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026-1137-35-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 399453 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: Goulet, Steve I Richmond Township 026- 1137 -35 -000 CST BM Elev: ' Insp. BM Elev: IBM Description: Section/Town /Range /Map No: °► .10 I CsT Z'44* Z- 21.30.18.991 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic E � BenchmarC -4L\ 1 1 ot5o C4 1 1 . zo 0390 99 -:'O Dosing Alt. BM O Aeration Bldg. Sewer Holding St/Ht Inlet Ct. 23' 9 • }Z r St/Ht Outlet a TANK SETBACK INFORMATION 9 T-I r I ' TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic ) SCI )L 1 I Dt Bottom Dosing ) Header /Man. •9S Aeration Dist. Pipe 9 95 Holding Bot. System Li 10.9t) 93•/O 6 I t. o z•9S PUMP /SIPHON INFORMATION Final Grade 3• 0 w•o,f" Manufacturer Demand St Cover GPM Model umber TDH Lift fiction Loss System Head TDH Ft For cem ' Leng Dia. Dist. to Well IL ORPTION SYSTEM RENO idth Length No. Of Trenche PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DI S �$ SETBACK SYSTEM TO /L JBLDG IWE LL LAKE /STREAM LEACHING Manufacturer. INFORMATION CHAMBER OR W O D r–u Type Of System: J• UNIT Model Number: ' •C 1 f DISTRIBUTION SYSTEM 1\ Header /Manifo d Distribution x Hole Size x Hole Spacing Vent to Air Intake p 9 S �niA� tt Pi e( s) 1 Length Dia Len is pacing 9 O 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 0 No � Yes [7] No COMMENTS (Intl de code Iscrepencies, persons pr sent, etc.) Inspection #1:v/ 0` 1 20 0 .3 Inspection #2: � — r 7 — C) OA I�nS�ec T. V Gas;. W . Loc on: 1119 148th Avenue New Ric nd, WI 54017 (SW 1/4 NW 1/4 21 T30N R1 8W) Golf View Acres Lot 35 Parcel No: 21.30.18.991 1.) Alt BM Description = t�..�a./ eke Ri ic 2.) Bldg sewer length = 1- ` Q - amount of cover = > '+2 K . Plan revision Required? H Yes No X91 �I Use other side for additional information. 47±7 SBD -6710 (R.3/97) (1 _ '�l�N Insepctor s Signature 4 Cert. No. rQXA. �V�CO• /07403'� Sanitary Permit Applicaffoh 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 NV&4�onsin Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of commerce [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 syste on pape n less than 8 -1/2 x 11 inches in size. County State Sanitary Permit Number ❑ Check if revision to previous application State Plan I. D Number S A C / 34 1' S- N 1; I. Application Information - Please Print all Information Location: Property Owner Name A � Property Location _/ lie C/ s' / /4 /.0 l/4, S �S T`3�,N, xl �(or) Property Owner's Mailing Address [` I � Lot Number Block Number City, State Zip Code Phone N r Subdivision Name or CSM Number Aly Aj [_ 55 D q� 7' � ,_- of , II. Ty 6e of Building: (check one) 6' ! ❑ City 1 or 2 Family Dwelling - No. of Bedrooms : - - t; 1 r , Otdv4C ' ❑Village ❑ Public /Commercial (describe use):_ ; 'YTown of ❑ State -Owned -- Nearest Ro Parcel Tax Number(s) III. Type of P mit: (Check on line A. Check box on line B if applicable) A) 1. w ❑ eplacement 3. ❑ Replacement of 4. (o 7 . p Q 6. ❑ Addition to System tem_ Tank Only Existing System $) Permit Number Date Issued ❑ A Sanitary Permit was previously issued IV • (Check all that apply) on- pressurized In- ground ❑Mound ❑Sand Filter ❑Constructed Wetland urze n -group ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculat' ❑ Other: L � .sci w V. Dispersal/Treatment Area Information: 1 4- 14 , yo 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System ElevatMn 7. Final Grade Required Proposed Rate (Gals. /day /sq. R. (Min. /inch) Elevation 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 C.C! Yt I ter �O ( 0 ❑ ❑ ❑ [3 VIII. Responsibility Statement I, the undersig assum responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (print) Plumber's Si a (no stamp w. MP/MPRS No. J � Business Phone Number Plumber's Address (Street, City, State, Zip Co IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued I g Agent Signature (No stamps) pproved ❑ Owner Given Initial Adverse Surcharge Fee) .aa Determination . -o�S Ii, to /o d X. Conditions of Approval /Reasons for Disapproval: 1. Effluent filter to be installed and maintained per manufacturer's recommendations. 2. Well setbacks to be maintained per NR 811 & 812. 3. All setbacks to system and residential structure must meet applicable code requirements. 4. This system shall be installed in accordance with the in- ground soil absorption component manual (version 2.0). SBD -6398 (R. 07/00) PLOT PLAN PROJECT Steve Goulet A RESs 2394 Schaller Drive Maolewood Mn 55109 SW 1/4 NW 1/4s 21 /T 30 N 18 W OWN Richmond COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 9 /26/01 BEDROOM 3 CONVENTIONAL XXX IN -GROUN RESSURE 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 IL BENCHMARK V.R.P. Top of 1.5" Pipe ASSUME ELEVATION 100 Filter Zabel A -100 ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark SYSTEM ELEVATION 96.3 148th Ave Vent >6 „ Standard Biodiffuser of Cover Leaching Chamber pro 3 Bedroom 6' Long 11 " 34" Grade at System Elevation House 50 Plans Designed Using 120' Conventional Powts T Manual Version 2.0 70' Vents B - 4 70' 2-3'X 69' Cells 20 ' B -1 with >3' Spacing a 0' a 0' AS — 1 g << �, 't Vents 0' •M•' B -1 Ir— 40' 20' Property Line Alt. B.M. 20' r Wmconsin Department of commerce SOIL EVALUATION REPORT Page of Division of safety and BUIr ings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 81/2 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. Date R by Please print all information. \ 0 3 Personal hWwm Wn You provide may be used for secondary purposes (Privacy Law. s. 15.04 (t) (m)). Ply Property Location )) Govt Lot � 1/¢' - 1/4 S ( T3� N R E ( w Property O�rr>er's „ Address Lot # Biodc # Name or CSMtl/ Cfly State zip Code Phone Number ❑ City Village �Ic Town Nearest Road D ( ) New Construction Use: / Number of bedrooms Code derived design now rate _ GPD ❑ Rat ❑ Pubic commercial - Describe: iL Parent materW l � �[� - Flood Plain elevation if applicable General conwrients and recommendations: Being # 9 � � Ground surface elev.�� -�-- ft. Depth to IUnitin9 factor -- _t._ =— in. © i Pit Sod Rode Horizon Depth DominantColGr Redox Description Texture Structure Consistence Boundary Roots GPQW In. Munsep Qu. Sz. Cont. Color Gr. Sz. Sh. 'EfW1 'Eff#2 cs s Z c s6�' c 3 0- -� Boring ❑# 0 Boring ❑Pit Ground surface elev. fL Depth to limiting factor �• Sol App0q@§qn Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDlfP In. Munsel Chi. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Etf� ' Effaw t #1 = BW > 30 < 2M mg& and TSS >30 <_ 150 n�f ' Effluent #2 = BM < 30 mg& and TSS <_ 30 nqL - r NWW CST Name -c,, P" s n 1� ``'� l / n Date Evaluation Conducted Telop wm Ntumber PLOT PLAN PROJECT Steve Goulet DDRESs 2394 Schaller Drive Maplewood Mn 55109 SW 1/4 NW 1/4s 21 /T 3 /R 18 W TOWN Richmond COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 9 BEDROOM 3 CONVENTIONAL ) IN- 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. Top of 1.5" Pipe ASSUME ELEVATION 100' Filter Zabel A -100 ❑ BOREHOLE WELL *H.R.P. Same as Benchmark SYSTEM ELEVATION 96.3 148th Ave A Vent l2 Sidewinder High 1 k j to C x ( Ot e Capacity Leaching Plans Designed Using Chamber Conventional Powts 6 " Grade at System Elevation Manual Version 2.0 ` 34" • Pro Bedroom House 1 20' B -1 0' a 2 -3' X 69 Cells with >3' Spac' 0' g B -3 N 0 , M., � 0 B -1 40' Vents 20' Property Line Alt. B.M. 20' t �� a� ,. . �� , L .�!f r �r � �, '� .�� ����. Wacorrsin Department of Commerce SOIL EVALUATION REPORT Page I of Divis`ari of Sa and Buildings in accordance with Comm 85, Wis. Adm. Code County S4 C roi x Attach complete site plan on paper not less than 81/2 1.1 inoWin size. Plan must x include, but not limited to: vertical and horizontal pointJ17 direction and Parcel I.D. percent slope, scale or dimensions, north arrow,��tion and dktinpb to nearest road. b Date Please print a 1 Personal information you provide may be used Secondary pur�8l8 ( Law, s 15;04 (1) (m)). Property Owner property Location R .� „ _d e SQ�I u f Govt; Lot 1114 �j l4 S Z� T 3 p N R / E (or)1� Property Owner's Mailing A dress C,C� /M /Lot Block # 1 = 1 a (:view ne or CSW i�.o . box Ib(o z,,� f `5 Acres Stem Zip Cade �ber ti ° 11 City ❑ Village [,Town Nearest Road i (c�3�� w d ch M mi ® New Construction Use: ® Residential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material 0y 4W l'1 Flood Plain elevation if applicable /U�� ft. General comments -S �� t' ewl � (-e ur qG ' 3 v and recommendations: L�_ t?(-e ✓• 9�y• 3 p I F1 Boring a Boring # ® Pit Ground surface elev. ( 7' 7- �r d ft Depth to limiting factor 113 in• V*E cation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary RoD/fP in. Munsell Qu. Sz. Cart Color Gr. Sz. Sh. 'Eff#2 1 2" 1,b --fir C- c I v Z (O- (D I 3 /Z� 9 -� l0 m5 rn M Boring # Boring ® Pit Ground surface eiev. 9'9' 8d ft. Depth to limiting factor in. H 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 'Eff#2 I - ►I 1 d r Z S. I Z rnrrb k nor c 5 lv� 8 , 2 /- S r( 2 rno b k mCr- LS r 8 3 3�O -lID 1 r`t �lp ,n�S �5 1 — — /•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 nature CST Number A,6o m Sc leer - - - - -- 2533og Address Date Evaluation Conducted Telephone Number 2u3 8�'` -' SomerseA \.t I 2402C) S — _ cv Z`I l -`1d0S Property Owner NJ e ISon Parcel ID # Page 2 of 3 F31 Boring # ❑Boring Pit Ground surface elev.ft Depth limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Conk Color Gr. Sz. Sh. *Eff#1 'Eff#2 1 c) —I/ lb 2 SS Zrt'bk Z �� - I r I s' ► rrab -fir' C m5 rn L v F-1 Boring # ❑ Boring ❑ pit Ground surface eiev. ft. Depth to Mniting factor in. Soil Application 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 ❑ 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/fF 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. saD -M30 R07/00) PAGE 3 OF NAME ti e Son LOW 3 LEGAL DESCRIPTION 5 w llww' / Sz 1 T o N R IV E(or) SCALE: I "= yy i BM 1 ELEVATION BM I DESCRIPTION }o jo I %z jQQG Q � BM 2 ELEVATION 17 - 70 J < <G Z / BM 2 DESCRIPTION 4- ,Qn n SYSTEM ELEVATION 0 ALTERNATE ELEVATION 3 y CONTOUR ELEVATION ✓1 y S (o -G. s ic P �0 z 3 ' v ar^ • ■ Q -� 4 �n2 DATE SIGNATURE �-- -- S - C'/ Maintenance and Contingency Plan for a Septic System Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Effluent filter is to be cleaned once a year. Please note: a larger fker is being Installed in order to extend the maintenance interval of the filter. 3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of the cells. 4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system. 5. The owner agrees to save this plan. 6. Do not plant trees nor park nor drive over system. 7. Watershed is to be diverted away from system. 8. Discharge into system is not exceed those required as per Comm. 83 Contingency Plan 1. If system fails, determine cause of failure, use alternate area and install new system or install system at a lower elevation. as needed. 2. Replace an other failing components p Y Plumber: Shaun Bird 715 -246 -4516 P Shaun Bird #226900 I ' - ST (TOIX COUNTY - PTIC: TANIK i`n.AIIkTTE)�l,�hi�'F_, .AariR1�;I~'�1F'NT ANI:) OWNTER-SHIP CERTIFICATION FORM IL 1119 (Verifica� ion required froln Planning Department for new construction), CItyt Parcel Identification Numb, Prol. Iv Lo-:a ,n _S '..;, v" %,. Sec. / ._.. _j(_)_.,N- R,..L_ h', Town of.A,c..Gi�rr!_;r.v�.. 5i.,.jtj: ar3oi(7It tC'e.rti'ed yt::r,+' tr Mu.p N__ . _ � ___.._. ,_......._._,...,. �`crturzty _-�.._.... Page /' War arty 111e r�. t` `7 � - z- I� agz! A .,......�r.,�,.�. �. .. Spec, .iouse + :s K'no Lot lines identifiable wyes U no DuprePe r . t . ue! and maiutenauceof your septic system could result in its premature. failure to handle wastes. ProWiriain e nmWe. consis ;of puxtapia ; out the sep, tank every three years or sooner, if needed by a iiecnsed pumper. What you put; into the.;. system can. a1 3:set the Tier: r ,rion of the si ::ptic tank as a treatment stage in the waste. disposal system.. 11c pm:: ,. ,ty owner aliaees to subrmt to St. Croix Zoning Department a certification form., signed by the.owner?,t:rid by a maste `olumbc-, ictt:.tneymanpinmboi°. restrictedpluidber or a liccased,pumper verifying that (1) the on -site WastewatetdifiPWx j :system is in p 5per opemi t is ;g condition and /or (2) after inspection and puraoing (if necessary)., the septic tank is less than 113 full of. Audge. Uwe, . to undetsi i; d have reac,. the above. requirements and agree to maintain the private sewage disposal system with the.- ;.tgadards set fort 13, herebi, ;i ,.et by the Lie3partinant of Couxmerce and the Department of Natural Resow.ces; State of Wisconsin. cei.oAcation stativ. g that yot =r , :n rtio system fas been maintained must be completed and returned to the St, Croix County Zoning, Ofyica +hin 30 clays tr �hr.. tI•r, ;e I . sir OX. -PiTatill ;late. � ; 7 X DATE I (wc) c that all Uatements on this form are true to the best of my (our) knowledge. I (we) am (arc) the ovi:nor(s) of the p,r::.erty dt'tcc: a i'! t above, t: y virtue: of a warranty deed Tecorded in Register of Deeds Office _ . 17 y ; clj 5irr'�!: I I_f* k" ;.1' I,l "F'i: it..A.t' T)ATP Any irif rt nation that i:; rus- .represented may result in the sanitary permit being revoked by the Zoning " 1ni mde with a h 19 applieati'm: a stamped warranty deed f'rorh the Register of Deeds office a copy of the certil:rcd survey map if reference is made in the waria.nry deed Yt 1101 PAGE 516 r J STATE BAR OF WISCONSIN FORM 2 - 1999 6!t5 -S KATHLEEN H. WALSH WARRANTY DEED Document Number REGISTER OF DEEDS ;T. CROIX CO., WI This Deed, made between Hillvale Devel Limite a RECEIVED FOR RECORD Min nesota Limited Liability Partnership, — 08 -11 -2001 9:30 AM -- - WARRANTY DEED Grantor, and Steven T. Goulet and Candace A. Go ulet, husba and EXEMPT 8 wife — CERT COPY FEE: -- - - -- COPY FEE: -- -- - -, _ _ TRANSFER FEE: 18.90 REMRDING FEE: 10.00 Grantee. PAGES: I Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area Lot 35, Golfview Acres, St. Croix County, Wisconsin. Name and Return Address KRISTINA OGL4ND ATTORNEY AT LAW P.O. BOX 359 HUDSON, WI 54016 Ptot026- 1060 - 80,026- 1063 -95 & 026 - 1064 -10 Parcel Identification Number (PIN) This - is not homestead property. (}K) (is no[) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this day of Au gust 2 001 Hillvale Development Limited + __— • By: Richard S. Ne son r AUTHENTICATION ACKNOWLEDGMENT Signature(s) Hillvale Development Limited, a Minnesota STATE OF WISCONSIN ) Limited Liability Partnership, by Richard S. Nelson ) ss. _ County ) authenticated this r day of August 2001 Personally came before me this _ day of the above named . Kristina Oglajo — - - - -- _. TITLE: MEMBER STATE BAR OF WISCONSIN i (If not, to me known to be the person(s) who executed the foregoing authorized by § 706.06, Wis. Stats.) instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY + Attorney WI Kristin16 a Hudson, 540 Ogland Notary Public, State of Wisconsin My Commission is permanent. (If not, state expiration date: (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. Intormanon PmfQSSi als company. Fond du Lx W STATE BAR OF WISCONSIN 800-6554 021 WARRANTY DEED FORM No. 2- 1999 ry 000 N89°18'1 7 "E ip io im 0 0 •° 402.00' I io is i;o rn rn 0 !-- ioo -- l z ic,, i i0 N * N v ( IZ j IN 1--1 IC ha v ° o W 1 0l iP iD I< IW I 1 10 i 0 cn U ° Ito C 'I I I a IPJj I 10° I(0 1 -0 N89°18'17 "E N89 7"E 1 133.46' Z 402.00' 'y R tV 00 co I Ca�� M .P 1 4 `` O ca w o (,, r•w I v O ° W I o1 ' cj cD 7 �i fn I rr o O c r., I oo y §, ; I Z op , o Cl'� N89°18'17 "E I g R n. I -P iA 402.00' C o `� c n. °� �5 00 i I o w �� :0 � N.1 I o � Ca. pv - - — o0 0 — — — — - — - — o -� - I n. fn .0: c p o I m • _ Cl 86.26' 402.00' - -- -------- - - - - -- - - - - -- w S89 7"W 488.26' .; 148TH—AVE.- 1 "i N89 7"E 488.26' o i - - - -- -- - - - - -- ------ - - - - -- m f H 56.26 -34 ' 216.00' 216.00' C) I 0oR� o I w I ° ' e* Ca E o I = E Z !� rn Z col C D w° ocD rQ � I R cc o� C o 0 0� I n �o E CO N w g o I °° R � o "g „ c (I I iz �\ ; P I I CO) A N, $i. bwt I I i — D i R �► 4 cS �r''��i 201.00'► 216 00' I C p �1 N89 7"E 417.00' I ab 1 r O o v !� I 1 C/) ► N - I \� �� oLn CQ i oI 0 ° w of R o o °` I ti 1 o I 8 . ;t s �• o. N8 17 " F I (I Cf= Gown x PRELBM4ARY RAT r�r L .ACS < _< I m . 2t romlr. x, RORRI AMOf • wsr. RE. «'"%: w '' r J . 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