Loading...
HomeMy WebLinkAbout026-1165-29-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division + INSPECTION REPORT Sanitary Permit No: 488021 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). Permit Holder's Name: City Village X Township Parcel Tax No: Frank, Tom & Pam Richmond, Town of 026- 1165 -29 -000 CST BM Elev: Insp. BM Elev: BM I Description: tionlrown /Range /Map No: b� ✓AA, X C� l r 22.30.18.1295 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 12— /z 1 _n C 0 5.5 /a5. /ad ! •I g � ►�Y� �V LJ Alt. BM Aeration Bldg. Sewer Holding StiHt Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL ZBLDG. ent t o Air Intake ROAD Dt Inlet ✓ Septic i / y[ G Dt Bottom �. Dosing Header /Man. i .Z3 9(• 7.7 1 O"7 Aeration Dist. Pipe f Z(p Holding Bot. System PUMP /SIPHON INFORMATION Final Grade 4,0 0 /na• -67 Manufacturer De St Cover 1 6) 3 I &Z • .q Model er 75- rj 7 TD Lift Friction Loss S ead TDH Ft ; /6 r Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width Length N o.. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 ��Z� f �$ Z " �_ �-- �- -\ SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR /O Type Of System; ! A) UNIT Model Number.0 DISTRIBUTION SYSTEM l -z0= 39 a..., Header /Manifold Distribution ` x Hole Size x Hole Spacing Vent to Intke f7 / L/ Pipe(s \ ` z e ��.• p v`•• Length � Dia T Length Dia Spacing ✓�dt SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over j Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center 5. Bed/Trench Edges Topsoil \es Noes j No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2: Location: 1455 129th Street New Richmond, WI 54017 (NE 1/4 SE 1/4 22 T330N R18W) Lundy Meadows Lot 29 Parcel No: 22.30.18.1295 1.) Alt BM Description = ' (L GpU 2.) Bldg sewer length = 2 5�.� - amount of cover = / `�` � �� i•��0 __- -' 'Pit -- -- -- � T _ Plan revision Required? ] Yes No ,z 6�3 Use other side for additional information. _. -__� Cert . No. I e ctor nature ' i D 9 Date p SBD -6710 (R.3/97) Safety and Buildings Division County ` 201 W. Washington Ave., P.O. Box 7162 5 t✓ra is Madison, WI 53707 - 7162 Sanitary Permitumber be filled in by Co.) eonsin Department of Commerce (608) 266 -3151 f Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you pr may be used for secondary purposes Privacy Law, s VED P7jt Address (if different than ilin ad Tess) 1. Application Informati Ple Pri All �rmation - 7 � Property Owner's Name Par . ak Lot "T ""�_` Cpt1NN Property Owner's Mailing Address f / ` r pe ation Section City, State Zip C4e Phone Number r�� or�1 X 4 T.30 N; II. Type of Building (check all that apply) L or 2 Family Dwelling - Number of Bedrooms Subdivision Name C Number �SM 'al ❑ Public/Commercial - Describe Use ❑ State Owned - Describe Use ❑City_❑ it age ownship of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) (9 24P - // t 5 — 2 2 � 4 r 12 95' A. New System El Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System B. ❑ Permit Renewal A Permit Revision Change of Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber caner IV. Type of POWTS System: Check all that apply) VNon - Pressurized In- Ground ❑ Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Ch ber ❑ Drip ❑ Gravel -less Pipe ❑ O er (expl in) V. Dispersal/Treatment Area Information: r S Z />e s ( S Design Flow (gpd) Design Soil Application Rat sf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) Sxtem Elevation q 4.40 ' VI. Tank Info Capacity in Total Number / M � Prefab Site Steel Fiber Plastic Gallons Gallons of Units 0. C' [ If � 'v Concrete Constructed Glass New Existing lK Tanks Tanks tic ` Holding Tank Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the unde rsigned, assume responsibility for installa of the POWTS shown on the attached plans. Plumb (Print) Plum 's Signature MP/MPRS Number Business Phone Number Plu is Address (Street, City, State, Zip e)� VIII. County/Department Use Onl Approved El Disa rove Sanitary Permit Fe i cludes Groundwater Date Issued Issuing gen`Signat re ( o Stamps) Surcharge Fee) El O en Reason or Denial p ,� `� IX. Conditions o Approv 3 l S r71 T alwg&Z- SYSTEM OWNER: S /a� h6__ 1 Septic tank, effluent filter and r� n I � &A � dispersal cell must all be serviced / maintained G�°"�` �n.lnrt�. f as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code /ordinances. St�M Attach complete plans (to the County only) for the system on paper not less th 81/2 x J4 inche m size SBD -6398 (R. 01/03) PLOT PLAN PROJECT Tom Frank ADDRESS 5686 Had1v Ave. N Ant. 108 Oakdale Mn. 55128 N 1/4 SE 1/4S 22 /T 30 N/R 18 W TOWN Richmond COUNTY ST. CROIX MPRS Byron Bird Jr. 220527 / 12 - 07 - 05 BEDROOM 4 DATE CONVENTIONAL XXX Grade CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1200 gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ❑ LOAD RATE .7 ABSORPTION AREA 857 # of chambers 28 BENCHMARK V.R.P Top of Survey Iron ASSUME ELEVATION 100' LJ BOREHOLE O WELL IH.R.P. Same as BM Vent SYSTEM ELEVATION T - 1=94.7 T - 2=94.2 AT' Bio Diffuser with 31.1 ft^2 per chamber 6" Long 34" Elevation /off Lot 29 Pro We Drivew garage 4 Bed Ho e O:ob.pipe 10' � st i IZ � o' o B2 292' PL 1 � BIT PL 375' 10 BM COPY PLOT PLAN PROJECT Tom Frank ADDRESS 5680 Hadly Ave. N Aot. 108 Oakdale Mn. 55128 N 1/4 SE 1/4s 22 /T 30 N/R 18 w TOWN Richmond COUNTY ST. CROIX MPRS Byron Bird Jr. 220527 'ATE 12 BEDROOM 4 CONVENTIONAL XXX - Grade CO� / N / YE ``` NTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1200 gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE 13 LOAD RATE .7 ABSORPTION AREA 857 # of chambers 28 BENCHMARK V.R.P. Top of Survey Iron ASSUME ELEVATION 100' BOREHOLE (DWELL *H.R.P. Same as BM Vent SYSTEM ELEVATION T -1 =94.7 T- 2=94.2 >12 of Bio Diffuser with ft Cove 3 1. 1 ^2 per chamber 6 ' 6„ Long 34" Elevation ��yfs f Lot 29 Pro We Drivew garage 4 Bed Ho e O :ob.pipe 10� st 0' 88' B2 o , 292' PL 1 BIT ' S PL 375' 8 10' BM Wisconsin De P artm ent of Commerce SOIL EVALUATION REPORT Page 1 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 ' i t :vertical and horizontal reference point (BM), direction and Parcel I.D. include, but not limited o C� percent slope, scale or dimensions, north arrow, and location and distance to nearest road. pri ry 7vie Oat �) Personal information you provide ay be used 6r'seco da rrposei (env y Law. s. 15.04 (1) (m)). U Property Owner Property Location ,` • /�`� .5 4, Govt. Lot 1/ �j 1/4 S T N R E Property Owner's Ma Address (o W Oct tom _ Lot Block # Subd. Name or M# i ' City fate Zip Code Phone Number City ❑ village �T Nearest Road New Construction Us Residential / Number of bedroom Code derived design flow rate _ GPD 40 Replacement Public or mercial - Describe: __— ._ —_ - -- _ -- -- - — Parent material �� >�/CJ� Flood Plain elevation if applicable ft. General carnrnerrts � and recommendations: -e /V---/ L csr�r�✓ 9� ✓ J aYtd s Boring # Boring Ground surface elev. ft. Depth to lime actor in. Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#I Eff#2 /v/ " Lo 0 IK 30 C � ® Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rat 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 -tq I 3 / — S a ;?, s .7 Effluent #1 = BOD > 30 < 220 mglL and TSS >30 _< 150 ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mWL CST Name (Please Print) Sig CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 54017 715 - 246 -4516 Property Owner _ Parcel ID # Page of a Boring # El Boring Pit Ground surface elev. � ft. Depth to limiting fact m Soil Application Rate Horizon Depth Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr, Sz. Sh. 'Eff#1 'Eff#2 ( 0'I D 3 %z Z, S � s . Z '3 F1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication 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 F-1 Boring # Boring Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots 'Ef1#1 'E in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. " Effluent #1 = BOD > 30 < 220 nwjL and TSS >30 1150 mg/L ' Effluent #2 = BOD, < 30 mg/L and TSS <_ 30 m9/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 (8.6(00) 4 Soil Test Plot Plan Project Name William Stock/Steve Dalton ShauyfAird Address 1748 112th St. New Richmond Wi 54017 M #226900 Lot 2 9 Subdivision Lundy Meadows Date 8/11/03 N 1/2 SE 1/4S 22 T 30 N /R W Township Richmond El Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of Survey Iron System Elevation 94.7/94.2 *HRpSame as Benchmark Alt. BM Top of 2" Pipe @a 100.2' Please note: Installer must verify all lot lines and setbacks before installation. Scale is 1" = 40' unless otherwise noted Please Note: Tested area may not be suitable for desired building area. Check system location before excavating. 7% Slope -2 100' 292' 13-1 -3 Property 4 Line 30' 375' Property Line 98' 10' 95' * Alt. B. Pa e I of POWTS OWNER'S MANUAL &MAN AGEMENT PLAN g FILE INFORMATION SYSTEM SPECIFICATIONS Owner ` Septic Tank Capacity �,� �j g al _ O NA Permit # S O ©Z� Septic Tank Manufacturer O NA DESIGN PARAMETERS Effluent Filter Manufacturer 4-_ ❑ NA i Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units P(NA Pump Tank Capacity al O NA Estimated flow (average) gal /day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) p—z� aliday Pump Manufacturer ❑ NA Soil Application Rate al /da !ft2 Pump Model ❑ NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit O NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter O Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) O NA Biochemical Oxygen Demand (BOD 530 mg /L XIn- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100m1 ❑ Drip -Line ❑Other: Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA * Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ onth(s) (Maximum 3 years) ❑ NA AR�vearls) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y,) of tank volume ❑ NA Inspect dispersal cell 1i:3 s) At least once every: ❑ mon (Maximum 3 years) ❑ NA �years Clean effluent filter At least once every: ❑ month(s) ❑ NA year(s) Inspect pump, pump controls & alarm At least once every: ❑ m ) g NA ❑ yeaarr((s) s) Flush laterals and pressure test At least once every: ❑ month ❑ yeaarr((ss) ) ) 4VNA Other: ❑ month(s) ONA At least once every: ❑ year(s) Other: RNA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of :512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) Ili Page Z of Z START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tanks► removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: .. A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. • A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. • The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. • Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name Name Phone Phone l) SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name �✓ 1� / Phone Phone 6 This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. M. CRO1X COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM ,r Owner/Buyer /� :�. 1' c�r� -� w >,`- S S %z Mailing Address Property Address VA -f (Verification required from Planning & Zoning Department for new construction.) City /State Parcel Identification Number LEGAL DESCRIPTION Property Location /4 ✓�� i p Y /4 ,Sec. �'d , T �d N R / - O W, Town of /C, Subdivision ,Lot# Certified Survey Map # , Volume , Page # Warranty Deed # 8l 3 °� 9 , Volume 2 9`f/ , Page # 5 Spec house yes n Lot lines identifiable &' no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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 Owner maintenance responsibilities are specified in §Comm 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, 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 Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms SIGNAtORE OF AP LICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08 /05) U� 2941' y6 as._3C3 s9 KATHLEEN H. WALSH State Bar of Wisconsin Form 2 -2003 REGISTER OF DEEDS WARRANTY DEED ST. CROIX CO., WI RECEIVED FOR RECORD Document Number Document Name 12/09/2005 12:30PH WARRANTY DEED EXEMPT I THIS DEED, made between Dalstock. LLC REC FEE: 11.00 TRANS FEE: 140.40 ( "Grantor," whether one or more), COPY FEE: 2.00 and Thomas R. Frank and Pamela A. Frank, husband and wife CC FEE: PAGES: 1 ( "Grantee," whether one or more). Recording Area Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant Name and Return Address �f interests, in St. Croix County, State of Wisconsin ( "Property") (if more space �51re�t+� r 6 1�;1N is needed, please attach addendum): 304 ucSr -- S t Lot 29, Lundy Meadows. St. Croix County, Wisconsin. 026- 1165- 29-000 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Exceptions to warrantiesEasements, restrictions and rights -of -way of record, if any. Dated o Dalstock, LL (SEAL) (SEAL) * *By: Bill Stock, Member (SEAL) X 6 ^_1 . (SEAL) * *By: Steven M. Dalton, Member AUTHENTICATION ACKNOWLEDGMENT Signature(s) Dalstock. LLC By: Bill Stock, Member and Steven M. Dalton, Member STATE OF WISCONSIN ) ) ss. authenticat do ST. CROIX COUNTY ) Personally came before me on *Kristine O land the above -named Dalstock, LLC, by Bill Stock and Steven M. TITLE: MEMBER STATE BAR OF WISCONSIN Dalton, member (If not, to me known to be the person(s) who executed the foregoing authorized by Wis. Stat. § 706.06) instrument and acknowledged the same. THIS INSTRUMENT DRAFTED BY: * Attorney Kristina Ogland Notary Public, State of Hudson, WI 54016 My Commission (is permanent) (expires: ) (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED © 2003 STATE BAR OF WISCONSIN FORM NO. 2-2003 * Type name below signatures. INFO -PROTm Legal Forms 800 - 655 -2021 www.infbprofbrms.com Wiscdnsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 463026 0 GENERAL INFORMATION 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: LeQue Builders LLC I Richmond Townshi CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Ra /Map No: 22.30.18. TANK IN ORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS I FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet SUHt Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic DY16M Dosing reader an do Aeration Dist. Pi Holding Bot. Y> PUMP /SIPHON INFORMATION Final Grade Manufacturer Obemand hSt Cover GPM Model Number I to or TDH Lift Friction Loss System Head TDH Ft Forcemain Lengt7 Dist. to i SOIL ABSORPTION SYSTEM BED/TRENCH Width 7ength No. Of Trenches PIT DIMENSIONS No. f Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEA NG Manufacturer: INFORMATION CH MB OR Type Of System: UNIT Model Number: j i DISTRIBUTION SYSTE Header /Manifold D' ibution x Hole Size x Hole Spacin Vent to Air Intake e(s) Length Di ength 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 Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes � No [] Yes L No COMMENT (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 1455 129th Street New Richmond, WI 54017 (NE 1/4 SE 1/4 22 T30N R18W) Lundy Meadows Lot 29 Parcel No: 22.30.18. 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? i_1 Yes No l IkO Use other side for additional information. l SBD -6710 (R.3/97) Date Insepctors Signature Cert. No. j2 G ® 0 . % \ 2 \ ��j� � A \ `` °k @m2�� 0 � / _ oa2a � k 0 a 0 E) ƒ \\(32 $ // ƒk/ \ � \ §\ \\ , E/E � ke\ §/{ LL. M -0@770 2) �k{> =c \ \jay °° ¥ < <eoeB c % j B U) .. 0 z / �I ) 2 N R w \ (L ■ N w z \ � 0 B k 2 » z § I = f ƒ \ / k # f z j § jj � § \I § C : } « § § k cc o \c- CL . < 0 3 o a § ( j q \ j k k EL a # $ a 2 a -� a. � � k §\ \7 z . 2 § k § c = �/ @ / % <g 7 z = - � B / - ca & \ , k k \ � m ! " E o o n E § E \ 3 $ o z / § I' r E $ $ \ k a / / 3 a \ 3 0 Safety and Buildings Division County s 201 W. Washington Ave., P.O. Box 7162 z�t ei M N visconsin Madison, WI 53707 - 7162 Sanitary Per / mi t t Number (to be fill in by Co.) De artment of Commerce T' Sanitary Permit tion Stagy Plan I.D. Number In accord with Comm 83.21. Wis. Adm. nai ' j"0rovW,,; t) O G_ l may be used for secondary purposes Privacy Law, s 5.04(I)(m) Project Address (if different man rill address) I. Applica ion Information - Please Print Ail Information ZO N N C U r f I C; E q-5 5 a N O a the a �a� Blocky 0 3 N 4 (� Proveny&ner s A&Uing Address Property 'on Id IC � © 1� Sp 1A,Secu n ; v-X City, State Zip Code Phone Number N� S o ?6s a -as H. Type of Building (check all apply) N; R�E o .Q/f/ Subdivision Name CSM Num or 2 Family Dwelling - Number o ` O 4 L1 PubliclCommerciai - Describe Use d ❑ State Owned - cri Use _ ❑City ❑VillageTowruhip of t IQ. Type of Permft: (Checir only one box A. Coin tine B if ) A. New System ❑ Replacement System ❑ TreatmentiHolding Tank acemetit Only El Other Modification to Existing System I--- B. 11 Permit Renewal 11 Permit Revision \Chaage of ❑ rmit Transfer to New List Previous Permit Number and Date Issued IL Before Expiration net IV. T of POWTS stem: (Check all that a ) N - Pressurized I n- Ground ❑ Mound > 24 in. of suitable so Mo < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter Cot Bttucted Wetland ❑ Pressurized In Ground ❑ Holding T ❑ Peat Filter El Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media: Filter ❑ Leaching Chamber ' ine Gravel -less 11 Other (explain) V. reatment Area Information: Design Flow (gpd) — diciaq Rate( f) 1 Area red (sf) is Area Proposed (st) System Elevation -� 3 3 gab VI. Tank Info pacity in Total N r M er Prefab Site Steel Fiber Plastic Gallons Gallons nits Concrete Constructed Glass New Existing Tanks Tanks Septic or oiling "tank t t.V t�S�rS Aerobic TreatmeraUnit l �4al ,, fpm Dosing Cumber fit/ fJ l `� VII. ResponsNft Stattn wW - 1, the responsibility for WOA4mr of the shown on the attached plans. tier's Na me ) s Si to RS umber Business Phone Number of Lkj Plumber's Addre ss (Street, City, State ip Code) f vlu. v Approved ❑ Disapprov Sanitary Permit Fee (includes Groundwater Da f rttg m Sirtur Stamps) Surcharge Fee} q1 ❑ Owner en Reason for Denial U v V IX. Candlitionsof A prfvalt s or Dis Y E 9�lER' -- C�PiL `y ,,'�0�' 1 Septic tank, effluent filter and (�( a�a'j'LC,e, �pli,t/� dispersal cell must all be serviced / maintained 3 w sir ,� � as per management plan provided by plumber. "` , `�l Q 30 2. All setback requirements must be maintained S4'►+Q 4f '71t j as per applicable code / ordinances. yr% vi' G�ai a '�,e SR/ytc✓ a , Z Attach aompkta plans rya, am Conaty 9aW for *e t lass than sin x It in sirs -A C�-o�� 46 7L A 8 M Top eO; 5ur� ac, ° i ro,.�� t oo l top' err 3 a�` v NS . N � E / I o � � o C�y CA Q � o / �g0 �'° . ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer .p l�t , �t `�\ �rS LL r Mailing Address A ) Property Address ) y SS 1 lS "cJ WL© f'c (Verification required from Planning Department for new construction) — City /State Parcel Identification Number LEGAL DESCRIP IOI+d Property Location Y4, '/,, Sec. -2�, T -R [� W, Town of Subdivision , Lot # a Certified Survey Map # /,1�at' Volume . Page # Warranty Deed # 770`7(03 Volume _ �(o3 � , Page # , Spec house yes 0 no Lot lines identifiable yes 0 no SYSTEM MAINTENANCE Q Cb A � Improper use and maintenance of your sep 'c 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 gut 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 plumber, journeyman plumber, restricted plumber Ora licensed pumper 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 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 MGNATUREJ ' as set by c rtment of commerce and the Department of Natural Resources, State of Wisconsin. Certification eptic a has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 yea e . tion date. 16" APPLICANT DATE O C `R ATION e) cc ' at atl statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the o rty des d above, by virtue of a warranty deed recorded in Register of Deeds Office. id 2 SI Of APPLICANT DATE ** * * ** Any information that is mis- represented may result in the sanitary rmit being revoked b the Zoni Department. Pe 8 Y g P " Include with this application: a stamped warranty decd from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed IIL POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of ATIOtM SYSTEM SPE�T1t�NS fawner t�'� � Tank 1►Ar�nufar�tun+ar (,1 � 4, .2s �r S 0 kA Permit Z Se�dc p D p Howing Vol. laso gat DES MW PANAMFTERS Tank Manufec ulOr 0 NA NU mbeir of Sedroorr s Ai D NA O Sepdc O Dose U Vol- gal Number of R is Fecility Units O NA Effluent F#tW Manrtfacturer Ql-•e vvc d NA Eudmated (average) flow � c7 F-Muent FOtar Model +-' - C)9 as - l Design (peak) flow = (Estimated x 1.5) p0 Pump Man+uFscturer O NA VmLft `soil App(icetion Rate ♦ 7 PAP !Model Standod lerfkaahti>Effluent 0" y Monthly average Unit NA a &Grease {t-OG) 530 mg/L d Sandleravel Fear O Peat Filter eiocrwWcal oxygen e (BOD s220 mg/L 11 NA D Mechaaral Aeration 0 wetland Total Suspended Solids (TSS) 5160 mall O Disinfection D other Pretreated Effluent Ouallty Monthly average Manufacturer Siochendcal oxygen Demand (8013 530 mall Disci Cell(s) O NA Total S'usporrded Solids MSS) 530 mgfl. ) !'W4rouitd (gr+mty) © weround (pressurized) Fecal Colifor m (geornstric mean) 0 D At -Grade ❑ Mound Maximum Eftiuent Pam Size Yi in dia. d NA D Drip - Lipe D Other. NA 0 NA 'Vakas typicel elc for dornea waster and septic tank effluent. other. O NA tlrUfdil(TI NCE SC1 EDILM SlanrWt Event Santos Inspect condition of tank At least once ovary: mo (S) � 3 �) ❑ NA WWhen combined sludge and scum 04us k One -third (Y of tae volume p NA Pump out contents of tank(s) tl When Ow hilgh water abNrn is- activated Inspect dispersal eefi(s) At least once every: ►inptftlt {s)axm 3 l yaarai G NA Clean effiueW f S Iv y: At least once eva rnortthta) ' Nk O month(sY D NA Inspect pump, pump controls & alarm At least once every: D s) Rush laterals acrd pressure test At least once emery. O D y (s) DNA (a) ❑ month(s) D NA ' At !seat once every: Q ❑ NA Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following lieefWaS or certifications_ Master Plcunbw, Master Plumber Restricted Sewer; POWTS inspector, POWTS Maintainer, Septage Servicing Operator (pumperl. Tank inspections mast include a visual inspection of the tan k,$) to identify any mdssing or broken hardwere, identify any cracks or leeks, measure the vokwo of combined sludge and scum and a check for any back up or pownB of of kmft on the ground surface- The dispersal celIW email be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a fading condition and requires the Www hate notification of the local regulatory authority. When the coned occumulation of sludge and scum inn any treatment tank equals one -third (Yy) or more of the tank volume, the entire contents of the tank shell be removed by a Sept"e Servicing Operator and ftiosed of in accordance with chapter NR 113• Wisconsin Ada»rdstrative Cottle. All other services, including but not limited to the servicing of effluent fitters, mac har*Aj or pressurized components. Pretfeatmen' emits, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report stroll be provided to the local regulatory SuVwdW within 10 days of completion of any service event. GMw ti /era► Pave af START UP AND OPERATION For new construction, prior to use of the POWYS dnsck treatment tm*fs) for the presence of painting products. solvents or other chemicals that may impede the bwbraant process WWVor damage the soil d Wersd cents). ff high concentraRions we detected how" contents of the tank(s) removed by seplage savich operator prior to use. System start up strait riot occur when sob carar#t)orns ace fttonn at the infiltrative surfece. During enteoded power outages pump tanks nary fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cdjW in one large dose arad may overload them resulting in the beditup or surface charge of effkmnL To avoid this situation have the corr N I I of the pump tank removed by a Septage Servicing Operator prier to restoring power to the etfkwnnt pump or contact a Rurwbw or POWTS Msbumireer to assist in manually operatiM the pump controls to restore normal loveia within the purnp tank. Do not drive or park vehicles over tanks and dispersal calls. Do not drive or pork over. or otherwise disturb or compact. the area within 15 feet down slope of any mound or at -grade soil absorption anas. PO WTS: Ptedt"on Of � `,,,� bab the following from the wastewater stream may Improve the pe and prob l i f e the PO . WTS: ontibiotics; y wipes; cigarette butts; condoms. CoMn swabs; �reesers; dental floss; cfigma; &*decWa; fat; focaICladon drain (sump pump) discharge; frail and vegeaabla paefir M oftob ; grease; herbicides: meat screw medi oil; Ming his! Pte; sanitary ; tarmpOnw, and avatar softeow brine. ABANDONMBff When the POWTS fa8s and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in conwhance with chapter Comm 83.33, Wisconsin Administrative Code: e AN piping to tanks and pits shall he disconnected and the abwKkwmd pipe openings sealed. a The contents of all tanks and pits shall be removed and property disposed of by a Septege Servicing Operator. • After purnping. all tanks and pits shall be excavated and removed or thalr covers removed avid the void space filled with sod, gravel or another insert solid material. CONTBVGMCY PLAN if the POWYS falls and cannot be repaired the following measures hays been. or must be taken, to provide a code compliant Twint systern: A suitable replacement area has been evaluated and may be utilized for the location of a replacement sod absorptionn system. The n0mmnent arse should be protected from disturbance and Compaction grid should not be bdrkVW Won by required setbacks from and pronosad structure, lot ines acid walls. Failure to protect the repliscement area will result ,in the need for anew sob and site evaluation to establish a suitable replacement area. Repbacomert "atoms must comply with the rules in effect at that time. ❑ A suitable replecerrneit area is not available due to setback and/or soil limitations. Barring advances in POWTS tedvmlogy a holding tank may be iraattalled es a hint tnneop to nonce the failed POWYS. IP 4b oo ts as not been evaluated to identify a suitable replacement area. Upon fallue of the POWTS a soil and site m rform6d to locate a suitable "I no tank as a ❑ Mouid and at- grade sod abs rp6on systems may be reconstructed in place following rwrKr.W of the bkmW at the infiltrative surface. of such syaterns must comply wRh the rides in effect at that time. < <WAfVQW> > - P~ AM OTHER TRIFATUMT TANKS MAY CONTANV LETHAL GASSES ANDIOR n UUAgW NY OXyGM. DO NOT 811TINI A NWI' .PUMP OR OTHER TI EATRUNT TANK UMM Ally CWA= STAt4=. DEATH MAY RESULT. RESCUE OF A PHJtSQM FlIOM THE INTINUM OF A TANK MAY BE DFRCULT OR IMnOSSOLE. ADDnMNAL Ct7iMIIIIEWS POWTS ArUJM POINTS M8!EAUh t Nye lr i ry Q Name Phi 7 s 1 Phone OPTAGE SEMACBVG OPERATOR (PUMPER LOCAL RMIt"TORY AUTHORITY Manna Name Phone Phone LS (� QqA 'his document was drafted by the staffs of the Green take. Marquette and Waushaera C*MW 2aning avid Sw*ndon agendas in =wvRance with j""a Comm 83.22i21(b)l1) &(f) end 83.5401, (2) & (3). Wisconsin Adminisarative Code. ' I r I EZ1203H wow r } � r ( • �TSTTs sTrT+rss - _ rrrTrs s� w RRrTTR f Rs• RMRT ♦Tw TRT -'� ` w�'T TTT► 1 ! RRR wR r�ry wRT .. + _ wRT 4 -625" T• •T► I ' RT RR} V RR ♦R � tt w Viet ( wRT ♦TR RRRR J/2 Ciyc www We r '"ws T i►M t w ww i � stet ReRTS♦ RRSS wRSwwTrir WeTTwss •RTwsTM i f f � _ _3 r ��,�,��� ��`� Void Catfl..'a A g+m N 57.4x, sto im f t at) or 4- 4t+_ IQ EL i ° 4-625 Swcvajf E2 V aM , - t__ pear jiftU ft . 3.1 -� 2j 123° 3 s ( . rte r a) °�' " rr_ t a rt TOW S" lattrtact Arta 4 6itt'e� ate of Ccaw ,. 3.1 a i i 3.. '- �� 5.14 SQ, f 422 ft- �� C}.D. aCu rcyrt a t2 t"Ch s � Vold v otdrtfE to atttsx* CWind�y 3 t - a„*`__ ""0110cled Trtac* Arta { IiatrA,t Say 901 f �! i Stdeya!! tteq#U _ 12 to 3 old kafu+m at b."a. a 2,00 Sq.Ft r I tterwcrr st •. 240 s� BotEOrRt = 36 4n a tt ?arh ! r2�n R ltap _. 0,*t 5 Sq.Ft. t2;a,}t rf rroj- t Trt1c6 Arra i — t Vold volw tc u OtId 11 $q.Ft. i t bflttoart t�'aers (If? Of votrt vol ' J Tart! vgKj -# -I- 4. t t.T . ttet.racn ` 110 -dt 8 0 215 _ e tl to's R` i { 0.42.2 + Q.90 t . f tr8 k 7.3 vatb+c ft r R Gallons Pct R 1- 763 X 7.48 @ 3 j i tpS A 99' egate Trench System EZ i 203H Rat9 Industrial Group W � I 65 btdUWiw Pork Rd. ) Oakland, TM X8050 EZr3f -,s, i I J.. 2632P 005 ' - 7E,a � STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH REGISTER OF DEEDS Document Number WARRANTY DEED ST. CROIX Co., YI RECEIVED FOR RECORD This Deed, made between Dalstock. LLC 08/05/2004 10:00AN Grantor, and LeOue Builders LLC WARRANTY D EED Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee REC FEE: 11.00 the following described real estate in St. Croix County, State of TRANS FEE: 156.00 Wisconsin (if more space is needed, please attach addendum): COPY FEE: CC FEE: Lot 29, Lundy Meadows, St. Croix County, Wisconsin. PAGES: 1 Recording Area Name and Return Address ^. p — 4e 6 cceA �a 026- 1066 -84- Q � Parcel Identification Number (PIN) This is not homestead property (is) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this day of July 2004 Daltto t, LLC��� -• � ' � Bill Stock, Member * Steven M. Dalton, Member AUTHENTICATION ACKNOWLEDGMENT Signature(s) Dalstock, L L_C STATE OF _ _ _ _ - _ -_ ___ _ _ ._- ) By: Bill Stock, Member a Steven M. Dalton, Member ) ss. _— � �1 County ) authenticated thisl�_ `_ of . July , 2 004 Personally came before me this day of the above named ---- -- --- ---- - - ---- - - -- -- - - . . * Kr istin O Land --- _--- -. - -.— - -- TITLE: MEMBER STATE BAR OF WISCONSIN (If not, — — to me known to be the person(s) who executed the foregoing authorized by § 706.06, Wis. Slats.) instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY Attorney - Kristin Hudson, WI 54016 Notary Public, State of 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. information Professionals Co.. Fond du La wt STATE BAR OF WISCONSIN 800.65: !oz l WARRANTY DEED FORM No. 2 . 1999 f i R ', • a .rwj�K- IA \!1i t Tj S ` N 1� sa O N 6-4 . N y I t MS.�Z .age 9 + gt t8 tN � ' 99.9 • ,��" M ' "'�� a�' � ' • \�� � J/ 6� /rb � s'� t s 6 9 � 6 _ �_,gZ'g '`- \ \\ \\ � c � W � • M y 0 °j ,�• \\ O 0 s 1 m C A y N p �, \\• . \ N �, ' ' ' • , O ao \ \\ ' ' ' • V \ V r r , 'Z6£' M 9.50 a h \ \ ,PL 4 07.88 \ -� 8 90.8 6 t 'ca • Oo \ o . •ac 5 0 6 .35' 02 O N rn • . / / \ , , • ' Cif 4 / • ' °' 'cam � ° w 6-4 2•