HomeMy WebLinkAbout026-1168-32-000 r Wisconsin DcjUartment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safeb, and Building Division
INSPECTION REPORT sanitary Permit No: 479421 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:
Hale, Brett I Richmond, Town of 026- 1168 -32 -000
CST BM Elev: Insp. BM Elev: BM Description: G Section/Town /Range/Map No:
D - a :7 y Sf' 2, 22.30.18.1338
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ,n ^ J j Benchmark W-04
Dosing / S` Alt. BM r, C4 S- 9 S 3 bi
Aeration ` Bldg. Sewer O 3 h
t'o G 13,
S
Holding St/Ht Inlet � � ,Z• L
St/Ht Outlet /� ( G Z-. 3 S
TANK SETBACK INFORMATION ( SG �fo 2�3 7
TANK TO �L WELL BL Vent to Air Intake ROAD Dt Inlet
Septic 1 / Dt Bottom -
Dosing C A Header /Man. (-
Aeration Dist. Pipe 0 !�O•
Holding Bot. System
Final 0� S D
PUMP /SIPHON INFORMATION 53 -8S
Manufacturer " Y V
GPM Demand St Cover 2 5 03 G S
4 /
Model Number
TDH Lift Friction Loss Sys Head TDH Ft r ► S
Forcemain Length Dia. Dist. to
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length f No. Of Tre es PIT DIMENSIONS No. Of Pits inside Dia. Li uid Depth
DIMENSIONS 3 -+a � /
SETBACK SYSTEM TO P /L.,� JBLDG WELL LAKE /STREA LEACHING Manufacturer:
INFORMATION CHAMB
Type Of System: IT Model Number. 7TH
Eli. 52S 5� � >J
DISTRIBUTION SYSTEM F ej
fi
anif D x Hole Size x Hol acing V nt t it Intake
e(s) �� 10
Length Dia Length D Qv O� Dia Spacing �— � '
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Ove Depth Over xx Depth of xx Seeded /Sodded xx Mulch
Bed/ rre h Center 1 (�t c Bed/Trench Edges Topsoil
Yes No D Yes [] No
COMMENTS: (Include gde discrepencies, persons present, etc.) Inspection #1 :q � / ( (� Inspection #2: ! /
Location: 1257 146th Avenue New Richmond, WI 54017 (NW 1!4 NE 1/4 22 T3 N R18W) Pond View Meadows III Lot 3 Parcel No: 22.30.18.1338
1.) Alt BM Description = IWvU amd•S
2.) Bldg sewer length =
- amount of cover => Z /� .a'/�+ ` •�� / �r�
b S � rS
Plan revision Required? I,. i Yes 160
Use other side for additional information. LLD 5
Date Insepctor's Si ature Carl. No
SBD -6710 (R.3/97)
Safety and Buildings Division County
I visconsin W 2 W. Washingt n . Box 7162
mj�W Madison, 1 53� °�
Sanitary Permit cr Number (to be filled Co.) ,r7�
( )266315 b� i , ,- J �oZ P
Department of Commerce
be
Sanitary Perini p 1' ions,!` S e Plan I.D. Numb rl
In accord with Comm 83.21, Wis. Adm. Code, ona fo ation you provide t ? r
may be used for secondary purposes Priv La "b Address (if different than mailing address)
ROfX �, , [ / oject
as
I. Application information - Please Print All Information ° yJ
�J
Property Owner's Name j Parcel # t # Block #
Property Owner's Mail ing Property L( ca 2_ - '
y., M6 , Section
City, State Zip Code � 7,6 6 hone Number
5S 1a 3 _ ry t trcle one)
In P 7 T _0N; R/ E or W
H. Type df Building (check all that apply)
41 or 2 Family Dwelling - Number of Bedrooms Subaivisio Name CSM Number
,
❑ Public/Commercial - Describe Use
❑ State Owned - Describe Use ❑City_ illage ownshi of
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. New System ❑ Replacement System g Tank Replacement Only ❑ Other Modification to Existing S
❑ Treatment/Holding g stem Y
B. ❑Permit Renewal 11 Permit Revision El Change of ❑ List Previous Permit Number and Date Issued
Permit Transfer to New
Before Expiratfbn Plumber Owner / -7
� J -
IV. Type of POWTS System: Check all that appl
kNon - 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
A Leaching ambe rip , i e ❑ Gr vel -less & ❑Other (explain)
V. Dis ersal/Treatment Area Information: ✓
Design Flow (gpd) Design Soil Application Rate Dispersal Area Required (sfj Dispersal Area Proposed (st) System Elevat� n 2
�� z 95 Ss
VI. Tank Info Capacity in To Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement - 1 , the unde igned, assume responsibility for i ailation of the POWTS shown on the attached plans.
Plri t� Plu is Sign Z MP RS � Business Phone Number
7TW s 7eS- a
Plumber's Address (Street, City, State, , p Code)
s o�
III Count /De artment Use Onl
Approved El Disapproved Sanitary Permit Fee (in des Groundwat Date Issued Issu' g Ag=Siatur No t s)
Surcharge Fee) /_O 0 6 9 Z �
11 I Owner Given Reason for Denial ( O
IX. Conditions of Approval /Reasons for Disapproval /Z
D2- �i'�2�•a � � {��U7c -a� tL'- li�rn� min c� /�P�t�rt 2t�' �
AAV ` �� ch coin m to the Coun only f t system qn paper nO��S -' x 1 es 'o si ej
SBD -6398 (R. 01/03) Wl t,� �� .
T- a
N
RAt
y
13/x- 1 /v° ` 7ye�
Wisconsin Department of Commerce SOIL EVALUATION REP Page of
Division of Safety and Buildings
in accordan 'th Comm 8
County
Attach complete site plan on paper not less than 81/ 1 in in e. P ust
include, but not limited to: vertical and horizontal reference nd
I I.
n I –
percent slope, scale or dimensions, north arrow, an tion and dist ce o " �'st rdad'
Please print all inform wed y Date
Personal information you provide may be used for secondary purposes (Privacy w, s. 1544 t LN� O F v ICE ` 1 ! Zvi �S
Property Owner P cation
Govt. Lot , U' 1 14,fjF- 114 S ZZT 30 N R !8 E (o
Property Owner's Mailing Address Lot # Block # I Subd. Name or CSk*
IN 0
City t State Zip Code Phone Number ❑ City ❑ Village (Town Nearest Road
/V LJifn J I wt Syul LZIS - ) - -L - �~ nc, ,act G
(D New Construction Use: Residential / Number of bedrooms Code derived design flow rate _�Sd GPD
❑ Replacement ❑ Public or commercial - Describe: __—
Parent material G /) + t.AJ 4 5 Flood Plain elevation if applicable
General comments I
and recommendations: �I e ! ®� ll� `/ tJ n
Borin g
Boring # E] ® P Pit Ground surface elev.�� ft. Depth to limiting factor /C� — in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff #1 •Eff#2
I o-1 � 31 4 Cf v
�/• 2 Z ' 47 - 7- 2 '
® Boring # C3 Boring q
C° Pit Ground surface elev. /' S Depths to limiting factor /� S in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft`
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `E111#1 'Eff#2
0 - w 32
Zd 16 to ql
w - i is
•
Effluent #1 = SOD > 30 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mglL and TSS < 30 mglL
CST WM (Please Print natur e
CST
- -�`,
Address 4F Date Evaluation Conducted Telephone Nutnber
Property Owner D O / (• A� Parcel ID # •Y ! fL.J z- Page of
Ili Boring # ❑ Boring CJ (
E] p i t Ground surface elev. / �' v ft. �, �.DeptM� "li►nitin9 factor ?r JS �n• Soil Application Efate
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
r0V r y
V-6 ��• -2 4i
Boring F # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2
Q Ong # C] Boring
❑ Pit Ground surface elev. ft. Depth m 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 1150 mg/L ` Effluent #2 = BOD < 30 mg/L and TSS 130 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.
SM4330 (RA/bO)
PAQ8 OF 3
NAME ��.�� LOT# Z — LEGAL DESCRIPTION A/+,r/'/a Ors /a,S2,LT JG1NA ZJ�,
f
SCALE: I"
i `_ 1rrr Mr'
BM I ELEVATION
BM I DESCRIPTION 44' 4-
{�P o wz�i �en p
BM 2 ELEVATION
BM 2 DESCRIPTION
SYSTEM ELEVATION
SYSTEM TYPE ('Yl(lc ✓i.Jd /LC .-
�CX
Tz ,00
r �V
7 2 Y40e-
T T
2
i
pft
SIGNATURE DATE d
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
i l OWNERSHIP C;:RTIFICATION FORM
Owner/Buyer rj r 1 Ci I P
Mailing Address 1 /33 1 'Ra 0 At � + I iU
Property Address a $ ) J V Q
(Verification required from Planning Department for new construction)
At
City/State Parcel Identification Number C)�A L✓ - ) !) b J - 3L v5a
-5NO 17
LEGAL DESCRIPTION
Property Location �( U/ /., N EL Sec. r►a . T - 3 N -R —jK- W, Town of Mond
Subdivision H1 Lot #
Certified Survey Map # `� 3 0 a --1 Volume _ ) b , Page # o?
Warranty Deed # 7c . 7 5 Volume _2$ a -4 Page # y S
Spec house 0 yes ❑ no Lot lines identifiablexyes ❑ no
SYSTEM �NANCE
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 agrees to submit to St. Croix 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.
I/we, 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. Certiftcation
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 APPLICANT
DATE
OWNER CERTIF
O
I (QOF ll statements on this form are true to a best of my (our) knowledge. I (we) am (are) the owner(s) of
rope , b irtue of a warranty ed recor d in Re er of Deeds Office.
S GNATU It l / 1 LICANT �� los DATE
« "` *« Any information that is mis- represented may result in the sanitary permit being revoked b the Zon Department.
y nn g « * « « ««
«` Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
07/28/2005 THU 14!47 FAX 715 386 4687 ST CROIX CO REG OF DEEDS Q50 02/003
2 8 2 4 P y 5 8 -
K ATHLEEN H. BALSA
State Bar of Wisconsin Form 2 -2003 REGISTER OF DEEDS
WARRANTY DEED ST. CROIX CO., WZ -
RMEIVED FOR RECORD
r)ocument Number Doeumonl Nartic
06/26/2005 03:29PA
WARRANTY DEED
EXEMPT #
THIS DEED, made between Loren D. Derrick, Rose H. Derrick, Richard L. Derrick, REC FEE: Li. 60
Joan L..berrick and Robcrt J, Derrick TRAKS FEE: 290.70
( "Grantor," whether one or more), COPY FEE n
and Brett Hale CC FEE;
("Grantee,` whether one or more). PAGES; I
Grantor, for a valuable consideration, conveys and warrants to Grantee the following Recording Arco
described real estate, together with the rents, profits, fixtures and other appuRenarit
interests, in St. Croix County, State of Wisconsin ("Property") (if more space is Name and Return Address
needed, please attach addendum): A-,11,� r,4 -f-, —WV i CQS
Lot 32, Pond View Meadows M. St. Croix County, Wisconsin, 4 W i.;4-e— P>ear h
wk, -k t"n" taKe S Ilp
026- 1065 -3050
Farrel Identification Number (PIN)
This is not homestead property.
(is) (is not)
Exceptions to warranties: Easements, restrictions and sights -of -way of record, if any.
Dated _ 065
Robert J. Derrick
40&y &6u EAL} X00C AU (SEAL)
*Loren D. Derrick, by: Rob 4( J. Derri *Rose H. Derrick byjtiobertd. D . 0 rick,
I orney Fact Attorney i F t
(SEAL) ' 1 SEAL)
'Richard L. Derrick "Joan L. Derrick by: Richard Derrick, Attorney in Fact
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Richard L, Derrick, Attorney In Fact and_
D c r rrir tan in . act STATE OF )
authenticated on to ( ) ss.
COUNTY )
*Kristine 1>tnd Personally carne before me on ,
TITLE_ MEMBER STATE BAR OF WISCONSIN the above -named
(If not, to me known to be the person(s) who executed the foregoing
authorized by Wig. Stat- § 706 -06) instrument and acknowledged the same.
THIS INSTRUMENT DRAFTED BY:
Attorney Kristina Ogland Notary Public, State of
Hudson, W11 54016 _ My Commission (is permanent) (expires: 1
('Sigwimures may be autbenticated or acknowledged. Ro(h are not necessary.)
NOTE. THIS IS A STANDARD FORM. ANY MODIFICATIONS TO TIRS FORM S11OVLD 131; CLEARLY IDENTIFIED.
WARRANTY DEED 0 2003 STATI= BAR OF WMCONSIN FORM NO. 2-2003.
a TSTe name below signatures. INFO-PRO Legal Forms ODO- 655 -2021 wwnw.infoprofoffmcom
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Septic Tank Capacity al ❑ NA
Permit # Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units ❑ NA Pump Tank Capacity al ❑ NA
Estimated flow (average) g al/day Pump Tank Manufacturer ❑ NA
Design flow (peak), (Estimated x 1.5) Gib gal/day Pump Manufacturer ❑ NA
Soil Application Rate Z, al /da /ft2 Pump Model ❑ NA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit ❑ NA
Fats, Oil & Grease (FOG) 530 mg /L ❑' Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) s150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (SOD.) 530 mg /L In- Ground (gravity) ❑ in- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) 510 cfu /100ml ❑ 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: ❑ month(s) (Maximum 3 years) ❑ NA
y ear(s)
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
ye ar(s)
Clean effluent filter At least once every: / ❑ month(s) E3 NA
ear(s)
Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA
❑ ear(s)
Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA
O year(s)
Other.
At least once every: ❑ month(s) ❑ year(s)
13 NA
Other:
❑ NA
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.
Page �' of 2
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 tank(s) 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 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 ft r 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.
T .
alua ' C
b e ai a '�kwlz 17� fbi2 N/�✓ Conr�(Jc-n tank
❑ 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 #4 iwl Name
Phone Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name 5D7 C ( 20/Jl "
Phone Phone — 71'5_ .— 3ec"o-
This document was drafted in compliance with chapter -Comm 83.22(2l(b)(1)(d) &(f) and 83.5411), (2) & (3), Wisconsin Administrative Code.
I
Parcel #: 026- 1168 -32 -000 08/26/2005 09:42 AM
PAGE 1 OF 1
Alt. Parcel #: 22.30.18.1338 026 - TOWN OF RICHMOND
' Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
08/30/2004 00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner
BRETT HALE O - HALE, BRETT
1138 PARK VIEW LN
EAGAN MN 55123
Districts: SC = School SP = Special Property Address(es): ' = Primary
Type Dist # Description * 1257 146TH AVE
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 2.020 Plat: 10/21 -POND VIEW MEADOWS III 026/04 LOTS 3
SEC 22 T30N R18W PT NW NE BEING POND Block/Condo Bldg: LOT 32
VIEW MEADOWS 111 ('04) LOT 32 (2.020AC)
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
22- 30N -18W NW NE
Notes: Parcel History:
Date Doc # Vol /Page Type
06/16/2005 797875 2824/458 WD
08/30/2004 773003 10/21 PLAT
10/15/2003 743759 9/87 PLAT
07/23/1997 952/538 more
2005 SUMMARY Bill #: Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 06 /21/2005
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 2.020 300 0 300 NO
Totals for 2005:
General Property 2.020 300 0 300
Woodland 0.000 0 0
Lottery Credit: Claim Count 0 Certification Date: Batch #:
Specials:
User Special Code Category Amount
I
Special Assessments Special Charges Delinquent Charges
I
Total 0.00 0.00 0.00
Safety and Buildings D' ' I�sI County ,
` 201 W. Washington Ave., P.O. 16 6
�
1sC0ns,n Madison, WI 53707 — 7I amtary Permit Number (to be filled in by Co.)
Department of Commerce (608)266 -3151 � 41Z
Sanitary Permit Applicat' you r vi e
>� _ ED Slat Plan I.D. Nur�iber,�
In accord with Comm 83.21, Wis. Adm. Code, personal informat n
' N
maybe used for secondary purposes Privacy Law, s15.0 0(m) Proj t Ad ss (if different than mailing address)
9.
t? }�
I. Application Information — Please Print All Information 6-7 / f-
N
A
Property Owner's Name BONING OFF'C P l .) Lot # Block #
!BOL
Property Owner's Mai Address Property Location
i " , AA� /
City, State Zip de Phone Number N Y <, �''> Sectio
71S - 74 O _ a circle one) I 3�
T ; RE or W �
11. Type uilding (check all that apply) 01C 4S P"
or 2 Family Dwelling- Number of Bedrooms vie- o ( Subdivision Name CSM Number
`
El Public /Commercial - Describe Use
❑ State Owned - Describe Use ❑City_❑V ge p --ship of
III. Type of Permit: (Check only one box on line A. Complete lin if appy able)
A. ((,New System p y g V.k p g Y
❑ Replacement System ❑ Treatment/Holdin placement Only they Modification to Existing System
B. El Permit Renewal El Permit Revision El Change of ❑ r t Transfer to New List Pr 'ous Perini a sued
Before Expiration Plumber O er J
IV. Type of POWTS System: Check all that appl
Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mou < 24 in. of suita\soil El At -Grade ElSingle Pass Sand Filter El Constructed Wetland Pressurized
In- Ground El Holding Tank El Pe Filter El Aeroent Unit El Recirculating Sand Filter Recirculating Synthetic Media Filter Leaching Chamber ❑Drip Line ravel -less
Pipthey (e)Splain)
V. Dispersal/Treat ent Area Information. G o
Design Flow (gpd) Design Soil A licatio te(gpdsf) Dispersal rea V ` Disp sal ArN Proposed (sf) System Elevation
Z0 Dd
VI. Tank Info Capacity fn Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank
Aerobic Treatment Unit w
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume 4sponsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumb s S natur P PRS Number Business Phone Number
y o ?ao 3s 7•s a� - �� .s""
Plumber's Address (Street, City, State, Zip C de
//D A-) � �J� A ). w� S o0
VIII. County JDe artment Use Onl
pproved Disapprove Sanitary Permit Fee (includes GtWundwater Date Issued Issuing ent Signatur to s)
Surcharge Fee) r� �-�a �5
eason for ettial
IX. Conditions of Approval/Reasons for Disapproval C I t "
SYSTEM OWNER: 3 Z C_ I►t` �l` o� lZ 1. 'Sslic flint, effluent filter and . 6.,
dispersal cell must all be services / maintained
sa per management plan provided by otumb'r.
2. AN selback requirements must be ma ntamed y 1 per , ace, Jai' re
as per applicable code / ordinances. ✓✓✓ U
Attach complete plans (to the County only) for the system on paper not less than 8112 111 inches in size
SBD -6398 (R. 01/03)
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�. RECEIVED
. Wisconsin Department of Comm PPIL VALUATION REPORT p age 1 of 3
Division of Safety and Buildings NOV 1 26
in accordance with Comrr 85, Wis. Adm. Code
UN Y County St. Croix
Attach complete site plan on paler note Inches size. Plan must
include, but not limited to: verb I and h ), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
Richard/Robert/Loren Derrick Govt. Lot NW 1/4 NE 1/4 S 22 T 30 N R 18 ® )W
W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
1310 Hwy 65 32 Pond View Meadows IjL
City State Zip Code Phone Number []City Village ■ Town Nearest Road
New Richmond I WI 1 54017 1 ( 7j 5- 246 -5425 CTH G
S New Construction UseE] Residential / Number of bedrooms 3 to 4 Code derived design flow rate 450 0 600 GPD
0 Replacement [] Public or commercial - Describe:
Parent material Loess over outwash sand and till Flood Plain elevation if applicable N-A ft.
General comments These are massive soils with the need for extremely careful installation techniques of the system being used by the
and recommendations: installing contractor. My recommendation would also be to consider a pressurized system, where the effluent can
be dosed over the entire distribution area. Not required, but recommended.
Thi 'table for a below a conventional sys
F-1 Boring # 0 Boring
Q pit Ground surface elev. 105.35 ft. Depth to limiting factor >80 in.
Soil Application Rate
Horizon pth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f?
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2
1 0 -8 10yr3 /3 sil 2mgr dsh cw 2f .5 .8
2 8 -16 1 4/4 sil lmsbk dsh cw if .2 3 Z
3 16 -32 10yr4 /4 sl Om dsh cw - •3 e
4 32_51 7.5yr4/4 s Os dl cw - 1.2
5 51 -80 7.5yr5/6 si 0w dsh
[_2 Boring # Boring 102.31 16 -20
El 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
1 0 -9 10yr3 /3 sil 2mgr dsh cw 2f .5 .8
2 9 -16 1 4/4 sil lmsbk dsh cw if 2 .3
3 16 -20 10yr4 /4 fl d5 5/8 sil lmsbk dsh cw if •
4 20 -30 7.5yr5/8 5 1 �� is 0m ds cw - .5 .7
5 30 -82 7.5yr5/8 s* Om* ds -- - .3 .5
e
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 150 mg/_ ' Effluent #2 = BOD < 30 mg/_ and TSS < 30 mg/L
CST Name (Please Print) Signature ? CST Number
Thomas C Nelson -"' 227387
Address Date Evaluation Conducted Telephone Number
1432 120th Street, New Richmond, WI 10/31 03 715- 246 -2454
r
Property Owner Derrick Parcel ID # Page 2 of 3
Boring
F T ] Boring # pit Ground surface elev. 100' 18 ft. Depth to limiting factor >8U 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
1 0 -10 10yr3 /3 - sil 2mgr dsh cw 2f .5 .8
2 10 -24 1 _ bk dsh cw if .2 .3
3 24 -35 7.5yr4/4 - Om dsh cw _ .3 .5
4 35 -80 7.5yr5/8 - s* Om dl - - .3 .5
r
v�
❑ 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/fP
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
F Boring
Boring # Ground surface elev. ft. Depth to limiting factor in.
Pit Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP
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.
M- 8330Test(8.07/00)
PUBLIC ROAD
POND VIEW MEADOWS
LOT 32 t 4
N K
O�e
15T BM 2
106'
B1 4% B 2
SLOPE
104' SCALE 1"=
BM P OF CONDUIT 100.00'
2 TOP OF CONDUIT 102.40' 410'
B1 105.35'
B2 102.31'
102' B3 100.18'
2.02
85 ACRES 195' 202'
B3
55'
BM
53'
62'
55'
100'
SW LOT CORNER
THOMAS NELSON
227387
i
` M � M � 2.09 ACRES c7 1.75 ACRES
bi
1 SO. FT) (76,411 SO. FT.)
wit
y w I 8 U)
35
1 84 ACRES M
01 O!
80.199 SO. FT.) .. ... .. .... .
.. ...............................
co CL
— .-- .-- .- -._ —. 33 8 L- - "_250.00'. - -.—_. —. —_.� -- --
200. 0
N89'40'23 "A' 743.84'
N89 40'23 "A 400.00'
PUBLIC STREET
S89'40'23 "E 1209.08'
308.43' _
— . — —
215(- .—
........ ... .............................
... ................. ....
33 32 31
34 2.02 ACRES 2.90 ACRES
ACRES 2.02 ACRES g (126,456 SO. FT.)
00 A 0, $ 150 SO. FT (88,150 .) SO. FT
181 CR S 1 o
0 0 L,13.0. = 968.0 ` A
8 8
co DRAIN
tEASEME
A HIGH WAT
l ELEVATION =
L
210.27' 215.00'
.215.00'
589°40'23 "E 123829'
------- - - - - -- - - - -- CURV
COUNTY TRANSPORTATION COMMITTEE Curve
S CERTIFICATE CERTIFICATE Number!
C1
RESOLVED THAT THE RIGHT -OF -WAY OF COUNTY TRUNK HIGHWAY "G" AS Bound
DEDICATED ON THE PLAT OF POND VIEW MEADOWS IN THE TOWN OF
Y ELECTED, QUALIFIED AND ACTING RICHMOND IS HEREBY ACCEPTED BY THE ST. CROIX COUNTY HIGHWAY C3
CERTIFY IN DEPARTMENT AS APPROVED BY THE ST. CROIX COUNTY HIGHWAY
. DO HEREBY TAX SALES AND I UNPAID TAXES OR THAT THE RECORD COMMISSIONER AND THE ST. CROIX COUNTY TRANSPORTATION
_AFFECTING THE LAND COMMITTEE
IEW MEADOWS III.
C4
C5
TIM E. RAMBERG
DATE
_ DATE HIGHWAY COMMISSIONER THIS