HomeMy WebLinkAbout026-1149-16-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Divitf'rpn ,
INSPECTION REPORT Sanitary Permit No:
463460 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:
Fox, Jon I Richmond, Town of 026- 1149 -16 -000
CST BM Elev: Ins p. BM Elev: BM Description: Section/Town /Range /Map No:
�� ( - 36.30.18.1116A
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic u� / j Benchmark 106
Alt. BM 1 .(V 3
Aeration J Bldg. Sewer / 4715
Holding St /Ht Inlet ` C� fp q14111 •
St/Ht Outlet
-
TANK SETBACK INFORMATION �J
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic , Q / n f + / + i Dt Bottom \\
Dosing f Header /Man.
Aeration Dist. Pipe.
9
Holding Not. System
Q� a�
PUMP /SIPHON INFORMATION Final Grade C ( C/�• 5
Manufacturer Demand St Cover A
GPM to b
Model Nu m _T\ 7. Q - q 1
TDH Lift Friction Loss stem Head H Ft Z
Forcemain Length Dia. Dist. to Well /
SOIL ABSORPTION SYSTEM
BED /TRENCH Width 1 Length No. Of Trenches PIT DIMENSIONS No. f Pits Inside Dia. Liquid Depth
DIMENSIONS '2 Q'C Z -- �t( „ ^ \
SETBACK SYSTEM TO O I P/L BLDG i WELL ^J LAKE /STREAM LEACHING Manufacturer:
INFORMATION Type Of System: r _ o /�/ �� / AI� CHAMBER OR Model Number. 5 j U
OdvUP� O /✓ Q
DISTRIBUTION SYSTEM 1.�12bE-C2 / ��� z: y d
Header /Manifold Distribu ion x Hole Size x Hole Spacing Vent to Air nta�
L \ p g\ Zr dvti
1 Leng t h _ _jZ,_ Dia Len th Dia S acin
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over f Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed /Trench Center 4 / Bedrrrench Edges Topsoil Yes No Yes ' 1 No
- 1
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 1259 142nd Street New Rich ond, WI 54017 (SW 1/4 NW 1f 4 36 T30N R18�jW. )) Torey Pines II Lot 16 Parcel No: 36.30.18.1116A
1.) Alt BM Description
2.) Bldg sewer length =
- amount of cover = I ZO ?4Z �l � �-6
Plan revision Required? [ `l Yes XNo -6
Use other side for additional information. _ I — AL
_ - -- --
Date Insepctor's nature Cert. No.
SBD -6710 (R.3/97)
I
Safety and Buildings Division Counry� /� �
201 W. Washington Ave., P.O. Box 7162 (, 7-
` Madison, I -7162 Sani ermit Number (to be filled in by Co.)
iscons�rn �' (60 ) 266'
Department of Commerce S to Plan I.D. N umber
Sanitary Permit A 'ion ��,, �1
In accord with Comm 83.21, Wis. Adm. Code, perso i ation ydu.povif ar roject Address (if different than mailing address)
may be used for secondary purposes Privacy La 5. (S(m) C (�(� j
I. Application Information - Please Print All Information ZONING OFD (-- ,
ias9 iya �d s r.
Parcel # � Lot # Block #
Property Owner's Name ( / o
Property Location
Property Owner's Mailing Address f
tL / / 1 Section
City, State J _ - Zip Code Phone Number
ct r e
) � � � � � N ; or on
1T. T e nilding (check all that apply) �f Subdivision Name n L. Number
or 2 Family Dwelling - Number of Bedrooms
❑ Public/Commercial - Describe Use ❑City ❑ la ship o /
❑ State Owned - Describe Use
III. Type o Permit: (Check only one box on line A. Complete line B if applicable)
A " w System ❑ Replacement System C1 Treatment/Holding Tank Replacement Only ❑o Modification to Existing System
B. ❑ Permit Renewal rmit Revision El of ❑ Permit Transfer to New
List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. T e of POWTS S stem: Check all that a 1
Non - Pressurized In-Ground [I M ? 24 in. of suitable soil ❑Mound < 24 in. of suitable soil At -Grade El Single Pass Sand Filter
Con ed Wetland 11 Pressurized In -Gr d ❑Holding Tank El Peat Filter ❑ Aerobic Treatment Unit El Recirculating Sand Filter ❑
❑ Other a
Recirculating Synthetic Media Filter hing C r 13 Drip Line 11 Gravel-less Pipe P
i
V. Dis ersalffreatment Area Information: i Dis ersaI At o (sf) System Elevatio
Desi Flow (gpd) D , esignS it Application Rate(gpdsf) Dispersal Area Required (sf) p Y 7 //!l�jJ
` f�'� 8
C aci tal Number Manufacturer Prefab Site tee/ Fiber Plastic
VI. Tank Info ap t in To Concrete Constmcted Glass
Gallons Gallons of Units
New Existing
Tanks Tanks
Septic or Ho Tank
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement- I, the under ed, assume responsibility for installation of the POWTS shown on
Plum er's Name (Print) the attached P one N e
Pl s Signature MP/M�� Number �/� � �7/ }anr
—T,)
2 2
Plumber's Address (Street, City, State, Z" ode)/1
VIII. oun /De artment Use Only
Sanitary Permit Fee (includes Groundwater Date Issued uing Agen tgn a ps ) `
Approved El Disapproved Surcharge Fee) O 0-0 0 I
❑ Owner Given Reason for Denial �
IX. Conditions of ApprovayReasons for Disapproval
0�/
��. /007-
/V ul cvi� �' e�
,A,c (
Attach complete us (to the County only) for the system on paper not les than 8112 x 11 inches in size
SBD -6398 (R. 01/03)
' Soil Test and System PLOT PLAN
PROJECT John Fox ADDR SS 261 155th St. Amery Wi 54001
'SW 1/4 NW 1 /4S 36 /T 30 N/R 1 W TOWN Richmond COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 7/6/05 BEDROOM 4
CONVENTIONAL XXX IN- GROUND PRES E CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK IZ 1255 LIFT TANK SIZE DOSE TANK SI
S E
HOLDING TANK SIZE .7
LOAD RATE ABSORPTI AREA 872 28
ON AR # of chambe s
BENCHMARK V.R.P. Top of Lookout foundation ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL *H. R. P Same as Benchmark
Plans Designed Using SYSTEM ELEVATION 93.0/92.0 5' below qrade
Conventional Powts Property Line
Manual Version 2.0 W
Town R oad
Drainage easement elevation is
2. below basement floor.
Well is to meet all This elevation was verified by the
S( required by local building inspector!
WDNR Pro 4
Bedroom
House
0
140'
0'
25' ST
B- 20'
10% Slope 5 9 ,
150' ? 5 9 -
0 '
? 30'
B -2 #UU4_ ie- 1007.
Vents b Drainage i v l la
r
Vent q� easement,basid on
elevations taken!
ALo Standard Biodiffuser 3. S �"
^ Leaching Chamber U,
with 3 1. 1 ft2 of Area g&
7 Sl -
Grade at System Elevation
Town Road
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page / of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County �. ✓17 i
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 1� — �(p
Please print all information. viewed Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner _ Property Locca J ''tionll
X Govt. Lot W 1 /4XA4)A S T -� ON R
Property Owner's Mailing Address Lot I Block # Subd. Name or CSM#
City State Zip Code Phone Number ❑ City ❑Village W own Nearest Road
Construction Use: Residential / Number of bedrooms Code derived design flow rate A5;�d GPD
❑ Replacement ❑ Public or qqmmercial - Describe:
Parent material Flood Plain elevation if applicable ft.
General comments o n f1
and recommendations: _5 Y d
FFJ Boring # Bonng?—
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/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2
Z. C.rw' k fu G
A/
Boring # E] Boring C^
V-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/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
/
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 ' Effluent #2 = BOD 130 mg/L and TSS < 30 mg/L
CST blame (Please Print) re CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date Evaluation Conducted Telephone Number
1008 192nd Ave, New Richmond, WI 54017 7 — �� D 715 - 246 -4516
Property Owner Parcel ID # Page of
FN Boring # Boring r/
� III Ground surface elev. Y ' ft. Depth to limiting factor I D in.
Pit Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Z, _ — C, bl F c
Boring # ❑ Boring
❑ ❑ pit Ground surface elev. ft. Depth to limiting factor in.
Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2
E Boring # ❑ Boring
11 Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Akpplication Rate
Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Effluent #1 = BOD. > 30 < 220 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.
SBD -8330 (8.000)
Safety and Buildings Division Coon CC
201 W. Washington Ave., P.O. Box 7162 V
Madison, 2 Sanitary Permit Number (to be filled in by Co.)
V &conaffn '
Department of Commerce (608) - 51 RE 3 `f6�
Sanitary Permit Applic c P'an D Number
In accord with Comm 83.2 1, Wis, Adm. Code, personal info ti providMAY o C
may be used for secondary purposes Privacy law, 1)( " jest ess (if different than mailing address)
1. Application Information Please Print All Information J, Z NINGOFFI E Y 12" PA
Property Owner's Name 'i^_ arce Lot # Block #
..........
Property Owner's Mailing Address Pro lion /
l S�S� `��. _ st d % / Section :3 .b
City, State Zip (Code l Phon umber
G / T 2N; 1 or W
/ G .-az6
Z 11. T pe of Bu' ng (check all that a ly)
S _� Subdivision Name CSM Number
1 or 2 Family Dwelling - Number of Bedr s
❑Public/Commercial - Describe Use
El State Owned - Describe Use ❑City ❑Vil ship of Zi
III. Type of ermit: (Check only one box on lin . Complete e B if applicable) OZb - g -16- am • U m 6A
A. System ❑Replacement System Treaimen olding Tank Replacement Only ❑ er Modification td�xisting m
B. El Permit Renewal El Permit Revision El ange f ❑
r Permit Transfer to New
L t v' us d
Before Expiration Plum Owner
IV. kpe of POWTS System: (Check all that apply)
essurized In - Ground ❑ Mound > 24 in. of suitable s it 10 Mound < 24 in. of suitable soil ❑ At -Grade 11 Single Pass Sand Filter
Constructed Wetland El Pressurized In- Ground ❑ Holding ank ❑ Peat Filter 11 Aerobic Treatment Unit ❑ R atrng Sand Filter ❑
❑ Drip ex
Recirculating Synthetic Media Fil hing Chamber p e ❑ Gravel -less Pipe ❑ Other (explain)
)
V. Dis ersaLlTreatmcut Area ormation:
Design Flo d) Design So Application Rate(gpdsf) Dispersal Required (sf) Dispersal posed (sfl '
VI. Tank Info Capacity in Total umber CJ Manufacturer O � J Prefab Si ' S AI Fiber Plastic
Gallons Gallons f Units ( W �j _ Q� Concrete Constructed Glass
New E)dsting �+
Tanks Tanks
Septic or Holding Tank y S
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility State nt- 1, the undersi ume responsibility for instal do of the POWTS shown on the attached plans.
Pl r' Name (Print). Plumber' store MP N ber Business Phone Number
/a-,,_ 20 o)
Plumber's Address (Street, City, State, Zip a ��
VIII. Conn /De artment Use Onl
Approved ❑ Disa proved Sanitary Permit Fee 'eludes GrounDate Issued Issum Agent Signature (No Stamps)
Surchar Fee) 3� 10
❑ o n for Lial IV
IX. Conditions of Approval/Reasons for Disapproval 3 S
SYSTEM OWNER. J __ -�Q .v�.��uC
1 Septic tank, effluent filter and iS �Q
dispersal cell must all be serviced / maintained
as per management plan provided by plumber.
2. All setback requirements must be maintained � , ;, p� �(� d�,v1�•Q "ot,�Qas
as per applicable code /ordinances.
Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size
SBD -6398 (R. 01/03)
430/ T PLAN
PROJECT John Fox D ESS 261 155th St. Amery Wi 54001
SW 1/4 N W 1 /4S 36 /T 18 W TOWN Richmond COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE5 /6/05 BEDROOM 4
CONVENTIONAL XXX IN -GROU RESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1255 LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 872 # of chambers 28
IL 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 98.4/97.2 3' below qrade
Plans Designed Using Pro 4 Bedroom House
Town Road Conventional Powts
Manual Version 2.0
15'
Well is to meet all T
setbacks requir d by
WDNR 20'
B-
30 15' B.M. #1
' 15'
30' 50'
.M. #2
B- 10 ,
Vents
B -3
2 -3' X 88'Cells with >3' Spacing
150'
G Vent
ALo Standard Biodiffuser
Leaching Chamber
with 3 1. 1 ft2 of Area
1 "
34" Grade at System Elevation
Town Road
430/ T PLAN
PROJECT John Fox AD ESS 261 155th St. Amery Wi 54001
SW 1/4 NW 1 /4s 36 / 18 W TOWN Richmond COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 5/6/05 BEDROOM 4
CONVENTIONAL XXX IN -GROUN RESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1255 LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 872 # of chambers 28
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 98.4/97.2 3' below qrade
Plans Designed Using Pro 4 Bedroom House
Town Road Conventional Powts
Manual Version 2.0
15'
Well is to meet all T
setbacks requir d by
WDNR 20'
�z y
B- .
30 15, B.M. #1
' 15'
30' 50'
.M. #2
B- 10'
Vents
B -3
2 -3' X 88'Cells with >3' Spacing
150'
Vent
>6 „ Standard Biodiffuser
of Cover Leaching Chamber
with 3 1. 1 ft2 of Area
6' Long 11 "
Grade at System Elevation
34"
Town Road
`Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of
Division of safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
� � county
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must
Include, but not limited to: vertical and horizontal reference point (BM); direction and Parcel I.D. ( /
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. vi by Date
Personal lnfarmation you provide may be used for secondary purposes (Privacy law, s. 15.04 (1) (m)). � / -71
Property Owner _ Property Location _ .. .. .
a Govt. Lot �� 114 Nik) /4 S 3(p T I' N R ($` E (or)A
Property Owner's Mailing Address Lot # I Block # Subd. Name or CSM# PincS
City State Zip Code Phone Number ❑City _ ❑ Village Town sorest Roa
lV [ O 1
B -New Construction Use: Residential / Number of bedrooms ` .. Code derived design flow rate GPD
❑ Replacement �( ❑ Public or commercial - Describe:
Parent material 1 t I 1 Flood Plain elevation If applicable jq R.
General comments 5� S-. e yi -e / ru, cs Sd /�� w - V,! , O U R
cc
' IV
and recommendations: LED
' -)L 2 2002
Bi F�i - vti d f (W L� b wec Gas- c&i&/ 44v,,- s B
F I ❑ Boring E
Boring # � �- ....: _
Pit Ground surface elev. / R Depth to limiting factor in
Soil Appl(cai6n Rate
Horizon Depth Dominant Color Redox Description Tex ture Structure Consistence Boundary Roots GPD/R
In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sti. •Eff#1 •Eff#2
-12 lb 3 sl I vy' S .q
Ito — ms
F72-1 Boring # ❑ Boring oa- a0
Pit Ground surface elev. R. Depth to limiting factor W in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/R'
in. Munsell (]u. Sz. Cont. Color 1. . Gr. Sz. Sh. 6 01#1 •Eff#2
iris
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 _< 150 mg/t- ' Effluent #2 = 1301) : < 30 mg/. and TSS < 30 mg&
CST Name (Please Print) Si nature A CS Number 3
AAarn r 25
Address Date Evaluation Conducted Telephone Num4er
2115 . arf 4, wt. Noz5 -- - 7-// - 0 70 (1tS)Zqj_g00
i a
Property Owner Parcel ID # Page
D Boring # ❑ Boring
Pit Ground surface elev. 9 7, d 1 Depth to limiting factor 1 in.
t Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDittz
In. Munsell . Qu. Sz. Cont Color - Gt. Sz. Sh. 'Eff#1 •Eff#2
I o -lo to r31. sc_ 2msbk m� r c s I a
m
7] Boring
Boring # ❑
❑ Pit Ground surface elev. R Depth to limiting factor in.
Soil Application Rate
Horizon Depth • Dominant Color Redox Descxtpdon.._ ., _. Texture _ _Struch re Consistence Boundary Roots GPD/ft
In. Munsefl Qu. Sz. ConL Color Gr. Sz. Sh. •Eff#1 •Eff#2
F-1 Boring # ❑ Boring
❑ Pit Ground surface elev. fL Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture . Structure Consistence Boundary Roots GPD/ft
in. Munsefl Qu. Sz. ConL Color Gr. Sz. Sh. •Eff#1 'Eff#2
• ' Effluent #1 = BODS > 30 < 220 mgA- and TSS >30 < 150 mg/L • Effluent #2 = BOD, < 30 mg,% 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 608-266-31 or TTY 608 - 264 - 8777.
SBDE330 (R07100)
� \ ��►; = 101 �
5.
`
-::-'LOT 26 ,, _ . . _ _ ! �.a
2.0 � C7 R
� (2.3 ACR S) 1 (1.0 i
30 bR
LOT 25 • - • -f / • - LOT 1 1 / 1 F .000 ,r
\` t- / I / / 2.074Z:RES �a /
� �2.3 ACRES • ,� N � ,
(2:3 ACRES) // $ / / �"- (
,3�
LOT 24
ACRES
(2.0 ACRM - -� I // / / / �F
418' 1 ' �J
L 6T / 1
LOT123 / �� ,� �� ,�/ / / MIN F� /
J 05
�' i
2.0 ACR ) / , 45 A REII�
317'
1
496'
/
1 9 ' ' - 1 I -7- �- 7 / /-
_� I 409'1 66
Lpt 1 1,6o x I LO �P 18 I
/2. Rig / /� ;! 1000. 1 2.1 ArCRE�S
ES / i I (1 ACRES)
(1. A
)► f
/� ,
/ TORM WATER , 1 ,
/MI F ( \ I J 1 /
R TION AREA, I 1 , 1 MI FFE I o
NWI _ i I ', =1�nn
PAGE 3 OF
NAR:E �- S LOT# I LEGAL DESCRIPTION -<,(-j Y � ` 4 ,S 36 T 3a N R 19 E(or
SCALE: 1 "= ' G
BM 1 ELEVATION / O c - O
BM 1 DESCRIPTION P c ,o, p -e — t
BM 2 ELEVATION 9 7
BM 2 DESCRIPTION -� c • 3
SYSTEM ELEVATION
ALTERNATE ELEVATION ItilA-
CONTOUR ELEVATION 101. U d - /'O c> o a' 9 )f, C>6
0
a
10v
0
/ ox)
, '
i
SIGNATURE DATE
"ORIGINAL 1666
Wisconsin Department of Commerce SOIL EVALUATION REPORT of 3
Division o f Safety and Buildings �il Testing
in accordance with Comm 85, Wis. Adm. Code
Cou ty DF
Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must t. Cr,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. Par I I.D C1 _
Please print all information. NTY ate
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). OF ICE- I �(O r0 Z
Property Owner Property Location
Ames Investment, LLC Govt. Lot NW 1/4 NW 1/4 S 36 T 30 NR 18 W
Property Owner's Mailing Address Lot # Block # I Subd. Name or CSM#
34 Peninsula Rd 10 Tory Pines
City Dellwood State Zip Code Phone Number City iA Village Pj Town Nearest Road
MN 1 55110 1 715 -386 -2007 Richmond I 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 //
co
W+-
Fq Boring # Boring I �h
Pit Ground Surface elev. 96.0 ft. Depth to limting factor min. Voil Application Rate
Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPDIft'
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
3 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
a Boring # J Boring
set Pit Ground Surface elev. 97.0 ft. Depth to limiting factor min. Soil Application Rate
Horizon I Depth I Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDtft'
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2
1 0 -7 10YR 3/2 - sil 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 = BOD 30 < 220 mg /L and TS ffI >30 < 150 mg /L e 2 = BOD < 30 mg /L and TSS < 30 mgL
CST Name (Please Print) CST Number
Sin ure:
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
II
Property Owner Ames Investment, LLC Parcel ID # Page . 2 of 3
a Boring # 2j&, Boring ki Pit Ground Surface elev. 94.9 ft. Depth to limiting factor 45 in. Sol Application Rate
Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2
1 0 -9 10YR 3/2 _ SO 2 f sbk mvfr CS 1f /m .5 .8
2 9 -16 10YR 4/4 _ sicl 2 m sbk mfr cs 1m .4 .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 SCI 0 m mfr - - 0 0
I
F-1 Boring # Boring
Pit Ground Surface elev. ft. Depth to limiting factor in. Sol Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots '
in Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
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❑ Boring # Boring
j 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 '
in. Munsell Qu. Sz. Cord. Color Gr. Sz. Sh. •Eff#1 `Eff#2
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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.
SBD -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. r filter is being installed in
2. Effluent filter is to be cleaned once a year. Please note: a large
order to extend the maintenance interval of the filter. pipes at the ends of
3. Once every 3 years, cells are to be inspected via the P
the cells.
4, Owner agrees to limit greas es , garbage, and water conditioner discharge into the system.
6. 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
Contin ency Plan
p
tion #1. I system fails, determine cause of failure, use a'ernate and and install new
system in tested replacement area.
option #2. Install system at a lower elevation, by removing chambers, removing biomat,
and install new system.
d uate area is suitable for replacement area, and system elevation
Option#3. No a eq
cannont be lowered. Install holding tank as last resort.
3. 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 -5
Shaun Bird #226900
ST CROIX COUNTY
• SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
owner/Buyer _
Mailing Address
5 � -
Property Address -
(Verification required from Planning Department for new construction)
City/State Parcel Identification Number
LEGAL DESCRIPTION
'on �� ' /•, r,,�, > Sec. � 4:') � � N -R Town of _&
Property Location �� /
Lot it
Subdivision °
Certified Survey Map #
�^ , Volume � - --� _Page #
Warranty Deed # gg 7Z� , Volume 2 . Page #
Spec house ❑ y <no
Lot lines identifiabres ❑ no
SYSTEM MAINTENANCE
m could result in its premature failure to Pumper- Wh wastes- P i hem
Impro use and maintenance of your septic syste if needed b
consists of pumping out the septic tank every three years or sooner, icens pumper y P
can affect the function of the septic tank as a treatment sta in the waste disp syste
own to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
The pro owner agrees verifying that 1 the on site wastewater disposal system
mastorplumber, Joumeymanplumber, restrictedplumber or a licensed rig the () tic tank is less than 1/3 fun of sludge.
is in proper operating condition and/or (2) after inspection and pumping (if necessary), SeP
m with the standards
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system Wisconsi systh Certification
ent of Commerce and the Department of Natural Resources, Office ti
stating that your septic system has been maintained o
set forth, herein, as set by the Department be completed and returned to the St. Croix County Zoning
dayypf the three year expiration date.
DATE
NATURE OF APPLICANT
OWNER CERTIFICATION our e I we am (are) the ownCr(s) of
I (we) certify that all statements on this form are true to the best of my ( ) knowledg • ( )
the property descr above, by virtue of a warranty deed recorded in Register of Deeds Office.
J
DATE
IGNATURE APPLICANT
artnient.
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning De p
*• 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
. i
74Be e+27
Isco'nsin 2 KATHLEEN H. WALSH
State Bar of Fo 3 2103 REGISTER OF DEEDS
WARRANTY DEED ST. CROIX CO., WI
RECEIVED FOR RECORD
Document Number Document Name
02/28, 01:00PK
WARRANTY DEED
EXEMPT I
THIS DEED, made between Ames Investment Corporation, a Minnesota Limited
REC FEE: 11.00
Liability Company TRANS FEE: 154.00
( "Grantor," whether one or more), COPY FEE:
and Johnathan E. Fox and Holly M. Fox, husband and wife CC FEE:
PAGES: 1
( "Grantee," whether one or more).
Recording Area
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate, together with the rents, profits, fixtures and other appurtenant Name and Return Address `
interests, in St. Croix County, State of Wisconsin ( "Property ") (if more space is �� rte"
lease attach addendum):
Lo , Plat of Torey Pines I I in the Town of Hammond, St. Croix County, 5y&wl
Wisconsin. /
026 -1149- 16-000 /!lb
Parcel Identification Number (PIN)
This is not homestead property.
(is) (is not)
Exceptions to warranties: Easements, restrictions and rights-of-way of reco , if any. ;
Dated /
(SEAL (SEAL)
* *Ames estment Corporation
(SEAL) (SEAL)
* *
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) �'QQ
authenticated on STATE OF �4 )
r � ) ss.
Uid COUNTY )
* TITLE: MEMBER STATE BAR OF WISCONSIN Personally came before me on �j t , lQ ncc —
(If not, the above -named Ames Investment Corporation, a Minnesota
authorized by Wis. Stat. § 706.06) Limited Liability Company
to me known to be the person(s) who executed the foregoing
THIS INSTRUMENT DRAFTED BY: ins ent and acknow the same.
Attorney Kristina Oeland
Hudson, WI 54016
Notary Public ate o
My Commissi n (is permanent) (expires:
(Signatures may be authenticated or acknowledged. Both are not necessary.)
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED.
WARRANTY DEED ® 2003 STATE BAR OF WISCONSIN FORM NO. 2-2003
* Type name below signatures. INFO-PRO— Legal Forms 600 -655 -2021 www infoproforms.com
I
• ' • : 2.002 ACRES (87,200 SO. FT.)
-� - .... .
MIN FIFE = 1015.00
J
I I m
O I N 89°57'10" E 436.00'
F.
?"
• W I
30' DRAINAGE
EASEMENT
ro
• ^31 ,IA
��$ a�
LOT 15 I 111
S q
' ♦-- : 2.002 ACRES (87,200 SO. FT.) I _
I I rn
l MIN FIFE = 1009.00 I �' I 10
N 8957'10" E 436.00' ;, . - ��
°
r. A
6. 0' �. 100.
` ELEVATION = 102
/'..' 4`.� -.
LOT 16 /. AZ. y ... .
2.613 ACRES `�.
(113,802 SO. Ff.) �/ 10 Ip
MIN FIFE = 1009.00 . ---- - Ig I�
Iq
/. ......./ OD 10o
I� I
,• ; LOT 17 I� 1
....... Q' / Ill ID
• i- • • � •' Q' j 3.473 ACRES (151, 296 SO. FT.)
/.:.:.:.:.:. �O� / MIN FFE = 1009.00 Is la
A•
/. /
% ...... ............................... • Soy RADIUS TEMP
r , .... - CUL -DE -SAC EAS
TO BE AUTOMAT
/ ;rGt'.','.' / ���� EXTINGUISHED
►'� — ROAD EXTENT
527.
55'
1