HomeMy WebLinkAbout024-1036-95-300 W * .
isconsin Department of Commerce PRIVATE SEWAGE SYSTEM County Safety and Buildings Division
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 374916
Permit Holder's Name: E] City [] Village [] T n of: State Plan ID No.:
Pollock, Robert Pleasant Valley Town hi /O /0 3
CST BM Elev.:. Insp. BM Elev.: BM Description: Parcel Tax No.:
o f a CST g ,�, -( 024 - 1036 -95 -300
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic UA w Benchmark Up- a
Dosing p� L �(, (� �j Alt. BM
Aeration Bldg. Sew 4, 1U(,
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P / L WELL BLDG_ Air I to ntake ROAD Dt Inlet
Air
Septic y 5D / r 3 3' NA Dt a6C 2 Q, 10 /
Dosing 1> Sr 3s NA Header/ Man. 7 ,`S'
t
Aeration NA Dist. Pipe
Holding Bot. System .6o q�. oo r
PUMP / SIPHON INFORMATION Final Grad -a ;t( 1 0L 7
4 Manufacturer 5 e )A� St cover Demand �• �
p odel Number �c� (-�- �1oGPM b9l, �(,� Q2• '
TDH Lift Wj.,j Friction eDia. Systemb s TDH 24• Ft 1 9J• p r
Forcemain Length Os Z rl D ist. To Well
SOIL ABSORPTION SYSTEM. = . (O + (10,q = 21. 5a
B D I Width / Length / o. Of PIT No. Of Pits Insid i uid Depth
EN I N io 6� DIMENSION
SETBACK
SYSTEM TO P/ L BLDG WELL LAKE/STREAM L G Manufacturer:
INFORMATION Type Of I 1 r / CH AMBE
o e Num er:
System: "ZD $O b(p OR UNIT
DISTRIB ON SYSTEM (o S, (o
Header / ani rr Distribution Pipe(s)f n x Hole Size 1 ' 2 x Hole Spacing Vent To Air Intake
Length 3.0' Dia. 2 Length Dia. Spacing 36 ( u f ``
j 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 ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) "
�s Inspection #1: 0 1 05 / 0 ( Inspection #2: 7
Location: 131 County Road W, River Falls, WI 54022 (NW 1/4 SE 1/4 30 T28N R17W) - 302817238D -Lot 3
1.) Alt BM Description= T�,r•F ��� • ���- 3 S�t' 0 (•9�� I$3
2.) Bldg sewer length=
- amount of cover = n p-
3.) contour = Ak 0 ((, -p ` C SC a Cj • = 10 1. (a 0
Plan revision required? ❑ Yes N No 2
Use other side for additional information. M t ?ml T `SZ 6 F1441
SBD -6710 (R.3/97) 1 to � Inspector's Signature Cert. No.
`—i Gx.
.C. s
ADDITIONAL COMMENTS AND SKETCH
T � 1
SANITARY PERMIT NUMBER:
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Sanitary Permit Application Safety & Buildings Division
In accord with Comm 83.21. Wis. Adm. Code 201 W. Washington Ave.
See reverse side for instructions for completing this application PO Box 7302
NViscons Personal information you provide may be used for secondan purposes Madison. WI 53707 -730,
Department of Commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if r
state owner
Attach com lete plans (to the county cop) only) for the s s a t less than 8 -1/2 x 11 inches in size.
County State Sani a pp • ermit Number ❑ Chec ' ,ce�vi o !9p cation State Plan 1. D. N tuber
C rn.`S< 1 3 �l( �� ��f "& -t 01'03
I. Application Information - Please Print all Information "'` Location:
Property Owner Name / - pp^^ Property Location
fi .4 !� (� G 1 QLU ' 1/4 , ZIT ,N. /"E or W
Property Owner's Mailing Address o Lot Number Block Number
City, State Zip Code Num .t1 Subdivision Na or V Number
6 v ,� Da 3 7 In dj �}KK .3 7
II Type of Building: (check one) ��_�: ❑ City
❑ 1 or 2 Family Dwelling —No. of Bedrooms ❑ village
❑ Public /Commercial (describe use): R,Town of
O State -owned e .A M
III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest
0 k."I
A) 1. ,$New System 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Addition to Parcel Tax N� be s) q5 _1W
System Tank Only Existing System
B) Permit Number Date Issued
❑ A Sanitary Permit was previously issued p
IV. Type of POWT System: (Check all that apply) 30• AS , /7. d3 p D
• Non - pressurized In- ground aMound ❑ Sand Filter ❑ Constructed Wetland
• Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
• At -grade t ❑ Aerobic Treatment nit ❑ Recirc sting ❑ ther:
• Disperskqreatment Area Information:
1. Design Flow (gpd) 2. DispersalArea 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade
Requir d Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) Elevation
Aft. d
VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks
0 ❑ ❑ ❑ ❑
VII Responsibility Statement
I, the u ndersigned, assume res on ibility for installation o the POWTS shown , , 8p the attached plans.
Plumber's Name (print) Plumber's Signature (no stamps): P PRS No. Business Phone Number
Plumber's Address (Street, City, State, Zip Code)
sC. G 5211-1)
VIII County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps)
',Approved ❑ Owner Given Initial Adverse §jxwharge Fee)
Determination D
. Conditions of Approva /Reps or isapprova
I IL
4
SBD -6398 (R. 07/00)
Safety and Buildings
10541 N RANCH ROAD
HAYWARD WI 54843
- TDD #: (608) 264 -8777
isconstn www.commerce.statemims
Department of Commerce M: ., Tommy G. Thompson, Governor
Brenda J. Blanchard, Secretary
July 31, 2000 � •; >� �� V `\
CUST ID No.691727 A7TN.• POWTS INSPECTOR
ARTHUR L. WEGERER V ZONING OFFICE
421 N MAIN ST ST CROIX COUNTY SPIA
PO BOX 74 1101 CARMICHAEL RD
RIVER FALLS WI 54022 HUDSON WI 54016
RE: CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 07/31/2002 Identification Numbers
Transaction ID No. 410103
Site ID No. 186840
SITE• Please refer to both identification numbers,
Site ID: 186840, ROBERT & SHARAI POLLOCK above, in all correspondence with the agency.
ST CROIX County, Town of PLEASANT VALLEY; CTH W, PLEASANT VALLEY 54015
NW1 /4, SETA, S30, T28N, R17W
Lot: 4,
FOR: MOUND, 600 GPD
Object Type: POWT System Regulated Object ID No.: 647286
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:
1. This plan action is subject to designer comments on the plan.
2. The maintenance plan for this system must be given to the owner of the POWTS.
3. The orientation of the mound system must be such that the mound's longest dimension is oriented along
the surface contour per COMM 83.44(6)(a)2.
4. The proposed pump is near its limit with the proposed total dynamic head. If upon installation, the total
dynamic head increases, the proposed pump must be reevaluated and may be inadequate.
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.
Inquiries concerning this coTr be made to me at the telephone number listed below, or at the address
on this letterhead. Sincerely, DATE RECEIVED 07/13/2000
FEE REQUIRED $ 60.00
FEE RECEIVED $ 60.00
PATRICIA L SHANDOR'F; POWTS PLAWREVIEWER BALANCE DUE $ 0.00
Integrated Services
(715) 634 -7810, FAX: (715) 634-5150, M -F 7:45 AM - 4:30 PM
PSHANDORF @COMMERCE.STATE.WI.US WiSMART code: 7633
cc: ROBERT & SHARAI POLLOCK
Safety and Buildings
10541 N RANCH ROAD
HAYWARD WI 54843
TDD #: (608) 264 -8777
*isconsi www.commerce.state.wi.us
Department of Commerce Tommy G. Thompson, Governor
Brenda J. Blanchard, Secretary
July 31, 2000 _
CUST ID No.691727 r ��\
ATtN POWTS INSPECTOR
I Ar %
ARTHUR L. WEGERER -.. `/ ZONIfiT OFFICE
421 N MAIN ST `„ ��� �i�%%T CRO COUNTY SPIA
PO BOX 74 — ; 1101 CARMICHAEL RD
RIVER FALLS WI 54022 as HUDSQN WI 54016
RE: CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 07/31/2002 �'/ ��_ `�� �/ y Identification Numbers
/ � 1/ Transaction ID No. 410103
Site ID No. 186840
SITE: ;, Please refer to both identification numbers,
Site ID: 186840, ROBERT & SHARAI POLLOCK above, in all correspondence with the i' agency.
ST CROIX County, Town of PLEASANT VALLEY; CTH W, PLEASANT VALLEY 54015
NWl /4, SETA, S30, T28N, R17W
Lot: 4,
FOR: MOUND, 600 GPD
Object Type: POWT System Regulated Object ID No.: 647286
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes P.O.
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in L'oid
chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements.
The followin g g
conditions shall be met duri construction or installation and prior to occupancy or use: AP P
1. This plan action is subject to designer comments on the plan. R
2. The maintenance plan for this system must be given to the owner of the POWTS.
U pF1 OF SJ
3. The orientation of the mound system must be such that the mound's longest dimension is oriented along
the surface contour per COMM 83.44(6)(a)2. SEE COh
4. The proposed pump is near its limit with the proposed total dynamic head. If upon installation, the total
dynamic head increases, the proposed pump must be reevaluated and may be inadequate.
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.
Inquiries co4 �dence may be made to me at the telephone number listed below, or at the address
on this lette
Sincerel DATE RECEIVED 07/13/2000
FEE REQUIRED $ 60.00
FEE RECEIVED $ 60.00
PATRICIA L SHANDORF , POWTS AN REVIEWER BALANCE DUE $ 0.00
Integrated Services
(715) 634 -7810, FAX: (715) 634-5150, M -F 7:45 AM - 4:30 PM
PSHANDORF @COMMERCE.STATE.WI.US WiSMARYcode: 7633.
cc: ROBERT & SHARAI POLLOCK
TITLE SHEET Page 1 of
MOUND SYSTEM
FOR
A L4 BEDROOM RESIDENCE
This plan has been prepared in accordance with the Mound Component
Manual SBD- 10572 -P and the Pressure Distribution Manual SBD- 10573 -P
LOCATED IN THE ) , W 1 /4 OF THE SE 1/4 OF SECTION 3 l� , T Z- 8 N, R Y1 W,
TOWN OF COUNTY, WISCONSIN.
LOT
(37- 12S" I IJ V 0 L. L3 1�9 3 6 - � 9
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 of 7 PUMPING CHAMBER CROSS SECTIM.T.S.
PAGE 7 of 7 PUMP PERFORMANCE CURVE 'tion
PREPARED FOR �� E
JT OF CO
cF UILDINGS
�jBL ZT } }1vD SN'A R 1�l [�UL�C�2
3�� Iv. �'IZ12 s'RZT •RESPONDENCE
l�- 0�3� — R� - S, k11 S�oz3
i
PREPARED BY
WEGEREFt SOS L TEST S "Ca
AND .
DES 2 CS" SERVICE
P.O. Box 74 421 N.Main St.
River Falls, WI 54022 +SCO3
Phone 715- 425 - 0165, `
Fax 715 - 425 -6864
ARTMUII �
M4GEgEp
DG1S �
4
'ri �SIGN�
JOB NO. OO-C�7
JUL -31 -00 MON 01:47 PM NELSEN WEBER SURVEYING.M 1 715 425 6864 P -02
Mound System Management Plan Page of
Pursuant to Comm 83.54, Wis. Adm, Code
Septic Tank
The septic tank shalt be maintained by an individuai 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. The outlet filter shall be cleaned as necessary to
ensure proper operation- The filter cartridge should not be removed unless provisions are made to retain solids in the tank that
may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if
the alarm is activated 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
maximum n m m n I
the owner of when the next service needs to be performed to maintain less than a scum and s udg e accumulation in
rf i II
the tank- The add!t!on of biological or chemical additives to enhance septic tank performance n a ce s generally not reA uired.
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 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. Traffic
(other than 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 80D5, 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.
Genera
This system shall be operated in accordance with Comm 82 -84 Wis- Adm_ Code, and shall maintained in accordance with its'
component manual [S80-1 0572-P (R. 6199)) and local or state rules pertaining to system maintenance and maintenance
reporting,
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.
Contingency Plan
If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the
system in proper operating condition.
If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component shalt 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 Rs' 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 on the operation or maintenance of this system should be
directed to the County Zoning office at'7)S_ V680or to the
licensed lumber who installed ].ed the system.
PLOT PLAN Page 3 of
Scale 1"= �I0
2
l
0 OD o
i Q cy
0
Aj
.�° S 12
I
DO �
QQT e�^'1P11C - r `' 10S'6F
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to' or
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Fl (-TQ-)Z RT.Tktj� 00 -TLE', OF
4 BD 2� 4F= _Z� . COMPt;TtTM'IIWT
Trtz Sep uc 1 RA!D
\� K'1,1'Cl IJ T�t1�711C� 1 N S[R.0 C(1WJ S
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S WELL Lu c ft G Q
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F
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 1 /6S0 gallon capacity manufactured by
Ft LT�2 �M' , jftk h1 8 E - 7S0 Gt�c ►�i CW 'R� .
4. Bench mark S : Sf-r� Pn3cUN.
5. Divert surface water around system to prevent ponding at the uphill side.
Approved Synthetic Covering
ASTM C33 Distribution Pipe
Medium Sand
H _ G
:JrI
Topsoil =__ —____ F Elev. as O
3 E D
3 � -
b
1 % Slope
Distribution Cell of Force Main Plowed
2" to 2 % Aggregate From Pump Layer
D Ft.
E Ft.
CROSS SECTION OF A MOUND SYSTEM F o. a Ft.
G 0. S Ft.
A Ft. H l O Ft.
Linear Loading Rate- 6.0 GPD /LN FT
B 100 Ft.
Design Loading Rate= 6.2$GPD /SQ FT j 1 S Ft.
J S Ft.
K Q) Ft.
�lt� +._ D n c itin n L ZA Ft.
W Z Ft.
J Pipe
T Observation
---------- ----- - - - - -- Sax
V
- - -- --------- - - - - -- - -- { Force Main
Distribution Cell of 2" to 2k"
Pipe aggregate
l -
Observation Pipe
(Anchbr securely)
PLAN VIEW OF A MOUND SYSTEM
r MUM
Submersible
;.�. Effluent Pump
3885
11 �
EENwM hw•
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.
• Shaft: threaded 400 series an o following uses: p ■Bearings: Upper and
stainless steel.
• Homes •Bearings: ball bearings •Casing: Cast iron volute lower heavy duty ball bearing
• Farms type for maximum efficiency. construction.
• Trailer courts upper and lower. 2" NPT discharge adaptable ■ Power Cable: Severe duty
Power cord: 20 foot
• for slide rail systems. Motels • Y rated, oil and water resistant.
• Schools standard length (optional m Mechanical Seal: SILICON Epoxy seal on motor end
• Hospitals lengths_ available). CARBIDE VS. SILICON provides secondary moisture
• Indust Single phase:
Industry ,, , CARBIDE sealing faces. - barrier in case of outer jacket
• Effluent systems /3 and /2 HP —16/3 SJTO Stainless steel metal parts, damage and to prevent oil
with 115 V or 230 V three
B NA -N Blast mer . wicking.
prong plug. U o s cking.
SPECIFICATIONS • 3 / -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.
3 - phase models to guard
/4 " maximum. • /2 1 /2 HP — 14/4 STO P 9
• 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 " Canadian Standards Association
TDH. are standard. high -grade turbine oil for
• Mechanical seal: silicon lubrication and efficient heat I Underwriters Laboratories
carbide - rotary seat/silicon FEATURES transfer.
carbide - stationary seat, 300 m Impeller: Cast iron, semi- ■ Designed for Continuous
series stainless steel metal open, non -clog with pump- Operation: Pump ratings are
parts, BUNA -N elastomers. out vanes for mechanical seal within the motor manufacturer's
• Temperature: protection. Balanced for recommended working limits,
104 (40 continuous
140 °F (60 °C) intermittent. METERS FEET
• Fasteners: 300 series
stainless steel. 90 ' i SERIES: 3885
• Capable of running dry 25 80 ' I SIZE:1r'sOLIDs
WE1 J RPM: VARIOUS
without damage'to — —. 5GPM
components. 70 i
20 WEI( 5FT I
D
t
Motor i
Single phase: W 60
_ EQ
•'/ HP, 115 V, 200 V, 230 V, 9 15 50 I l
60 Hz, 1750 RPM;'' /2 HP, z
115 V, 60 Hz, 3500 RPM; 0 40 w EO
'/ HP —1'% HP, 230V, 10
60 Hz, 3500 RPM. ° 30
• Built - in overload with - '
uvEO3s
20 I ! f
automatic reset. I I
• Class B insulation. 5
Three'phase: '° i �i4o 1 i i 1
•'Y2HP -1 %HP 200/230/ OIL o
460 V, 60 Hz, 3500 RPM. 0 10 20 30 40 50 60 70 80 90 100 110 120 130GPM
• Class B insulation. o io 2 30 m /h
CAPACITY
C 1995 Goulds Pumps, Inc. Effective May,) 995
11 83885
Wisconsin ' 6partment of Commerce S SITE EVALUATION
Aivisi& of Safety and Buildings , Page � of
`Bureau of Integrated Services /in CP G�bnrlth �. R 83.09, Wis. Adm. Code
County Attach complete site plan on paper not less than 11 inchk�/f Ian myst 1
include, but not limited to: vertical and horizontal rAfes�nce point (gIW7, dire lion and
4, rz) t
percent slope, scale or dimensions, north arrow, d.. ocati tr'nd istance to ne d.
jA. t t Parcel I. D. If
y P;9.
APPLICANT INFORMATION - Please pr`�rj #all in n. R viewed by Date
Personal information you provide may be used for secondalAr pu{poses 15.04 � )) .
Property Owner P perty Location
(1 `e .Sp ✓� �•.` i °, , t \
GouLLot /lam 1 14SF. 1 /4,S50 T N,R E(or)�l
Property Owner's Mailing Address 0U0 Block# Subd. Name or CSM#
rd l - 2- - 3
City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road
� fTe f rat [ W Sy (7i5�')Y -X 0 1c _5C -r OJ M CA.)
5L New Construction Use: EgResidential /Number of bedrooms 3 — ' L / Addition to existing building
❑ Replacement / El Public or commercial - Describe:
Code derived daily flow 0 dd gpd Recommended design loading rate "7' bed, gpd/ft . trench, gpd/ft
Absorption area required fs bed, ft I Za0 trench, ft Maximum design loading rate . ` bed, gpd/tF 5 trench, gpd/tt
Recommended infiltration surface elevation(s) q ? Ur ft (as referred to site plan benchmark)
Additional design /site considerations r C f1 1 ' , U o
Parent material &ACC t C � Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
I U = Unsuitable for system ❑ S Cg U [X'S ❑ U EIS R U ❑ S [� U El (0 U - Is ® U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
o - / t S f ( rya b r C-5 �.r. .
Ground y�'yg 16 S _ JnIJ +. .2
elev.
%
Depth to
limiting
factor
Remarks:
Boring # C _ L n
Z
i ii - .3y /0 r l0
3 3, 1 3, 1 - yo to `� N � 7, S`,- /S C ,ry, C_ — -
Z ,J
Ground
elev.
Qx� W-tt• ,
Depth to
limiting
factor
3 Lin. Remarks:
CST Name (Please Print) Signature Telephone No.
Gam.
7xLr ; 2 '�17-
Address Date CST Number
O S Sdme, -fie. S�YDZS Z 9 - 9� 3�
T SOIL DESCRIPTION REPORT
PROPERTY OWNER 1_ (�� ^ — Page - P7 0 f
s ,
PARCEL I.D.#
Boren # Horizon Depth Dominant Color Mottles Structure 2
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
a l6 7, r 311
S "C- �' ma -�' � C S
Ground Z' 10 f — 7 S c�tb W, LJX;
•� r
elev.
q'
Depth to
limiting
factor
L in.
Remarks:
Boring #
13
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # ;
Ground
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�VI3YOR' S CERTIFI ATR
I. Douglas J. Y Zahler,
certify that b Registered
the Wisconsin
and ma direction of Dale Iverson ILand Surveyor, hereby
SE1 /4 an d pat o f °f the NEI /4 of the SWl 4 have surveyed, divided
the NW1 /4 of the SEl 4/ part of the NEl /4 of the
Town of pleasant Valley, St. / of Section
follows Croix Count 30 ' T28N, R17W,
Y� Wisconsin; described as
Conunencing at the S1/4
along the north corner of said Section 30
aoutheast corner of said 1/4 line of thence NOOo20'26 "W,
thence Nggo5 n NE1 /4 of the SWl /4 Band the inning;
1317.36 feed to the
880.53 feet; 20 W, along the so uth line Point of beg
thence N00oon 1 nd n -3A _ of said NR1 1d „� �t
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06/06/2000 19:14 17156844630 ALWIN EXC INC PAGE 01
ST CROIX COUNTY
SEPTI TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer I �C� 21 �O L- —O c-<
Mailing Addross
Add, y n Net' Fn (5 .-P PI-.�s
(Venticatioo required 5vm Manias Depattmest for new cOmbuction)
City/Stau TlCh5 r. - t Uotte I Parcel Idartification Number I $ `fO
At - DESCRI ON
PropeRy Location Y$. SF ' /.. See. 30 . T IN -R�W. Town of P � a �l
Sttbdivition 4C . Lot M �.
Cerdtled Surrey Map M � IQ , volume / � -- Page * I�
Warrmty Dead f . /_ s� . 5 . S7 y w , . Volume '99 - Page # 3.2 6
Spec hotter 0 ya 4 no Lot lines identifiable 0 yatt A
Iatprvp Emu rod maloeraaaoeotyaar eeptle Mtem could result la is pnmatuntailtse m 6attd4e wattles. ?roper made
consists of pmpieg out the septic test every three yeah nr momw. if srteded by a tkessed pumper. Wbat pa pot Into the syteese
sera ad6et the ftwtioe of ere tteptic tart so a trees sale is 6e wasis disposal Byslaae.
'Ilse pc peM owner agroes b tttbtait W St tact Zomag Deprtmeat a eettification form, aimed by the owes and by a
matter plumber. Joueueyrmsnpltsmber rzsedeledplamba a a liemmdpsmper ventymg that (1) tie on -aloe wastewaeerdispowl rtme
a in proper opeating coaditim and/a (2) deer htspecdca and pumping (if necesaty). the septic tank is lea Qum 1/3 NU Ot dudde.
Uwe. the undersigned bsve read the above requirements asd Wft to maintain the private sewage dLposd system with du stasdsrds
set raf Win. u set by tic Department of Commerce and do Dept tmw of Natural Resources. State of Wisooesin. Cet dketioa
saft Wet yaw septic ayatem bat beet maiaained mat be ooespleted wad returned to the St. Croix County Zoning Office wMbin 30
dap of the three year expiration due.
MOW Pc�tZ — 6 1 ? 1 2z oO
SIGNATURE OF APPLCANf DATE
mm czftmcAmlq
I (we) cati!)r that stl s4rtes mM on this farm are awe to the best of my (our) knowledge. 1 (we) am (arc) to owners) of
tie p^��opper'tY des
cribed above. by virtue of a warranty dead tecaded in Register of Deeds Office.
1GNATURE OF APPLICANT DATE
•..��• Aay that m y result in the nuitary permit being revoked by the Z.oaiog Department. $ 00000
•• lade& with We applkattes: a camped wanasty deed tiom the Rssiaer of Deeds *free
a copy of the certified survey neap if reference 12 made in the wommty deed
1522M 320
6255 1 4
STATE BAR OF WISCONSIN FORM 2.1998 KATHLEEN H. WALSH
WARRANTY DEED REGISTER OF DEEDS
ST. CROIX CO., 11I
Document Number RECEIVED FOR RECORD
This Deed, made between Dale W. Iversen a single 06-8 -2000 10:15 AN
person YARAAINTY DEED
EXEMPT 8
Grantor, CERT COPY FEE:
and Robert W. Pollock and Sharai E. Pollock COPY FEE:
TRANSFER FEE: 149.70
husband and wife as survivorship marital property RECORDING FEE. 10.00
PAGES: I
Grantee.
Grantor, for a valuable consideration, conveys and warrants to Grantee
the following described real estate in St. Croix
County, State of Wisconsin:
Lot 3 of Certfied Survey Map recorded in Volume 13
of Certified Survey Maps on page 3679 as Document Re Area
No. 605978, being a part of the NE 1/4 of the SW Na ne and Return Address
1/4, part the NW 1/4 of the BE 1/4, and part of the
NE 1/4 of the BE 1/4 of section 30, Township 28 RETURN TO: TITLE ONE
North, Range 17 Went, Town of Pleasant Valley,being 706 1 9TH STREET SOUTH
Lot 2 of Certified Survey Map on page 3573 an HUDSON, Wi 54016
Document No. 594225
024 - 1036 -5n -1 00._0 4- 10 - 109. - -
Paicel Identification Number (PIN)
This in not homestead property.
(is) (is not)
Exceptions to warranties:
easements, roadways and Restrictions of record
Dated this day of
• Dale W. Iversen
a �
AUTHENTICATION ACKNOWLEDGMENT
STATE OF WISCONSIN )
Signature(s) ) ss.
St. Croix Court
Person illy came before me this t day of
authenticated this day of —'7t-4 t 9 Qz the above named
Dale W . Eversen
TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the person who executed
(If not, the fore oin; instrument and owledged the same.
authorized by § 706.06, Wis. Stats.)
THIS INSTRUMENT WAS DRAFTED BY jv
* /le
Michael H. Foreeki Attorney Notary Yubl c, State of Wisconsin
Eau Claire, Wisconsin My Commission is petmane .117not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are ( 7 —~ ]r � 3 - ,)
not necessary.) Tracy
Notary Public
Slala f Wisconsin
-Names of persons signing in any capacity must,be typed or printed below their signature.
WARRANTY DEED STATE BAR OF WISCONSIN
FORM No. 2 -1998
Produmd with LPFOrm° by Vareaca Inc. 18025 FBlaen Milo Road, Clrltm Tow ithip. M04W 48035, (800) 383 -9805
Attorney Mi chel H Fomcki 1330 Br.ekm Ave, Emu Claim WI 54701.4627 r— :1115)735 -7029 Fu'. (715)8354112
Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In- Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWTS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
10567 -P (R.6/99).
Table 1: System Design Specifications
Sanitary Permit Number
Number of Bedrooms
Design Flow - Peak (gpd)
Estimated Flow - Average (gpd)
Septic Tank Capacity (gal)
Soil Absorption Component Size (ft2) Z
Type of Wastewater Domestic
Table 2: Soil Abso rption Com ponent - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow - Peak (gpd) z
Maximum Influent Particle Size (in) 1/8
Maximum BOD (mg /L) 220
Maximum TSS (mg /L) 150
Table 3: Maintenance Schedule
Septic Tank Inspect and /or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years
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 (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the septic tank and outlet filter shall be assessed at least
once every 3 years by inspection. The outlet filter 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
Management Plan for a Septic Tank and Soil Absorption Component
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 scum and sludge 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 an 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.
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 the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
Management Plan for a Septic Tank and Soil Absorption Component
Plantings of deep- rooted trees and shrubs directly over or within ten feet of the
component should be avoided since root intrusion into the component may obstruct wastewater
flow.
3
FAX
ST. CRODC COUNTY ZONING OFFICE
1101 Carmichael Road
Hudson, WI 54016
(715) 386-4680
DATE:
TO: Fax Number.
Name:
ART w c - G ox-12-
FROM: Fax Number. 386 -4686
Name: �rL►
Number of Pages Including Cover Sheet t
IF COMPLETE AND LEGIBLE INFORMATION IS NOT RECEIVED, PLEASE
CONTACT:
NAME:
TELEPHONE NUMBER: 3_ �(�b
Ss n�� rtme nt of Commerce S SITE EVALUATION
n of Safety and Buildings Q , Page of
.j of Integrated Services in �rltM_ a R 83.09, Wis. Adm. Code
t�- 4. ! l County
Attach complete site plan on paper not less than 1 11 inchW�? an nays} 1
include, but not limited to: vertical and horizontal r-6% nce point (gM , F lie tion arid• 1 C t
percent slope, scale or dimensions, north arrow, d ocatl&rd distance to neareis d. Parcel I.D. #
'r
APPLICANT INFORMATION - Please art alzln#gr R ewed by Date
Personal information you provide may be used for seconds )y ptirposess Eft. 15
Property Owner - ` P perty Location
Li-p- ✓� T i i ` l \ G ' X t j 1 /4SF 1/4,S 30 T N,R E (or)�l
Property Owner's Mailing Address L Block# Subd. Name or CSM#
rJ — �'' -
City State Zip Code Phone Number ❑ City ❑ Village [ Town Nearest Road
( W
t.✓ t Sy�z�. (7 �) yzs - i {� n t tX�-(c C I�cl
New Construction Use: EgResidential / Number of bedrooms 3 — y Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow dd gpd Recommended design loading rate bed, gpd/ft . � trench, gpd/ft
Absorption area required /'oy bed, ft 9 trench, ft Maximum design loading rate _ bed, gpd/ft - .5 7 trench, gpd/ft
Recommended infiltration surface elevation(s) 9 - 7, (as referred to site plan benchmark)
Additional design/site considerations r U y
Parent material CeJO-C i � � T �' I � Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system ❑ S �9 U Qi�S ❑ U ❑ S 5ir U ❑ S Pi� U I ❑ S [K U ❑ S ® U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /112
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
6 - lz 7firsl t -S #'( Ma" k P%x r C-5 '�I « S . c
Z /Z 6 — S :c r nit CS -S
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CST Name (Please Print) Signature Telephone No.
71.s� 2 y7- G /oo
Address Date CST Number
. T-
PROPERTY OWNER _.1—(/ e ��O r1 SOIL DESCRIPTION REPORT
_ Page y
PARCEL I.D.#
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Texture Consistence Boundary Roots
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