HomeMy WebLinkAbout026-1141-18-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building - Division Sanitary Permit No:
INSPECTION REPORT 404929 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- 1141 -18 -000
CST BM Elev: Insp. BM Elev: BM Description:
0D.0 lc,fl.�' C 9t - lSw. ( =T&r Pdc
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark • i� ,
1. s l c1so d Y y (10l;-34 .7
Dosing Alt. BM LD'a p ,4Z`
Aeration Bldg. Sewer
6j.1 53 `Ez 98. �
Holding St/Ht Inlet u
S'S y. 8'S • 3
St/Ht Outlet tf
TANK SETBACK INFORMATION b .I� •5f
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic ti 2 S I Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe
Holding Bot. System
PUMP /SIPHON INFORMATION Final Grade
Manufacturer Demand St Cover «
GPM �3 h OZ • /
Model Nu ber
TDH Lift ction LosLila System Head TDH Ft .S . S.� 3+
Force Length Dist. to Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. L,quid Depth.
DIMENSIONS 3
SETBACK SYSTEM TO oI P/L BLDG WELL LAKE /STREAM LEACHING Manufac r /I
INFORMATION CHAMBER OR
Type Of stem: f i UNIT Model Nu b r: ��
I �S ��oy -
DISTRIBUTION SYSTEM j! 6. ( /I
Header /Manifold j � Distribution x Hole Size Ix Hole Spacin Vent to Air Intake
S Pipe(s)
Length - LengjL Di Spacing ��,
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded /Sodded j xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil Yes No es No
COMMENTS: (Include c akriscreoenci e t n #1: 1 /�/ � L Inspection #2:
Location: 1192 1 st Av V) Duck Pond E cape Lot 18 Parcel No: 33.30.18.102
1.) Alt BM Description s
2.) Idg sewer length = Z p ` 9S, &Y
- amount of cover = 36 "�-, �jS •�
fs A0
-
Plan revision Required. Yes No j J
Use other side for additional information.
I 21 '?ao2'. �I
Date Insepctors Signature Cent No
SBD -6710 (R.3/97)
Safety and Buildings Division County /
201 W. Washington Ave., P.O. Box 7162 1. �)
*6consin Madison, WI 53707 - 7162 Site Address
Department of Commerce
1192 1z � A%/6
Sanitary Permit Application Sanitary Permit Nu�`jmber
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide [I Check if Revision
may be used for secondary ses Privacy Law, sl5. 1 (m
I. Application Information - Please Print All Information State Plan I.D I.D. N�
Property Owner's Name 2 O �----- Parcel Number . 33. 3D • 1 Ou
c o t .acv L>�✓ OZ6
Property Owner's Mailing Address A- i (� _Property Location
54: S T N, R L
City, State Zip Code Phone Number �;) Lo Imber Block Number
n 7 + Spbdit ision Name CSM Number
1 g
U. Type of Building (check all that apply) icy
or 2 Family Dwelling - Number of Bedrooms ❑Village
❑ Public /Commercial - Describe Use ownship
❑ State Owned Nearest Road
III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable)
A For County use
1 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to
y m m Tank Onl Exis ' System
B. ❑ Check if Sanitary Permit Previously Issued
Permit Number Date Issued
IV. Type of permit: (Check all that apply)(m mbering scheme is for internal use) - *
414on - Pressurized In- Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland
22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line
45 11 At-Grade 46 ❑ Aerobic Treatment Tjwt 49 0 . ula N 30 ❑ Other -Z, a'G L *Ott 3.-� .3e/
V. D' rsal/Treatment Area Information: o • - e`+ �4
Design Flow (gpd) Dispersal Area Dispersal Area oil 1 cation Perco lion Rate SysteElegation Final Grade
Required Proposed Rate(Gals./ Days /Sq.Ft.) (Min./Inch) JJ Elevation
X5 6Y3 bb 2
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Tanks Concrete Constructed Glass
New I Existing
T Tanks
Septic or Holding Tank _ Gj
Dosing Chamber
VII. Responsibility Statement- I, the undegggried, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print PI s Signature MP/MPRS Number Business Phone Number
2`Zg 0
Plumber's Address (Street, City, State, ! rdW Code)
zw l �,� l.��/
VIII. Count /De artment Use Onl
,Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
Surcharge Fee)
❑ Owner Given Initial Adverser, �-
Determination
Ix. Conditions of Approval/Reasons for Disapproval
tM04`
Attu comp P e or x 11 Jhches in size
SBD -6398 (R. 05101)
PLOT PLAN
PROJECT P.C. Collo Builders Inc. ADDRESS 705 Ctv Rd E Hudson Wi 54016
SE 114 St 1/43 33 /T 30 /R 18 W TOWN Richmond COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 2/26/02 BEDROOM 3
CONVENTIONAL XXX IN -GRO PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 667 # of chambers 3
BENCHMARK V.R.P. Top of 1" PVC Pipe ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
SYSTEM ELEVATION 95.6/95.1/94.6
275' Propert Line
80'
Vent
ALong 611 Sidewinder High
Capacity Leaching Plans Designed Using
Chamber Conventional Powts
Manual Version 2.0
X -
3 4 11 Grade at System Eleva n 4
3%
Slope
M.#2
B- 80'
30'
Vents 30'
Vents
B.M. #1
40
30'
a T
v1 �
30'
a
0
Pro 3
Bedroom
House
121st. Ave
i
PLOT PLAN
PROJECT P.C. Collova Builders Inc. ADDRESS 705 Ctv Rd E Hudson Wi 54016
SE 1/4 SE 1/4s 33 /T 30 /R 18 w TOWN Richmond COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 2 /26/02 BEDROOM 3
CONVENTIONAL X)OC IN -GRO PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 667 # of chambers 39
IL BENCHMARK V.R.P. Top of 1" PVC Pipe ASSUME ELEVATION 100' Fitter Zabel A -100
❑ BOREHOLE O WELL +H.R.P. Same as Benchmark
275' Property Line SYSTEM ELEVATION 95.6/95.1/94.6
80'
Vent
ALo Sidewinder High
Capacity Leaching Plans Designed Using
Chamber Conventional Powts
Manual Version 2.0
6" /,'
3 Grade a t System Elevat n.4
�,
3%
Slope
M. #2
30'
Vents 0'
Vents
B.M. #1
40'
a 30'
o T
kn y
30'
0
Pro 3
Bedroom
House v
IF 121st. Ave
Vftcor� Department of Commerce SOIL EVALUATION REPORT pap l of
* Di�n of Safety and Buildings in accordance with Comm 85, VWs, Adm. Code
count
Attach complete site Plan on Paper not less than 8112 x 11 indM in sine. Plan nd parcel tD.
include, but not Trmited to veybmi and hor¢entat reference � (BM), direction
percent slope, scale or dimensions. north arrow, and location end distance to nearest road. � Date . - + �.� ,.{ �p ,�� ��,y I .. F -any
Pieria Alin aN 1/IIVi���7�YVlh ,
Pemnsi irdormsew you p se
may be ud ra'secondavp (P � s.1b.04 (1)
Location
property Owner a �.�L��� ( or)
Lot t SE 5 �Q E 1/4 114 S T N R I g (
Properly owners Maift Address 1 7 200 t# Brock # Subd. Name or CSWW C�
ST CHOiX
Town Nearest Road
State Code Phone r FF +^ t O � Vd �i Cp �� S ✓
[� New Construction Use. �] Residual / Number of .
Code derived design flow rate e- SO DO GPD
p Replacement ❑ Pubic or conwwdal - y/ 4 R
Parent material d U + Vic, Flood Plain elevation if applicable
General comrtsrits 5 y S 4t s� e I e V• qS S
0
and recommendations. 4t-4 eke V • y 6 56
F-1 I Boring # D Boring factor � in Rate
® Pit Ground surface elev. � O tt Depth to —. Sol
1 Structure Consist roe Boundary Roots GPOW
Hormon Depth Dominant Color Redox Dee�ption *EfW1 *
in. Munsell Qu. Sz. Cont. Color
Stu 2m L� 5
D # ®
pit Ground surface elev. 9 Q C� ft Depth to limiting factor in.
l Rate
Horizon Depth Dominant Redox Description Texture Sirudure Consistence Boundary Ro GPM in. Munseii Qu. S7- Cont. Color Gr. S7- Sh- *Etf#2
b— Z. la '� 2 I v
3_ 32 -7p �D
g O m c s `7 1.2
2 r�r75 k m�' • 9
{.
ar t, S
yz s
Effluent #1 = Btu > 30 ZM mg& and TSS >30 150 mg& ' Event #2 = BCC —` 30 mg& and TW `— 30 mg&
CST Name (Please Print) ��"e C ST Number C{
Address Date Evaluation Gaxtucsed Telephone Number
i
prop" Owner Col 1 D va,- Parcel ID # �f
par 2 Of 3 ,
51 80"
p G round yd ft Depth — in. Soo Rafe
Gnwnd surface �►-
Roofs GPDW
edact oescription Texture Stru Corrtiisfsnoe Boundary
Horizon Depth >�� R Cs7. Sz Sh. *0101 'ER#2
in, Mwrseu tau. Sz Cont COW �� �S , v �" • `�
1p — 5,' I 2�,�.btc GS
3 — 5)i 2 k m�
3 32- 7d I L S 1 mss/ c ur /. Z
L 2— rn b)L re, r S 9
❑ Boring D
# D Pit Ground sudhm elev. fL far in Soul AppIcation Rafe
Horizon Dept D color Redox Description Texture S6uchre ConsMsnoe Boundary Roots GPD/ff=
in. Murusell
chL Sz. Cont. Color Gr. Sz. Sh. `Eff#t 'Eff#2
F—I Boring # O Boring Ground surface elev. ft. Depth to lanuhng factor )n.
pi Soil Rate
Horizon Depth Don*=ft Redox Description Texture Structure Consistence Bouaudary Roots GPD/ll:
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'EMM •Efl#2
I
• Effluent #1= BOD > 30 _< 22o mg& and TSS >30 150 mQ& ' fffAmd t92 = ®DD 5 30 rngIL and TSS 5 3 rng/'
The Department of Commerce is an equal oppmtunitY service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the departmerd at 608"266"3151 or Try 60 9-264 -8777.
SBD03o M07/00)
I
PAGE 3 OF 3
NAME Co k to yc- LOW LEGAL DESCRIPTIONS
SCALE: 1 "= ya
✓ BM I ELEVATION /00 O
BM I DESCRIPTION �op o- ) " pvc
/ BM 2 ELEVATION 9 q, eG .33
BM 2 DESCRIPTION �o� (JUcr P,_ C
SYSTEM ELEVATION
ALTERNATE ELEVATION Sd X
i
CONTOUR ELEVATION q 9-00 3 !J7.00
h}
�
v pc tiwa N
q � � w a--
0
A StA l
q•a°
B -3
DATE
SIGNATUREG�
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 fitter 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
Z
7� Y4J
Shaun Bird #226900
FROM P C COLLOVA BURS, INC PHONE NO. : 715 549 5911 Feb. 01 2001 07:33AM P1
ST CROIX COUN'ry
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer - Ir• C6 10VA g k1 i� N r
Mailing Address , ®
Property Address
(Verification required from Planning Departirrent for new construction)
City/Stato Ue&i ) Y' 1 L tNz Parcel Ideatificalion Number
UGAL DESCRIPT QN
Property Location a(� tY" il Set:. 0 T 3 U N -R t4', Town of \C
Subdivision 1 C� Lot if .
Certified Survev IYMan 11
2
Wamaty Deed 0 1 � `1 J L J I p� Volume I ( O a D Page # tG
Spec: house ❑ yes ❑ no Lot tin- identiGabic 0 y es ❑ no
SYSTEM MAINTENANCE
Improper use rind rnai.UtCwmcc of your scp i system could r+estult in its premature failure to l;andic wastes. Proper maintcnamc
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. what you put into the system
c= affect d= function of the septic tank as a treatment stage in rho waste disposal syucm.
The property owner agrees to submit to St. Croix Zoning Department a certuication form, signed by tht: owner. and by a
P r,1 y Phuuber, mtrictod plumber or a Ikensed pumper verifying drat (1) the on -site wastewaterdisposal system
is in groper operating condition audlor (2) after inspection and pamping (if ne=ssary), the septic tank is less than 1/3 full of sludge.
Vwe, the uadcrsipod have read the above requirements 'Ad agteo to maintain the private sewage disposal system with the standards
tot forth, herein, as set by dw Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
sfnting that your septic system bas been maintaiucd must be completed and returned to the St. Croix County Zoning Office within 30
days of the three ;N ;; a.
4 — 2-- /4 102 —
SIGNATURE OF APPLICANT DATE
ONVNETt CEI2WICATION
I (we) certify that all statements on this form are true to the best of my (cur) knowledge, I (we) ant (arc) flue ownet(s) of
the sOperty described a ove, by virtue of a warranty decd recorded in Register of Deeds Office.
i-'2& 0-;t-
SIGNATURE OF APPLICANT DATE
*04444 Any information that is mis- reprereyted may result in the sanitary permit being revoked by die Zoning Dcpartmcnt. "•'•'
•� Include with this applteattan; a stamped warranty decd from the Register of Deeds omee
a topy of the cartified survey map if reference is made in the warranty deed
I
FROM P C COLLOVA BIERS, INC PHONE NO. : 7 549 5911 Nov. 16 2001 09:40AM P1
YO!..1U20PAUE GU7
STA OAR Of WISCONSIN FORM 2.1991 Cie ,a--cj X a9
WARRANTY DEED REMSTEa lit DEEDS
DoeamtnlN r ST. CFC(TX
This Deal made belwcen Kenneth L Bro Co., . and Kathleen B. gEC FM o.,
)frown, Hushed and Wife
04 -11 -2001 1.43 0
A ANIY 1EEt1
Grantor, and P. C. Collora Bullders, Inc. _ EuE9. 1
COOL fFt;
COPY FEE:
-SAIIM FEE: 12
RM38110 rLcl 10.00
Orawco. USES1a. 1
Qtaalvr,fer s valuable , onsidcration, conveys and warrants to
Orsalee 1ho fallowing descried real Vitale in St. Croix �{lt✓ �G s ��
Counly, State or Wisconsin;
Rccasd Atq
Nan. and 1leeate Allies:
1?X part of SE 1.4 SW 1/4 and SW t/! SE l;4 S ec. 3N3GN -R16W describVt: David J. Estrec.
au rbllows: Lots 1, 2 an Survey d 3 of Certt[cd Suey tap ra ordcd in Vol. 19 of 304 Loclal SL
Cetti9ed Surve • aa• p ace vta a e 3698 as Doc No, 677591. Hudson, WI 54016
St. Croix Counry, Wiswnain 9 0.11146 -fi0 J 5 -l0 ti.o1)d ),
026 - 1096.70.000
Pnreel Ides {littt4ao Yttabtr (PINt
This ienot I:omalcadproleny.
(41 (is not;
i
Excemloas :0 a;Rra!ttics: EAi:ting h�211wsys. easel -tri13 is n %L'IS of way c ntcord.
Dat:d this 1 y" day of April — . 2003
• Kennetk L. Wawa.
1
grE+0"l Srh'J
I Kethlean B. Browa
AUTHENTICATION ACKNOWLEDCmwr
STAff1OF Wisttonsln )
Signature(,) �� ) is.
St. Croix Cot +ntv. )
Personally come before me this 13 day if
l aullicatteued this _ day of April , 2001 lice aoo•e Uuted
Kenneth L Brown and KAthimes B. Brown
J•ts�� _
T1TLn: ��/lR OF WISCO,%'IN
�. to ,own to b,r ate p.tt ne(e) ..ita a <eetutl the forcguind
I mcul and ackrewledge tie same.
9A0% Wis. a:ab.)
7 a DR£D By
Ai! r AS A't
, vid J. Lrstin"a
1 304 tt notemll. W1 54016 _ No" Public, State of Wisconsin
(SiV be twtheruleated Or aeknowlodgtd. fdotlt are rot My Com,slssioa is F n d' axptr ton u:
necessary.) }
•Names or Muni slanHy Ina" eaptslty should be typed or printed blew their siviolu e
tYARRwMTY attaa eTAT9 aAA Oa WIrOANtIN
FORM 1* a • to"
1"I'CAMAI' ON Kut eaEtONALSCO W—T KIN017U L.AC'tT reGAl1.'!M,
JO OWNER OR RESIDENT SHALL DO ANYTHING WHICH WOULD INTERFERE WITH OR
�HANGE THE OPERATION OF THE APPROVED COMPREHENSIVE WATER DRAINAGE AND
SOIL EROSION PLAN FOR THIS PLAT. THIS INCLUDES BUT IS NOT LIMITED TO BUILDING
JPON, OBSTRUCTING, ALTERING, FILLING, OR EXCAVATING OR PLANTING IN ANY POND
= ASEMENTS, WATER DRAINAGE DITCHES, WATER RUNWAYS, WATER CULVERTS, BERMS
)R GRASS SEEDINGS.
rn I�3'I 33'i
o
EAST 1/4 CORNER, SECTION 33, t
T30N, R18W, FOUND 3" COUNTY to
SURVEYORS MONUMENT
145.35' 275.57' 239.48'
33.00'- I I z
I I >
i ► to
�CD
I
,I
LO T 19 LO
T 18 LOT 17 rn
I I
06299 Sq. Ft. N 1 933 S 121742 Sq. Ft. I
2.44 Ac. 2. C. 2.79 Ac. cr I
A 5 1 33 m 33 1 y
p I N I Ln
I I fTl I I cn (A I (-
Z
I I i O O I M
O
DEDICATED TO I I m
9\S8 THE PUBLIC (p cp
co
O O
191.60' 233.72' J CN11
\2 -- - - - - -- cl)
N 89'35 53 W 425.32' I m
23 �_ _ 121st AVENUE — . —
\ 24 o I O
S 89'35'53" E 425.32' Z
— — —
47.60' — 187.85' —
_O L
I rTi I —
Z I o
\ —1
I D I O
LOT 14 LOT 15 LOT 16 I n
Sq. Ft. I
Ac. 65568 Sq. Ft. 68637 Sq. Ft. �, 66635 Sq. Ft. m
1.51 Ac. w 1.57 Ac. c, 1.53 Ac. o I C I I <
I° "° i A; m I�