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HomeMy WebLinkAbout026-1119-09-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y 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)]. 353329 Permit Holder's Name: ❑ City ❑ Village ❑ TcWn of: State Plan ID No.: Cruz, Carlos Richmond Township CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: ao NE It-t S4­6_ 026 - 1119 -09 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic G021 -r P J 12Sv/-+sb Benchmark 11.30 I (3D ' Dosing 1--S� � Alt. BM 3.10 10-4-11)' Aeration Bldg. Sewer [ Holding r , St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Air I ntake ROAD Dt Inlet - Air Septic > 5P ( -, � NA Dt Bottom Q t o C/3- 2.0' Dosing NA Header / Man. a S pp , 35 Aeration NA Dist. Pipe -( �� �, o Jac . So Holding Bot. System lZ- Z� oS / PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand St cover a ./6 ]p-3- f Model Number W It L_ GPM TDH Lift �,b� Friction 1, �o System TDH qS Ft Head Forcemain Length (bo Dia..3 ` Dist. To Well SOIL ABSORPTION SYSTEM (�j) eat (o. - q o 4- OT Aeg, BED/TRENCH Width ( Length N(?. O Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK kl-�` ( WRIww.�1Lr' INFORMATION Type Of , CHAMBER Model Number: System: OR UNIT _ r DISTRIBUTION SYSTEM Header / Manifold N Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Spacin { (o r) SOIL COVER SN 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.) Inspection #1: 0571e /C_ Inspection #2: Location: 1272 146th Avenue, New Richmond, WI 54017 (NE 1/4 NE 1/4 22 T30N R18W) - 22.30.18.704 Pondview Meadows -Lot 9 C q y 1.) Alt BM Description = J 2.) Bldg sewer length= a0 6 - amount of cover = '> 24 4 Plan revision required? ❑ Yes ® No Use other side for additional information. D Il as Z b k SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. l ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ..... z 3 e i , , e sue_ e _ , € t p 4 i i e.�. ;.�. ....... =a. _a �.... , e, i r x a a . E E } € a , G m_ E 3 € E a� € y 3 i R � 3 m,a ........ . ..... g gg z pp p ,. sm .. » -_ e t fi } �... ? , € i E �2 € S F a 7 t f F � e 3 r � t ST. CROIX COUNTY ZONING DEPARTMENT �1 AS BUILT SANITARY REPORT Owner o 5 C r t N Property AddTess ,7 - /', d e• City /State ! 1 Y Legal Description: Lot _ 9 Block Subdivision/CSM # '?b yl d V l 'e N ' /4 ' /a, Sec. ,22 , T .30 N -RAW, Town of PIN # `" 11/9 09 co o SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Wt�� Size ST/PC !zs / Setback from: House 42 Well WA- P/L 80 Pump manufacturer a 004 ids Model W tF Lt" Alarm location W .�. (HOLDING TAN NLY) Setbacks: Service road--,- Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSO TION SYSTEM e Type of system: n �i Jkr* Width 3 Length �� Number of Trenches Setback from: House i70' Well &110. P/L 42 Vent to fresh air intake / $� 'I ELEVATIONS Description of benchmark 1J Ca'- S �`t Elevation Description of alternate benchmark Elevation Buildin g Sewer ST/HT Inlet ` 7i ST Outlet PC Inlet PC Bottom �• Header/Manifold Top of ST/PC Manhole Cover Distribution Lines (l) / L (�) )�. 2 Y w G�°4 Bottom of System (�) 9 $ • 9 (ta 9 ?� (3) g � Final Grade (I) / o 7 (a) Date of installation S / 14 P- mit number 3 s 33P? ?State plan number Plumber's signature License number ° ' 5 '� 7 Date .9 Inspector Complete plot plan � x NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. le PLAN VIEW G w tQ e INDICATE NORTH ARROW P A&nSl Safety and Buildings Division ` iscons ATION P 201 W. O Box 7302ngton Avenue Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. ` • See reverse side for instructions for completing this application State Sanitary Permit Numbe y ou p rovide may be used for seconds Z Personal information Y P Y second purposes heck if revision to previous application [Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Ow er Na Property Location S te.. Ftia A t E 1/4,5,)L;) T Q, N, R j �EWW) W PropertyQwner's Mailin ddress Lot Number Block Num �1 C l -e -2va. au r 1 S ate Zi Code Phone Number Subdivi Na a or CSM Number MN S` ( ) S 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit Nearest Roa Illage QU P Public 1 or 2 Family Dwelling - No. of bedrooms own OF 111. BUILDING SE: (If building type is public, check all that apply) Parcel Tax Number(s) AA. 1 ❑ Apartment/ Condo ©ao ^ t I ' c� _ d cl 'o o O 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. New 2. ❑ Replacement 3_ E] Replacement of 4_ E] Reconnection of 5, ❑ Repair of an System System Tank Only_______ ____ Existing --------- B) _______, _____________ B) A Sanitary Permit was previously issued. Permit Number 302 Date Issued 3-9- V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 Q Holding Tank 12J%Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABS ORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5_ Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) G Elevation O S 1 ;IL_ q O rQ4eet / /t Feet VI Ca acl I. TANK in gallo s Total # of r Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete con Steel glass Plastic App New Existing structed Tanks Tanks / Ge tic Ta r gel�g�enkr s7( j ' Q S'e r $ ❑ ❑ ❑ 11 El Ift Pump ank i ❑ 1 ❑ I ❑ 1 ❑ 1 ❑ RESPO TEMENT I, the undersigned, assume responsibility for ins ation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print o Stamps) FINW/MPRSW No.: Business Phone Number: pco c-S I M991 J~3 �tS "oZ Ca `� Plu` ky8r (Street, C��A ip Code): � � � O _ v e- N +2 - k� L IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuin Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination V C 4 -OD X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD -6398 (R. 4199) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber L INSTRUCTIONS ` 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained - The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. ` 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, - Safety and BuildingsDivision,:608 -266 -3151. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. Il. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit- Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc,), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, Go bf holding tank(s); septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if,required by the county; €) soil test data on a'1 15 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. C � r `` I 0. I X4 I I I , / A l I �0 ti s`�- .1.9.9 �- _ -- _ _ w 1 , - - - - - -- - ��--� , , I QQ l,I • I I — � i I I I (o 1 C7 I — 1 , 7 5 , , b , - - - -- -- -- -- - - - • I I , , I ; , I I I 3 I .. 1 1 . r I , � I � I , , J , 1 i I ; 1 I LL- 1 , I 1 1 I I ! 1 , I • I 1 I � L , , 1 , ! I ••ll _ t � c C: co c S l l JJOAUJ —� o? a) 7 o I r � 0 N 0) i c ' 0 1 a 4 M N O U T 2 C U -U (o . • I a cd 'D L d N N 3 0 i U co T cu:gQ -6 0 Tcn p cU. CO o f N � � Q) z o o 0 0 N o�o� Na x c3 U J N Oro N C: X e> LL _ a _0 �JO= n t © - AAdl�,^d Q 1' N co cla � oo T w U �Re 1 t, - °° S EPTIC TANK & `P CHAMBE CROSS SECT -Lu t"4u °r''" 4" Cl VENT PIPE 12" MIN. ABOVE GRADE £ WEATHER PROOF' >_ 25. R FROM.DOOR, WINDOW JUNCTION BOX APPROVED AIR INTAKE WITH CONDUIT MANHOLE COVER FRESH W/ PADLOCK £ FINISHED GRADE 4 Cl RISER WARNING LABEL 6" MIN. PALM , _4" MIN. ABOVE GRADE 18" IN. 6" MAX. :,� 'INLET � '\ GAS- WATER TIGHT SEALS TIGHTi SEAL APPROVED 4 ++ BAFFLE f JOINTS W/ CI CI PIPE B ON PIPE 3' ONTO 3' ONTO -T- SOLID SOIL 'SOLID C f I ' RISER EXIT 'SOIL PUMP OFF ELEV. FT. �-` OF PERMITTED ONLY D IF.TANK . MANUFACTURER HAS APPROVAL 3 APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE NUMBER*DOSES PER DAY: TANK MANUFACTURER: �� •..n S .p s ' TANK SIZES SEPTIC l 50 GAL. DOSE VOLUME INCLUDING 0 Z GAL. FLOWBACK: a DOSE �7 T� GAL. -- i ALARM MANUFACTURER: CAPACITIES: A = INCHES = lI- GAL. . MODEL NUMBER: !4 B = 2 INCHES = o�q�y GAL. SWITCH TYPE: �1��: PUMP MANUFACTURER: r \� S C = 15' INCHES = �a3 GAL. ���� MODEL NUMBER : 35 w �0 3 it L D = _ e INCHES = GAL . SWITCH TYPE: REQUIRED DISCHARGE RATE GPM PUMP £ ALARM WIRING AS PER ILHR 16.23 WAC FEET VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE 2.5 FEET + MINIMUM NETWORK SUPPLY PRES URE • • ' %. FEET + /5O FEET FORCEMAIN X FT /100 FT. FRICTION FACTOR • . --��� FEET T.OTAL DYNAMIC HEAD = - -�=-�- INTERNAL DIMENSIONS OF PUMP TANK: LENGTH b ; WIDTH DIAMETER / - s LIQUID DEPTH Sl l�'7 `X f Qa7s37 DATE: SIGNED: LICENSE NUMBER: i J - 3 ~dam c Goulds A. c�z Submersible Effluent Pump 3885 APPLICATIONS • Overload protection must smooth operation Sillcon 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. - #y ■ Bearings: Upper and stainless steel. ' • Homes ■ 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 Cable: Severe duty • Motels • Power cord: 20 foot for slide rail systems. I rated, oil and water resistant. standard length (optional • Schools n Mechanical Seal: SILICON Epoxy seal on motor end lengths available). • Hospitals CARBIDE VS. SILICON provides secondary moisture Single phase: • Industry CARBIDE sealing faces. barrier in case of outer jacket and •'' '' /x HP -16/3 SJTO • Effluent systems Stainless steel metal parts, damage and to prevent oil with 115 V or 230 V three BUNA -N elastomers. wicking. plug. g pl SPECIFICATIONS • a pronpron x pl -14/3 STO with m Shaft: Corrosion - resistant ■ 0 -ring: Assures positive Pump bare leads. stainless steel. Threaded sealing against contaminants • Solids handling capabilities: Th7ee phase: design. Locknut on three and oil leakage. W maximum. •' /r1' /x HP -14/4 STO phase models to guard • Discharge size: 2" NPT. with bare leads. On CSA against component damage AGENCY LISTINGS • Cap acities: u to 128 GPM. listed models - 20 foot on accidental reverse rotation. P p SP Canadian Standards Association • Total heads: up to 123 feet length SJTW and STW ■ Motor. Fully submerged in TDH. are standard. high -grade turbine oil for • Mechanical seal: silicon lubrication and efficient heat Ui Underwriters laboratories carbide -rotary seat/silicon FEATURES transfer. carbide - stationary seat, 300 ■ Designed for Continuous series stainless steel metal •Impeller: Cast iron, semi- en Operation: Pump ratings are parts, BUNA -N elastomers. op, non -clog with pump- within the motor manufacturer's • Temperature: out vanes for mechanical seal recommended working limits, 104 °F (40 °C) continuous protection. Balanced for 140 °F (60 °C) intermittent METERS FEET • Fasteners: 300 series 90 stainless steel _ _ _ SERIES: SOLI SIZE: W SOLIDS • Capable of running dry.. 25 80 wE1 RPM: VARIOUS without damage to - - �SsT" components. 70 w „ sFT 20- _ �_ _ _ - Motor ° a so Single phase: _ -MEO - - I • '/3 HP, 115 V, 200 V, 230 V, � t5 50 60 Hz, 1750 RPM; %x HP, 115 V, 60 Hz, 3500 RPM; 0 40 EO %z HP -1' /x HP 230 V, o to 30E - _ 60 Hz, 3500 RPM. 1 _ • Built -in overload with. 20 'A 0 automatic reset. 5 _ • Class B insulation. Three phase: qs • '/x HP -1' /x HP 200/230/ 0 0 460 V, 60 Hz, 3500 RPM. 0 10 20 3o ao 50 so 70 so too tto 120 130cPM • Class B insulation. 0 10 20 30 ms/h CAPACITY 01995 Goulds Pumps Effective May. 1995 B3885 i Safety and Buildings Division Visconsi SANITARY PERMIT APPLICATION 2 1 Box Washington Avenue Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. -5 T • See reverse side for instructions for completing this application State Sanitary Permit Number 3S3 3 __)_9 Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Prop Own r Name Property Location C- Z NF 1 /a 15 1 /a, S as T .3(:), N, R `eE' r) W Property _wrier's Mai i Address u Lot Num Block Aytjaer City, S ate Zi�C� `�� ( hone Number Sub ' 'on Na�e or CSM Number /� 55 V� II. T Y E OF BUILDING: (check one) ❑ State Owned 0 cit Nearest R o dd ❑VII age I U Public 1 or 2 Family Dwelling - No. of bedrooms own o CL III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 3 6 • , 1 ❑ Apartment/ Condo (O — _09 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT (Check only one box on line A. Check box on line B, if applicable) A) 1. New 2, ❑ Replacement 3, ❑ Replacement of 4 ❑ Reconnection of 5_ E] Repair of an System -------- System ------------- Tank On ly_____ ____ ___Existing5ystem _ Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 [:]Holding Tank 12 ffSeepage Trench 22 E] In-Ground Pressure 1 1 _ " 42 E] Pit Privy 13 Seepage Pit ( 3 X M 43 ❑ Vault Privy 14 ❑ System - - Fill 1 VN,".kt�J VI. ABSORPTION S INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade ff Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) q Elevation `Q� SOO j if Feet /0f•• Feet Capacity VII. TANK in Ca allon g Total # of r Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed T nks Tanks - � e _ ptic a r ng ank I ❑ ❑ ❑ LI ump Tank !Siphon Chamber ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for ins ation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) PI ber's Sign ture N Stamps) MPlMPRSW No.: Business Phone Number: or� It V I A po _& t7 53 71-5 Plumber's Address (Street, City State , Z' Code): soh S" o l IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved wipitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) � Approved [ Given Initial Adverse D etermination ads Surcharge Fee) 3-9 -21�v X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVA : }-_t P SBD -6398 (R. 4/99) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS ' 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin AdministrativL- Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or.plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the county.prior,to installation 5. Onsite sewa systems be ro erl mainfai4cl -The septic tank(s) must be pumped b a licensed um er whenever 9 Y P P Y P ( P p Y P P necessary, usual`( every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code,adm�aistratoc of the State; of Wisconsin, Safety and Buildings Division, 608.266 •%. a — Y To be complete and accurate.thi . I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone.number. Plumber must sign application form. IX. County/ Department Use Only. v X. County/ Department Use Only. 1 4Corflplete plan�aiii�ldpgcifications not smaller tha`ft 8,1/2 x 11 irtche� most be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location'of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E)' soil test data on 6 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SUACF1ARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regul ated practices which can effect groundwater. ; The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. p r l,DT kN ell V _99 /S PL /.5o �7a i 36 P i Wisconsin Department of Industry SOIL AND SITE E V A L U 7 t;,, I R T Page 1 of 3 Labor and Human Relations � � Division of Safety &Buildings in accord with ILHR 83 aY' s. Adm. Code ;', ,. COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in fie: Plan mu�t`rftrltL + �`N not limited to vertical and horizontal reference point (BM), direction a -% of slp scale or RCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. ! c? 6 �g 026- 1065 -50 -000 APPLICANT INFORMATION- PLEASE PRINT ALL INFORMA 'fON ST CRtgX VIEWED BY DATE BOUNTY Ca4_4N(40— /WO6 f? 114 PROPERTY OWNER: )SRO N Richard Derrick ,e . j LOT ._N c' "" 1t4�' vas22 T 30 N,R 18 Igor) W 0 UBD. NAME OR M # PROPERTY OWNER':S MAILING ADDRESS L L CS 1310 H #6 9 +na Pondview Meadows CITY, STATE ZIP CODE PHONE NUMBER [ ❑VILLAGE ®TOWN NEAREST ROAD New Richmond, WI. 54017 (715)246 -5425 1 Ri I 146th. ave. [ New Construction Use [X] Residential / Number of bedrooms 4 [ ] Addition to existing building [ J Replacement [ ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate • 3 bed, gpd /ft • trench, gpd/ft Absorption area required 2000 bed, ft 1500 trench, ft Maximum design loading rate • 3 bed, gpd /ft •4 trench, gpd /ft Recommended infiltration surface elevation(s) area A= 98.95/B =97.95 ft (as referred to site plan benchmark) Additional design / site considerations na Parent material glacial drift Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem IRS ❑U [XS ❑U CS S ❑U K S ❑U ❑S ®U ❑S ®U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouincfary Roots GPD /ft .................. in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench ................. 1 0 -10 10 r4/3 none 1 2c 1 mfr gw 2f .5 1.6 2 10 -20 10yr4 /4 none sic lcsbk mfr gw if .2 1.3 Ground 3 20 -55 7.5yr4/4 none sl lcsbk mfr gw na .4 1 .5 elev. 1 4 55 -84 7.5yr4/6 none sl M na na na .3 .4 Depth to limiting factor 84" Remarks: Boring # 1 0 -8 10yr3 /3 none 1 2msbk mfr gw 2f .5 [ .6 2 <<' 2 8 -19 7.5yr4/4 none sicl lcsbk mfr gw if .2 .3 3 19 -70 7.5yr4/4 none sl lcsbk mfr gw na .4 .5 Ground elev. 4 70 -84 7.5yr4/6 none sl lcsbk mfr na na .4 .5 10 ft. Depth to limiting 4 factor S•`f I Remarks: CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200 Address: 1554 200th. Ave w Richmond I 54017 Signature: ols Date: 4_23 - CST Number: m02298 PROPERTY OWNER Richard Derrick SOIL DESCRIPTION REPORT Page? 01 3 PARCEL I.D. # 026- 1065 -50 -000 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed 7 T rench >' 1 0 -8 10yr4 /3 none 1 2f l mfr gw 2f n .3 3 2 8 -16 7.5yr4/4 none sicl lcsbk mfr gw if .2 .3 Ground 3 16 -68 7.5yr4/4 none sl lcsbk mfr gw na .4 .5 elev. l 4 68 -84 7.5yr4/6 none sl M na na na .3 .4 Depth to limiting factor 84" Remarks: Boring # 1 0 -9 10yr4 /3 none sil 2cp1 mfr gw 2f np 4 2 9 -50 7.5yr4/4 none sl lcsbk mfr gw if .4 i.5 3 50 -80 7.5yr4/6 none lfs lcsbk mfr na na .4 .5 Ground elev. 100 - hf -- Depth to limiting factor Remarks: Boring # 1 0 -17 10yr3 /3 none 1 2fpl mfr gw 2f np i.3 5 2 17 -28 10yr4 /4 none sicl lcsbk mfr gw if .2 ;.3 3 28 -80 7.5yr4/4 none lfs lcsbk mfr na na .4 .5 Ground elev. lO ft. Depth to limiting factor 80" Remarks: Boring # Ground elev. ft. i Depth to limiting factor Remarks: SBD- 8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel Richard Derrick 1554 200th Ave. CSTM2298 NE4NE4 S22 T30N -R18w New Richmond, WI 54017 MPRSW -3254 town of Richmond (715) 246 -6200 lot #9- Pondview Meadows This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. N 1 =40' BM.= top of NE lot stake @ el. 100' Alt. BM.= top of ang. pt. survey stake @ e1. 99.151 �r. o ��1 �. oC Gary L. Steel / 4 -23 -99 y o Cd s .. °E�� ' > c cd E y O C: X CO Uj 0 a3 p fl LO )` `" O (� S] ti CO r a� E c� SJ _ X (d O O c co d N V 0 to d � -0 o c - - -- �CY) ° a = ro •- E€ c w r owo�� CL CL _ E N -0 U J . c 0)"D U O S td m 3 = _ o JJO y5 i Q� V ,b 'mot E a y � a i m v CL Lo l w _ f Y� o a �� z From: CALVIN POWERS Fax: +1(715)246 -5135 To: DAN Fax: +1(651)7730169 Page 2 of 2 Monday, February 07, 2000 2:45 PM ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer cc( ( -"1 [ 05 S k 4A/7 0/1 C—rL4 z Mailing Address N 7 vsw vim. N .:S la Property Address `�� ^U e- N t4 -j � ('JMapt W Z S (Verification required from Planning Department for new construction) City/State U T- Parcel Identification Number d �2- to /119 0 1 boo LEGAL DESCRIPTION i Property Location . '/4, N C ' /4, See. 2 TQN -RAW, Town of W16`nd Subdivision 6V1 u) M{a Lot # �. et:rme su . Volume Page # Warranty Deed # o u�5 y g 7 . Volume c to Page # S (O 7 Spec house ❑ yes �no 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 fora, signed by the owner and by a master plumber, journeyman plumber, restrictedplumberora licensedpumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank Is Ian 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 of the three year expiration date. SIGNATURE OF APPLIC DATE I OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) imowledge. I (we) am (are) the ownet(s) of the operty described above, by virtue of a warranty deed recorded in Register of Deeds Office. /00 SI0 ATURE OF APPLICANT DATE "••'• Any information that is mis- represented may result }n the sanitary permit being revolted 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 trade in the warranty deed 14 90 PAGE 567 ' � 618487 STATE BAR OF WISCONSIN FORM 2-1998 KATHLEEN H. WALSH Doe t Bent Number WARRANTY DEED REGISTER' OF DEEDS ST. CROIX CO., WI This Deed, made between Richard L. Derrick individually and as RECEIVED FOR RECORD attorney in -fact for Loren D Derricks Rose H Derrick Joan 1, Derrick and Robert J. Derrick 02 -17 -2000 10:45 AM WARRANTY DEED EXEMPT N CERT COPY FEE: Grantor, conveys and warrants to Carlos A Cruz and Shannon T. Cruz COPY FEE: as survivorship marita property TRANSFER FEE: 10 .70 RECORDING FEE: 10.00 PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin Recording Area (The "Property "): Name and Return Address LAND TITLE, INC. SURE 200 1900 SILVER LAKE ROAD NEW BRIGHTON MN 55112 FILE NO. �` LY 026 -1119- 09-000 Parcel Identification Number (PIN) This is not homestead property. Lot 9, Pond View Meadows in the Town of Richmond, St. Croix County, Wisconsin. Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this d { ' 1 day'of February, 2000 Pr ,t ►, 1 v * Richard L. Derrick, individu3ti and as atto ney -in -fact for Loren D. Derrick, Rose H. Derrick, Joan L. Derrick and Robert J. Derrick AUTHENTICATION ACKNOWLEDGMENT Signature(s) Richard L. Derrick, individually and as STATE OF WISCONSIN ) attorney - in - fact for Loren D Derrick Rose H Derrick ) ss. Joan L. Derrick and Robert J Derrick County ) Personally came before me this day of February 2000, the above named �uthe s day of February, 2000. to me known to be the person(s) who executed the foregoing instrument and ' Krishna Ogland acknowledge the same. TITLE: MEMBER STA E BAR OF WISCONSIN , (If not, Notary Public, State of Wisconsin authorized by § 706.06, Wis. Slats.) My Commission is permanent. (if not, state expiration date: THIS INSTRUMENT WAS DRAFTED BY Attorney Kristina Ogland 304 Locust St. Hudson, W154016 (Signatures may be authenticated or acknowledged. Both are not necessary.) 'Names of persons signing in any capacity should be typed or printed below their signatures WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 2 -19% INFORMATION PROFESSIONALS COMPANY FOND DU LAC. WI 800855 -2021 W, MEADOWS L Cl� [E• NE 1 14 AND IN PART OF THE SE 1 _ V. 4.0 ROIX O 18 W, TO WN OF RICHMOND, S T. C 0 I <N88 ' N87 °35'23 "\ I 452'93 115,6a� 128.28' 36 43 17 493.90 S� 8° '33-7 25 10 9 2.001 ACRES 2.001 ACRES N `� QD u�� 87,179 SQ.FT. 87,171 SQ.FT. 8 EA ❑UTLUT 1 0� 3 .159 ACRES �. F` •.• M CD 2.001 ACRES 930 SQ. FT. \ w 87,177 SOFT, . x,38' z ni \ In � 66.00' i. ... i 2. -------- OUTLOT 100' i i V. 8 0 ......... ui ° 273.73' 10 0' _ _ _ — 197.81' -- ��� — 75.92 M 8 _ <- 9q4OW5 %,D 50 Ss 5 . � � 66 . I 146TH A �' ° I 33'I33' CD j co (� o .1 .. _ _ -• -• -o LOT - - -4 0o j • • 7 cu (U s • o `u `° w C,S_M,IN ti • o ! 3 ` V, 10, PG. 2745 ° I - ------- - - - - -- W m I -------- - % .- a - - - -- -- �.6s' : - i � o OWNED BY OTHERS --4 0� N _ -------------------------------- - - - - -- o � S I i ___ 2.003 ACRES • o -------------------- Z I - - -- � � 87,266 SQ.FT. • o I I Ln BENCHMARK O I I n T n ATUM 1929 ST. CROIX COUNTY h- WISCONSIN ZONING OFFICE I I x x 1 n ■ - „��, ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016 -7710 (715) 386 -4680 Fax (715) 386 -4686 June 21, 2000 Joe O'Brien P.O. Box 180 Lake Elmo, MN 55042 RE: Septic Inspection for Carlos Cruz located at 1272 146th Avenue, Pondview Meadows (Lot 9), Richmond Township, St. Croix County, Wisconsin Dear Mr. O'Brien: A septic inspection of the above referenced property was conducted on 05/16/2000. This property is located in the NE 1/4 NE 1/4 of Section 22, T30N R18W, Pondview Meadows (Lot 9), Richmond Township, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a four (4) bedroom home. If you have any questions regarding this, please contact our office at (715) 386 -4680. Sincerely, Qulvk (�o-�� Kevin Grabau Zoning staff /sm cc: file