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026-1149-12-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 578978 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: Newman, Justin Richmond Town of 026-1149-12-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: l,#, loin OZ) 6 R-T lAJU Pwr P(,#}A~• 36.30.18.1112A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic SK~~ rngo 16J0 Benchmark q.7O 1,W. 1D lGID, 40 Dosing W Alt. BM l olr~-tl Erg 60D 441#rt44V- r (.o 103.G6 Aeration Bldg. Sewer Holding SVHt Inlet SO TANK SETBA out t y„slu $-Rs K INFORMATION oo 0 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet O Septic I, 7D. ~/a D . 7I I Dt Bottom /Z. 36 f2 V Dosing K v %A Header/Man. '57/JO Aeration Dist. Pipe 7 (rr Holding Bot. System 641 PUMP/SIPHON INFORMATION Final Grade ~7j ~S~ 1D1 Manufacturer iaDL~L Demand St Cover ~ZS GPM •q Model Number E.. 00L I Y. 7 ~~~•D~ TDH ILift_7. , Friction Loss System Head Ft -7. f3 I - to /s !8 Forcemain Length Dia..9 Dist. to Well SOIL ABSORPTION SYSTEM /V BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS Ze) mej i SETBACK SYSTEM TO ` P/L BLDG WELL LAKE/STREAM LEACHING Manufacturers INFORMATION CHAMBER OR Type .f- Of System: } . n UNIT Model Number: coa vc Ni toK/AL ~g0 /v IL 5 eD DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake t / j! Pipe(s) Length l Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over TID Depth Over t xx Depth of r-Seeded/Sodded pwxx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ~y( Yes ~ No ® Yes [No i SF" COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:- Z~ le- Inspection #2: / Location: 1281 142nd Street New Richmond, WI 54017 (NW 1/4 NW 1/4 36 T30N R18W) Torey Pines II Lot 12 Parcel No: 36.30.18.1112A 1.) Alt BM Description = Fok~p 1.4j ~WwAf of tt/A 6"'Ar 01j 'ST "PC DF j>WJCZt-IA 6, 2.) Bldg sewer length = tYD ' r $QIL - I 4570- 44 - amount of cover = ty 4,> 501t- Irsr ap/LxJ65 ~ F~uN~ N AREA ~ vjelAJ~ C-1,45 106'& F*4 6 is P~.i 60 o,2i~~u~i p~dr,vG~CIF~u ,~ti~rsp E1.~-✓ P 2~7 ~ 3~ slL, ~'uST ~aed~ SicL Plan revision Required? Yes No / Use other side for additional information. SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No. 0. -~-,jPd14s tdo Ac~n SID 073rgy~ County) A =t Industry Services Division ✓T a X 0 „ ® 1410 E hington Ave Sanitary Permit Number (to be filled in by Co.) `z} $ p S% y ox 7162 y O Madison WI 53707-7162 A N oJ2015 f r07 b S 79'7 79 AOSIONP~'y r Permit Application State Transaction Number :OMMUNETY Dr= In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit AJA7 is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address (if different than mailing address) purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. 1. Application Information - Please Print All Information 1 Z-8 Y Z A-d Property Owner's Name Tt, L17 0 2- ~ / / Parcel # y9 /z-ooo Property Owner's) Mailing Address Property Location 1' 1 Z A- 9 d / 7 7- Q L/ C Govt. Lot City, State Zip Code Phone Number W '/4, )kA A .J `/4, Section (circle one) o A- T-3() N R/0 E oC II. Type of Building (check all that apply) Lot # 9-1 or 2 Family Dwelling - Number of Bedrooms 3 ' Z Subdivision Name as Xe El Public/Commercial - Describe Use ok Block ' Jam.. pz ~ El City of El State Owned -Describe Use ❑ Village of G CSM Number J 3 Or`J~ aY 1 J [B Town of d h✓YYI 0 U III. Type of Permit: (Check only one box on line A. Complete line B if applicable) G ^.a- A. 4J 4 New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Pate I sued Before Expiration Plumber Owner IV. Type of POWTS System/Component/Device: (Check all that apply) on-Pressurized In-Ground [I Pressurized In-Ground El At-Grade El Mound > 24 in. of suitable soil El Mound < 24 in. of suitable soil ]gHolding T er ispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treatment/Area Information: -C £ •S- 3 ' Lo Y o~~ y Design Flow (gpd) Design Soil Application ispersal Area Required (s ispersal Area Proposed (s CSystem Elevation / c, Rate(gpdsf) s g0 O goo Y /e O T VI. Tank Info Capacity in Gallons Total # of Manufacturer t -6 Gallons Units o New Tanks Existing Tanks G ! • I fs p U V1 y Cn w C7 f~, eptic o olding Tank x U6 D ' 5 K~ V-1 7TT` / 19, ❑ ❑ ❑ ❑ sing Ch r x (0 0 U ❑ ❑ ❑ ❑ ❑ VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. P er's Name (Print) Plumber's Signature MP/ PR Number Business Phone Number CSC ((E a w 1 ~ P ~ ~ L L Z 23 7,7- 10 - 4th/ --,EE/9 Plu ber's ddress (Street, City, State, Zip Code) el o. , K uele VIII. _Gou /De artment Use Only )proved Permit Fee Date ssue Issui gent Signatur ~41 4D~~ 1 5 Reason for ' 1 $ 1476 &P f ;t, ,~6 5 1 IX. Cond18YffMp f teasons for Disapproval 12-11 q G 1 `Septit tank effitflltef! n U dispers mustall ' ' U to O f~ GO J r as per rnaiiag"M plan pro ' -byplumber. , A$. "tback re jnueit.be rr► ►tainbd, n A)p Da 01- 6 Attach to complete plans for the system ands mit to t e Coun only on paper not less than 81/2 x 11 inche 'n size 1 0.6.-w.e~.-. SBD-6398 (1103/14) D N~3 c Ac 3 G f s, ~ v CONVENTIONAL IN-GROUND POWTS DESIGN With DOSE CHAMBER Residential Application Index and Title page Owner's name: 6 4 Owner's address: 1; q 1-72- d G e e A- C/ " Site Address: 12,6 ! / Y z, Legal Description: /V :~4 N Town: County: Subdivision Name: C o ( n f Lot No. Z Block No. Parcel Identification Number: Pave Index Page 1 Index and Title Page 2 Plot Plan Page 3 Distribution Cell(s) Cross Section Page 4 Dose Chamber Cross Section (with ST & filter specs) Page 5 Pump Curve and Specs Page 6 Maintenance. Management and Contingency Plans Plumber Name: 6 n • Lt ~ a~ rv ~ Credential No. 7 2,2- 7 Plumber Address: Signature: Date: Phone No. 71 ' Y5 Designed Pursuant ;o the: in-around Soil Absorption Manuai for POW-! S% ersion SSWMP Publication 9.6 Design of Pressure DIsrrlDull on iNelvorhS o- S7-S Da17e o o s 3 b Z M ~ V S U3 N Soil Absorption System Cross Section ~--~or v ft [ ft 4" Schedule 40 Final Grade PVC Vent Pipe . 0 With Vent Cap w 74 Leaching Chamber ft J System Elevation ft ft s ft Soil Absorption System Plan View ~v ft ft { S ft Leaching Trench 1 r Chambers 4" Dia. Trench 2 Header Vent Or Observation Pipe I-m'mff= F-1 3 TFTren Leaching Chamber Specifications 41 J Manufacturer And Modelk EISA Rating ZO •0 sq ft per chamber Soil Application Rate S gpd/sq ft Yj-0 gpd Design Flow = - 5-- Soil Application Rate Z b.0 EISA = Yf Chambers 3 rows of 5- chambers each. Page of Page of PUMP CHAMBER CROSS SECTION Min. 2'ventPipe with cap Approved locking manhole Z 10 ft from door, window c w% warning label or fresh air intake venLCap + Awr TiglA Cap Junction Bn:: Final 4 ~ i 12"`MIN Grade 4" MIN 1 % f Inspection ~j Riser \ ` l I 16* 'A MIN ~ 1 % It ,,x.11 11 t R + I ' 114" Weep z I Pic i~dz a I-Icfe i f / = P,irLIaiTG + i Seal Joirr- Pa f i P - A t JI - - A t 11 Approved Alarms TB Joirrr outlet i'.1 / I% \I Manufacturer. f~ iZ f~ jllw 1 " Conc. , it t 7 \ q ,1 ~l~ ~~'l 7 l+ \ H ~ i 3" approveci bsdcire rno-t ;riai under sank III SPECIFICATIONS Note: Pump and alarm are on separate Number of Doses: `f Per Day I circuits as per ILHR 16.28 Ws. Adm. Code Gallons Per Day of Doses: 112- Gallons Volume of Baekflow: Z. a Gallons Tanis Manufacturer: Seg LA-1 Total Dose Volume: Gallons I Tank Si: e:_ 1,600 ~1,0 v - Gallons Alarm Manufacturer: yice-- o~ Capacities: A -7-y inches or 3Z9 Gallons Model Number: Pi'v B 2" inches or3z-9 Gallons Pump Manufacturer: C ~ Z inches or/.9-7 Gallons ' Model Nu D inches or _ Gallons tuber: ef o a Total........ _ eo inches or Gallons Minimum Discharge Rate: ,3s' GPP,~I ~ Vertical Difference Between Pump Off and Distribution Pir3e Minimum Reauireci Supply Pressure: I ° Fr. of Force main x Z.P- . - - rictlcr iactor,'? Glv~ Ft. 3 ~ )tai Jvnamlc He; U = iriternai Pump Tank Dimensions: Lencitr rV; 10Z)-b 9 ~eptf :u iriiet Gallons/inch Signature. l~~w--fem. ~n License Number ZZ 2 Date -Y-/Y I ` Page 7 of 8 GOULDS PUMPS Submersible Effluent Pump EP04 EP05 . 3871 APPLICATIONS • Fully submerged in high ■ EP05 Impeller: Thermoplas- ■ Bearings: Upper and lower grade turbine oil for tic enclosed design for heavy duty ball bearing Specifically designed for the lubrication and efficient improved performance. construction. following uses: heat transfer. ■ Casing and Base: Rugged • Effluent systems thermoplastic design provides AGENCY LISTING • Homes Available for automatic and superior strength and corrosion • Farms manual operation. Auto- resistance. 41- Canadian standards Awoasuon • Heavy duty sump matic models include ■ Motor Housing: Cast iron (CSA listed model numbers end • Water transfer Mechanical Float Switch for efficient heat transfer, in "C" or "F".) • Dewatering assembled and preset at the strength, and durability. factory. SPECIFICATIONS ■ Motor Cover: Thermoplastic Got" Purms is, ISO 9001 k0fted FEATURES cover with integral handle and • Solids handling capability: float switch attachment points. 314" maximum. ■ EP04 Impeller: Thermoplas- ■ power Cable: Severe duty • Capacities: up to 60 GPM. tic Semi-open design with rated oil and water resistant. • Total heads: up to 31 feet pump out vanes for mechanical • Discharge size: 1112' NPT. seal protection. • Mechanical seal: carbon- rotarykeramic-stationary, BUNA-N elastomers. • Tem~ture: 104`1' (40"C) continuous METERS FEET 140OF (60%) intermittent 10- • Fasteners: 300 series stainless steel. g 30_'_.. 5 • Capable of running dry without damage to s 2.5 Fr components. 25 Motor: s 20 • EP04 Single phase: 0.4 HP, - 115 or 230 V, 60 Hz, 1550 RPM, built in overload with c s 15: automatic reset. a -EPOS • EP05 Single phase: 0.5 HP, o 115 V or 230V, 60 Hz, 1550 3 1---~----- - RPM, built in overload with E automatic reset. 2- • Power cord: 10 foot standard length, 16/3 1 SJTOW with three prong grounding plug. Optional 20 ° 00 10 20 30 40 s0 GPM foot length, 1613 SJTW with three prong grounding plug (standard on EP05). o z a s a 10 12 m31h CAPACITY Goulds Pumps ® 2001 Goulds Pumps ITT Industries Effective May, 2001 83871 Installation and Maintenance Instructions Installation Step l Dry fit the filter case onto the outlet pipe going to the drain field. Ensure it is centered directly under the access opening. (if outlet pipe is already in a fixed position, additional pipe may need to be added) Step 2 If utilizing the additional single side support and the two bottom supports: While the case is still dry fit to the outlet pipe, measure and cut 1"schedule 40 pvc pipe to the length needed to extend from the hubs that are pre-molded into the case to the side wall and the inside floor of tank. solvent weld pipe into the hubs that are pre-molded onto the case. Step 3 Solvent weld the case to the outlet pipe. Insert the filter cartridge into the case pressing down on the cartridge until it locks into place at the bottom of case. Step 4 if utilizing a vertical read switch: Insert switch into the hole pre-molded into the top of the filter. Press straight down until it locks into place - Maintenance 1) Remove the access lid of the tank. Note: To ensure undesirable solids do not exit the tank and into the drain field, the tank should be pumped out until the level of effluent is below the outlet level of the tank. 2) To remove the filter cartridge from the filter case, pull up firmly on the handle of the cartridge dislodging it from the case. (if utilizing a vertical read switch, removal of switch is optional) 3) Using an ordinary garden hose, rinse the filter cartridge ensuring all visible septage material is removed. 4) Place the filter cartridge back into the filter case pressing down on the cartridge until it locks into place. 5) Place the access lid back onto the tank ensuring it is secure. Lifetime filter has a lifetime limited warranty: Lifetime filter LLC warrants the filter will be free of manufacturing and workmanship defects during normal use for the period of time the original purchaser owns the product. Lifetime filter will provide a replacement filter in the event that the original filter was not damaged during the installation or maintenance process. Damage to this product caused by accident, misuse or abuse will not be covered under this warranty. Improper care or malfunctions resulting from product not being installed, operated or maintained properly will void this warranty. Lifetime filter assumes no responsibility for labor charges, removal charges, installation or other incidental or consequential costs. Contact: mike@lifetimefilterllc.com Phone: 502-724-2231 Page of 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 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. 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 -213- - yq/ -,.S13 U8 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name S cl ti Name Sf ('rt,oi K < ti "ti Phone '7 ~-S - R Y Phone Y(o 8U 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. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner K~ 71'j Septic Tank Capacity /000 gal ❑ NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms 3 ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units _LWA Pump Tank Capacity 64) O gal ❑ NA Estimated flow (average) -/)'b gal/day Pump Tank Manufacturer ~'~j~w ❑ NA Design flow (peak), (Estimated x 1.5) G 7j gal/day Pump Manufacturer d S NA Soil Application Rate gal/day/ft' Pump Model ❑ NA Standard Influent/Effluent Quality Monthly average" Pretreatment Unit AffS Fats, Oil & Grease (FOG) <_30 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODO 5220 mg/L .,01QA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD5) <_30 mg/L n-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L 4q-NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) :!00' cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y3 in dia. Et-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 8'year(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: [I month(s) (Maximum 3 years) ❑ NA 8-year(s) Clean effluent filter At least once every: ❑ month(s) ❑ NA ! , f -8-year(s) Inspect pump, pump controls & alarm At least once every: / ❑ month(s) ❑ NA . $year(s) ❑ year(s) F~-PdR Flush laterals and pressure test At least once every: ❑ month(s) Other: At least once everY ❑ month(s) l~lA ❑ year(s) 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 (Y3) 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) Page of 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 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 yl~/ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY r --7 Name 5 kc~ ti Name Phone i / j -'7S j - R Phone / j - 3,51 9 = Y(, 8U 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. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer t4 s ~ ~ t" w rri, N - Mailing Address 17 L C Property Address VI L 01 `f Zti-~ ,5-4 (Verification required from Planning & Zoning Depa t for new construction.) City/State AIcw ,'c h 0 /4 Parcel Identification Number Z 61 LEGAL DESCRIPTION Property Location Nw `/a , N~ `/4 , Sec. 3 4 J-30 N R / t? W, Town of 4 . f 'ev'"dN C / Subdivision Plat: / d Lot # / Z. Certified Survey Map # , Volume , Page # Warranty Deed # (before 2007)Volume , Page # Spec house f7 yes/no Lot lines identifiable/ yes 'Ci 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. 1/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. 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. I/we certify that all statements on t Pis form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a w rranty deed recorded in Register of Deeds Office. Number of bedrooms J' , f J"_ / z- /S _SIGNAT RE OF APPLICANT(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) #M FFE - 108100 PC / AMES INVEST) 34 PENNINSM N 80.4920" E 3@ 3i' DE1 VMD, MR s ee64ya ~ 611.er ~ _ ~ ` rw 1r o~v■Rr w■a+w~o *o L r 11 os awo In LOT 2.000 ACFES (97,180 80. FT.) 9e OFJAwAAN.ft/mm/T an Liar t,. AMES O W744 80. FT.) w ~R I LOCA17 N !0"5134' E 4O0.97 N B=0` E `E`\ 486.00' 1 y~ ! se I Oar I sa rMA1 AGE !A EASEK*NT 4~,~ + 1 \ LM as ACRES IM070 SO. FT.) I ! tDT 1$ ~ j 2.oaz ACM (s-.IRoo OMOO Fr.) N SO'S1"SO E 4OW W N SW571 W E 496.00' ..1 / . ~-N ~ 2.002 AiCFEB (87.90080.Fla r ..'OW 1/4 LO? $'T AIOFF6 496,061 80. Fr.) LOT 1$ OLT i I - MN FFE ft 1016.00 F~:, ; ~EG"i10N' 19 .i ~ • H.w.E.•1o1ao.•.~ N 6$'5134' E 400.47 >a~ N WS M0, E 436.00''.'.....'....'...1 BtVAtioM- LCrF'14 V., LAT : 2.007 ADZE S 467.:!00 80. FT.); f-- I ,~oAE6 (06.066 sa. Fr.) km ME - 101B.DD t`. N W51SC E 400.44' N 64'67'1 WE 496.00' - W ~ .'9D' pftACVRL7~ 1 i 76EASEMENr ~ ~ ° • ~ AOM 449,= SCL IT.) ooa 467,200 80. Fra i $ I MN FEE - 1000.00 I W I Fmil AI u•-0• !p p' 114' ee 1'4 rw K4' n•o' $C. 3w scusoRe~Tnrpe~ Y . u'orc roveR) 2 ~ ± ~ c A e RAN,pIb I r f I ' * )Y 4 Q zcl ~ ~m R p Y ~ I {o" e~ • aa4t r Rao ~ IL 2 1 ~ ~ E ~ ~ ~ I S MIV ~ {'O.. Ql. s s y~ ~ I Y fi' z ° + I n 4 b ~ m ~ o ~ `CTS ~ ~ 6 h r r ID" Rop TRU"n - - - . - - J MLAap! ----a . u'arc tovp~! ID , se atD7e. ti W.vp 7{.y. 1Y0" ri) aL Z .4 Wd i A A A ♦ r Z H +4' 24W n~ I i - ° ° - - j tioow nassn y' i : Kro.e. ~ovee, 1 ~j a DY gg T r Q ~gii~ F° ~ y S p 6 ~ ~ - I- T- 1111111 b - - - - - j - 1.J_J _l_ _l.! - - t( 4 F r 4 - - I - ~ I ; i I~ III e'+• ~ E I Ij j X r4'- • ~ ti / w - E ; -Ad i<S T 1f T J; y 8 AAt~ I I I~ r S 14 I I I o• b a n I ' - - - - - - - - - - - - Q s•aK• r.sa• t4 ab• F a 0 s FF'o ~C~FFF~ N F w 1'C rs'o' Y s Y yy ecY~onslnaiesu y i . x•erc rove~ei 22 ~ } s ~ ! I ~ ~ 1 C qq~ ~ i ;y V I~ ~ 9x> S e G\ s g I Z - I I t Y r r K I »K. i 6 r• ~ - x a 4 mm ~ AA s Z y r. a c s b Im T ~ ~ I so• o' soar , wm _ n ~ ~ a _ /V r L b 1 S = s e ~ s V I Y." ►.D. r D r D T~ 5 ~ I n ~ A •''O' rr' A in ~ r L s i a ~ P Aeon -----J waDM . u•orc fovea LO • N OLD7C K )t'4• CYO' tp 7a'-s• a ~ z D s~ A y iD W $ ~ I A D t Property Owner YIy n 1~~ LLB. Parcel lD'# Page of FF Boring # ❑ Boring Ground surface elev. ft. Depth to limiting factor Soil Application Rate Horizon FDepth Dominant Color Redox Description Texture Structrue Consistence Boundary Roots GPD/ft2 Munsell Qu. Sz. Conn diAw Gr. Sz. Sh. •Eff#1 •Eff#2 JC) Nr L4 144 3 Lipp 0 41(0 SL rn~r C (Ovc-l(o -L1 E -1 .5 -J N Boring # ❑ Boring ❑ 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/ft2 In. Munsell Qu. Sz. Cont color Gr. Sz. Sh. •Eff#1 •0142 F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture . Structure Consistence Boundary Roots GPD1112 in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 •Eff#2 • Effluent #1 = BOD, > 30 < 220 mg& and TSS >30 < 150 mg/L • Effluent #2 = BOD3 < 30 mg/4 and TSS < 30 mg/L r> ; 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-3330 (R.07100) Wisoonsio~Department of Commerce SOIL EVALUATION REPORT Page I of 3 Divisiori of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must County 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. evi by Date Personal hfarrnation you provide may be used for secondary purposes (Privacy Law. s.15.04 (1) (m)). • Ajd11)1 04 3 Property Owner .4.1 _ • Property Location Nff-- ~~llV e5} i C GovL Lot Ni i3 114 N,} 114 S 3~n T jo N R M E (or) Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 2 City State Zip Code Phone Number ❑ City _ ❑ Vdlage IS Town Nea t Road ~el~r M+v 55110 (I 15) 1461b CZA- &New Construction Use: & Residential / Number of bedrooms Cade derived design flow rate 0 GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material -4' Flood Plain elevation if applicable ff. General comments O and recommendations: Sy{ "e~~U • ~a~ 9T1 G v w 9~ sUIL 1 2 2002 ) -,I ST~iy 1 l iJ=Y PU-N ❑ Boring F (I Boring # Pit Ground surfaee.elev. /00,00 fL Depth to limiting factor Soil Application Rate Horizon Depth Dominant Color Redox Description MTexIu,e Structure Consistence Boundary Roots GPD/fti In. Munsell Du. Sz. Cont. Color Gr. Si. Sti. 'Efl#1 'Ef1#2 - Z.rY`Q1C1 r S V 5 2 l CS C5 3m~ rr'~ - 5 9 Boring # ~ Boring Depth to limiting factor 1 p~ Pit Ground surface elev. ~q ZO ft. pl Application Rate Soil Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Du. Sz. Cont.Color Gr. Sz. Sh. •Eff#1 'Eff#2 0-0 10 2 S'1( Lnnabk r -)Vr 0-5 t V~ 5 2 Ip- ((-)-qc Li ILA 2rn5 yr Fr C'5: S g -3 -51 r- LAo st_ _ 2rns k m ~'r e 5 5 1-9 6 -6q I S~ F -1.5 9 lq ~ ~3ms k Y,n~i - 5 9 Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = GODS < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) S nature CST Number _ 2~ '3 3 09 /Odofn Address Date Evaluation Conducted Telephone Number 07- - ~ a~ C11 f,) Z47 `fppg 2113 $~T3 e el-4 W l 5 4 t, Properly Owner Am-a 1. L LULC Parcel ID # page ' ,Z-of 3 F Boring ❑ soft 3` ®.p t Ground surface elev. 98 R Depth to limiting factor Application Rate l-" Depth Dominant Color Redox Descrip" Texture Structure Consistence Boundary Roots GPOW ln. Munsefl ilu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 2 1b 14 Iq c5 _ 3 0 4110 SL r r C5 19 . Z~ a Boning Boring ❑ pit Ground smfaee elev. fL Depth to limiting factor in. Sob tfon Rate Horimn Depth. Dominant Color . Redaoc Description Texture -Struchxe Consistence ammdary Roots GPOW I% Munsell Ou. Sz. ConL Color Gr. Sz. Sh. -EM -0#2 i oe # ° Boring _ ❑ pit • Grmxxl surface elev. R . Depth to i'imiting factor in. Sob &Vkaftn Rate Horimn Depth Dominant Color Redox Description Texture Shuchse Consistence Boundary Roots GPDW In. Munson Ou. Sz. Cont. Color Gr. Sz Sh. •Eff#1 •Eff#2 • Effluent t" = SOD$ > 30 < 220 mg& and TSS >30,c 150 mg& • Effluent 92 = BOOS 130 ff*k and TSS < 30 n V& i The Departroent 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. saoe3"PL071 t PAGE OF `3- NAME A tM-~ 5 T OT# )Z- LEGAL DESCRIPTION Nw X Y 4,S 3 Cn T 3y N R I 9- E(u)~O SCALE: I" BM I ELEVATION 4 U U BM I DESCRIPTION BM 2 ELEVATION q y BM 2 DESCRIPTION S-~,~ of ~r L P'Qr , 3 SYSTEM ELEVATION q SS Zv Jf) L,, - r q U y ALTERNATE ELEVATION V~ CONTOUR ELEVATION q q, od f oo . o C s i SIGNATURE DATE -/Z' o Z Wisconsir £'epwtment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety anAuilding bivision INSPECTION REPORT Sanitary Permit No (ATTACH TO PERMIT) 430517 0 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)j. Permit Holder's Name: City Village X Township Parcel Tax No: Crombie, Tim Richmond Township 026-1149-12-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 36.30.18.1112A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Se er Holding St/Ht Inlet TANK SETBACK INFORMATION S Ht Outt TANK TO P/L WELL BLDG. ent to A r I ke ROAD t nlet Septic Di ttom Dosing Hea r/Man. Aeration Dist. ipe Holding Bot. System PUMP/SIPHON I FO MATION Final Grade Manufacturer Dem d St Cover GPM Model Number TDH Lift ri tion Loss System H TDH Ft Forcemain Le gt Dia. Dist. ell SOIL ABSORPTIO S BED/TRENCH Width Length . Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS I- I SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of System: CHAMBER OR UNIT Model Number: DISTRIBUTION SYSTEM to Air Intake Header/Manifold Distribution x Hole Size x Hole Spacing Vent Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Mulched Depth Over Depth Over xx Depth of 7 Seeded/Sodded T Bed/Trench Center Bed/Trench Edges Topsoil Yes 5 No i `Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 1281 142nd Street New Richmond, WI 54017 (NW 1/4 NW 1/4 36 T30N R1 8W) Torey Pines Lot 12 Parcel No: 36.30.18.1112A 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? Yes 0 No Use other side for additional information. SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No I Safety and Buildings Division County __J NVAS11consin 201 W. Washington Ave., P.O. Box 7082 , crdl MT(.. Sanitary Permit Number (to be filled in by Co.) 1, 1A gpa; "nui Department of Commerce )R4EIVED State Plan ED. Number Sanitary Permit Appli n~ 7y In accord with Comm 83.21, Wis. Adm. Code, personal i" ~ oT it pr&ise 2003 may be used for secondary purposes Privacy Law 05.04(1)(m) Project Address (if different than ling address) 1. Application Information - Please Print All Information ZONING OFFICE 1.29/ I ~Z PropertySywoF:;Name ~J Parcel # Lot # Block # Property Owner's Mailing Address Al- i Jv., Section / C' , Stn Zip Code Phone Number AAj (ircl ne) T N• -E r W IL Type of Building (check all that apply) 7041 vision Name CSM Number r's S 0h ht r 2 Family Dwelling -Number ofBedrooms WA ~ /,2J ❑ PublictCommercial - Describe Use Gt, 1 S AD Yoj State Owned - Describe Use ❑City ❑ ag Fownship rl III. Type of Permit: (Check only one box on Iine A. mplete lice B if applicable) ONO- l lif ~ 12 - MV C. al Z A. yttem ❑ Replacement System ❑ Treannmt/Holding Tank Replacement Only Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New Ust Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. -Type of POWTS System: Check all that apply) 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 ❑ Rec" 1 Recirculating Synthetic Media Filter hing Chamber ❑ Drip Line ❑ Gravel-less Pipe ❑ Other (explain) Le- V. Dis eraslrTrestment Area I formation: S t Elevati Desi ow (gpd) Design Soil Application Rate(gpdsf) Disp I Area Required (sf) Dis rsal Area Proposed (s , ~3 2 , s- Tank Info Capacity in Total Number Manufacturer Prefab 41 Fiber Plastic Concrete Constructed Glass Gallons Gallons of Units New Existing T Tanks Septic or Holding Tank Aerobic Treatment Uab Dosing Chamber VII. Responsibility Statement- 1, the undernigne some responsibility for installation of the POWTS shown on the attached plans. Pl 's Name (Print) Plumber's re MP/MPRS Nu ber Business Phone N ber Plumber's Address (Street, City, State, Z' ) VIII. Coun /D a meat Use Only Approved ❑ Disapproved Sanitary Permit fee (includes Groundwater Date Issued Is uin gent Signature (No tamps) Surcharge Fee) ❑ Owner Given Reason for Denial 2sz - .Ix. Conditions of APproval/Reasons for Disapproval SYSTEM OWNER: 'lltx~+v~, 1 Septic tank, effluent filter and L3- . ~,,,tl dispersal cell must all be serviced I maintained as per management plan provided by plumber. i Sz 2. All setback requirements must be maintained as per applicable codeJordinances. t - t. Attach complete plans (to the county only) for the system oa paper not less than 81/2 x 11 Inches to size ~Z c(+ _ A rolTe'r t7Lre~ S~~pW,~. I ~ vl ~~t}t.JG. \ SBD-6398 (R. 08102) a~ C&AoA PLOT PLAN PROJECT Tim Crombie ADDRESS 3050 Lisbon Ave N. Lake Elmo Mn 55042 NW 1/4 NW 1/4s 36 /UND 0 N/R 18 W TOWN Richmond COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 10/31/03 BEDROOM 3 CONVENTIONAL )00( IN-G PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 933 # of chambers 30 BENCHMARK V.R.P. Top of 1" PVC Pipe = g tµ* I ---ASSUME ELEVATION 100' Filter Zabel A-100 ❑ BOREHOLE O WELL +H. R. P. Same as Benchmark SYSTEM ELEVATION 98.2/98.5 1' below grade 70' 436' Property Line 10' B.M. #1 B-1 50' 50' 0 30' 25 B.M. #2Vents Vents 3% Slope e 5 B- IkA,* 20' E° T 2-3' X 94' Cells with >3' Spacing 15' Q~ 3 Bedroom House I Further Testing will be done to lower system elevation and find better soils, the lot to the north of this one was found to be a fine sand, a .5 loading rate with in 20' of this soil test and was field verified by Pam Quinn. This test appears to have been done in a sway/lowland. Vent >6„ Standard Biodiffuser of Cover Leaching Chamber with 31.1 ft2 of Area 11 „ Plans Designed Using 6' Long Conventional Powts 4„ Grade at System Elevation Manual Version 2.0 PROJECT Tim Crombie ADDRESS 3050 Lisbon Ave N. Lake Elmo Mn 55042 PON/R OT PLAN NW 1/4 NW 1/4S 36 18 W TOWN Richmond COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 10/31/03 BEDROOM 3 CONVENTIONAL XXX IN-G UND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 933 # of chambers 30 BENCHMARK V.R.P. Top of 1" PVC Pipe - g VA* I - ASSUME ELEVATION 100' Filter Zabel A-100 ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark SYSTEM ELEVATION 98.2/98.5 1' below grade 70' 436' Property Line 50' 50' 10F 30' 0jr 2Vents 3% Slope C 5 i Poo 20' ack 99.3 0 F° T 2-3' X 94' Cells with >3' Spacing 15' 0 3 Bedroom House Further Testing will be done to lower system elevation and find better soils, the lot to the north of this one was found to be a fine sand, a .5 loading rate with in 20' of this soil test and was field verified by Pam Quinn. This test appears to have been done in a sway/lowland. Vent >6„ Standard Biodiffuser of Cover Leaching Chamber with 31.1 ft2 of Area 11 „ Plans Designed Using 6' Long Conventional Powts 3 4" Grade at System Elevation Manual Version 2.0 wisconsi De0artment of Commerce SOIL EVALUATION REPORT Page I of 3 Division b Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Chi Attach complete site plan on paper not less than 81/2 x 11 inches In size. Plan must include, but not limned 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. evi by Date Personal intorrrradon you provide may be used for secondary purposes (Privacy Law. s.15.04 (1) (m)). 3 Property Owner Property Location Nnc C GovL Lot N Lx~ 1/4 N td 1/4 S S(o T jo N R N' E (or) Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 54 Pen k~i-,W RA - . •.l. 2 _ _ _ _ ( e-4 f~~ City State Zip Code Phone Number ❑ City _ ❑ Village ElTown Nea t Road )-OL0008 HN 55it0 (~~5) -2u~1 i & New Construction Use: & Residential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material - II Flood Plain elevation if applicable ff. General comments and recommendations: SY ~I ~U rj J U L 1 2 2002 _ k ak U-A4-A%4-,, ST l 1'X (J Y 0 F~ iC © Boring # Pitring Ground surface.elev. C00-00 ft. Depth to limiting factor Lt Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' In. Munsell Qu. Sz. Cont. Color Gr. Sz. 8h. 'Eff#1 'Eff#2 O- Z~ Sul ZrY r e5 v-E _q It) L- J (I 2rm bk- r GS - 5 • 8 10\4Y-4A- 3L ` grins rn~r c , ~J - 9 10 ~l r/ F r 5 3m k "4--, - '1-9 Boring # Boring q9 24 Pit Ground surface elev. fL Depth to limiting factor I Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fl' in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 ~_fp 10 2 '50 Lrriabk rn r c 5 ~ v~ 5 :1~ 2 (p I Si t 2- m5 yr F,r c,5 . - 5 ; g 3 ZMt) k m r cs .5 1-9 51-(Dy ID ~r- So 1 1.5 y st- ~3ms 1< - - 5 .9 • Effluent #1 = BODS >-30 < 220 mg/L and TSS >30 < 150 mg1L ' Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) S' nature CST Number o- Adam ~--na~gr Address Date Evaluation Conducted Telephone Number 211 SC;T-h ~1. e wi 5 4 0 Z °z C~►5)7-47^-tO 0% Property Owner Y 1U2 ~7~( C Parcel ID # Page ' 2 of Boring # ❑ Boring Ground surface elev. 9 R Depth to limiting factor • : , Soil Application Rate Horizon FDepth Dominant Color Redox Description Texture Struchue Consistence Boundary Roots GPDlftz Munselt Qu. Sz. Cont Cobr Gr. Sz. Sh. 'EMI -Eff#2 ( C 4 tD ~ Si'~ c 5 - Boring # ❑ Boring ❑ Pit Ground surface elev. tt Depth to limitng factor in. F-1 ..oil Application Rate Horizon Depth - Dominant Color . Redox Description Texture _ _Structu a Consistence Boundary Roots GPDt t2 in. Munsell Qu. Sz. Cont Color Gr. Sr- Sh. •Eff#1 'Eff#2 F-1 Boring # ❑ Pit Boring _ ❑ - Ground surface elev. R Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture . Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. •Eff#1 *01#2 • Effluent #1 = BOD, > 30:! 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BODS < 30 mg/6 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. SBD4330 (809/00) a PAGE 3 OF `f- NAME rr' S LOT# )Z LEGAL DESCRIPTION Nw XI/,; Y 4,S Cl 3T 3c),N R i 5K E(or)~ SCALE: I"= BM 1 ELEVATION r5 CU - U BM 1 DESCRIPTION 4-c) A o I ~OvL pj'pe- - BM 2 ELEVATION q y BM 2 DESCRIPTION j* o T ~r P'QT- 3 SYSTEM ELEVATION JV q Z v ~~,,,J r q T. U 14 ALTERNATE ELEVATION /y/ CONTOUR ELEVATION 1q,oy a- (oo- c.) I ~~,ti 1, a - n I SIGNATURE / DATE I _ "ORIGINAL _7M. 1666 Wisconsin Department of Commerce SOIL EVALUATION REPORT Pag I of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Cert ied Soil Testing Cou ty Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must oix 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. Pa I I or Please print all Information. NTY ate you provide may be used for secondary purposes (Privacy Law, s. 15.04(1) (m)). Personal information OF iCE'" ~[O rOZ_ Property Owner Property Location Ames Investment, LLC Govt. Lot NW 1/4 NW19 S 36 T 30 N R 18 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 34 Peninsula Rd 10 Tory Pines City Dellwood State Zip Code Phone Number ; City ~ij Village 0 Town Nearest Road MN 55110 7157386-2007 Richmond 142Nd St. ✓i New Construction Use: Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement Public or commercial - Describe: Parent material loess over till Flood plain elevation, if applicable NA General comments and recommendations: install 6'x 100' rock ell mound on 96.4 contour as upslope edge of rock w/ 05 sand fill ' 0, C'&4,11] ` Boring # . Boring ► F-71 Pit Ground Surface elev. 96.0 ft. Depth to limiting factor __4n. il Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 1 0-11 10YR 3/2 - sit 2 f sbk mvfr cs 1f/m .5 .8 2 11-29 10YR 4/4 - sicl 2 m sbk mfr Cs 1m .4 ! .6 i 3 l 29-36 7.5YR 4/4 - sl 1 m sbk mfr gs if .4 j .6 4 36-56 7.5YR 4/4 - Is 1 m sbk mvfr Cs 1m .7 1.2 5 56-66 5YR 4/4 f2d 7.5YR 5/3 scl 0 m mfr - - 0 0 i1 Boring #_t Boring Pit Ground Surface elev. 97.0 ft. Depth to limiting factor min. Soil Application Rate Horizon I Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2 1 0-7 10YR 3/2 - sit 2 f sbk mvfr cs 1f/m .5 .8 2 7-38 7.5YR 4/4 - sl 1 m sbk mfr cs 1 m .4 .6 3 38-62 7.5YR 4/4 f2d 7.5YR 5/8,5/3 Is 1 m sbk mfr - - 7 1.2 i i soils are suitable for an at-grade system; available length (shed proposed in future west of B-1) leads to recommendation for mound; horizon 2 ha some inclusions Is; horizon 3 has occasional inclusions 5YR 4/4 scl Effluent #1 = BOD5> 30 < 220 mg/L and TS >30 < 150 mg/L ffl e 2 = BOD5 < 30 mg/L and TSS < 30 mgr CST Name (Please Print) Sin ure: t7 n CST Number Henry F. Grote 222774 Address Certified Soil Testing Date Evaluation Conducted Telephone Number E. 4366 353rd Ave., Menomonie, WI 54751 11/16/2002 715-233-0398 I Property Owner Ames Investment, LLC Parcel ID # Page 2 of 3 3 2d Boring F Pit Ground Surface elev. 94.9 ft. Depth to limiting factor 45 in. Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD& in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0-9 10YR 3/2 _ sil 2 f sbk mvfr cs 1f/m .5 .8 2 9-16 10YR 4/4 _ sicl 2 m sbk mfr cs 1 m .4 i .6 3 16-45 7.5YR 4/4 _ sl 1 m sbk mfr cw 1 m .4 ; .6 4 45-58 5YR 4/4 f2d 7.5YR 5/3 scl 0 m mfr - - 0 0 ❑ Boring # j Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Sot Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/W in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 i i i I ❑ Boring # Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon I Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GEDW in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 I I I Effluent #1 = BOD5> 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD5 <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. S613•8330 (R 07/00) Certified Soil Testing 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 St. Croix County Zoning 715-386-4680 Pumper Tom Mondor 715-246-5148 Shaun Bird #226900 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT- AND OWNERSHIP CERTIFICATION FORM OwnerBuyer c~ ~0 Mailing Address Property Address (Verification required from Planning Department for new construction) l ate Parcel Identification Number 07-G- 11q1-17-- QUO C' / j 12 A/ City/St LEGAL DESCRIPTION -3_L Property Location Sec . T N-R W, Town of . 4 Subdi Lot # vision Certified Survey Map # Volume , Page # Warranty Deed # ~3g 1 . Volume 9 ~1 Page # Spec house es ❑ no Lot lines identifiabl~d4es ❑ no SYSTEM MAIlNTTENANCE 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 Department a certification form, signed by the owner and by a masterplumber, journeyman plumber, restrictedplumber 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. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 ee year expiration date. 2 /ATE :SIGNK!'URE OF APPLICANT OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the pro cribed above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT DATE Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department.****** 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 nab-4s'~a•'e ZOZ.38' ~ ~w~mvw A WISCONS 9T ELEVATION=1030.55 / ORM WATER =NTION AREA . 1 / N 09 LOT 10 H.W.E. 1031.0 1.820 ACRES (79,263 SQ. FT.) O . / T.ti`O~ N 89°43'29" E 386.31' \ ey 1't / \ AN 19' CULVERT 18 RE( W INSTALLED WHERE' / / , LOT 11 DRIVEWAY CROSSES Ti \ 2.000 ACRES (87,138 SQ. FT.) w DRAWME EA8!'MENT I I@o ICS' N 89°57'10" E~ \ 436,00' IQ i~ Mal 1 1 6 8' ( \ \ 95 l oo I 30' DR INA E \ a `(3~\ I I 33 1 3& EAS 4^S~' \ ~ - I Ill I ~ 1 LOT 12 1 I ; 2.002 ACRES (87,200 SQ. 1 MIN FFE = 1015.00 \ \N 341.8T 82.38' N 89057'1-&-E- 436.00' • 2.002 ACRES (87,200 SQ. FT.) % • • • • • • . . Z Z i........1N CA 0°D LOT 13 r 1 N MIN FFE = 1015.00 i.. • • • ' yS~P' ION=103125 4 v H.W.E.= 1013.0.-.1 Co ELEVATION=1029.12 v N 89°57'10" E 436.00' • I ELEMION=1010.23 14 I.'.'. I LOT 14 V..4 2.002 ACRES (87,200 SQ. FT.) 0 : MIN FFE = 1015.00 I ~~I 30 i I$A /1 I N 890571 n" F aas nn, Irt' Parcel 026-1149-12-000 11/21/2007 09:46 AM PAGE 1 OF 1 Alt. Parcel 36.30.18.1112A 026 - TOWN OF RICHMOND Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - CROMBIE, TIMOTHY S TIMOTHY S CROMBIE 838 NEAL AVE STILLWATER MN 55082 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description 1281 142ND ST SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 2.002 Plat: 09-031-TOREY PINES II 10/30 026-02 SEC 36 T30N R18W PT NW NW TOREY PINES II Block/Condo Bldg: LOT 12 LOT 12 (2.002AC) Tract(s): (Sec-Twn-Rng 401/4 1601/4) 36-30N-18W NW NW Notes: Parcel History: Date Doc # Vol/Page Type 09/05/2003 738912 2401/170 WD 09/09/2002 689563 9/31 PLAT 2007 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/01/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 31,500 0 31,500 NO Totals for 2007: General Property 2.000 31,500 0 31,500 Woodland 0.000 0 0 Totals for 2006: General Property 2.000 31,500 0 31,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00