended, a distance of ,14Q; thence N89 °56'44 "E parallel to the South line of the above - described Certified Survey Map, a distance of 150' to the East line of said Northeast Quarter of Southeast Quarter NE '-4 of SE 1 -4); thence N00 °13'49 "E along said East line of said Northeast Quarter of Southeast Quarter (NE 1 - , 4 of SE k) a distance of 140 1 , more or less, to the Point of Beginning. The rights herein granted may be assigned by the GRANTEES in whole or in part. The grant likewise includes the right of ingress and egress on the lands of the GRANTORS for the purpose of exercising the rights herein granted; the right to install a gate or to make a temporary opening in any fence on said lands at the point where such fence crosses the route of said sewerage pumping pipe or lines. The GRANTORS, for themselves, their heirs, successors and assigns, covenant not to erect any structure or other barriers or to take or allow to be taken any action on said lands that would interfere with the installation, replacement, maintenance or removal of said unit and pipe. To have and to hold such right and easement to GRANTEES, their heirs, successors and assigns, forever. IN WITNESS WHEREOF, GRANTORS have hereunto set their hands on the date first above written. U�.1859P 428 Subscribed and sworn to before me the date and year first above written. C1 e S. J , #6obson David G. Hauge A nne E. Ja son Carol J. Hauge STATE OF WISCONSIN ) COUNTY OF ST. CROIX ) ul?;§cfi_ qnd sworn to before t y of August, 2002. pZ�F7� - t j Notary Public t. Croix Curit,y, Wisconsin '3 - '6 .aa -o� THIS INSTRUMENT DRAFTED BY: Thomas A. McCormack Attorney at Law 1020 10 Avenue PO Box 2120 Baldwin, WI 54002 State Bar No. 01011884 SAFETY AND BUILDINGS DIVISION Field Operations Bureau 13 East Spruce Street Ivisconsin INSPECTION REPORT w Chippewa Falls, 54729 ww.commerce.sto tate.wi.us Scott McCallum, Governor Department of Commerce Philip Edw. Albert secretary Date of Inspection: July 18, 2002 Plumber Name and Address: Project Name: Hauge William Schumaker, MP 222990 Use: New - Residence 1070 Scott Rd Legal Description: SE, NE, 21, 28,17W Hudson, WI 54016 Site Number: 630840 Subdivision: Certified Soil Tester Name and Address: Municipality: Pleasant Valley Arthur Wegerer, CST 220254 County: St. Croix 421 N. Main St River Falls, WI 54022 RECEIVED Plan Transaction Number: 649814 Sanitary Permit Number: 405012 Owner Name and Address: David & Carol Hague JUL 2 4 2002 Wastewater Flow: 600 gpd 12221 80 " St North Persons Present: Jon Sonnetag, Stillwater, MN 55082 ST. CROIX COUN Rod Eslinger I ZONING OFFICE An onsite soil verification was conducted with the county inspectors after a third county inspector Kevin Grabau recommended to the installer not to continue with the mound installation because of unsuitable soil conditions for the installation of a mound system. We reviewed soil conditions in several locations in the area of the proposed mound and the slightly altered location where the mound was to be relocated if allowed. One soil boring at the approximate location of CST B -2 appeared to be marginally suitable for an A +4 mound design but did not have the 18 inches suitable depth as reported. All other soil borings revealed distinct redox concentrations in the A horizon and redox concentrations and depletions in the subsoil. It is my opinion that the soil conditions viewed are not suitable for a mound system because the level of seasonal soil saturation is less than 6 inches from the ground surface. A different location for the mound should be sought or a soil saturation determination completed under Comm 85.60(3), Wis. Adm. Code using observation pipes. If there are any questions regarding this report, please contact me. L y G. nsky, W ewater S cialist Ljansky @commerce.state.wi.us E -mail 715/726 -2549 Fax 715/726 -2544 Voice cc: 59county Plumber 9 CST 29 Owner ❑Other Safety and Buildings 4003 N KINNEY COULEE RD LA CROSSE WI 54601 -1831 Vhsconsin TDD #: (608) .wi.us 77 REC. �d� �� www.commerce.statewi.us /sb Department of Commerce www.wisconsin.gov AU 6 2 1 2002 Scott McCallum, Governor Philip Edw. Albert, Secretary ST. CROIX COUNT ZONING OFFICE August 19, 2002 CUST ID No.691727 AYTN. POWYS Inspector ARTHUR L WEGERER ZONING OFFICE 421 N MAIN ST ST CROIX COUNTY SPIA PO BOX 74 1101 CARMICHAEL RD RIVER FALLS WI 54022 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 08/19/2004 Identification Numbers Transaction ID No. 783341 SITE: Site ID No. 630840 David & Carol Hauge Please refer to both identification numbers, County Hwy T above, in all correspondence with the agency. Town of Pleasant Valley St Croix County SE1 /4, NE1 /4, & NE1 /4, SE1 /4,521, T28N, R17W Lot: 1, Subdivision: Proposed CSM FOR: Description: Four Bedroom Mound System - Revision Object Type: POWT System Regulated Object ID No.: 795694 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 Requirements: t'vnatly D � • This system is to be constructed and located in accordance with the enclosed approved plans and with the "Mound Component Manual for Private Onsite Wastewater Systems VERSION 2.0" SBD- 10691 -P (N.01 101) F COMMERCE and the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems VERSION �D PADING S 2.0" SBD- 10706 -P (N.01/01). PONDENCE • Per manual cited above, limited activities are allowed in the area 15 feet down slope of the component area. Soil compaction, excavation, vehicular traffic and other similar activities that impact the treatment and dispersal are prohibited. • The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption area. chs. NR 811 & 812c • A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stat • Comm 83.22(7) A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. 1 ARTHUR L WEGERER Page 2 8/19/02 Owner Responsibilities: • Comm 83.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(1). • Comm 83.52(2) A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. • Comm 83.55 The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required S 60.00 Fee Received $ 60.00 0. Balance Due S 0.00 Charles L Bratz POWTS Reviewer II , Integrated Services WiSMART' code: .7633 (608)789 -7893 , 7:45 am - 4:30 pm Monday - Friday cbratz @commerce.state.wi.us cc: Leroy G Jansky, , Wastewater Specialist, (715) 726 -2544 r TITLE SHEET Page L of MOUND SYSTEM FOR A BEDROOM RESIDENCE This plan has been prepared in accordance with the Mound Component Manual SBD- 10691 -P and the Pressure Distribution Manual SBD- 10706 -P (N.01 101) (N.01 101) LOCATED IN THE TJC 1 /4 OF THE S 1 /4 OF SECTION _Z) , T _�P N, R l__? W, TOWN OF y�Lq"-( , Z. j- `- )( COUNTY, WISCONSIN. DoT' I OC =�-S�l �DL.�S, Pg LlL.1 � INDEX �A ��(► PAGE 1 of 7 TITLE SHEET PAGE 2 Of 7 SYSTEM MANAGEMENT PLAN PAGE 3 of 7 PLOT PLAN PAGE 4 of 7 PLAN VIEW -CROSS SECTION PAGE of 7 DISTRIBUTION PIPE LAYOUT 6 of 7 PUMPING CHAMBER CROSS SECTION Oy� PAGE 7 of 7 PUMP PERFORMANCE CURVE y O PREPARED FOR PREPARED BY WEGEF< ER SC3 I L TEST I hl CG Condi, AND. pp lp'R ]DES 2 Gam! S1ER�1 I CE o PPARTMENT� P.O. Box 74 421 N.�fain St. 00 "_ O �� River Falls, WI 54022 Phone 715- 425 -0165 C�NS /� SEE CORRES Fax 715 - 4 2 5 - 6 8 6 4 X}-..✓ •� - j hHTMJR t • WFGEfiEN D91S► N.ISWOR7 «, i 1 _ _P LPs -- ' ••'... Z i JOB NO. O "Z- 1S Z _Mound System Management Plan page Z of Purguant to Comm 83.54, Wis. Adm. Code Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. 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 filter shall be assessed at least once every 3 years by inspection. Th u shall be cleaned as necessary to ensure ro er o eration. The filter cartridge should not be removed unless p 00Vtlet��il�te' vl'Stn% are made to retain solids in the tank that may slough o the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated 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 and scum in the tank exceeds 113 the liquid 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 maintain less than maximum scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Pump Tank The pump (dosing) tank shall be inspected at least once every 3 years. All switches, 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 d as necessary. Mound and Pressure 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. other than P on. Traffic ( n for vegetative maintenance) on the mound is not recommended since soil compaction may hinder aeration of the infiltrative surface within the mound and snow compaction in the winter will promote frost penetration. Cold weather installations (October - February) dictate that the mound be heavily mulched for frost protection. Influent quality into the mound system may not exceed 220 mg /L 8005, 150 mg /L TSS, and 30 mg /L FOG. Influent flow may not exceed maximum 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 test is 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 effluent ponding. Ponding levels shall be reported to the owner, and any levels above 4 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. 9 General This system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall maintained in accordance with its' component manual and local or state rules ertainin to s yste m m maint n reporting. S � � 0 6q I _P P g Y maintenance and maintenance No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall 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. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into a tank or component. Contin enc Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. If the dosing tank, pump,. pump controls, alarm or related wiring becomes defective the defective component shall be immediately repaired or replaced with a component of the same or equal performance. If the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or replaced in its' present location by increasing basal area if toe leakage occurs or by removing biologically clogged adsorption and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. Questions about the operation or maintenance of this system should be directed to: The County Zoning-Office at l S - 38 °LzUIx The system installer at The tank 'manufacturer at The effluent filter manufacturer at AU� The pump manufacturer at PLOT PLAN • �,_,� , •Page 3 of �] Scale 1 I i I � � f �.7�- t`�f7hJC� � S•� °`� X30 � � � 7� a L4 H , D�Lm owl J � T • g } `' l�l - L. 100,x` 6t..) 1 \�Lc1.1 �- /6C. LoT LINE �a Ivor �- ow►Pt�T oR � ; � j �\sr v�za �-� ►fig -�' / j � i S•O PStUN� S `�s __.. ?�ZMlSSI.IIr� �—(� / \�( / 0! ro t a o Zo6 NOTES: 1, Elevations shown are existing ground elevations unless otherwise noted. 2. Install 4" observation pipes with approved caps. ( Z required). 3. Septic tank to be tz /800 gallon capacity manufactured by wt �Z �j L2 w /A - 19 60 �3EL H LTER 4. Bench mark _3 UL S. Divert surface 'water around system to y prevent ponding at the uphill side. Page Of Approved Synthetic Covering ASTi C33 Distribution Pipe Medium. Sand Topsoil �H =W G S F Elev. VCJ(3 3 E p i p � b (� % Slope Distribution Cell of Force Main Plowed Z" to 2-2 " Aggregate From Pump Layer D CO S Ft'. E 0, 8 6 Ft. CROSS SECTION OF A MOUND SYSTEM F Q) - S Ft. G O•S Ft. A Ft. H 1, b Ft. Linear Loading Rate = •O GPD /LN FT B 1\Y3 Ft. Design Loading Rate= O,V.GPD /SQ FT I Q Ft J 5 Ft. K Ft. r„� W Z0 Ft. I j - Observation Pipe c •---------- - - - - -- --------- - - - - -- - - - - - -- @ox _ o _ W �— -� _ _ - -- ------- - - - - -- Force Main Distribution \— Cell of 2 ,12'r CP OS1 t�vD z to Pipe aggregate Observation Pipe (aachcr securely) PLAN VIEW OF A MOUND SYSTEM ` Distribution Pipe Layout p e 5 o f '] Place the holes at the bottom of the distribution pipes at'equal spacing. Remove all burrs from the pipe and holes. Extend the end of each late:ai up with the use of Iong turn or 45° firrng to a point within si; inches of the final grade. Te.- urinate the ends of the laterals with a valve,:threaded caD or • waded plug. Provide aces from final grade for the valve' threaded cap or threaded pIuQ. F [ Lw ) C F NJC eral Ilia Lateral x z x V2 I xQ x x x x Lateral Imath — F Lateral Ungth — P Distribution Une P ql.SFt. Hole Diameter `� Inch S 3 Ft. Lateral Inches) X 3 InchPS Manifold - Z - Inches Force Main " Indies # of holes /pipe �1 Invert Elevation of.Laterals 1D1.0 Ft. • 1�x v. y(- b. g-) x y = Z 6 tr , Combination Sep4c: Tank and PQMP CHAMBER CROSS SECTION AND SPECIFICATIONS' PAGE 6 OF -VEWT CAP WEATHER PROOF JUAICTIOIJ BOX . `I'C.I. VENT PIPC APPROVED LOCKING :10' FROM OOOR. MANHOLE COVER WIV :11NOOW OR FRESH t.uRRtJ11JG LF4gEl_, �3D}aW PIPE A.�IJUTAKE S couDu�r w lt�tCZ�1 s ttT' �cQ t , FINLSItp r.` I Y•HIAl. • G �'SD E � �• I IIJLET i" PROVIDE I AIRTI6HT SEAL 81�TrFLC I Approved zfi8�. H� A � Approved joint ra/ ��_t�p il l joint w/ PVC pipe ALARM PVC pipe 6 .I II � I I OM C i ELEY. FT I P U I" P - -� OFF 0 COAICRETE C� i -tJ • ` U 3 . , 6 O BLOCK RISER EXIT PERMITTED OQLy IF TAWK M AIJUFA CTURER HAS SUCH APPROVAL 3~AP oveB REDOtN4 SEPTIC E SPEGIFICATIO&JS DOSE T_AWKS MAAIUFACTURER: wt C ON WUMBER OF DOSES: S' 3 PLK DA-w TAMK SIZC: 1Z �D ` 800 GALLOAJS DOSE VOLUME r ALARM MAIJUFACTURE.R: E IWCLUOIAI 6ACKI'L G AU or�Is MODEL QUMBER: 1 iiw CAPACITIES: A= �V I OR �Z 3 GALLOAIS SWITCH TtIPE: 7t�oa-Wr 8 = IAICHES % OR u �' S G p LL0A1S PUMP PkAMUFACTURER: Gou� -DS C= S Iucx OR X66 8 GAL LOWS MODEL NUMBER: y� 0= 8' S INCHES OR N $�'� GALLOWS SWITCH TYPE: - I�ZL°�R- DOTE: PUMPAMDALA0.M ARE 5E MINIMUM D15CHARGE RATE Z�'g4v GPM INSTALLED OIJ SEPXRATE CIRCUITS VERTICAL DIFFERENCE 15ETWEIIJ PUMP OFF A D15TRIBUTIOM PIPE.. �� �g FEET f MIQIMUM NETWORK SUPPLY PRESSURE , ; 6 -S (7 FCET 5,,0 xl.'�� f 330 FEET OF FORCE MAIN X A l F oFCFRtCTIO►J FACTOR.. FEET TOTAL DyNAMIL HEAD FEET As per manufacturer Z,Z_ Z.4 gal /in. Liquid depth CUk.UE 7 Submersible Effluent Pump 3885 APPLICATIONS • Overload protection must smooth operation. Silicon can be operated continuously Specifically designed for the be provided in starter unit. bronze impeller available as without damage. following uses: • Shaft: threaded, 400 series an option. ■ Bearings: Upper and • Homes stainless steel. ■ Casing: Cast iron volute lower heavy duty ball bearing • Farms • Bearings: ball bearings type for maximum efficiency. construction. • Trailer courts upper and lower. 2" NPT discharge adaptable • •Power cord: 20 foot ■Power Cable: Severe duty Motels for slide rails stems. Y standard length (optional rated, oil and water resistant. Schools lengths available). ■ Mechanical Seal: SILICON Epoxy seal on motor end • Hospitals Single phase: CARBIDE VS. SILICON provides secondary moisture • Industry CARBIDE sealing faces. barrier in case of outer jacket • Effluents stems •'/3 and '' /2 HP -16/3 SJTO Y Stainless steel metal parts, damage and to prevent oil with 115 V or 230 V three r BONA -N elastomers. wicking. SPECIFICATIONS P ong plug. • % - 1'/2 HP -14/3 STO with ■ Shaft: Corrosion - resistant ■ 0 -ring: Assures positive Pump bare leads. stainless steel. Threaded sealing against contaminants • Solids handling capabilities: Three phase: design. Locknut on three and oil leakage. W maximum. • Y2 -1'/2 HP -14/4 STO phase models to guard - • Discharge size: 2" NPT. with bare leads. On CSA against component damage AGENCY LISTINGS • Capacities: up to 128 GPM. listed models - 20 foot on accidental reverse rotation. • Total heads: up to 123 feet length SJTW and STW ■ Motor: Fully submerged in SP Canadian Standards Association TDH. are standard. high -grade turbine oil for • Mechanical seal: silicon lubrication and efficient heat Underwriters Laboratories carbide -rotary seat/silicon FEATURES transfer. carbide- stationary seat, 300 ■ Impeller: Cast iron, semi- ■ Designed for Continuous series stainless steel metal Operation: Pump ratings are parts, BUNA -N elastomers. open, non -clog with pump- within the motor manufacturer's Temperature: • out vanes for mechanical seal , protection. Balanced for recommended working limits, 104 °F (40 °C) continuous 140 °F (60 °C) intermittent. • Fasteners: 300 series METERS FEET stainless steel. 907 —1-4 SERIES: 3885 • Capable of running dry 25- 80 SIZE: 3r: SOLIDS I WE15H I t # RPM: VARIOUS withou dam - -- ag to �PM 1 —1- —�- - - - ��s components. 70 WE, i sFr Motor a 20 60I Single p hase: W # # r 9 P x = •/ 0 # 3 F HP 115 V 200 V , 23 OV a 15 50, 60 Hz, 1750 RPM; ' /z HP, — — Z i r ! i 115 V, 60 Hz, 3500 RPM, 0 40, I WE05H i I '/2 HP -1 Y2 HP, 230 V, a ` 60 Hz, 3500 RPM. lo- 30 • Built-in overload with v►iE03L -- - automatic reset. `. • Class B insulation. 5 I 10 Three'phase: •' /2 HP - 1 HP 200/230/ o o 460 V, 60 Hz; 3500 RPM. 0 10 20 30 40 50 60 70 80 t 90 100 110 120 130GPM • Class B insulation. I ;0 20 30 m CAPACITY ®1995 Goulds Pumps, Inc. Effective May, 1995 11 B3885 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety4hd Building Division a , ' INSPECTION REPORT sanitary Permit No: • I - � 405012 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: Hau e, David & Carol I Pleasant Valley Township 024- 1029 -40 -200 CST BM Elev: Insp. BM Elev: 7 Description: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchmark , Septic 3, S �' I (P . D Dosing Alt. BM Aeration Bldg. Sewer (12— Holding SVHt Inlet �•8 TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom �Z, t Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM 4 , spa S 20 BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L JBLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: I DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) 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 Bed/Trench Edges Topsoil Yes - No i Yes 9,i No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 258 County Rd T Hammond, WI 54015 (SE 1/4 NE 1/4 21 T28N R17W) NA Lot 1 Parcel No: 21.28.17.180B 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = 3.) Contour = Plan revision Required? Yes joI No Use other side for additional information. Date Insepctor's Signature Cert. No. SBD -6710 (R.3/97) Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 ons�n Madison, WI 53707 - 7162 Site Address' ar Department of Commerce /o( '-FFr p� -C ©f/37 � Sanitary Permit Application Sanitary Permit Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide�� L ` ❑ Check if Rev>sron may be used for secondary purposes Privacy Law, s15. 1 m I. Application Information - Please Print All Information State Plan I.D. Number to 4 Property Owner's Name Parcel Number Z(, Z8. U", oL bzL( -10 29 - `(O - ZAD ) I Property Owner's Mailing Address Property Location le a/ PO 7 "/ �'" r EcE�vE % pF '-A; S.? / T ,? N, R City, State Zip CodePhone Number Lot Number Block Number APB ?00 Subdivisi ame CSM Number ST CR H. Type of Building (check all that apply) A,z S F i01 1 or 2 Family Dwelling - Number of Bedrooms S ❑ Public/Co ,,ial -_I_ _'be Use .Township , a ❑ State Owner "'r '14 , 46 q t p Nearest Roa 2 .o ?Zf S III. Type of Permit: (Check onl a box on line A (numbering scheme for int al use). Complete line B V applicable) F F 1 New 2 11 R m 3 ❑ Replacement of 6 11 A or County use ou stem Tank Only Existi m ❑Check if Sanitary Permit Previously Permit Number Date Issued Type of Permit: (Check all that apply)(nlkabering scheme is internal use 44 ❑ Non - Pressurized In- Ground 21��Mo 7 ❑ Sand Filter 9ne ucted Wetland 22 ❑ Pressurized In -Ground 41 ❑Holding /nit 8 ❑ Single Pass ` 45 11 At-Grade 46 ❑ Aerobic Tr a 9 11 Recirculating V. DisversallTreatment Area Information: Design Flow (gpd) Dispersal Area Dispersal Areaa 9 oil Application Pe ation TP re f abs , non Requi red Proposed s./Days/Sq ) /Inch) ado L VI. Tank Info Capacity in Total Number Manufacturer Fiber Plastic Gallons Gall of Tanks Concrete Co Glass New Existing Tanks Tanks Septic or Holding Tank �Q Dosing Chamber 8 r Y VII. Responsibility Statement- I e undersigned, assume responsfbllity for installation the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature RS N r Business Phone Number Plumber's Address (Street, City tate, Zip Code) VIII. Coun /De t Use Onl Approved ❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Surcharge Fee) ❑ Owner Given Initial Adverse Determination IQfC� ''SS3�7t�honditi� of Approval/Reasons L ns for Disa A �s wurA+a.� C+iL.vv�ort • Attach complete phuu (to the Couaty ody) for the system on paper not less than gin x 11 Inches in size SBD -6398 (R. 05101) ! a M y3 PLOT PLAN ` Scale 1 " =L Pale 3 of 7 • �� 10 N a.M WL = IE L, :L0o- 0.'_ary S "%'H6H , Wa" 01 A SrZEL - TnhS MN a 3Z I o J V o� -Z6o •� i FL q y,16 �►�1E x W V,j u1v C NY'cs SLOL o� 11v I LOT l.l►vE NOTES . 1. Elevations shown are existing ground elevations unless otherwise noted. 2. Install 4" observation pipes with approved caps. ( Z required). 3. Septic tank to be NZ$b 800 gallon capacity manufactured by 4. Bench mark �. Divert surface water around system to prevent ponding at the uphill side. a' Or i Safety and Buildings • ` 6 ; 4003 N KINNEY COULEE RD LACROSSE WI 54601 -1831 i fisconsin A- f ! TDD #: (608) 264 -8777 www.commercestate.wi.us /sb h j' www.wisconsin.gov Department of Commerce p ,\ Scott McCallum, Governor Brenda J. Blanchard, Secretary June 11, 2001 c 5� V et �rk- dp� CUST ID No.691727 �. � 2 , ATTN POWTS Inspector ARTHUR L WEGERER ! .� -ZONING OFFICE 421 N MAIN ST ST CROIX COUNTY SPIA PO BOX 74 1101 CARMICHAEL RD RIVER FALLS WI 54022 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 06/11/2003 Identification Numbers Transaction ID No. 649814 SITE: Site ID No. 630840 DAVID & CAROL HAUGE Please refer to both identification numbers, CTH T above, in all correspondence with the agency. TOWN OF PLEASANT LLEY ST CROIX COUNTY SE1 /4, NEIA, S21, T28N, RI LOT: 1, SUBDIVISION: PROPO CSM FOR: DESCRIPTION: FOUR BEDROOM UND SYSTE OBJECT TYPE: POWT SYSTEM RE ATED O CT ID NO.: 795694 The submittal described above has been reviewed conf nce with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CO NALLY APPROVED. The following conditions shall be met during constructi r installation and prior to occupancy or use: y • This system is to be constructed and located in a ordance the enclosed approved planytnd with the "Mound Component Manual for Private Onsite astewater Sy VERSION 2.0" SBD- 10691 -P 0X1 and the "Pressure Distribution Component Ma al for Private On Wastewater Treatment Sys t VE ON 2.0" SBD - 10706 -P (N.01 101). • In the event this soil absorption system or a of its component parts mal tions s a heal hazard, the property owner must follow the ntingency plan as described in ap ad , the owner must insure that the operation, main ance and monitoring duties as des 'be c on VI e mound manual, and section VI of the pres a distribution com onent manual are comp d with. py of this i nformation must be given to the owner u n completion of project. • Access to the filter for cleaning must provided per Co in 84.2 ( nd ,Wis. Code product approval conditions. • A Sanitary Permit must be obtained om the county where t cated in cordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the private sewage system installation is required. gements for inspection shall be made with the designated county official in accordance with the provisions Sec. 145.20(2)(d), Wis. Stats. • The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption area. � l ,�, + � +Y •, 1 � t �' ��� �� � � :��;. +t:� ,�� �,. ,, � � ,: � ' '� i �.:, ' • ' i ARTHUR L WEGERER Page 2 6/11/01 • Comm 83.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(1). In addition, 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. • Comm 83.52(2) A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. • Comm 83.52(3) The activities relating to evaluation and monitoring mechanical POWTS components after the initial installation of the POWTS in accordance with an approved management plan shall be conducted by a person who holds a registration issued by the department as a registered POWTS maintainer. • 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. 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. 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. Sincerely, FEE REQUIRED $ 175.00 FEE RECEIVED $ 175.00 BALANCE DUE $ 0.00 �( J Charles L Bratz POWTS Plan reviewer II- Integrated Services WiSMART code: 7633 (608) 789 -7893, Mon. -Fri. 7:45 AM to 4:30 PM cbratz @commerce.state.wi.us TITLE SHEET Page 1 of MOUND SYSTEM FOR A y BEDROOM RESIDENCE This plan has been prepared in accordance with the Mound Component Manual SBD- 10691 -P and the Pressure Distribution Manual SBD- 10706 -P (N.01 101) (N.01 101. LOCATED IN THE 5(Z 1/4 OF THE NE 1/4 OF SECTION Z L )T Z$' N, R 17 W, TOWN OF pL ST-. 0 UC COUNTY, WISCONSIN. INDEX - PAGE 1 of 7 TITLE SHEET PAGE 2 Of 7 SYSTEM MANAGEMENT PLAN PAGE 3 of 7 PLOT PLAN PAGE 4 of 7 PLAN VIEW -CROSS SECTION PAGE 5 of 7 DISTRIBUTION PIPE LAYOUT PAGE 6 f 7 PUI.IPING CHAMBER CROSS TION PAGE 7 0 7 PUMP PERFORMANCE CUR EPARED FOR A 'l - \2 Z2.t _ 60 ST'• orZrN _ - __ 2 S1Jl Ll_In1fr''`'E5Z 5 S o_'P _ 19 � o 0 PREP ED BY ,- Wa(3E=FREZ}R C1 I L T T S I'll (S AND. DES I ice! SERV C P.O. x 74 421 N.Main St. Rive Falls, WI 54022 � e �C ry��'��► P h o 715-425-0165 fjr Fa 715- 425 -6864 .r %% t ARTtAiR c WEGEFfEA Z D-0 P r RLSWORTH, Coni idonally APPROVED DEPMUNWOFCOMmme ama °F 5 z-b —ol JOB NO., t - 4i � w 4. :$k .. � .� A yy({ � �p'Y.�tiyl4��lil' iR'M+B�'1� �+�# Mound System Management Plan . Page Z of - 7 Pursuant to Comm 83.54, Wis. Adm. Code Septic Tank - The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Slats. 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 filter shall be assessed at least once every 3 years by inspection. Th out et filte shall be cleaned as necessary to nsure prop u.090fetieQ. The filter cartridge should not be removed unless provisions re made o re ain so i s in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated 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 and scum in the tank exceeds 1/3 the liquid 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 maintain less than maximum scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Pumc Tank The pump (dosing) tank shall be inspected at least once every 3 years. All switches, 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 Pressure Distribution S tem 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 soil compaction may hin r aeration of the infiltrative surface within the mound and snow compaction in the winter will promote frost penetration. weather installations (October - February) dictate that the mound be heavily mulched for frost protection. Influent quality into the mound s item may not exceed 220 mg /L 8005, 150 mg/L TSS, and 30 /L FOG. Influent flow may not exceed maximum design flow ecifled in the permit for this installation. The pressure distribution system is p 'ded with a flushing point at the end of each late and it is recommended that each lateral be flushed of accumulated solids least once every 18 months. When a pres a test is performed it should be compared to the initial test when the syste was installed to determine if orifice clo g has occurred and if orifice cleaning is required to maintain equal distribution within a dispersal cell. Observation pipes within the dispersal cell shall checked for effluent pond' Ponding levels shall be reported to the owner, and any levels above 4 inches considered as an i riding hydraulic failur quiring additional, more frequent monitoring. General neral This system shall be operated in accordance with Comm -84 Wis. m. Code, and shall maintained in accordance with its' component manual BOH arid local or reporting. rule ertaining to system maintenance and maintenance SBD - 1p - C tv of /D No one should ever enter a septic or pump tank since danger s es may be present that could cause death. Septic and Pump tank abandonment shall be in accordance with Com POWTS components. 33, Adm. Code when the tanks are no longer used as Septic or pump tank manhole risers, access risers and vers should be insp d for water tightness and soundness. Access openings used for service and assessment shall be led watertight upon the letion of service. Any opening deemed unsound, defective, or subject to failure must be re ced. Exposed access openin reater than 8- inches in diameter shall be secured by an effective locking device to prev e accidental or unauthorized entry i a tank or component. Con" _ __ cv Plan If the septic tank or any of its components bec a defective the tank or component shall be rep or replaced to keep the system in proper operating condition. If the dosing tank, pump, pump controls, al or related wiring becomes defective the defective component shall be immediately repaired or replaced with a co nent of the same or equal performance. If the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or replaced in its' present location by increasing basal area if toe leakage occurs or by removing biologically clogged adsorption and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. Questions about the operation or maintenance of this system should be directed to: The County Zoning Office at 11S - Q ST. C°. �X The system installer at 1lS - 6R'a- Iz;(, smtsyc The tank manufacturer at 800. - B Z,9 _ LIU L - Tr The effluent filter manufacturer at The pump manufacturer at �p� °t2 PU►`'1P`- • PLOT PLAN • - Page 3 of 7 Scale iZL.:10o -0 c))., S "�{ tGN, 3 �8'` o q m-UL 2jE - _ qp 2 w /t-A . ,_ .L �. GT Z - ..�•L _ -/ � _G,- ._h -_�1__ y___ - ,_ _ , h 4 M _.. N 4 Do N PAeZ• IRM +E z `frf'l S r111t.e14 �, z f i I1 / r i F* i P / /V o� k, 5 b � g•3 G - zL�p'� W-I i � BuZ C'L1L 4'j • l��►v1E x W�.L LLl Uhf i C �'3T' SLO` O'F �lvvSN� I Loi Lt�tr NOTES: I. Elevations shown are existing ground elevations unless otherwise noted. 2. Install 4" observation pipes with approved caps. ( Z required). 3. Septic tank to be XZLO 80t) gallon capacity manufactured by eAJ&� PROZVO - % kJ 8 - 4 00 ZPrk3�t. f=1 L�TR 4. Bench mark S- SQ ppU� 5. Divert surface water around system to prevent ponding at 'the uphill side. Page 4-.Of Approved Synthetic Covering - ASTH C33 Distribution Pipe Medium Sand Topsoil __ "'� i ' G p -- F �' E l ev . D- 3 E b - 7. % Slope Distribution Cell of Force Main Plowed " to 2- " Aggregate From Pump Layer 0 Z -O Ft. E - Z.6 3 Ft. CROSS SECTION OF A MOUND SYSTEM F p.'b Ft. G 0. S Ft. A F Linear Loading Rate =g• gS GPD FT 8 61 t. Design Loading Rate= 0.3 /SQ T j Ft. J Ft. 13 Ft. Aiftma Position L a3 Ft. of Force Main 3 3 Ft. - Observation Pipe -- r ---- - - ---- - -- - -- ------- - --- == - - - -• Ao- -I-- -- - - - - - -- - -- - - -- -------- - - - - -- --- - -- w - -- Box _ Distrib on � �� 12, Pipe Cell of z to 2 ag gregate Observation Pipe (Anchbr securely) ~ PLAN VIEW OF A MOUND SYSTEM Distribution Pipe Layout Page `j of 7 Place the holes at the bottom of the distribution pipes at equal spacing. Remove all burrs from the pipe and holes. Extend the end of each lateral up with the use of long turn or 45' fitting to a point within six inches of the final grade. Terminate the ends of the laterals with a valve cap or . threaded plug. Provide access from final grade for the valve, threaded cap or threaded plug. FV C FVA Laterai Manifold Zral X x x x xf2 x!Z x x x x ateral Length — Late ength —P Distribution Line F, i}CC.a}s sox t'rru 1 Fr7lp S 0 -- ��uC Y•oscCt 1nR•tN P 3I -S Ft. Hole Diameter 3/� 6 Inch - S Z Ft. Lateral Inches) X 36 Inches Manifold Z - Inches Force Main " Z Inches I of holes /pipe 1 Invert Elevation of. Lateral s `lq•40 Ft. U = - . Z6 x 6 .z L43 . 6 s VA-1 I L.A.. VL I nri i APPROVED LOCKING 1 10' FROM DOOR, T&WHOLE COVER lti7IV :AMDOW OR FRESH 1 wA(iN11JG LA�6EL. 3 P1oW �iPE ALP, IJJTAKE colaCut _ wlPnSl1 & r e4rP T c G LSD 1 IIJLET i PROVI -- • AIRTIG SEAL I I • I Approved- �� A i III Approved joint w/ t9 Op I II I joint w/ PVC pipe • II ALARM PVC pipe b I t C i O!J I L.88 ' LLEY. ° FT __� Pump —� OFF D CRETE t1 °il•�b' D - RISER EXIT PERMITTED OUL IF TA►JK MAUUFACTUR!<R HAS CH APPROVAL SEDOI r, 8r<DO I �4 SEPTIC F PC ,IFICATIOUS DOSE ' TAWK MAUUFACTURER: 1 FS IJ0 IJUMBER OF DOSES: S ' 4 PER DAy TAWK SIZE: ZZ-0O GALLOUS DOSE VOLUME a ALARM MAMUFACTURCR: g IMCLUDIAI 6ACKFLDW: � 13 � GALLOh15 MODEL QLIMBER: 101 CAPACITIES: A= ZO WCHES OK L4 lZ'O GALLOy5 SWITCH TtIPE: B= IIJCHES'OR U I ' GI LLMJS PUMP KAMUFACTURCIt: C: � I �Z WCHE 213. S OR GALLOIJS MODEL UUMBER: 9a D= 11 3 11 INCHES OR lt6 ' 3 GALLOUS SWITCH TYPE: L,`(Zcup -y MOTE: PU AUD ALA TO 5t g MIMIMUM DISCHARGE -RATE L13. S 6 GPM INSTALLED OW SEPARATE CIRCUITS VERTICAL DIFFERENCE OETWEEU PUMP OFF AUO..DISTRIBUTIoM PIPE., $' z FEET + MWIMUM ' METWORK SUPPLY PRESSURE . 3 •ZS 'FEET • SK L. �� Z� FEET OF FORCE MAIM X 3 'gg F oFLFRICTIOrJ FACTOR �'�8 FEET TOTAL DyWAMIC. HEAD = l ? • � S FEET As per manufacturer Zo. t I P 60 gal /in. Liquid depth 3 $ W HEAD CAPACITY CURVE 3 7/8 6 1/a 30 MODEL "98" 4 5/8 8 2 3 5/8 = s ® O U + + Q 0 15 O �` 4 4 3/16 LZ .p5 10 5 1 1/ 1 1/2 NPT . 0 , U.S. GALLONS 10 20 30 40 50 60 70 60 LITERS 80 160 240 0 FLOW PER MINUTE AL DYNAMIC HEAD/FLOW PER MINUTE EFFLUENTANDDEWATERING CAPACITY 12 HEAD UNITS /MIN FEET METERS ALS LTRS 5 • . 1.52 273 -� 10 3.05 6 231 15 4.57 45 170 4 3/16 15 ' 6.10 25 5 Lock Valve 23' SKI 102 ■fin ✓i CONSULT FACTOR SPECIAL APPLICATIONS • Electrical alternators, for duplex systems, are available an - Variable level float switches are available for controlling single supplied with an alarm. and three phase systems. • Mechanical alternators, for duplex systems, are availa with Double piggyback variable level float switches are available or without alarm switches. variable level long cycle controls. SELECTION GUIDE Standard all models - Wei ht 39 lbs. - H.P. 1. Integral t operated 2 pole mechanical switch, no external control required. 2. Single pigg ck variable level float switch or double piggyback variable level, 98 Series ContrQ1111belection float switch. r to FM0477. Model Volts-Ph EAuto Amps Simplex Duplex 3. Mechanical alte or 10 -0072 or 10 -0075. M98 115 1 9.4 1 or 1 & — 4. See FM0712, for c ct model of Electrical Altemator, E -Pak. N98 115 1 9.4 2 or 2 6 3 or 4 & 5 5. Control switch 10 -02 sed as a control activator, specify duplex (3) or (4) D98 230 1 4.7 1 or 7 — float system. 6. Four (4) hole J -Pak, junction , for watertight connection or wired4n E98 230 1 4.7 2 & 6 3 or 4 & 5 simplex or duplex operation, 10- 7. Two (2) hole J -Pak for watertight co ection or splice. CAUTION ForinformationonadditionalZoellerproductsreferto catalog on Combination Starter, FM0514;Piggyback All installation of controls, protection devices and wiring should be done by a qualified Variable Level Switches, FM0477; Electrical Alternator, FM0486; Mechanical Alternator, FM0495; Sump/ licensed electrician. All electrical and safety codes should be followed Including the most Sewage Basins, FM0487; and Single Phase Simplex Pump Control/Alarm Systems, FM0732. recent National Electric Code (NEC) and the Occupational Safety and Health Act (OSHA). RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. R MAIL TO: P.O. BOX 16347 �� ' - nlle, 347 Manufacturers o/. . - � SH IP P TO T0: 3649 49 Cane ane Ru n Road Lobe, KY 40211.1961 Qom,- /�usivs �.vrE /9.�9 rF PUMP CO (502) n &2731.1(800) 928-PUMP .. .. .. _ _ FAX(502)774-W4 I � . Wsdonsin DepartineM of gommerce SOIL EVALUATION REPORT Page of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.�U� ! 1v G percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Reviewed by Date Personal information ou provide may be used for seconds I� Y P Y secondary purposes (Privacy Law, s. 15.0' 1) (m)). Property Owner 0- L Z ) L Property L cation ". 4evt -. E -- � 1/4 X1/4 S Z T Zg N R 1 2 E o W Property Owner's Mailing Address B # Subd. Name or CSM# 1 Z a I `3o �f 5 "o 2T lZ-oP� S �D �Swt city tate Zip Code Phone m tY p t>JU ber C 7Y ❑ Ci q ❑ Village ® Town Nearest Road S Mti SSo�Z (bS,I, � i S `' [� New Construction Use: Residential / Number of b obrrls ` a ode derived design flow rate 60O GPD Replacement ❑ p ❑ Public or commercial - Describe: Parent material L- Flood Plain elev ion if applicable General comments and recommendations: �t'10U 1, nj w / ' k 61 zt V r/ U L° LTLL , h� IKjt hivM Z`1, L eorv�uv �, qZ_4 ' ❑ Boring # ❑ Boring ® Pit Ground surface elev. "� S-?S ft. /epth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Te a Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 o - L6 31 — 1 2 1b vn ft,- a I� •5 8 p'o'rt M f �"- S - • t► 3 1 - -3'4 toy -irL Y13 z S/ ❑ Boring # ❑ Boring 0 pit Ground surface a ft. epth to limiting factor 15 in. - - f c Soil Application Rate Horizon Depth Dominant Color Red ' f Description Texture cture Consistence Boundary Roots GPD/ft in. Munsell Qu. z. Cont. Color Gr. Sz. 'Eff#1 'Eff#2 i 0 - S 1A`1yZ 3 Lz — si I Z-0 -31 T -� -S love C-% •y -� 3 Ii 3S IovTLY!3 S/'b `` 1esbk rn-R- — -Z -3 Effluent #1 = BOD > 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) Signature 6 CST Number Arthur L. Wegerer 1 _ 220254 Address tij e g e r e r Soil Testing & Design Service Date Evaluation Conducted Telephone Number 421 N. Hain St. River Falls, WI 54022 Y1 3--0) 715 -425 -0165 Property Owner $SON Parcel ID # !�Q CIA/ G Page Z- of 3 Boring # ❑ Boring ® pit Ground surface elev. aq- Z ft. Depth to limiting factor 1 Z 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 C) --! o H Q. 3J b 1 Yn 'F- C_g l' - S -g Z - 7 - � - L I0`1 R 316 — sic.l Z sbk. M ft ca - L( - 6 - 3 �z 31 10 11 FL V IA K2 s/e cl it m Z .3 i F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 w 4 �* wr N F-1 Boring # ❑ Boring s ❑ 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. SBQ8330 (86100) . PLOT P LAN Page 3 of 3 -Scale 1' = ' CM 'Ok3lugz ! �v�l �l _ -. �L. tDO•D` a�., s "�HGN, 31g'� I�t ►� - S��t -. 2E -?Pi-� w />�fit� , i II ni-t S H U - � �o $ m W-i FL � a i O Lol LI Ki y - 3 -OJ 715- 425 -0165 220254 CST Signature Date Telephone No. CST No. Job NO. .. • 4 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT .AND OWNERSHIP CERTIFICATION FORM )wner/Buyer C_ - Mailing Address ,1 Z property Address (Verification required from Planning Department for new constructton) l.. City/State Parcel Identification Number 0 Zt' �• 1} • `fig LEGAL DESCRIPTION Property Location , 1 /4, Sec. � / T of � N - R / 7 - W. Town of c ea .d-� �---- Lot it l Subdivision ed Survey Map # �3�? I S Volume _ _L Page erhfi Y C Warranty Deed # !:�_ - 7 21 i�L!:? Volume Page # Spec house D yes 0 no Lot lines identifiable Dyes D no TEM NANCE o maintenance SYS MAINTE a to handle wastes. Pr Improper use and maintenance of yottr septic system could result in its premature f What consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. you • P ut into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. ent a certification form, signed by the owner and by a J0 The property owner agrees to submit to St. Croix Zoning D e P � verifying that (1) the on -site wastewaterdisposal system masts rplumber,loum- ymanplumber, restrictedpiumber or a licensed pumpe the s tic tank is less than ter full sa sludge- is in proper operating condition and/or (2) after inspection and pumping (if necessary), eP of 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 oin. withrr f Wiscons stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning days of the year expiration date. DATE SIGNATURE OF APPLICANT OWNER CERTIFICATION a m (are) the owners) of I (we) certify that all statements on this form are true to die best of my ( our ) knowledg g I (we) the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. / 9 / DATE SIGNATURE OF APPLICAI «• * « «« A 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 + c r .0 . vw, I846FA t 169 STATE BAR OF WISCONSIN FORM 3- 1999 6 7 9R 5 9 Document Number QUIT CLAIM DEED REGISTER OF DEEDS ST. CROIX CO., MI This Deed, made between Clyde Jacobson, a/k/a Clyde S. Jacobson RECEIVED FOR RECORD and Joanne Jacobson, a/k/a Joanne E. Jacobson, husband and wife 03 -01 -2002 1:45 PH DUIT CLAIM DEED Grantor, and David G. Range and Carol J. Hauge, husband and wife, EXEMPT t holding as survivorship marital property REC FEE: 11.00 -- TRANS FEE: 15.00 COPY FEE: 2.00 Grantee. CERT COPY FEE: Grantor quit claims to Grantee the following described real estate in PAGES: 1 St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Part of the Southeast Quarter of the Northeast Quarter (SE 1/4 of NE 1/4) of Section Recording Area Twenty -one (21), Township Twenty -eight (28) North, Range Seventeen (17) West, Name and Return Address Town of Pleasant Valley. St. Croix County, Wisconsin. more particularly described _ / as follows: C (yA S. J.-croj►5O� r Lot One (1) of Certified Survey Maps dated April 12, 2001, and recorded July 25, .`Z S7 C�l� R o -%J T 2001, in Volume 15 of Certified Survey Maps, Page 4134, as Document No. 652128, 11)q office of the Register of Deeds for St. Croix County, Wisconsin. L O: 2 - 1029 -40 — ZCro ldentifrcation Number (PIN) This is not homestead property. (ix) (is not) Together with all appurtenant rights, title and inte sts. Dated this t.'. day of /, 2002 + _ _ • yde S. Jacob A • - Joanne E. Jacobson AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSI ) ) ss. -- St. Croix County ) authenticated this day of Persona 1 ,came before me this � day of 0./(tril/ , 2002 the above named - Clyde Jacobson, a/ Clyde S. Jacobson and Joanne Jaco bson, a/k/a Joanne E. Jacobson C . TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the perso s) wjto utc tt)e foregoing (if not, ins m nt and�acknor dg tlt . rtie. authorized by § 706.06, Wis. Slats.) THIS INSTRUMENT WAS DRAFTED BY Thomas A. McCormack Notary Public. State. of Wiscgasil" B aldwin, WI 54002 My Commission is perm nL. .. tisi. Q at " (Signatures may be authenticated or acknowledged. Both are not necessary • Names of persons signing in any capacity must be typed or printed below their signature. int «mwbn N fe.jjb W1 C6mWy, Fond d„ I. wi STATE BAR OF WISCONSIN 000.6552021 QUIT CLAIM DEED FORM No. 3 - 1999 1 r �JW N Ca ■. j CU fq L ) r; 2 O Z'' L% rxi �`' o ta. O BaC W NWW0 M� W ~ 40 W RTIFIED SURVEY MAP i�rn Clyde and JoAnne Jacobson Located in part of the Southeast 1 /,e the Northeast % of Section 21, Township 28 North, Range 17 West, Town of Pleasant Valley, St. Croix County Wisconsin ST. CROIX COUNTY Planning Zoninq And Parks Committee JUL ' 5 .2001 N If not recorded witnm 3U days of BEARMIl3S ARE I IS I N MOM approval shalt be OWNERS ADDRESS THEL:AST -WEST IM SECT N1ind void OF SECTION 21, T2 N, R 17 W, 257 COUNTY TRUNK HIGHWAY "T" MEWED AS S WSW W. HAMMOND, WI 54015 SCALE N FEET 1" m =$ i6o 50 6 1 LEGEND o INDICATES 1" x 24" IRON PIPE SET (MIN. WT. -1.13 LB./LIN.- FT.) sECTIM211. T28N, R 17W • INDICATES 1 "IRON PIPE FOUND AL 0 SECTION CORNER MONUMENT (AS NOTED) A SOIL BORINGS (PROPOSED SEPTIC SYSTEM) W 1 y I 41.2& I CERTIFIED SURVEY MAP Clyde and Jo Anne Jacobson Located in part of the Southeast Y4 the Northeast % of Section 21, Township 28 North, n _.. _ _ .. 1. far- T --- - -- _! Ts_.__ ( /L...... l.s...,.s.. �l'..�.,y......, — - , tb 30Vd St '10A NosMb'7 awsar A6 03LdVdC71M3YYl1>:f LSMi S*U " v000ao� pN Y 1 V 40 0 0 ee � r s p , °• s �i ° �4 A e aanla ° k ,4H AA V4 I �'o?g � / y�NO r J� ✓ �Q '�Q�OC9GOC�A� Plan putt iinu eq iteys im mep ienadde jo step ne wq mm rep tom you 11 i IODZ 5 � 1���• „Wluuew AJ.Nnoo xiow us /e a3A0addV •ootnpg jo3 pnog umoZ algudoidde pug ooUj0 SuzuoZ f4unoj xloa0 - is aql logiuoo `loond fug Sutdolamp ao SuisgmInd wojag (oia `loond of ssaoog `ails iol wnwlunu `spugllom •a•l) su01I13ln80l pug salru SmvI dtgsun�oZ pug `�fiuno� `aigls of ioafgns sl dgw stgl uo Umogs loo and Nogg :aLOK . IOOZ `ZI INdd :polv(I joeiag4 uoligluasaidoa loauoo pug orm g on not }duosap pug dgw slgl wq4 pue Aiunoa xioio 'is 3o saougutpi0 aqi putt salnigls u�suoosiM3o ti£'9£Z .zal i� `spl000l lgtoiUjo qj!m comp -mog ui uoaiaq umogs spiel aql popinlp pue pa fansns aA I `uosgoogr auu� or pug apAl0 `siaumo aqi jo uolioaiI xq lm Aj!uoo kgoioq op `iofananS pue-I palais!Sa -d `AgdanW •M oouaingrl `I (oojaid jo AunoO (ulsuooStm jo algls • p aooai jo suoliouisa l pug s o f ioa Sum `sb iog 000• S to iaaj a n3nbs £08`L I Z Sumloluoo `ONIINNIOM 30 ZNIOd agi of t0£' I S £ 'M ,,6t £ I o00 S `autl jag ptgs Suolu aouagi `.uoiwS plus jo ,, iseaguoN oqi jo aull Isgg aq; of �00V9 `3 .,tt,99 068 N aouagi `•,0£'IS£ `g «6tr £I 000 N oouagi `•,OO'OZ93o oouglslp g `(IZ uonoaS p!" jo auq uol ►/r isoM -isug oql uo Suugaq pownsse) `M «�ti X95 068 S oouagl `.IZ uopooS p!vs jo jowoo >/ iggg agi iv &gw!Sag :smollo3 se paquosop Alln3 wow `umuoos% `Aunoo xioja *is `faPA W HOM JO UMOJ, `IsaM L 015UTH `g:PoN 8Z di . gsumoZ I Z uoilooS jo i/ Isgaq:voN agl jo +/ IsgaginoS agl jo tmd uc polgool pugl jo loond UmUw iggl Qo gTasa(j ...,...,.,.... , e ce—oo. e% M,^ re% in _4!'n�es4_ a tt #"rn so r fn u.44n r 'ton ii i r 49tim r Submi to non - enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin municipa'littes lor'nok 1- PERMIT APPLICATION Safety and Buildings Division 'and 2- family dwellings (Wis. Stats. 101.63 (7) & 101.65 (3)) D� h cte fy y .S < ��l- �. r b ./7, i �'O'/ � ,,_� P er sonal �. SEE INSTRUCTIONS ON BACK OF SECOND PLY - � q0 5 0 / ; L information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] d,�G Last Name First Name Middle Initi Y' APR 2 9 Y_ �d��� �' 200 Street Address Z Glix I City State Zip Code Telephone No. (Include area code) Building Address Subdivision Name Lot # Block # i l Legal Description Parcel No. 1/4, 1/4, Section T ° N, R E W S 1 Family k4ff Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump ❑ 2 Fan ❑ Boiler ❑ Central AC ❑ Other: a Big i Nat. Gas L.P. Oil Elect. Solid Solar Space Heating ❑ ❑ ❑ ❑ Water Heating ❑ ❑ ❑ ❑ ❑ Site Constructed Concrete ❑ Masonry ❑ Treated Wood ❑ Manufactured (to the WI UDC; not U.S. HUD code Other (specify). Living area = 1 7 LI d Square Feet $ l �t tQ600 i [ I vouch that all the above information is correct, and understand that the issuance of this permit is for administrative purposes only. I understand that onsite construction inspections will not be performed by the municipality, but that the Uniform Dwelling Code, Chapters Comm 20 -25, still applies to all new 1- and 2- family dwellings and must be complied with. I understand that the issuance of this permit does not relieve me of compliance with other applicable codes and ordinances. i Applicant's Si ature Date Signed 1' MUST BE COMPLETED BY THE MUNICIPAL BEFORE FORWARDING PLY 2 TO THE STATE DIVISION OF SAFETY AND BUILDINGS ll+ ` Town ❑ Village ❑ City ❑ County o All � I { t' SBD -8254 (R.2/00) Distribution: ❑Ply 1 - Issuing Lisdiction ❑Ply 2 - Municipality Forwards to State If New Dwelling ❑Ply 3 - Applicant iL 1t y� 1 Cap a(IU ISSUING JURISDICTION T N � � I a � d ts o � f o