HomeMy WebLinkAbout026-1149-14-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St, Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No: 429955 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:
Ames Investment I Richmond Township 026- 1149 -14 -000
CST BM Elev: / Insp. BM Elev: / BM Description: Section/Town /Range /Map No:
Q . - �d QOC = GSI Z 36.30.18.1114A
TANK INFORMATION I ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 5 `�� / Benchmark 2 99. fO
e I
Dosing �t Alt. BM
Aeration Bldg. Sewer t
�s 96• i
Holding St/Ht Inlet /
lv 9s•oo
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic ? / . 1 3z t Dt Bottom ,2 �•fo� /
Dosing ►t 4 Z Header /Man.
(Vu — Ivy
Aeration Dist. Pipe
• 20 ,
Holding Bot. System )�,Zo )*-to
o.z 9 .
Final Grade o
q
PUMP /SIPHON INFORMATION 5
Manufacturer � Dem d S Cover �35 • 6 f
Model Numb r
'v, A' 6 —40 �Q � 14.
r.
TDH P t Friction Loss System Head TDH Ft
4 A O.W - 4. 20
Forcemain Length.0 Dia. tt I Dist. to Well
SOIL ABSORPTION SYSTE
BED/TRENCH Width i Lengt No. f Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 V&fr. 3)
SETBACK SYSTEM TO I P/L BLDG IWELL LAKE /STREAM LEACHING
INFORMATION Type Of System: CHAMBER OR S
A t �_ UNIT Model Number:
D TRIBUTION EM '
�•
Hea d istribution x Ho x Hole Spacing Vent to Air Intake
Length Dia Length �71d —1 — 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 0 No
CCN=. _(Include code epencie , ;ons esent, etc.) Inspection #1: / / Inspection #2: ---fir op
Location: 1273142nd Street Hammo d, 1 54015 ( NW 1/4 36 T30N R18W) Torey Pines Lot 14 Parcel No: 36k50.18.1114A
1.) Alt BM Description
2.) Bldg sewer length
- amount of cover
t'vw�
Plan revision equired . ] Yes No I
o GW
Use other side for additional information. _
SBD -6710 (R.3/97) -- -- n ctor's Signature Cert. No.
Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162 C�b I e _
iseonsin Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled to by Co.)
Department of Commerce (608) 266 -3151 �ZCI� s�
Sanitary Permit Application State Plan I.D. Number
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide
may be used for secondary purposes Privacy Law, sl5.04(1)(m) Project Address (if Iifferer.t than mailing address)
I. Application Information - Please Print All Information / 2> 7_ /go ial 5-4 ,
Property wner's Na me Parcel # Lot # `�> Block #
Property Owner's M ailing Address Property Location
� � / t /A
PeAllAl el)
City, State Zip Code Phone Number - --
�LGe/p�� M,J Jam' /l0 oEC E IVED / (circle c)
II. Type of Building (check all that apply) / UP T N; I; c>
`LLor 2 Family Dwelling - Number of Bedrooms ✓ l Su ivision Name CSM Number
❑ Public /Commercial - Describe Used Q _�
❑ State Owned - Describe Use 17R�GHlGT /r/ / 1. CROIX Ol_JNl El y— 't ❑Villa
FILE g- k4iown: hip of
ZON �C aN (7
III. Type of Permit: (Check only one box on line A. o mplete line t applicable)
A. �,' —�
`�N w System ❑ Replacement System ❑ Treatment /Holding Tank Replacement Only ❑ Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. Type of POWTS System: (Check all th apply)
9 , Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade I Single Pass Sand Filter
❑ Constructed Wetland ❑ Pressurized In- Ground Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit Recirculating Sand Filter
❑ Recirculating Synthetic Media Filter eachfng Chambe ❑ Drf Line ❑ Gravel -less Pipe ❑ Other (explain)
V. Dispersal/Treatment Area Infor a t . 1' --
Desi n Flow (gpd)/ Design Soil Applicati ate(gpds Dispersal Area Required (sf) Dispersal ' Area posed (k) System E'ev itio t /
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steed Fiber Plastic
Gallotts Gallons of Units Gfit 4 76 �L Concrete Constructed Glass I
New Existing /�
Tanks Tanks
— - — -- —
Septic or Holding Ta:rk (2� ' Z - - --
Aerobic Treatment Unit — - '— — — —
Dosing Chamber �9 �D - -- -- -- — —
U t �. c
VII Responsibility Statement- I, the undersigned, assume resl7onsibility for installation of the POWTS shown on the :; p
Plu is Na me (Print) Plumb Si gnature MPRvNIRS Number Business Phone Nw:iber
6x� '� z 2
Plumber's Addre ss (Street, City, State, Zip de)
137
VIII. County/Department Use Only -- - - - - --
Approved ❑ Disapproved Sanitary Permit Fee (' cludes Groundwater jute Iss d suinl, Ag t Signature tamps)
Surcharge Fee)
Z � [> /� 0 `
El Owner Given Reason for Denial ' , i
IX. Conditions of Approval /Reasons for Disapproval
X 3. 0 4,0
-af
A,tt_ach o�lans (toAhe Count nly� r the system on paper not less than 81/2 x lliepches in size
SBD -6398 (R. 01/03) Gin f
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of 3
Division otSafgly and Buildings
in accordance with Comm 85, Wis. Adm. Code /�
Cou nty C r o;
X
Attach complete site plan on paper not less than 812 x 11 inches to 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. e
Please print all information. Rewed Date
Personal Inforrrwfion you provide may be used for secondary purposes (Privacy Law, s 1504 (1) (m)). !,L!/jijiyL " 9 1& 3
Property Owner _ Property Location • // /
Govt. Lot 3 I j 1/4 /\J LOM S 5(. T N R (� E ( or )(j)
Property Owners M 'ling Address Lot # Block # Su Name or CSM#
City State Zip Code Phone Number ❑ City _ ❑ tillage &town Nearest R
New Construction Use:8 Residential / Number of bedrooms / _. . Code derived design flow rate -Q 0
❑ Replacement � ❑ Public or commercial - Describe: RECE
Parent material `f Flood Plain elevation if applicable e1/
General comments Sys �Prn e %t� • 9 3 10 i til L j 2 Z 0 02
and recommendations:
d a.�
Boring # ❑Boring
a Pit Ground surface,elev. ft. Depth to limiting factor /0 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description kT t ure Structure Consistence Boundary Roots GPD/ft=
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sli. •Eff#1 'Eff#2
C) - 2- /U 3 1 2 i I 2- ff4r cs
a Boring # Prong Ground surface elev. J 910 ft. Depth to limiting factor 2 -0 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft:
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
[ -l2 (0 3 12 - 5i t 2r�,a b►L r c-5 (v �
s — 5
`7'3 Z A D r
Effluent 01 = BOD > 30 < 220 mg(L and TSS >30 < 150 mg/L ' Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L
CST Name (PI se Print) Signature CST Number i
Address Date Evaluation Conducted Telephone Number
7t,5)
Property Owner U -C. Parcel ID # Page L of
❑ Boring # ❑ Boring
" ' ` a Pit Ground surface elev. �X ft. Depth to limiting factor /0 In. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/(tz
In. Munsell 11U. Sz. Cont. Color Gr. Sz. Sh. •Eff #1 •Eff#2
1 0 3 4 Z _ fflobL rat- c5 I vV `� 8
Z
7] F 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/ftz
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
F-1 Boring # ring
❑ Bo -
❑ Pic • Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture . Structure Consistence Boundary Roots GPD/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2
- • Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOD, < 30 mg/l. and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 -264 -8777.
SBD4330 (Rmmoi
, PAGE 3 OF
NAME � ry` S TOT# J LEGAL DESCRIPTIONS LJ YNW X ,S 3& T 6 ,N,R, E(or)�
SCALE: 1"= t/O - `-
BM 1 ELEVATION (Q . U 1
BM 1 DESCRIPTION 12,p cs 12 �-i
BM 2 ELEVATION
BM 2 DESCRIPTION gic,
SYSTEM ELEVATION Q& O c
ALTERNATE ELEVATION 4
CONTOUR ELEVATION
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Combination Sep•tic;Tank and
P UMP CHAMB CR0S5 SECTION AND SPECIFICATIONS
VEIJT CAP WCATHEF PKODI`
J lJ ►J C T I L' M. 504
I'C.I. vE: JT PIPE / APPR0VE LOCK1K'(
.1O' FROM DOOR, f`1AIJHOLC COYF ' -; N � ' .
,iIIJDOW OR FRESH vuARr.� ai6 r:� 8'
Alk I1JTAKE co>`pU�r
FIL � � "r�». GKl1bC (� j MIL_. �i';
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PROVIDE ( -- _— -.— I - -y
INLET AIRTIGHT SEAL-
APPROVED JOItiT A �1PPfiGY.[: Jni T:
W /C.1. pip EORP Tank construction I I� as /c.z. r'IPE�RF =��
shall comply with
ALi�F M
83.15 and 83.20
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PUMP --�
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K15ER EXIT PERMITFED OIJLy IF TAWK MAlJUFACTUFLER HAS SUCH APPROVAL_
SEPTIC E SPE CIFICAT10QS
DOSE
TArJK MAQUF,ACTURCR IJUMhER OF DOSE5:
TA1,IK `dZC : GAI_L0kJS DOSE VOLUME
ALAR!l1 l�A1.IUFA.C- TURGR: S S � _TZ� S lsT�z i3 III CLIUDING
MODEL QUMBER: �� 1 �w _ CAPA '_ITIES: A=
SWITCH , APE: Jv� �Z°LUR
PUMP MAQLJFACTUREK: L "1 �ZS _ C= ILJCH' S Oft
MODEL IlUMBER: D ____INCHES OR SA,
SWITCH TYPE: MOTE: PUMP AMD ALAKv% ; -, L TO 5L
MWIMUM D15CKARGE RATE _L_vCPM IN5TALLE:D OQ 5E' RATL
VEKTIChL DIFFEKENCE DETWCE►J PUMP OFF AUO.DISTRIbUTIOQ PIPE... _- r E.ET
+ MII.JIMUM NETWORK SUPPLY PRESS FEET
+ -� M
" FEET OF FORCE Ajj X _7 j ipp p FACTOR - —� ( r EET
TOTAL 0tJQA,MIC. HEAD = — _ FEET
Pump chamber DIAMETER �+ -
J)JTF_Kk1AL. DIMEIJSicij4 OF TAIJK: LEtJ&T'H ;WIDTH �. - ,;LIQUID UEPT11 A..._ _.._
BOTTOM AREA — 231 _ Di GAL /I.NICH
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Performance Curve
MODEL ME4O EFFLUENT PUMP
CAPACITY LITERS PER MINUTE
0 50 100 150 200 250 300 350
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10 to
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10 1
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0 0
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CAPACITY GALLONS PER MINUTE
F.E. Myers, A Pentair Company • 1101 Myers Parkway, Ashland, Ohio 44805 -1923
419/289 -1144 FAX 419/289 -6658 Telex 98 -7443
K3326 7/91 Printed in U.,�.A.
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STATE BAR OF WISCONSIN FORM 2. 1999 KATHLEEN H. WALSH
WARRANTY DEED REGISTER OF DEEDS
Document Number I ST. CROIX CO., WI
This Deed, made between Paul J. Brown and Susan M. Brown, RECEIVED FOR RECORD
husband and wife, 10-02 -2000 10:00 AN
WARRANTY DEED
EXEMPT II
Grantor, and _Am Investment Corpor LLC, __ CERT COPY FEE:
a Minnesota limited liability company _ COPY FEE:
TRANSFER FEE: 1202.70
RECORDING FEE: 10.00
PAGES: I
Grantee.
Grantor, for a valuable consideration, conveys to Grantee the
following described real estate in St. Croix County,
State of Wisconsin (if more space is needed, please attach addendum):
Recording Area
W I/2 of NWI /4 of Section 36, Township 30 North, Range 18 West, Name and Return Address
St. Croix County, Wisconsin, except Lot 1 of Certified Survey Map in Vol.
13, Page 3537, Doc. No. 589045 and except Lot 2 of Certified Survey Map
in Vol. 14, Page 3958, Doc. No. 630593. ,r W- AG 9
026 1101 -80 and 026. 1 -90
Parcel Identification Number (PIN)
This is not homestead property.
Of) (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this ZA O" day of September 2000
+ + Paul J. Bro ,{ ,
+
+ Susan M. Brown
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Paul J. Brown and Susan M. Brown, husband and STATE OF WISCONSIN )
) ss.
wife, County )
authenticated this day of September 2000 personally came before me this day of
the above named
• Kristin& Ogtand
TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the person(s) who executed the foregoing
(If not, _ - instrument and acknowledged the same.
authorized by 0 706.06, Wis. Stats.)
THIS INSTRUMENT WAS DRAFTED BY
Attorne KrishncIand a O Notary Public, State of Wisconsin
u son, 1 5401 My Commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.)
+ Names of persons signing in any capacity must be typed or printed below their signature.
Irtormetlon Protou"Is Company. Fond
eo du Lai V
STATE BAR OF WISCONSIN
WARRANTY DEED FORM No. 2 - 1999
PAGE 3 OF
t ME lY� Q 5 LOT# H LEG L�R ip r inNS GJ 1Nw Y S 36 T a N R
SCALE: 1 "= �C)
BM 1 ELEVATION IQL O
BM 1 DESCRIPTION loo a - k , e- �t
I N
BM 2 ELEVATION
1 sic, 3C�
BM 2 DESCRIPTION c Jc�e
SYSTEM ELEVATION
ALTERNATE ELEVATION
CONTOUR ELEVATION
q8
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SIGNATURE DATE
4& C QP7
Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In- Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWTS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
10567-P (R.6/99).
Table 1: System Design Specifications
Sanitary Permit Number S
Number of Bedrooms
Design Flow - Peak (gpd)
Estimated Flow - Average (gpd)
Septic Tank Capacity (gal)
Soil Absorption Component Size (ft
Type of Wastewater Domestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow - Peak (gpd)
Maximum Influent Particle Size (in) 1/8
Maximum BOD (mg /L) 220
Maximum TSS (mg /L) 150
Ta ble 3: Maintenance Schedule
Septic Tank Inspect and /or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the septic tank and outlet filter shall be assessed at least
once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure
proper operation. The filter cartridge should not be removed unless provisions are made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
Management Plan for a Septic Tank and Soil Absorption Component
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, defective, or subject to failure must
be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption components operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Y
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
Y9 P Y
more intense, and earlier, organic clogging of the soil.
2
i
Management Plan for a Septic Tank and Soil Absorption Component
- Plantings of deep- rooted trees and shrubs directly over or within ten feet of the
component should be avoided since root intrusion into the component may obstruct wastewater
flow.
Pi�
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ST CROIX COUNTY
SEPTIC TANK MAINTEI�ANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM��
Owner/Buyer S�� � '/1�� �1✓9�5��
Mailing Address 3 t %/yS�L/� l� t�
Property Address � 7�� M �f Q— %die �
(Verification requi ed from Planning Department f r new construction)
o?&– liq9 _ 02- -g9q Sub .
City /State G( )� Parcel Identification Number 64 672 t I a t o
Q - // y
LEGAL DESCRIPTION
. 111 qA
Property Location -r ' /4, '/4, Sec. , T 36 N -R Town of 29 _W`J
Subdivision 1 U'�' �� 5 , Lot #.
Certified Survey Map # , Volume , Page #
Warranty Deed # -2 ?0 0 /0 `F , Volume _ /_5E7 , Page # / Z - 3
Spec house 0 yes no Lot lines identifiable y es D 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 Department a certification form, signed by the owner and by a
master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. 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 ar a ration date.
l L l O-3
SIGNA OF APPLICANT DATE
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 propert y cribed above, by virtue of a warranty deed recorded in Register'i of Deeds Office.
SIGNA 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
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