HomeMy WebLinkAbout026-1135-15-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Buffing Division
INSPECTION REPORT Sanitary Permit No: 405159 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:
P.C. Collova Builders, Inc. Richmond Township 026 - 1135 -15 -000
CST BM Elev: Insp. BM Elev: BM Descripti
CO .Q i � .c9 t � �#T A
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
W •S oeo 't 4 10-Go 1c�• o
Dosing Alt. BM U
Aeration Bldg. Sewer 1 9g. TO
Holding St/Ht Inlet
(0•�8 4 ) 1
TANK SETBACK INFORMATION St/Ht Outlet O
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic •�. 101 t ICY� 9 1 DtBottom
Dosing Header /Man._ ,
\_4
Aeration Dist. Pipe
Holding Bot. System
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer emand St Cover
G OZ,
Model Number
�L
TDH Lift F ion Loss System Head TDH Ft
Force n Length Dla. Dist. t
SOIL A
JJKRPTION SYSTEM •p
RENCH idth I Length ` o. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIM - 3 1 3
SETBACK SYSTEM TO P/L BLDG IWELL LAKE /STREAM LEACHING Manufact r:
INFORMATION CHAMBER OR r r
Type Of ystem: I v ",...� UNIT
� Model Number: 1z It
V - fC
DISTRIBUTIO M
Head jW istribution x Hole Size Ix Hole Spacing Vent to Air Intake
ftw ` s, Pip s)
Leng Dia Leng Dia
SOILVOVER 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
0 Yes NJ No [] Yes No
CO M NTS (Include spyi��ispr� pen 'es, persons present, etc.) Inspection #1:�/ 6 / 0 Z.. Inspection #2: —
f X it E'�fp , F , t • L.� v'
Location: 1411 143rd St New Richmond, )I 54017 (SE 1/4 SW 1/4 24 T30N R1 8W) Evergreen Overlook Lot 15 Parcel No: 24.30.1
1.) Alt BM Description = � '5' 14) S��
2.) Bldg sewer length = 32 ��V ....!!!! q. j Gj yt,Zp
� � g1 9s. m9
- amount of cover S 1p.c�D ,. DO
10-z0 a '13 •� �
Plan revision Required? Yes No 0 p2 �� •
Use other side for additional information.
`-7 C_ epct nature Cert. No.
SBD -6710 (R.3/97) � ^ � •
Safety =BuildingsDivision 2 Count S 201 W. Wash 716 e � S'n Madis Site Address 1<sco merce ��Z
Sanitary Permit Application Sanitary Permit Number
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide Check if Revision ��s�
may be used for secondary purposes Privacy Law, sl5. 1 m
I. Application Information - Please Print All Information State Plan I.D. Number
Property Owner's Name Parcel Number Z e f . /g.
Property Owner's Uaffing Address Property Location
/ l O�
City, State Zip Code Phone Number Lot Number Block Number
r--
J ..�� Subdiv ion Name CSM N r
U. of Building (check all that apply) 0 1 v ❑City
or amity Dwelling - Number of Bedrooms age e
❑
Public/Commercial - Describe Use luP
3 1ne� x
State Owned 3 ��cF Nearest Roa��
In. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable)
A For County use
2 ❑ Reptacetnent System 3 ❑ Replacement of 6 ❑Addition to
S stem Tank Oni Eris ' S stem
B. El check if Sanitary Permit Previously Issued
Permit Number Date Issued
I:V. of Permit: (Check all that apply)(numbering scheme is for internal use) b� .1 3l
5e� Z
Non - Pressurized In- Ground 2111 Mound 47 ❑Sand Filter 50 11 Co
Weiland
22 ❑ pressurized In- (sound 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line f
45 ❑ At -Grade
46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating
V. Dispe rsal/'IYeatment Area Information:
Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade
Required Proposed ✓ Rate(Gals./Days/Sq.Ft. (Min./Inch) Elevation
J v �� < ��
VI. Tank Info Capacity in Total Number Manufacturer Prefab S' Steel Fiber Plastic
Gallons Gallons of Tanks Concrete Constructed Glass
New Existing
Tanks Tanks
septic or Holding Tank
Dosing Chamber
VII. Responsibility Stateme I, the undersigned, responsibility for installation of the POWTS shown on the attached plans.
Plum is Name (Print) Plumber's Si MP/MPRS Number Business Phone Number
�q00 i z - L sI -�
Plumber's Address ( treet, City, State, Zip )
V v
VIII County /De artment Use Onl
Approved ❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issued I mg A Signature (No Stamps)
Surcharge Fee)
❑ Owner Given Initial Adverse T1 UD
Determination S v'
lX. Conditions of Approval/Reasons for Disap rZQti�,. ^ ;C vi- Syg,4,Gy�,,,
sf-c.Q / U""�`���i,;,,,,a
2) ,air e -4 #AU_
Attach complete plans (to the County only) for the system on paper not less than 8112 x 11 inches in she
SBD -6398 (R. 05101)
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UNP-ATTED LANDS
---- - - - - --
So' Test and System PLOT PLAN
PROJECT P.C. Collova Bldrs. Inc AD ESS P.O. Box 489 Somerset Wi 54025
SE 1/4 SW 1/4s 24 /T 30 W TOWN Richmond COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 6/22/02 BEDROOM 3
CONVENTIONAL XXX IN-GP46UN PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1 000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 933 # of chambers 30
IL BENCHMARK V.R.P. Top of Fence Post ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL H. R. P. Same as Benchmark
YSTE ELEV ATION 092.7/92.6/92.5
a�
:>6" � ent Standard Infiltrator
Leaching Chamber
r with 31.1 M of Area
ng 12"
3 2 5 Grade at System Elevation
Plans Designed Using
Conventional Powts
Manual Version 2.0
20' Pro 3
Bedroom Tested area has <1% Slope
House
30'
T
30'
3 -3' X 63' Cells with >3 Spacing
B -3
f•) �� ;) "t -.�� �:G.f f;a -.._� p� e.�('"''' ruff!
Vents
20 1 '"
5 '
30'
65'
Vents , 30'
75' A1t.B.M.
B.M.
r
Wisconsin Departnient of Commerce SOIL EVALUATION REPORT Page l of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
c«,r,ty
Attach complete site plan on paper not less than 8112 x 11 inches in size. Plan must
include. but not Imited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope. scale or dimensions. north ar row, and location and distance to nearest road. Z -- - 115-
Please print all Information. by Date
Personal Wannation you pro` 4s troy be used for seoondaty purposes (Privacy Low. s. 15.04 (1) (m))- 2 d
Properly Owner Property Location
Govt. Lot — 1/4 1/4 T ON R E W
131 el�ij, � � � (
Property Owner's Matting Add re Lot # Block # Subd. Name or CSM#
City State k Zip Code Phone Number ❑ cit diage Town Nearest Road
S a,' (
New Constriction r*W f Number of bedrooms Code derived design flow rate GPD
❑ Replacement ❑ Public or rcial - Describe: - -_ -- --
Parent nuts" V � Flood Plain eievation if applicable _ �' 7 R
Genera comments -e, l %� J ; 1 � fob . t%
J
f Pit Ground sturiace elev. R. Depth b limiting factor in.
Soil Rate
Had= Depth Dwrli wd Color Redox Description Texture Struck" Consistence Boundary Roots GPDff
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Efl#1 'Eff#2
Boring # �/
® pi Ground surface elev. -� ft. Depth to limiting factor `fin
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
r-f/ l
2 i ' 3 4(
Effluent #1 = BOD > 30 < < 220 mg/L and TSS >30 150 ' Effluent #2 = BOD < 30 mg/L and TSS < 30 nglL
CST �� p - - re CST Number
2� G
Address
_ Date Evaluation conducted Telephone Number
Property tanner Parcel 10 # Page of
r3 Bonng # Bonng
Pit Ground surface elev t ft. Depth b factor in. Rate
Horizon Depth Dominant Color Redox Description Texture Stnxttae Consistence Boundary Roots GPD/fF
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •EB#1 •Eff#2
rz -a �--- -- G -
f- 2,
h
F sofkv # [] Boring
❑ Pit Ground surface elev. ft. Depth to lirniting factor in. Sod Application Rate
Horizon Depth Dominant Color Redox Description Texhue Str Consistence Boundary Roots GPD/fF
im Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Ef1#1 I 'Eff#2
I
F Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to Nmiting 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 nxyL and TSS >30 < 150 mgA- ' Effluent #2 = BOD < 30 mgA- and TSS < 30 mg1L
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.
seo4330(P 6W)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
-- INSPECTION REPORT Sanitary Permit No: 405159 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:
P.C. Collova Builders, Inc. I Richmond Township 026 - 1135 -15 -000
CST BM Elev: Insp. BM Elev: BM Description:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe
Holding Bot. System
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
Model Number
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION Type Of System: CHA T OR
Model Number:
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
[] Yes ] No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 1411 143rd St New Richmond, Wt 54017 (SE 1/4 SW 1/4 24 T30N R18W) Evergreen Overlook Lot 15 Parcel No: 24.30.18.945
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? es No
Re ', Y - - - - - -- -- - II '
q � f ,� 1
Use other side for additional information. __ -- -
Date Insepctor's Signature Cert. No.
SBD -6710 (R.3/97)
Safety and Buildings Division County !_
201 W. Washington Ave.. P.O. Box 7162 'I
,�' c' na,� Madison. WI 53707 - 7162 Site Address
Department of Commerce -Y u -0 z- 4 43 4;4- .
Sanitary Permit Application S an it ar y �Number
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ❑ Cheek if Revision
ma be used for Law, s15. i m
L Application Information - Please Print All Information State Plan I.D. Number
Property is Name Number (2 • 9
113 Is'-fto
Property O wner ' s Unil S Address 002 Location
(') ! j S7. CROI
R R ',f ut1 "; T tE
City, State Zip Code fN OOFFICE Lt r umber
Subdivision Name CSM Number
H. Type of Building (check all that apply) ` P 41 s KA' P ""'S • OCity
7" r 2 Famti1y Dwelling - Number of Bedrooms u i
❑ PttblicJCommercial - Describe Use
owrtship
❑ State Owned Nearest
z 3 43.75 - tom �� r
111. Type of Permit: (Check only one box on line A (numbering scheme for in plate Line B if applicable)
A 2 ❑ Replacement System 3 11 Replacement of 6 ❑ Addition m For Comity use
stem Tank Only Existing Sysu em
B. O Check if Sanitary Permit Previously Issued Permit Number Date Issued
IV. Type of Permit: (Check all that apply)(numbering scheme is for internal me)
on - died In -Grwmd 210 Monad 47 ❑ Sand Filter 50 ❑ Constructed wetland
O Pressurized In -Ground 410 Bolding Tank 48 O Single Pass 51 ❑ Drip Line
45 ❑ As -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ ating 30 ❑ Other
V. Area Information:
Design Flow (gpd) Dispersal Area Dispersal Ana Soil Application Percolation Rate System Elevation Final Grace
Required Proposed Rate(Gals./Days/Sq.FL) (Min.Aach) 0 Elevation
�� � tl� � o
Yf 0
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Tanks Concrete Constructed Glass
New Exisft
Tanks Tanks
Septic or Holding Tank
Doft Chamber
VII. Resin onsibllity Sffi - I, the responah7sility for instsBation of the POWTS Shown on the attached plans.
Nam (Print) Plumber's MP/1�RS N ber Business Phone Number
Plumber's Address (Street, City, State, ? f
vm�. me t use Onl VII
C1 Disapproved Sanitary Permit Fee (includes Groundwater Date Ensued Issuing Agent Signature (No Stamps)
Surcharge Fee) 'dD
❑ Owner Given Initial Adverse �-
Determination �• n_ n - /
I7C. Choi` *` S�provaURessons for isapprovai , Kus-t 0 `Gt+ - G�4o ( •
ftF� 1�V�+UrO�- A •
TU ff�� tom
`
Attach phum (to the C muty only) for the syskm oa papas not Lw dm Sla X 11 caches In she
PLO PLAN
PROJECT P.C. CoNova Bldrs. Inc DRESS P.O. Box 489 Somerset Wi 54025
SE 1/4 SW 1 /4s 24 /T 30 8 TOWN Richmond COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 6/6/02 BEDROOM 3
CONVENTIONAL )00( IN- GROUND SSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 933 # of chambers 30
BENCHMARK V.R.P. Top of 1.5 Pipe ASSUME ELEVATION 100' Filter Zabel A -100
[:]BOREHOLE O WELL 'H. R. P. Same as Benchmark
B.M #2
SYSTEM ELEVATION 95.0
290' Property Line B.M. #1
Please note: Soil tester indicates a 15'
loamy sand on this site, the system Vents 30'
is to be installed by using �. 0 ° -4
a .5 loading rate for a sandy loam 2-3' X 94' Cells with >3' Spacing
Li 5'
90' B - 3 0'
Pro 3
Bedroom
House
10' B - 2
T 20 B -5
a
1~
143rd st J6'Long nt o
Standard Infiltrator
Leaching Chamber °`
with 31.1 ft2 of Area
Gr
34" ade at System Elevation
Plans Designed Using
Conventional Powts
Manual Version 2.0
Road
PL01 PLAN
PROJECT P.C. Collova Bldrs. Inc DRESS P.O. Box 489 Somerset Wi 54025
SE 1/4 SW 1i4s 24 iT 30 8 TOWN Richmond COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 6/6/02 BEDROOM 3
CONVENTIONAL XXX IN-GROUNDIPUSSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 933 # of chambers 30
IL BENCHMARK V.R.P. Top of 1.5" Pipe ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL - H.R.P Same as Benchmark
B.M #2
SYSTEM ELEVATION 95.0
290' Property Line B.M. #1
Please note: Soil tester indicates a 15'
loamy sand on this site, the system Vents 30'
is to be installed by using 0' -4
a .5 loading rate for a sandy loam 2 -3 X 94 Cells with >3 Spacing
5'
90' B -3 0'
Pro 3
Bedroom
House
10' B -2
T 20 B -5
a�
a
143rd st Vent o
ct
>6 » Standard Infiltrator ;
of Cover Leaching Chamber
with 31.1 ft2 of Area
6' Long 12"
Grade at System Elevation
34 71
Plans Designed Using
Conventional Powts
Manual Version 2.0
Road
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of
Bureau of integrated Services in accordance with Comm 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - Please t : a�l_i'€drmatid&:. Re iewed by Date
Personal information you provide maybe used for sec dt4; piirposes vacy Law, s. tS.Oq (t) (m)). Z00
Property Owner Property Location
r � Cott VG Go . Lot 1/4C 1 /4,SZ y T3G ,N,R E (or�
Property Owners Mailing Address Block# Subd. Name or CSM#
`It�S l�4 1� 1 G Gfx Eve!f 'Pen overlcoK
City State Zip Code ,` 'Phone N� rjFr�E ty Nearest Road
I f" city Village � Town
l� LA cl`�Cn � U I CQ (.'C{ )5z{�j 5�'�. i `o L t.'Z k VVL-cr .mot d 0C.-IL
v r
[� New Construction Use: Whesidential / Number of bedrooms / Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow gpd ^ Recommended design loading rate bed, gpd/ft trench, gpd/f1
Absorption area required _ bed, � r , y trenc / h, ft Maximum design loading rate T 7 bed, gpd/ft gpd/ft
Recommended infiltration surface elevation(s) 9G ' ! it (as referred to site plan benchmark)
Additional design/site considerations 1 e ?�_"e �Z
Parent material no S Flood plain elevation, if applicable it/ 44 ft
S = Suitable for system Conventional Mound In- Ground Pressure I AT -Grade System in Fill Holding Tank
U = Unsuitable for system S❑ U YS ❑ U [As 1:1 U S❑ U ❑ S U ❑ S
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
°I
I 1 x 1 4) r3) 7- — S, I Z 0 rr r C5 1 v 5 5
L r� -3e 10 iq 5,1 2 rr�k r7 T c5 — j� •r
Ground 3 l r q j 1p LS YY� r i >T7 C S , u a
elev.
Depth to
limiting QS •o
factor 6y 92 `y
C O in.
Remarks:
Boring #
Z rnc'bk fn �r c5
Z 2 12 -29 lb ( — q 5 I 2no able IY r
Ground
elev.
• yf g�, 2
Depth to
limiting
factor
9(-P in. Remarks:
CST Name (Please Print) Si n Telephone No.
jc�� urrlCJcer' �r )1�f 7- `
Address Date CST Number
21 13 8b S6M e CJ _ vZs -/ UU 2 5 3 309
r
SOIL DESCRIPTION REPORT
PROPERTY OWNER Page Z- of
PARCEL I.D.# Lo j 5 .
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
SIC-
Li C
Ground 3 Lil L S m ef 5 8
elev.
9 19 Z ft.
Depth to
limiting
factor i
yyyy'' in.
Remarks:
Boring #
r I b 5 Z,- iyy� CIS v ;
Zf it GS _ S (o
Ground
elev.
8 9.82 ft.
Depth to
limiting
factor
tin.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots PD /112
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # ( Z f 2 I
3 �m I Icy — L 5 1 rt 5 rn c s — - 7 '
.-,
Ground ,
elev.
l02 ft.
Depth to
limiting ;
factor
100 in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R.9/98)
3
PAGE_OF f
NAME �nUG, LOT# S LEGAL DESCRIPTIONSE `/+Sw' /, SLYT ?,O N R )Y E (or -
SCALE: 1 "= &Y
BM I ELEVATION «U • U
BM 1 DESCRIPTION } o� Z pyc 2 4 1-0
BM 2 ELEVATION
BM 2 DESCRIPTION vlo o - 2 ` ' P LJ/ ) a.-f-1
SYSTEM ELEVATION 1 ? & Z
ALTERNATE ELEVATION K
I
CONTOUR ELEVATION if/jw
1
p ly, of
.�
SIGNATURE DATE
iiAaintenance and Contingency Plan for a Septic System
Maintenance Plan
1. Septic Tank is to be pumped once every 3 years.
2. Effluent filter is to be caned once a year. Please note: a larger filter is being installed in
order to extend the maintenance interval of the filter.
3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of
the cells.
4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system.
5. The owner agrees to save this plan.
6. Do not plant Vees nor park nor drive over system.
7. Watershed is to be diverted away from system.
8. Discharge into system is not exceed those required as per Comm. 83
Contingency Plan
1. If system fails, cebermine cause of failure, use alternate area and install new system or
install system at a lower elevation.
2 Replace any other failing components as needed.
Plumber: Shaun Bird 715- 246 -4516
Shaun Bird #226900
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner /Buyer �. (� I I cVA 6 1 � tt S
Mailing Address LJ '[ (� I J
Pro perty Address �- 149 y -
(Verification required from Planning Department for new construction)
City /Statq L)eQ P: cAy,�rn� 4 Parcel Identification Number
LEGAL DESCRIPTION Property Location c�� ' /, ' /, Sec., T�N - R�W, Town of &&ffl
Subdivision oux 4 15
Certifcd Survey Map it , Volume , Page It
Warranty Deed it Z3 35 Volumc _ ! Sr z Page It
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 Dcpattuicnt a ccrtifrcalion form, signed by the owner and by a
master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewatcrdisposal 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 flit 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 our septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of e ree yea piration e.
6'� /O ,7 -
NA OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statenreats on this form are true to the best of my (our) kmawledge. I (we) am (are) the owncr(s) of
the propert cscribed above, by virtue of a warranty deed recorded in Register of Deeds Office.
GNA'IURI: OF APPLICANT DATE
* * * * ** Any information that is nris- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * **
** Include wifar this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey snap if reference is made in the warranty decd
1)9,'03;00* TLIE 11:31 FAY 713 386 4687 REGI91'ER OF DEEDS tonal
,- • 151z►uE 242 10
S1'.1TE BAIL OF ulL4CON5W FOkw: =.- 19ip �,'
DommerJ Nunoc( NVARRANTY DEED 4 t ^� lX u� t
I
This Dmd, made bcoveae 8 tav en J. Dterkk S-f" elikl
- c�i ltd
fi�p ply
t fr
j Orantur. and P Collova BuUdcri, Inc., a Miantrota Corporativa R f E � p,
Graattao.
Grantor, fir a voluuble comideratloo, Wnvays to Grantee the
followiry dcS;rl6:d real estate In SG Cray County,
Slott of Wisconsin (If more spset k needed, plaut ellach addendum):
'1 osts
110 Southr Qwuur of the $uu:hwest Qtmrter ISE ''A of SW %) of 3rction NstmaV00 d Ruulsl�Edle� . [
24 and that Iwrt of Iha N M of 8ccilats 25, Iylag Nort))erly of 140th Avcnuc ` ", ${t j� 0{ to
� 1 I sr
ALL In Township 50N 8 , RAPS* 16 Wr 6 St. CrOIk Catm SOtn -it 1
g ry
EXCEPT Port of N Li of Section 23 dnvtXscd as follows: ,; W4consln, Commcncing et N ' L $t/ 4�? * '� Y
V. corner of void Section 23i thcace North 69 dcgraa 06 rairwlts West on
North line of seld BaNloa 351 6x3 taxi, thcneo South 01 degree 21 minutes
Nast 1333 f eet, $h %U South 69 degre<s 06 minutes Eve 1290 feet; thence 26-1071 -40-CM dt 25 Ion- TO - oro
Nord I degron 23 miruueu E 1351 foot W Mid NocUt line, tbmao Nara: d9
Parent ldcnUnealml Nam* (PIN)
dalrea; 061nla:2101 Wcst an said N lino 691 feat to Plod of Beginning. St TIL it Dal holxatatd prol"ll,
Croix County. Wipccmirt. 01) (h sot)
Exceptions to werruties: P taement_, teanicticra end dgltU- uf•Nay of record, Irany.
Dated this ) 2144, day or his 2400
i
a _ a Stevan . Derrick
AUTHENTICATION 4CKNOWLEDCMENT
Signattre(s) Su \vn J. Derrick STATE OF WISCONSIN )
KA- Count). )
Ruthentionlod Ih c day of jtay �00G
__.ECiLts_ Poraon.liy crone barure me Wj
_. _
the above aaatcd
TITLE- MEMBER STATE BA'k OF WISCONSIN
(If eat. to me known to bo the pp ersoa{s) who etr4tutxd the forugoing
- -• lnttnlmont and ae{toowkJged UW La,
1111ti INSTRUMENT WAS DRUrl'kill Uy
wltoro• Krirllur Qel ►ad Nct Public. State of Wisconsiu
), { t:an miw.i�ptt Is pomlanerst. (if Dot, stoic cxpiraUwl duo:
(S51IM1 res m+.v be gtur.entleWcj or ecl;poatcdccd Balh tie not rucrsaar).) ,)
Nsm:scrpersoos signing 11 kyMast ktyptdctpr6ucJ6rlou uxlr rl ,tattle. wa.n.w.,harma..rC�w+`r. ►.r
W A88ANTY DEED 47ATE &A it Of WDCO.qatN �sass^ott
fault Na 2. It"
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