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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
514863 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:
Dorsey, Joseph I St. Joseph, Town of 030 - 1052 -90 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
/Ott I &A 1 c-0- 23.30.19.197Q
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 1 /� Benchmark
3.
AI7 1
Aeration Bldg. Sewer
Holding St/Ht Inlet 7• 05 9 6 x 5 3
TANK SETBACK INFORMATION St/Ht Outlet 7 -Z cr
TANK TO t P/L ' WELL S pLDQ j . Vent to Air Intake ROAD Dt Inlet
Septic / / i Dt Bottom _1
Dosing Header /Man.
Aeration Dist. Pipe
Holding Bot. System
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer Demand St Cover ,/ ..q
GPM F, I.�.a� C J C_. 7 + / ' 3
Model Number
T H Lift riction Loss S stem He T llH Ft
D y
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK Y TEM TO /L BLDG WELL LAKE /STREAM LEACHING anufacturer:
S S
INFORMATION
CHAMBER OR
Type Of System: 1 L t �+� 1 UNIT Model Nu
UT
DISTRIBION SYSTEM V a7 4a ka
Header /Manifold Distribution _ x Hole Size x Hole Spa Vent to Air Intake
Pipes)
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over IDepth Over xx Depth of xx Seeded /Sodded j xx Mulched
Bed/Trench Center Bed /Trench Edges Topsoil Yes No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 1416 Hidden Oak Trail New Richmond, WI 54017 (Gov't Lot 1 23 T30N R19W) metes bounds Lot f ar el No: 23.30.19 197Q
1.) Alt BM Description = e Z_ t � 4-' (> t Gk
2.) Bldg sewer length = C
- amount of cover = E� 6 �a.w 1<C
Plan revision Required? [6N] Yes No
Use other side for additional information. ()�
Date Insepctor's S ature Cart. No.
SBD -6710 (R.3/97)
t:olmme lrCe .wi.gov Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162 St. Croix
i sc o n s n Madison, WI 53707 -7162 Sanitary Permit Number (to be filled in by Co.)
Departmerrt of Commerce S / A I g (p
Sanitary Permit Application State Transaccti�on Number
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the riate govern roject Address (different than mailing address)
unit is required prior to obtaining a sanitary permit. Note: Application forms for state -o S are
submitted to the Department of Commerce. Personal information you provide may be used for seco t � 64
purp oses in accordance with the Privacy Law s. 15.04 1 m , Slats.
I. Application Information — Please Print All Information
.
Property Owner's Name � Parcel # �
Joseph J. Dorsey � MAY 0 2 2008 030 - 1052 -90 -000 (o /9
Property Owner's Mailing Address L LZO ROLGO UN Property Location /
NINFICE
1416 Hidden Oak Trail Govt. Lot 1
City, State Zip Code Phone Number �/. /4, Section 23
New Richmond, Wl 54017 3 F 15 246 -7627 (circle one)
T 30 N; R 19 W
II. Type of Building (check all that apply) l` t #
❑ 1 or 2 Family Dwelling —Number of Bedroo 3
t^ Na Subdivision Name
Block #
❑ Public /Commercial — Describe Use
Na ❑ city of
❑ State Owned — Describe Use CSM Number ❑ V' lage of
Na A Town of St. Joseph
III. Type of Permit: (Check only one bog on line A. Cyn1plete line B if applicable)
A, ❑ New System ❑ Replacement System Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
0 1.1
B. ❑ Permit Renewal ❑ Permit Revision ❑ C ange of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Lssue
Before Expiration Owner
IV. T e of POWTS S stem /Com onent/Device: Check all that appl
❑ Non - Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dispersal/Treatment Area Information:
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
750 sq. ft.
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units o °
' U
New Tanks Existing Tanks
Septic or Holding Tank 1,000 1,000 1 W Concrete X
Dosing Chamber 5 (0 6
VII. Responsibility Statement- I, the u dersigned, assu a responsibility for i on of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber' Sign MP/MPRS Number Business Phone Number
James K. Thompson s--- 30021 (715 ) 248 -7767
Plumber's Address (Street, City, State, Zip Code)
340 Paulson Lake Lane, Osceola, W1 54020 -5413
VIIL Coun /De artment Use Onl
proved isapproved Permit Fee Date I ued Issuing t Signature
❑ eason fo nial $ 225 co
VL Condit��g, r� al/Reasons for Disapproval
1. Septic tank, effluent filter and
dispersal cell must all be services /be services / mainlined
as per management plan provided by plumber.
2. All setback requirements must be maintained Rev: 01/16/05
29 PK21:1w.
Attach t r m submit to the County o on r not less than 81/2 x 11 inches in size
o complete sns o the system and ty y page
SBD -6398 (R. 01/07) Valid thru 01/09
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2096
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 2
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil 8 Site Evaluations
Attach complete sile plan on paper not less than 8% x 11 inches in size. Plan must ounty St. Croix
Include, but not limited to: vertical and horizontal reference point (BM), d' rid Parcel I.D.
percent slope, scale or dimemsans, north arrow, and location and distance 030-1052-90-000
Please print all Information.
Revie By Date
Personal infonnsfim you provide may used v y Law, 15.04(l m . /L Z O7
Property Owner Property Location
Joseph J. Dorsey Govt. Lot 1 1 1 S 23 T 30 N R 19 W
Property Owner's Mailing Address Subd. Name or CSM#
1416 Hidden Oak Trail ( Na Na I Na ST-
City State Vip Co poMml;W J City J Village a Town Nearest Road
New Richmond WI 1 54017 1 (715) 246 -7627 St.Joseph I Hidden Oak Trail
New Construction Use: 116 Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD
Replacement J Public or commercial - Describe:
Parent material Glacial Outwash Flood plain elevation, if applicable Na
General comments
and recommendations: Evaluation completed to verify suitability of existing dispersal cell to allow replacement of existing septic
tank.
Boring # J Boring
16 Pit Ground Surface elev. 94.37 ft. Depth to limiting factor >91 in. Soil Application Rate
Horizon Depth Dominant Color Redox Desoription Texture Stnxture Consistence Boundary Roots GPD
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. `E1f#1 `
1 0-22 varies none mixed fill Na Na as 2vf,f Na Na
2 22 -26 10yr2/1 none I lmsbk mvfr cs 1vf,f 0.6 0.8
3 26 -32 10yr4/4 none Is 0 sg ml cw 2vflfm 0.7 1.6
4 32 -50 10yr4/3 none Is 089 dl aw - 0.7 1.6
5 50-80 7.5yr4/6 none Is 0 sg dl aw - 0.7 1.6
6 80-91 10yr4/6 none s 0 sg dl aw - 0.7 1.6
92 I o ZW
I I /-� ' !�Zz I I
' Effluent #1 = BOD? 30 <220 mg/L a d TSS >30 < 196 mgA- ffluent #2 = BOD 1 mg4- and TSS 1_30 mg/L
CST Name (Please Print) N, CST Number
James K. Thompson 5 -- 3602
Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number
340 Paulson Lake Lane, Osceola W154020 1015/2007 715 -248 -7767
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Scale 1" = 50'
Q � Property address: 1416 Hidden Oaks Trail
ti New Richmond, WI. 54017
C.J // • indicates iron survey monument found.
as noted )
Q ' NOTE' shared driveway.
" ��' ( verbal agreement between Mariene Kielsa (seller) and
19. property owners to the North )
ly
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(In trsa) ro��n /e 22g
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NOTE: probable garage enc oactimerrt. o
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DESCRIPTION:
Part of Government Lot 1 of Section 23, T30N, R19W, To1Nn of St. Joseph, St. Croix County, Wisconsin, descrii--d
as follows: Commencing at the E1/4 corner of said Section 23; thence South 1700.00'; thence West 1981.4' to
the place of beginning; thence N70 18'W 287.5' to the shore of Bass Lake; Lhence S22 00'W on lake shore 60.0';
thence S71 02'E 311.7'; thence N01 30'W 60.0' to the place of beginning. TOGETHER WITIi easement for
access road from above described parcel to the Town Road on the South line of said Section 23.
NOTE: a full comprehensive survey was done on the property to the South and durine that survey the oz,rnoo G ,
the above described parcel was found to encroach onto the parcel to the South. An " agreement" was either signed
or is supposed to be signed by the parties involved to resolve this matter.
• ` ' -/ � ;rte
lie lucaliou of improvements on this drawing are approximate. The lot dimensions are taken born plats a deeds of
county records. 11tis draNving is for informational purposes only and should NOT be used as a complete; Lauri Survey.
r rst Fedrral has agreed to waive these reyuirernents ot'A 1.7.02, A - E7.03, A - 1;7.01, A - FTM.
E?.0i (1) (5), and !�- F.7.07. The PUTT u,cr of this harri[rar1h i^ to comely with ,1- Is'1.t11 C i
05/02/2008 12:02 FAX 715 248 7764 A C E SOIL & SITE EVAL. 001
NO 426 P 0
Mai, 2. 2006_ 9:17 _
ST. 0WIX COUNTY
SEPTIC TANK MAXNMANCE AGREEMENT
AND
OWIIERSHIP CERTII CATION FORM
Owner
M ailing Addreu
Property Address
(W.rifreadou xegwhvd from Planning dt Zoning Department f0r DOW oonw
Cigatnte Mmdfication Number O'er l diSZ "C
LE�,DE
PiaPetty l.ae atlan �� � /ot • _ sec. _.2- . T 3 O-..N R / Q w, Town Of SE - Ta s a P
Subdivision 4;4 _ , Lot #
Cw fmd Survey Map Volume 14 4 — , Page #
Warranty Deed # _ _ . Volume - Page #
Span 6ousa yea no Lot lh+es idortsifiabk (R) no
MTRM M&jMX TANCE AND O-Wb= 939 - 1 =AMN
lv4woper use and nwintaaame of yaw mpft system could rrsak in its pretnattam More to bwdlo wastes - Ptoper
maintr�tartae eeneigo of pWnpingout tiro sapdC IN* e+�ary Slate! years: o+: aoo=, if aeedad, by a licensed pamper. What you pat into
tbo systow can affect the fiWeLto n of the septic tank as a nu m a stage in the waste dispoW syoWm. OwxW toaint"mcs
rrapon ibdlities are specified in §Canon. 8332(1) and it► Cbepter 12 - SL Croix County 83nibwY OrdfimVde.
The property owner agrees to submit to St Croix CAongr Flaming do Zoning DapsetmwA a eerdflcadoa fo= aigned by the
own" and by a maaber plumber, lournayam pittnnber. ramb icmd plumber or a licen9eil putrtpatr Ve it iag that (1) the ert
wastewater disposal sygetn is in proper operating co"fkw and/or (2) alter bwMcdca and, pumping (if ascot WY). the septic mk is
loss than 113 full o(sludge.
Uwe, the undersigned have read the abovs tregadrements and agree to nWnasin the private cowaps disposal system with the
sundards sat ( bacK as sa by the Doonarn ni of C.ommeree and ft DCpwumx c of Namnl ReaoWAa. State of Wi$cw$b .
Crrti5oat#on sating that your adpde sy am bas beaca rnainrolned mast W cwnpletad and ratwtred to the St. Crot: C OU69Y PlOwdug &
2aning Depamrtent within 30 days of tha throe year espiradon dare.
Uwe certify that all statenrenta on tiffs form We taste to the best of MY/00r kDowledgc. Uwe am/are do owners) of the
proFarty destalibod above, by -inue of a wamuKy dead rwcorded in Ugister of DON& Office.
Number bed =ion®
SIGNATURE OF ,APPL S) DATE
rr wAny infortnedan that is toiat�spteasttted tttaY tssul[ yv fire aarursty Ferrate being revolved by the Ptrnrntrig 8 7,on+ug D�ererrmeae. +.w
Include with this application a neicorded warranty deed from the Roglsrer of Deeds OtHoe and a copy of ft eeRl V4 X"Cy ltwp if
refemnce is mido in the warmty dtte&
�v. aaros)
58002'i3 STa�z S_4Ek TRt.STEE - 5 DEED' 9c - 1432
Lit reEv r ski - 2 p f'u -1 90
CDFFIZ E
Kev " aLR. Kiel and Kris D. Klels -- - - - - -- T . WI
- - - -- - ---- ----
8:00 A
i.� s 4s9 a:s�.k t+oi>rca "ir�aPCin ati+reevs 3 =a} �!,; •.•9si. sae 7n —
]a`py 3. Dorsey and Cwotaae E. CgEigbo _as ;oiTet cenz
— --- -- - -_. - - -- - .S Si+t -�£ raF _c.F(ah= �� ,ze _.c�•8.'ruuL. ;GS,o<
tox Hca;�•ann�, �ci. �racnv3 r�ca rsnsr a:: ----- SH - ( — `�..,.:T,�z � /��
l
O irl_ (f)i2 -9D
Pan of Gavenvneft W 'i' of Secdort 23-3& 1 9 des=ted as lo8ow's." Cornmem*v Had E% Comeq of
said SOC90 23; l S 1700.0 10M dWboa W 1981. FBe t; f wmfI o SI* 3aE 227.9 feet to Ptace of
60 feet'thenice 571 311-7 l,ser lfi ice N1 A�► 60.0 feet p� of Lake Stlots
TOGETHER VATH easomwd for access road fmm above Ossc`,1TbW parcel to Town Road on S fine
of said Section 23-
TRANSFER
E E
i
�41,�F
Kevin R . Kie -- __ -_ —_ - K ris D. Ki - - _ - -- �
AtlTliEkslTtCAT10N ACf:lvO \\fLEDGM[i`'T �
Ke vin Ke - Kiel -- --- State of Wisconsin.
Kris D. 1
5(�u(ureisa -- - ' ..—_ 5 1
• Kielsa
Coart r
s:rtlta"ntr�' -- .x�•.x: _ .a}! 1i - 1'dcx .3me ix'Ivrc ii,e tlias. day of
i
TIrLL MEMBERS LATE CiR OF ? ".ISCUti51? - - - -- —
all nae- __ - -- --- - - - - -- i
3UC c by §..`06 Of*, \? v Sa]a5)
known !i t
an i8 Ce3 nfc'ItI .IfY(i �.: linlaaa "!i (Il?,r lR.' �S!Ue;
THIS I.7STRMAEhT VIAS GfVaFTL3 BY
Anotnev Krictina iand - - - -. -- — ---- - - - - -- -- -- --- -- j
6 .giia.ures ma iv authei n:a.ed or 3ek =wacri gc.i &Ph a. — noz M% a:on wsswn .s `•.morwca .!f ao• . si3(i espiraalazn 0
necessary)
- - T' Ia.in lxi � ��C..i \Si\ .. _: -.�_� l_yV Ela� �•J '
(L•1.�(EE'S DI 1D I{ F.,rrn �'o. IF -14e_ ..1... . .a