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HomeMy WebLinkAbout026-1137-30-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: is GENERAL INFORMATION (ATTACH TO PERMIT) State Ian D 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: P.C. Collova Builders, Inc. I Richmond Township 026- 1137 - 30-000 CST BM Elev: c Insp. BM Elev: BM Description: Q- 12✓t 1 U6 ' (� / r - % TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark •� 8 Dosing Alt. BM Aeration Bldg. Sewer •Q -� Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic ' f [ Dt Bottom Dosing Header /Man. Aeration Dist. Pipe �.9"� CIS.SIq 5 sx5 Holding Bot. Syste z Jr 9 Z.40 q (� PUMP /SIPHON INFORMATION Final Grade 31 D Manufacturer Demand St Cover GPM Model Number TDH Lift s System Head TDH Ft Forcemain Length Dia. Dist. to Well I I I L SOIL BSORPTION SYSTEM ENC Width Length No. Of Trenches ,PIT DIMENSIONS No. Of Pits Inside Dia. T id Depth DIME 10 ( S SETBACK SYSTEM TO P/L PLDG IWELL LAKE /STREAM CHAMBER OR M�pLZq INFORMATION n I[ _ Type Of System: �Z t r �^ UNIT M Number. �t�t v1d11C/ • 4 U 33 DISTRIBUTION SYSTEM Header/Mar Distribution x ole Size x Hole Spacing Vent to Air Intake Pipe(s) Length j K 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 [� Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:� 0 / �� / D Inspection #2: Location: 1473 111th Street New Richmond, WI 54017 (SW 1/4 NW 1/4 21 T30N RI 8W) Goltview A Parcel No: 21.30.18.956 1. Alt BM Descrip = N/44 2.) Bldg sewer length = ' p t - amount of cover = 1� 0 s• Plan revision Required? WYes ❑ No t e � t si e additional ' ff Q ' rmation. D�710- 7) _10Z) • Date Insepctor's Signature Cart. No. 1101N)o - [54o . AZ) Vt4,D t -z I'aq'3 Sanitary Permit Application Safety & Buildings Division In accord with Comm 53.21, Wis. Adm. Code 201 W. Washington Ave. PO See reverse side for instructions for completing this application Box 7302 ,�+dgir+� Madison, WI 53707 -7302 P ersonal information you provide may be used for secondary purposes D®partment of Commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not state owned. Attach co m lets cans to the county copy onl fo a system, on paper not less than 8 - 1/2 x 11 inches in size. oun State Sanitary tt Number WtURcck if tovi o to previous application State Plan I. D. N L A pplication Information - Please Print all information Location: Property Owner amt party Ucation I �s e-e7 ,l a �V a •-f 54_11 f4, SZ/ T30,14,11/ petty wn s Mal ng dress Lot Number 91ack 11 r A c ity, Stoft zip me e n �g�q ub v s on one or um r Y fie. .5' / � �,( ', � % of Building: (check one) t © City 1 or 2 Family Dwelling -No. of Bedrooms, S ❑ Village ^� own of L. © blic/Commercial (describe use):,, .. �` 0 State -Owned Nearest -_- - - F m — el Tak N um 111. Type of mit: (Check on one box on line A. Check WonJift B if applicable A) L w 2. U Replacement 31 13 Repiacern o d: P r . , 6. M Addition to System System 'tank Only r Bxi S stem B) t rm um r ate 1'a A Sattltary Permit was previously issued R E-Ed f WT System: (Check all that apply) urized ,In- ground O Mound ❑ Sand Filter E3 Constructed Wetland In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At-grade 0 Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. DispprsalfIrreatment Area Information: 1. an ow ) : capers Area 3. Dispetssd A Sall Application 5. Perco sa on Rate System E ev on 7. / ay `9 1 ( nJinc}e) <S evsalon ' ✓ R weed ✓ Prop ✓ ... Rata C3alsJd tt. VII. T ank Capacity in Total # of Manufacturer Prefab Site Steel Fiber - Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crew sMicted Tanks Tanks ❑ ❑ ❑ ❑ ❑ ❑ ❑ __ _ ❑ WrOtesponsibility Statement _ 1. the unders ed, " It ibili • for ins ation /VOJ shown on the attached plans. un s sane Plug :. •� o, _ �y ua nessc r , (Street; City, State, 7jp unto rta"t US4 o Disapproved sanitary Permit Pee inelu a Groundwater Date uad gasture NO sitartpt Approved C3 Owner Glvan Initial Adverse $urobarge Fee) Det ` �� . 6f �_ _;2 X. Coltr�t l ou o e Ins a eTa fi n ilPe�pe recommendations_ �. I 'This revision/transfer was submitted to reflect a change in plumber. 3. Chamber louver shall be in stalled ,in soils with a soil application rate of .7, approximately 55 inches below grade. SRn. f# own "I 43N/R T PLAN PROJECT P.C. Collova Builders Inc. DDRESS 705 Countv Rd E Hudson Wi 54016 SW 1/4 NW 1 /4s 21 /T 18 W TOWN Richmond COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 10/7/0 BEDROOM 3 CONVENTIONAL X04( IN- R ND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE 1.2 ABSORPTION AREA 377 # of chambers 22 BENCHMARK V.R.P. Topof 1" iron Pipe ASSUME ELEVATION 100' Filter Zabel A -100 ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark 111th St . SYSTEM ELEVATION 95.8 366' Property Line Plans Designed Using Conventional Powts Manual Version 2.0 B.M. #2 B -3 Vents 40 Vents 30' T 54' 60' Pro 3 20' Bedroom House B_2 35' 35' B_1 2 -3' X 69' Cells with >3' Spacing a� Vent > 1~ A Sidewinder High o Capacity Leaching Chamber 6" Grade at System Elevation 34" 299' Property Line B.M. #1 t3N/R T PLAN PROJECT P.C. Collova Builders Inc. DDRESS 705 Countv Rd E Hudson Wi 54016 SW 1/4 NW 1/4s 21 /T 18 W T OWN Richmond COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 10/7/01 BEDROOM 3 CONVENTIONAL )00( IN- R ND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE 1.2 ABSORPTION AREA 377 # of chambers 22 BENCHMARK V.R.P. Topof 1" iron Pipe ASSUME ELEVATION 100' Filter Zabel A -100 ❑ BOREHOLE O WELL *H. R. P Same as Benchmark 111th St . SYSTEM ELEVATION 95.8 366' Property Line Plans Designed Using Conventional Powts Manual Version 2.0 B.M. #2 B- 3 Vents 40 Vents Y 30' 50' 60' T Pro 3 Bedroom 20' House B_2 35' 35' B - 2 -3' X 69' Cells with >3' Spacing a� Vent ALo Sidewinder High o Capacity Leaching " Chamber 34" Grade at Sy stem Elevation 299' Property Line B.M. #1 Sanitary Permit A„r plication Safety & Buildings Division In accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 14.4consin Personal information ou p rovide may be used for second p urposes Madison, WI 53707 -7302 Department of Commerce y p y p [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not state owned.) Attach complete plans (to the county copy only) for the system, o less than 8 -1/2 x 11 inches in size. County State Sanitary P it Number ❑Check if re ' o t e i sap, lion State Plan I. D. Number .:__` p . 1 7 ' , '.. I. Application Information - Please Print all Information Location: Prope Owner Name roperty Location C , t 114 A)JO14, S T 30N, R/ or Pr perty Owner's Mailing Address t t - - of Number Block Number City, State Zip Code PIW& J44mber _. ,.�t3 Subdiviisi Name or CSM Number D ( IG3 T ype of Building: (check o ) E ❑city 1 or 2 Family Dwelling - No. of drooms : ❑Village Public /Commercial (describe use):_ Towi of ❑ State -Owned /J _1 ®/ T I Neazes 1�O (7 / P e Numbe s III. Type of Permit: (Check only one box on line Check box o me B if applicable) p. A) 1. ew 2. ❑ Replacement 3. eplacement 4. 5. a �. 3 O . /g. �6. ❑ Addition to System System Tan my Existing System $) ermit tuber ate ssued ❑ A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) A(Non- pressurized In- ground ❑ Mo ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Ho ing T ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ obic Tre ent Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment Are Infor mation: 3 � && 7S 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal ea 4. Soil Appli ion 5. Percolation Rate 6. System Elevation 7. Final Grade sed Required Propo Rate (Gals./da q. (Min. /inch) Elevation 5_j 80 VII. Tank Capacity in fb tal # of Manufactur Prefab Site Steel Fiber- Plastic Information Gallons allons Tanks Con- Con- glass New Existing crete structed Tanks Tanks ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ VIII. Responsibility Statement I, the undersigned, assume respo ibility for installation of the POWTS sh wa on the attached plans. Plumber's Name (print) Plumber' ign ur (no stamp P PRS No. Business one Number Plumber's Address (Street, City, Stle, Zip Co ) IX. County/Departme I Use Only ❑ Dis roved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Vent gnature (No stamps) pproved ❑ Ow er Given Initial Adverse Surcharge Fee) R r Dete ination ( " Z Ll G X. Conditions of J1ppr9va1 /Reasons for Disapproval: SBD -6398 (R. 07/00) L �— VV I c 3 goo `se,+4Lc, 3 P � 13 3 S� 9s go 0 3.x- Wisconsin Department of Commerce SOIL EVALUATION REPORT Page I of 3 Diyisiowa Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County C r�1 S4 Attach complete site plan on paper not less than 8112 x 11 inches in size. Plan must . include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, agd location andol tance to nearest road. Please prirrt al i( ormation. Reviewed by Da �1 Personal information you provide may be used r Secondary rpo (Privacy t , . 15.04 (1) (m)). 2 �' Property Owner i - ` : J rty Location ,,t,� i v Rt V �.tr d e ¢� n < Lot w 1/4/( W1 /4 S Z( T Cr N R j E (or) �V Property Owner's Mailing Address r g # Block # Subd. Name or CSM# , i�.0 . C'�x Ibco2 Y "''x o C- ,ol��►e� Acres l city State Phony, RC! City ❑ Village [,Town Nearest Road uoh.le6in cLakell-AN 155 11C) (051) - 7 8 _Q FN ® New Construction Use: ® Residential / Number d bedriii 3 ` Code derived design flow rate 4 5 Cn�C� GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material U u4 W o-5 i'1 Flood Plain elevation if applicable 1 /Y ft General comments 5 )/ S m✓, e (� u 9 S $ v and recommendations: f e(e U •9 5 $ D ❑ Boring # ❑ Boring ® Pit Ground surface elev. d ft Depth to limiting factor 1 1 Z in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 '01#2 I o -12 lb 5,1 2 c / Z - 31 16 ly S,' I 2rnab>'Z mfr c — S 8 Boring # E] Boring ® pit Ground surface elev. 99' eF ft Depth to limiting factor l 10 in. Soil Appi ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont Color Gr_ Sz. Sh. 'Eff#1 'Eff#2 I b --i Z 1p 313 -- S; I ZMC ry� C S 2 _ q j q ach . .v ' Effluent #1 = BOD > 30 _< 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and MRS : 5 30 mg/L CST Name (Please Pr rd) Signature CST Number A,dorv, Schu ke,r �� 2533tR Address Date Evaluation Conducted Telephone Number v A Property Owner N t'_ ISor, Parcel ID# Page 2 of 3 [-3] Boring # ❑Boring Pit Ground surface elev. q D ft Depth to limiting factor �_ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Sure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *Eff#1 I *Eff#2 ► a_r� I s,► 2 �s J,. . S- . 9 2 l I - 4H1 s; C -- s- 8 3 L q -li, - fin S L SQL F -1 Boring # F1 E] ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIfF in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *Efr#1 *Eff#2 F-1 Boring # Pit Boring ❑ Ground surface elev. ft Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Str Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOO 5 > 30 < 220 mg /L and TSS >30 < 150 mg& ` Effluent #2 = BOD 5 _ < 30 mglL 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. SBr}833o OL07/00) f PAGE 3 OF 3 4 u' /, S T N R E or N ! LOT# o LEGAL DESCRIPTIO Sw � NAME ti c l so r. •3 SCALE: 1 "= y� BM I ELEVATION �eQ ') , 0 � BM I DESCRIPTION o I''I +Cc p2 BM 2 ELEVATION q9. 9 / BM 2 DESCRIPTION o-Q l "-T e 1 D e SYSTEM ELEVATION -- - J S S , 8 0 ALTERNATE ELEVATION q S• 9 6 CONTOUR ELEVATION S I o 3m Z n o sly pe C3 -3 ■ ¢ .L B -1 III o i-n C'I, I : Sv� Qt SIGNA DATE /G 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) S� Estimated Flow - Average (gpd) Septic Tank Capacity (gal) O Soil Absorption Component Size (ft Type of Wastewater Domestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) Maximum Influent Particle Size (in) 1/8 Maximum BOD (mg /L) 220 Maximum TSS (mg /L) 150 Table 3: Maintenance Schedule Septic Tank I nspect 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. -57- N �O r ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 1 C' • 11 116 V4 od a'r AfPjs --tom �- Mailing Address 0.S E 11Lajsr A) WX S 4-0 % 4 Property Address / 4 r �� (Verification required from Planning Department for new construction) ____ --= City/State AUQ jqLC_UM_0,Ai �_ Parcel Identification Number LEGAL DESCRIPTION Property Location NW y,, y., Sec, T N -R_f Town of !Cl�l`n mo . Subdivision 6 0 1_ v' i W Asoe F y 3 0 Lot # CertiCed Survey Map # Volume . Page # Warranty Deed # Volume �� ` , Page # ` Spec house ❑ yesXno Lot lines identifiable *yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature.failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner. and by a master 'M journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin - Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days o ee year expiration date. / 7/0) SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of thS,propetly,4escribed above, by virtue of a warranty deed recorded in Register of Deeds Office. 7 / C SIGNATURE OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed 08,`08101 WED 08:01 FAX 715 986 4687 REGISTER OF DEEDS Q001 v 66�as -70 STAT RAR OF G; NSTAL 2 -1999 KATHLEE14 H. WALSH Document Number '4VARR TY 1���D REGISTER OF D , UI 5T. CROIX CQ. , Lt1 This Deed, made between Hiltv Deveto' m' n T.l . 4id, a REEEIVED FOR RECORD Min nesota Limited L 1abllity Part ;:: ;� ;'" ; 08- 07 -20Q1 9:30 0 _.., . Y...;• ----- SUMTY DEED Grantor, and P. C. Collova Buil Inc., a M oirpora IERT COPY FEE: COPY FEE: - -- TRANSFER FEE 760.60 _.. .. RRCt 0.00 E 18 S DINO FE 1 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. C County, State of Wisconsin (if more space is needed, please attach addendum); Rcccrding Area Nwne and Return Address Lots 1, 2, 3, 6, 7, 29, 31, 32 and 33, E AV}D J. ESTREEN Golfviev Acres, 'l'o'an of Richmond, St. Croix County, Wisconsin. 304 LOCUST ST HUDSON, W1 54016 & 5 Pt 026. 10 12.50 _ Parcel Identification Number (PM) This is not homestead property. IX) (is not) Exceptions to warranties:- Easements, restrictions and rights-of of record, If any. Dated this _ r9 9'J� day of June _ 2001 11111vale Development Limited + —. _ _. • liy: R ichard Nelson AUTHENTICATION ACKNOWLEDGMENT Signatnre(s) _ STATE OF WISCONSIN } ss. St. Croi County } authenticated this day of _ , „ 1'cr5on &liy came before me this �. day of June , 2001 the abovc named >Illlvale velopme Limited, a M Innesots Li mite d Liability s Kri stina Ogian Partnt a b Pi'chard Nel - TITIA -1: MEMBER STATE BAR OF WISCONSIN to -� tson(s) who cxacuted the fornguins (If not, in' gad the same, authorized by $ 706.06, Wis. �It THIS INSTRUMFNI' WAS DRAF 1'En BY * rt'-N _.•. _ . _ Attorne Kristina ODl Nat isconsin kludso 54016 My anent, (If not, state expiration date; - _.. (Signatures may be nutt aticalod or n4nowiedgcd. Both are not neccssiry.) "NrNuN„ —Nam—.s of persons signing in any ;opacity must be typed or printed below then signature. wo natan PrefaWoma company, kotd du L r2 WARRANTY DEED STATE NORM No. 2.1999 Sanitary Permit Application Safety & Buildings Division j In accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of Commerce (Submit completed form to county if not [Privacy Law, s. 15.04(1)(m)] state owned.) Attach complete plans (to the county copy only) or ystem, o e 8 -1/2 x 11 inches in size. County5/ n r State Sanitary P 't u b r heck if vision to previous appli ation State Plan L D. Number I. Application Infor mation - Please Print all Information Location: Property Owner Name Property Location 1 � t Ilea a 1 SUA AMa)4, � 'P� ,N d (orow Property Owner's Mailing Address Lot Number Block Number u � 1eJ 36 City, State Zip Code Phone Number Subdivision Name or CSM Number II. Type of Building: (check one) ❑ City I or 2 Family Dwelling - No. of Bedrooms ❑ Village Public /Commercial (describe use):_ own of ❑ State - Owned Nearest Roa Parcel Tax mber(s) III. Type of P rmit: (Check only one box on line A. C heck box on line B if applicable) A) 1. ew 11 Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to System System Tank Only Existing System $) Permit Number Date Issued ❑ A Sanitary Permit was previously issued Type of POWT System: (Check all that apply) A;W on-pressurized In- ground `� ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment Area Information: al l» 1 - fir / 77 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. SysTerrf Elevation 7. Final Grade Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) Elevation 3 - 7 .3 - 7 1. V...-5- r - 9e' VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks 'pry t/L/ ❑ ❑ 1 ❑ ❑ VIII. Responsibility Statement I, the undersigned, assume responsibility for installatioj# of the POWTS shown on the attached plans. Plumber's Name (print) Plumber's Sig r o tamps): MP/MPRS No. Business Phone Number Plumber's Address (Street, City, State, Code) IX. County/Department Use Onl Y ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued uing t Signa (No stamps) 1Rpproved ❑ Owner Given Initial Adverse Surcharge Fee) Determination X. Conditions of Approval /Reasons for Disapproval: 1� At.Ui'LIt;N" 4✓tu� - Zrw�.' -C� � a- �� '"" _w' 1� ""`� SBD -6398 (R. 07/00) Wisconsin,Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must • (, ` include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. a wed y Dat Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 6 ' v Property Owner Property Location ( �7 Govt. Lot 5L0 114A01 4 S , ; 2 1 T,3() N V� E ( ) W Property Owner's Mailing ddress Lot # Block # Sub .Name or CSM# s� (Do / 14C City State, _Zip Code Phone Number ❑ City ❑ Village w Nearest Ro 5 ybl b i 4 New Construction ljlse Residential / Number of bedrooms Code derived design flow rate fCJ GPD ❑ Replacement ❑ Public or c mmercial - Describe: Parent material Flood Plain elevation if applicable �✓� ft. General comments /► and recommendations: '7 2 FT I Boring # E] Boring r !, E4 Pit Ground surface elev .79- V 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 ' S os / i rf ,10 , GO Boring # ❑ Boring E] pit Ground surface ele .. 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 Z en - (:;2 - 7 Z 4 RZ *Effluent #1 = BOD > 30 < 220 mg /L and TSS >3 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L CST Name (P e e Print) Signature N�ymbe / , y v { �l/ Address Date Evaluation Conducte Telephone Number SBD -8330 (R07 /00) f - Property Owner Parcel ID # Page of 1Z . Boring # ❑ Boring it Ground surface elev. ft. Depth to limiting factor / in. Soil Application Rate Horizon Dep6 Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft i Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 z w Ile -a ❑ 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 ❑ 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 -8330 (R.07 /00) C- i k44 -r s LOT PLAN PROJECT (, 1 0 to) ADDRESS ADDRESS oui 6 ze& S � 1/4 /� /�, 1 /4S Z 1 /T N/ W TOWN ' COUNTY ST ` L5L rW A . MPRS Shaun Bird 226900 DATE �� �� BEDROOM J CONVENTIONAL ^ IN -GRO D PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND S TANK SIZE 1()00a004 LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE /, 2- ABSORPTION AREAS # of chambers c�2oZ. IL BENCHMARK V.R.P. 16 1 ASSUME ELEVATION 100° Filter Zabel A -100 ❑ BOREHOLE O WELL .R.P. Same as Benchmark SYSTEM ELEVATION , Vent > 12" Sidewinder High of Cover Capacity Leaching Plans Designed Using Chamber Conventional Powts 6' Long 16" Manual Version 2.0 jj 34" Grade at System Elevation oe c� 35 � 3 Pro C4zJz,'7A `29 t8.9 NOC • �c 8 r? S00 0 4 - -- - -- 209 - -- - - f - 209. - - - -- - -- 211 - 3� 0 - 1033.04'- VI N O o 1112TH f W W U 37 00 t< 38 00 � 39 87,153 sq.ft. � t 87,153 sq.ft. 87,325 sq.ft. t 2.00 acres Z 2.00 acres Z 2.00 acres O o rn yc �ti o Z N00 0 41'43 "W p -625.22 209.00' 209.00' 1 207.22' SECTK 130.78' 302.95' 191.49' b C! - 0 3 > 0) o Hit N ' P. 3 68,536 sq.ft. iV 30 i M p wl- 1.57 acres M 87, 254 sq.ft. N 3 32 0 ^����0. 2.00 acres ^. 'o 87,091 sq.ft. M oI SI 2.00 r i ao acres Tod Z rn N - - -- < Metr 00 N . _ \ i 332 pi Littl F—I 9 "E J �- -- -- - - - - -- C2 - \ 55 G ,yp \ � z i — — 116.92' — _C32 5�i \\ z \ 100• 1 - - M N15 °39, 2� M w � I N 29 E \ / 6 5,713 sq.ft. -ST' °3g 21 \ 1.51 acres 92 ' —� / ao � o _ — 5. 9 C24 V - o 212.01' — — — C23 C26 '� / CO3 sn �s� s