HomeMy WebLinkAbout026-1081-60-200 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County
Safety and43uildings Division $t. Croix
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanita's :
Personal information you provice may be used for secondary purposes [Privacy Law,*. 15.04 (1)(m)).
qp4 de jblM0a ❑City ❑ v �V`h�apff1'ownsh p State Plan ID No
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.:
uo .01 cx� . a r A v� -• /q� /— & —.w a
TANK INFORMATION ELEVATION DATA O.-Jo, le' Yzj
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic BA&HEildrk oaf, ab r
Dosing
Aeration Bldg. Sewer
Holding St /Ht Inlet .S� 9fe•5S�
TAN SETBACK INFORMATION St/ Ht Outlet $ . � 96•zs'
TANK TO P/ L WELL BLDG. Air ntake ROAD Dt Inlet
Septic 3 b / + - 26 �^ NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System q.Rd I
•$n •2n
P MP / SIPHON INFORMATI Ina
Ma ufacturer mand S-r; ( � �- 3S %,Qp'
Mode umW PM
}. DH ft Friction System TDH Ft
H r oss
b'� Forcemain Length Dld. Dist. To Well 2Y
SOIL ABSORPTION SYSTEM
Bil3 TRENCH Width Len th I f Trenches PIT Q p
No. Of Pits Inside Dia. L i qu id De
IMEN 3 r , 2 DIMEN I N
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manuacturer: ^ <; L � c i
SETBACK CHAMBER -
INFORMATION Type Of
System: C �J Z S t OR UNIT° e Number:
-' `
DISTRIBLITIO YSTEM
Header/ an Distribution Pipes) x ze x Hole pacing Vent To Air Intake
length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depttlfil ecti0 #I •Seedjd / Sodded In e #2: /
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
CA)MMW*TSl1p8cil4 @V&Axmnvgpjk Ns,F�6hmpr6Wt, M917 (NW 1/4 NE 1/4 8 T30N R18W) - -Lot 4
1.) Alt BM Description = 51
2.) Bldg sewer length = z.4 •o' �,..
- amount of cover = 2'f"+ sc� •( C4 '-
3)
s, c S ►. ` . f a P'.. -k -� � _
P!I� required? Yes
q fff No F77R±1
Use other side for additional information. B 11 0
SBD -6710 (R.3/97) Date Inspector's Signature Cert No.
Jl3 �• g3SZ D
�fl Sanitary Permit Application Saf & B uildings Division
In accord with Comm 93.2 1, Wis, Adm. Code 201 W. Washington Ave.
1 0
sconSin See reverse side fbr instructions for completing this application PO Box 7342
W partment of CornmWee Personal information you provide may be used for secondary purposes Madison, WI 33707.7342
(Privacy Law, s. 15.04(1Xm)] (Submit completed form to county if not
Attach comp lets plans to the county c only for s the stern, on paper not lass an 8-1/2 x 11 Inches in size, state owned,
Q � �f Number 1 ision to previous sp i on an um
` "
lla on Inform on - lease rint af! Info , Lacatio�:
►cputy Ow
a A/ nte 1 A
) Y f
U)14 l5 114, O 76 ,N, R F
s Adam , t Block Num
Slue
�• p ° '! `� 5 t x N Subdivisloin'Nam or CSM
N`
3/s tn
I FIL or 2 F
� of Family Dwelling -�No of Bedrooms . ��5 ,��J „S_y,. O Village
(doscrlbe ttae) :_ own of
13 State-owned
�� pp Nearest Roxy [/
2 / x b0•� �—��cL � r ax wn a
L o! rm t: (Check onl one box on line A. Check box on line B if licable)
A) 1. lacetrtettt eplacement o 4. S. ditty to
S S atom Tank Only 13 System
Perm um i ssue d O A Seri Pernnit was reviousl issued
• TYPQ Of tem: (Check all that apply) —!�
n- preasuritbd 1n- Sround ❑ Mound V 0 Sand Fitter ' ❑ Constructed Wetland
O Pressuri Inipumd ❑ Bolding Tank 0 Single Pass 13 Drip Line
D Aerobic Treatment Unit 13 Recirculatin ...O Other:
rssiUTreatment Area Information: S /�
I. Vesion ow aired al Aran per Area 4, pplicuion erco anon System ev Fin
3 � � Prop � � Rate (Ga1 sJdey /sq. R.) (MiaJinoh) Elevation
VIL 9s.� 9s
Tank spacity in Total # of ?vfanufacturcr Prefab Site tee Fiber - laatle
Iatormatlon Gallons Gallons Tanks Coe- Con- glass
Tanks Tanks Crete swded
VZIL Rai illty Statement
1, the undorsi ed, assume onsiblli for installation of the POWTS shown on the attached lens.
Flw
A sate m um ature no stamps): o.
S pass Pho ne um
w e r
�a -6) o 6 '71's -C:>1 � s�
e Hy, t
P Q A ae, ip Code)
IX. aaty/D"mriment U" Only S
Approved p �DProv tuy emus Fee (Includes water ssue
Ownw Given Initial Adverse Swohgr;e F�� Be"t o
Deterrainedott ` m Z S `
X. Condkions o A royal /Reasoas for Disapproval:
M1
C.o+Qsl, /'C4tKWKCes .
o.S AO_ tA^ S r� r�e -
SBD.6398 (R. 07t06) -
PLOT LAN
PROJECT Josh Faanan A DRESS 1152 140th Ave New Richmond Wi 54017
NW 1/4 NE 1 /4s 28 /T 30 18 W TOWN Richmond COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE5 /19/01 BEDROOM 3
CONVENTIONAL XXX IN- GROUND LASSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE 1.2 ABSORPTION AREA 377 # of chambers 22
BENCHMARK V.R.P. Ground elevation at wood post ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL *H. R. P. Same as Benchmark -
SYSTEM ELEVATION 95.3/95.0
B.M. #2
Property Line
2 -3' X 69' Cells
45' _ with >3' Spacing Plans Designed Using
0' -►LJ Conventional Powts
Vents Manual Version 2.0
ents
30'
40'
,
B-1 90 B -2 1 Please note: System
6% i elevation is to be set at 4'
Slope T below surface elevation
10'
Vent Pro 3
> 12 Sidewinder High Bedroom m
Ca Leaching
of Cover Chamber
16"
6 Long 34"
Grade at System Elevation
0
140th Ave
PLOT LAN
PROJECT Josh Faanan AA DRESS 1152 140th Ave New Richmond Wi 54017
NW 1 / 4 NE 1 /4 S 28 /T 30 18 W TOWN Richmond COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE5/19/01 BEDROOM 3
CONVENTIONAL XXX IN- GROUND SSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE 1.2 ABSORPTION AREA 377 # of chambers 22
BENCHMARK V.R.P. Ground elevation at wood post ASSUME ELEVATION 100° Filter Zabel A -100
❑ BOREHOLE O WELL *H. R. P. Same as Benchmark
SYSTEM ELEVATION 95.3/95.0
B.M. #2
Property Line
2 -3' X 69' Cells
45 _ ,B — with >3' Spacing Plans Designed Using
Conventional Powts
ents
0 Vents Manual Version 2.0
30'
40'
B -1 B-2 10 Please note: System
6% i
elevation is to be set at 4'
Slope T below surface elevation
10'
Vent Pro 3
Sidewinder High Bedroom
of Cover Capacity Leaching House
Chamber
6' Long 16"
a Grade at System Elevation
34"
0
9t
140th Ave
Wisconsin fit of commerce SOIL EVALUATION REPORT Page I of - L
Divis7`s afety and Buildings
in accordance with Comm 85, Wis. Adm. Code County
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. R by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 2.S 2W
Property Owner Property Location
Govt Lot A l" 1/4 A/ (= 1/4 S T 3,0 N R E (oro
Property Owner's Mailing Addre Lot # Block # Subd. Name or CS S t , �� J S-
city State Zip Code Phone Number ❑ City ❑ Village [RTown Nearest Road
ififw �,`c Nraonok wl S- Ol ( Zy` - S31S I,� , I'W'" 6�
New Construction Use: ® Residential / Number of bedrooms 3 Code derived design flow rate ySd GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material O U Flood Plain elevation if applicab 53 ft.
General comments .Sysfem 2( top q'( 3 Ga wtr- `I S' ?�
and recommendations: 4 L c (� • Sap 4S z O 4 0 w
-Z F
❑ Boring
F I Boring # ® Pit Ground surface elev. ft Depth to limiting factor O U nJ , 1
Z;0 tion Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistelrce. Boundary ` GPD/(1?
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. a ;; *Eff#1 *Eff#2
6 - 1 S!r ;�ma r L v� -5
z
1 10 - 16 r /4 — Sc -fir cS - . y
3 AQ - Ly iv 3r/6 r A I C — .7 I. Z
N 211 /01 a / - rhs - .7 / z
zbi - 15 -,
Sb •Y 92• Y
F�] Boring # ❑ Boring
® Pit Ground surface elev. ft Depth to limiting factor i n. 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. *EffM I *Eff#2
-3 r4 S
2� V �
Z
5 A 8 -11 Co ,,�,� l - - /.
9. 3
/
* Effluent #1 = SOD > 30 < 220 mg/L and TSS >30 < 150 mg/L " Effluent #2 = BOD < 30 mg/L and TSS < 30 mg1L
CST Name (Please Print) ---signature CST Number
25
Address Date Evaluation Conducted Telephone Number
2 - 2 12 + 51-40 _ 1-2 -{ 4 clid) Zq I-
Property Owner h a Al L- Parcel ID # Page Z of
F—sl Boring # ❑ Boring
Pit Ground surface Slay. 8. Depth to limiting factor / in. Appl ication Rate
Horizon Depth Dominant Color Redox Description Texture
Structure Consistence Boundary Roots GPDIEP
in. Munsell Qu. Sz. Copt Color Gr. Sz. Sh. E ff#1 Eff#2
O -1 Z 16 VZ G S /u� • S
3 16 (NP
`4 G -fog /o ►���� r� m t —
F-1 # Boring
❑g
❑Pit Ground surface Slay. R Depth to limiting factor in. Sol Appl ication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDff
In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. `Eff#1 `Eff#2
F � ❑
Ground surface surface Ste' ft. Depth limiting factor in.
1:1 pit
Soti Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `EfM `Eff#2
` Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 1 160 mglL ` Effluent #2 = BOD, < 30 mg1L and TSS c 30 mg/.
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 60 &264 -8777.
SBD8330 (R.07l00)
PAGE 3 OF_�
NAME LOT# V LEGAL DESCRIPTIONAW ' /<tF ' /e Szrr T-50 N Rl g E (or)(W)
SCALE: F= 0 r
lBM 1 ELEVATION /60 -0
BM 1 DESCRIPTION mos e
V sq "waod Q a5 { - j
BM 2 ELEVATION Q s 1S Z
BM 2 DESCRIPTION - f a P G U • S . ;u ru *-y work r`
SYSTEM ELEVATION -lop , - c- 96.30 L� 15 7v
ALTERNATE ELEVATION ,6 P dY, &O
ONTO ELEVATION
ti
0
g•3 n
�ao
SIGNATURE
DATE
i
yam q,'^e
L
Maintenance and Contingency Plan for a Septic System
Maintenance Plan
1. Septic Tank is to be pumped once every 3 years.
2. Effluent filter is to be cleaned once a year. Please note: a larger 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 trees nor park nor drive over system.
7. Watershed is to be diverted away from system.
8. Discharge into system is not exceed those required as per Comm. 83
Contingency Plan
1. If system fails, determine cause of failure, use alternate area and install new system or
install system at a lower elevation.
2. Replace any other failing components as needed.
Plumber: Shaun Bird 715 - 246 -4516
?t' rv, - bU �J - V � - - S - 7
S4 , C
Shaun Bird #2 6 0
1
ST CROIX COUNTY
SEPTIC TANK MA'[MNANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
I
Owner/Buyer n a t✓
Mailing Address O tt r 1 a
Property Address
(Verification required from Planning Department for new construction
City /State Parcel Identification Number
LEGAL DESCRIPTION
Property Location /., AA61 -, Sec, �. T &� N -R/1 Town of X.!
Subdivision — Lot #
Certified Survey Map # ��/ y , Volume Page # � .
c,
Warranty Deed # �' , Volume Page /
Spec house ❑ ye
s4 no Lot lines identi 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 fumcdon 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, restrictedplumber or a licensed pumper verifying that (l) the ou -site wastewater disposal system
is in proper operating condition andlor (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 Zoning Office within. 30
days of the three year expiration date.
SIG TURF OF APPLIOANT DATE
OWNER .CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. l (we) am (are) the owner(s) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
S i19i4
SIOYATLTRE OF AiSPLICANT DATE
Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.
Include with 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
t 1615 516
STATE BAR OF WISCONSIN FORM 3 - 1999 6'f 24 S T
QUIT CLAIM DEED KATHLEEN H. WALSH
Document Number REGISTER OF DEEDS
ST. CROIX CO., WI
This Deed, made between Richard Fagnan and Ann Fagnan, RECEIVED FOR RECORD
husband and wife
04 - 10 -2001 3:00 PM
_ QUIT CLAIM DEED
Grantor, and Joshua R. Fagnan, a single person EXEMPT If 8
CRY COPY FEE:
COPY FEE:
frR 40 FEE: 10.00
Grantee. — PAGES: I
Grantor quit claims to Grantee the following described real estate in
St. Croix County, State of Wisconsin (if more space is
needed, please attach addendum):
Recording Area
9 Lot 4 f Certified Survey Map recorded in Volume 15, P ea�v 4055 b eing part of the Name and Return Address
/. of the NE % of Section 28, T30N, RTM wn of Richmond, St. Croix
County, Wisconsin, being Lot I of Certified Survey Map recorded in Volume 1, 4�h� / / Qv✓7ty.-)
Page 274. 1 15 -q A/6 /—A SUE
/l- A*r 1,7 cnd� vim'Z Syc� /'
026- 1081 -60 -000
Parcel Identification Number (PIN)
This is not homestead property.
Together with all appurtenant rights, title and interests. 0f) (is not)
Dated this day of April 2001
+
+ Richard Fagnan
i
+ Ann Fagnan
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
) ss.
�- . r-C) !X —__ County )
authenticated this day of � rh
Personally came before me this day of
April , 2001 the above named
+ Richard Fagnan and Ann Fagnan, husband and wife
TIT (f n EMBER STATE BAR OF WISCONSIN to me known to be the person(s) who executed the foregoing
authorized by § 706.06, Wis. Stats.)
instrum t and ack wled a the same.
Gu [�
THIS INSTRUMENT WAS DRAFTED BY + FAY �STRFNKF
Attorney Kristina Ogland Notary Public, State
Hudson, N
54 16 Rgeyshbkl State of Wisconsin
My Commission is r�rmanent. (If not, state expirat
(Signatures may be authenticated or acknowledged. Both are not necessary.) // � ^��t
+ Names orpersons signing in any capacity must be typed or printed below their signature. Inrcrmatw PrOwsipnals Company, Fond du Lao, W1
STATE BAR OF WISCONSIN 800-655 - 2021
QUIT CLAIM DEED FORM No. 3- 1999
SSOtr abed SVIOA
n
? S
a z
zj m ' ° w O
Z W °z � W m N N
Z � W z 3 it II
r0 ~�0 8
o o Q � 2 000 cn N
Q - 2 (1) W Zdx W
� 0 Q S
Z
zm
o
LL 0 ui ,_z
Z
O Q a °�& z W
ct
LIJ o
LL i? yz 0000 V
3 p W o W N
W � %.-. �FT p p
!a W p7_pam �U O
J w O 3 S �d���� �Q 0 O N
L z g I — �a�1n QE C77d z J
,e9•e90 nlwaoaoba • / �
N N Y Z 8 � 33b3g e 61 L bze �• // AO'oEE Lb bb Ak
Go avi
N 0 - .. Q $" o; mil L ` N cr
23
LL LL 0
o 99'o +e W 0
cl� 89'9ZZ .• �' L°S
W �B +N nn.ss,sa�oN
p� z r, `ti d!�
W �; o
W z w o Z y� ? "
�C o I
E U
(t� p Uzi
MM L, + m jenad e
o W 2 N ® ~ p � 57C o ; 11 Dawom 301 1 )I O 4
r ZO'bZE Sb SE w 2 (� � w
cA 0 f w
i.
oC -
Z � z �LY'a�63.L�wOZ.00N
W 0 + p ¢ L6Z'89C 3�Ah,9Z.00N) / aaulm�..4 - ! -z Su{uueid
W ',,19 ¢ N 3Nn b/L Hinos - HIUON A.LNR 0 XIoLl7 - J �s _4
= y W O O
() x U --- -------------------------- .--------------------
LL cc i z po
a a w t7 O N
W
Z V^ �XLLam �� o g � w I
cm mo o '- z °z w c§ 3 Y Q
W 0 (( � z a � z m a w x 2 i ¢ C6 g U w 'm
V U a OZ¢Z W zw d ¢ a O C7
'v g z ~
Jo N r c v it m J cOi x $ ¢ a LU
a°c g o 0
a 0) O n to z uj
m
SU19.88N 8V38 01 03WfISSV'ez O
N d0 3N 3133 3 3NIE H1NON
3HI 0 03O V
3Hl 1N3l1333d FiV SE)NIkfd38 � I
t
4 � ,
I