HomeMy WebLinkAbout040-1272-60-000 (2)Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)],
Permit Holder's Name:
Troy A. and Tera L. Fox
City Village Township
TOWN OF TROY
CST BM Elev:
Insp, BM Elev:
BM Description:
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
Model Number
TDH
Lift
Friction Loss
System Head
TDH Ft
Forcemain
Length
Dia.
Dist. to Well
SOIL ABSORPTION SYSTEM
ELEVATION DATA
ceunty: St. Croix
Sanitary Permit No:
617840
State Plan ID No:
Parcel Tax No:
040-1272-60-000
Section/Town/Range/Map No:
17.28019.1513
STATION
BS
HI
FS
ELEV.
Benchmark
Alt. BM
Bldg, Sewer
St/Ht Inlet
St/Ht Outlet
Dt Inlet
Dt Bottom
Header/Man.
Dist. Pipe
Bot. System
Final Grade
St Cover
BED/TRENCH
DIMENSIONS
Width
Length
No. Of Trenches
PIT DIMENSIONS
No. Of Pits
Inside Dia.
Liquid Depth
SETBACK
INFORMATION
SYSTEM TO
I P/L
BLDG
WELL
LAKE/STREAM
LEACHING
CHAMBER OR
UNIT
Manufacturer:
Type Of System:
Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia Length Dia 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
11 Yes
COMMENTS: (Include code discrepencies, persons present, etc.)
Location: 415 LOST ROCK LN
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Inspection #1:
Inspection #2:
Plan revision Required? Yes 0 No
Use other side for additional information.
Date
SBD-6710 (R.3/97)
Insepctor's Signature
Cert. W,
1 GEC G[��d[�D
��, T .yj�y Itldil.4t[y .SeiViCCS Ii1VI5tOt
�r t ■ 41 M � R � ,2 � 20 I40� E Washington Ave
\� =J� 3 r.o. Box TI62
` St. Croix County M�1SOD� �,�� 7�:
.��lV- LaZ� - vy.�
-- anitary Permit Application 7 �-
stax �, p�q
IR accordance with SPS 383.21(2k Wis. Adm. Coder submission of this form to the appropriate govemmeotal emit f Y It
is nz}uined prior to obtaining a sanitary permit Note: ? pplication fomLs for slate-ovmed Pp1YIS are submitted to Pro}ect Adt
the Uepartroent of Safely and Professional Servitxx. Persona! infomtation you grovide may be used for secondary
Purposes in accordance with the privacy Law. s. 15-1k1I a Ym► cmr�
y,5 �-o5T �ceK L�u�
�. State
i-� i,l �� � tiLi-�- ' S4ol to
II. Ty�te ofBarh3mg (check all that aPPlY)
[ or 2 Pamiiy D�erlling—Number of Bedrooms _�_
❑ PuhlidCommer+cial—Describe Use
❑ State (htned — Descnbe Use
III. Typt of Permit~ (Ghee! enty oac 6oz on !i=e
❑ Ne+v System �R facemen2 System
� :!
vI.
VII.
J
Complete line B ifapplirable)
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Location i � . zti .� °I . � s� 3
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N 11�i %.,a111f Y., Section � %
circle one
T � N; R � E or
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❑ Cityof�
❑ Vllage of
Town of
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❑ Treatment/liolding Tank Replacement Qnly
Ci-rS
\pprovcd � Q IIisapproved Pkam�itJF�e
❑ Owner Given Reason for Denial
Ccaditions of q�rova!/Ressoss for Bisappn�
SYSTEM OWNER:
1. Septic tank, effluent filter and
dispersal cell must be serviced /maintained
as per management plan provided by plumber.
as per applicab
SBD-6398 (]L i)8/14)
�11 C6 N
I, �'�U
c�llans
for
�'�' � (st) System FJevat�o
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Agent
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Business Phone Number
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—�-- VvlilL/plGU YVillt .yIVIiG C]/11� LiI�C. �lT`ei�i':S�`w� �"!ff-.J^.
�.--- Always clean and free of fines
• Bundles are quick to install, saving costs on heave machines}r and labor
• Modular construction allows configurations to match trench dimensions for most system shapes and sizes
• Engineered for optimal storage and absorption efficiencies
Ability to contour along sloped sites and around trees or landscaping
• Lightweight system is perfect for repairs and tight job sites
Easily hand-cai'rled It position reducing time and labor
5' or 10' lengths with simple snap, internal couplers
Easier cleanup at the job site with the elimination of stone
• Manufactured from recycled materials rather than a mined natural resource
• A wide variety of diameters and configurations to meet any installation professional's needs
• Approved in many jurisdictions with an increased efficiency rating, reducing drainfield size
• Backed by the leader in the onsite wastewater industry
--=7by INFILTRATOR
f=or technical assistance, instailaticm instt'uctions or customer service, ta11 Infiltrator Systems at 800.689.7759.
ESTABLISH
VEGETATIVE COVER
FILTER FABRIC
12" EZflow
BUNDLE (TYP.)
EZflow 1203H - GEO
NATIVE BACKFILL
6" MIN. COVER
OR PER CODE
36"MIN.
TRENCH —
WIDTH
NOTE:
PRODUCT CONFIGURATION AND INSTALLATION
DEPTH MUST COMPLY WITH APPLICABLE
REGULATORY REQUIREMENTS,
4" PERFORATED
PIPE
EZ,�low
iuFtirr+nron
INFILTRATOR SYSTEMS INC.
4 Business Park Ru. Old Saybrook, CT 06475
(800)221-0436
EZFlow 1203H - GEO
rmrroccuslChcrked 6y DFH (Shtti 1 of 1
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1355
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page _ W 3,
Division at Sefatyand Buildings in aomdancaw th Comm 86, Wia, Adm• Code Oumtum Septic SeNca
Atta6n complete site plan on peW ao: ksa Ulm 8'/1 x 11 inetws n s¢e, plsn must County
inAludo, but not limited to: vertical and ho&wW ralmonce point (8,N)o dradw mid St. Croix
pWwt*M- %W6 Of dimtlnsWk 11W vrow, and loc2* old distmos io noateet roJd. Palcal I'D.
PlruJse print an information. pending
RM�Ned ElyDote • •
Pwftal m,omwon you prove• m.y Oo wed ra ceoonayrq,pq,�s (PMecy to r, s. 55.ei (1) Im1).
Property Ownor Property LocAW
Humhird Land Co oration _ Govl, Lot 1//1/ 1l4 SW I 5 11 T Z(t N R 19 W
Property Owner's Mating roddrass Lot # 81ock 0 ! Subd. Name or CSM#
332 Minnesota Street, East 1404 37 nis I Troy Wood Subdivision
City Slate ZipCoda Phone Number J It J ViilaQ* !e; Town Naarest ROW
Saint Paul i MN 55101 651-222.6555_ Troy E Cove Rd / Lost Rock lane
1Q NrN+ConsWction USV. � RWdential f Number of t>,drooms S Code derived design }low rat0 450 OPD
J Replacement 1 Public or wrtmetciat - Describe;
Parent maiwlal outwash pla;no __..... _ Flood glair etevotion, if applicable Na
General camment8 • ....._ _ _ .....,,...... .. ..—
and racmtmendations: Part of 1,52 acres. SM ;Y1= 10010% BM 42= 98.65', Recommeno 96 61 System elevation, P25 from
preliminary boring work done 6%6w00,
P25 sorinq# J Boring
id Pit Ground Surface, elev. 99.0 n. Depth to limding factor >75 In. Shc Apptdotion Rele
tioriton r Depth I --Dominant Co4or R MOeatriplion j Te>,ture I Stroctwe Coas,slanoe Boundary Rws-1 3Por",
i I •ET •E"2
1 0-10 I 10yr213 none SI I 2msbk mvfr oe i 2f,1m 0.6 069
1 10 314 r:one j
2 0-151 yr sl 2mttbk muff CW 1f 005 0.9
3 116.27 ! 10yr414 none sl I 2msbk mvfr CW
.... .. .
4• i 27.36 10yr4/6 none Is lmbbk mvfr cw 0.7 1.2
r i
5 j 36.68 f 7,5yr4/6 none I 1
— ,...._.. 9 .. t. 9 ml cw t
r,s Os
i .... I .. ;. .... 1 2
I
8 68.75 10yr5/6 none gr, s _.. _
— -- — — 0 a9 ml 0.7— 1,2
Jfl —
f
!6 Pit Ground Surface elev. 98 7 , IL Depth to kmiting factor �7goo Mky
2 ,_. In. oUsn acre
r,— r _ _
t o•10 ' to (d13 non• � sa '
!2 +10.17 i 10yr314 none cY
3 17.23 10yr413 I none sl
4 23-34 1 10yr4/2 none SI
S 34-56 1Oyr2r2 none ' sit I
_ 6 S6.88 10yr3l4 none ( cN
�-�---�---
7 65.72 1J Oyr41q ^ i none j
• Effluent E m(yL and TSS >90 it 1li0
2msbk mofr es it i 0.5 � 0,8
2rnpl muff cw 1t 0,5 0,800
2msbk 1 mvfr cw 1 - 0.5 I 089
2msbk mfr Cw j - ! 0.5 j 049
2msbk mfr cw - 0.5 ; 048
I I i
2Mabk mfr ow j 0,5 1 068
0
0 : BODe <30 mglL and TSS <,.30 mgA
ern Oustum
�}'yQ„7 /Ud'!`Y�''.'.',.;•'_ 227618
ddrass 44ustum Septic Service .. _... Data Evquallon Conducted 701100hono NU11bK .. _.
N13450 A37th SI. New Autwm, WI ti4757 t 1120/00 715.858-13at
10470'd 080bb5E1S9 N3583t7Nti J,fi 101`13N38 0:60 590Z-b0-NIVif
VI/L� 8. � � � � Gou•e� comer C, �_ ��—(�s ir -
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JAN-04-2006 09114 RENEwL BY ANDER�SEN
e
W
6512644000 P.06i0`7
r
'Wisconsin
Attach
Safety and Buildings Division
County
201 W. Washington Ave„ P.O. Box 7162
Madison, WI 53707 - 7162
Sanitary Permit Number (to be filled in by Co.)
Department of Commerce
(bog) 2bb-315 t
P.,
T:� p� gO0�
0
Sanitary niitalr y Permit rmit
Apip lcati®)tl
S'
State tan I.D Number
--
In accord with Comm 83.21, Wis. Adm. Code, personal informatio pr ide i
JAN
`___--
may be used for secondary purposes Privacy Law, 05,0
o Addr (if different than mailing address}
OUNTY
L Application Information— Please Print All Information
Property Owner'7Ne,,.
Parcef 11 Lot il 27 Block #
Pr perty er•s Met' ng Address
Property Location
ry % Section, �j�,'/.,
City, Stan
Zip Code
Phone Number
�," --r�--z ---
y
.�
(circio
►' WN; RI6 oto
II. TYPe of din S ( PPIY) check all that a
V P Qt St VA%
or2Family Dwo!ling-Number of Bedrooms
J
Subdivision Name �9MNnmber
❑ Public/Commercial - Describe Use
7
❑ State Owned - Describe Use
~ —~
QCity QVillagepi Pownship of
t9
114 Type of Permit: (Check only one box on line A. Complete line 13 if applicable)
A'
New System
Q Replacement System
❑ TreatmentMolding'rank Replacement Only
❑ Other Modification to Existing System
D;•
❑ Permit Renewal
❑ Permit Revision
Q Change of
El Permit Transfer to New
List Previous Permit Number and Date Issued
Before Expiration
Plumber
Owner
Type of
POWTS System@
Check
all that apply)
rIV. _
ya Non —Pressurized InoGround Q Mound? 24 in, of suitable sail ❑ Mound <24 in. of suitable soil
❑ At-Gmdo ❑ Single Pass Sand Filter ❑
Constructed Worland ❑ Pressurized Di -Ground Q
Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit Q Recirculating Sand Filter Q
Recirculating SynthcUc Media Filter XLeachingCl
ine ❑ Gravel4ess Pie ElOther
(explain)
V. Dis ersaUTreatment
Area Information:
Design Flow (gpd) Design Soil Application Rate(
Arw Reouired (st)
Dispersal Arcs Proposed (st) System Elevadon
o I0
%s r
.(�0
Vl. Tank Info
Capacity in
Tots!
Number
anufacturer
Prefab
Site
Steel
Fiber
Plastic
Gallons
Gallons
of Units
t`� 1y`�� o, BLS^ I `
Concrete
Constructed
Glass
Nnw
foisting
Tadct
Tanks
U �tI6�=;'ter
Septic or Holding Task
S
Aerobic Trenanent Unit
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, a unte responsibility for installation of the POWTS shown on the attached plans.
Plum c ' Nam (Print) Plumber' i
e
MP/MPRS Number
Business Phone Number
/7Plumbers
✓ 31
ddress (Street, City, State ip Code)
i
VIII.
Coun /
e artment Ilse C
Approved
❑ Di
6anitary Permit Fee neludes Groundwater
Date Issued
issin Agent Si at (No Stamps)
pro .-'.'
❑ Reason for iai
Surcharge Fee)
`, 14, Z&
IX, Conditio Approva ona its p(lroval
3�� ors w. r
SYST ER:
1 Septic tank, efllUent filter and
dispersal cell must all be serviced /
maintained
as per management plan provided
by plumber.
2. All setback requirements must be
maintained
as per applicable code/ordinances.
complete plans (to the County only). for the system on papler®not less
�then S;1y�1':1 t ine n t
Fs4!53'E5t5
Document Number
THIS DE
made between
State Bar of Wisconsin Form 3-2003
QUIT CLAIM DEED
Document Name
("Grantor," whether one or more),
one or more).
Grantor quit claims to Grantee the following described real estate together with the
rents, profits, fixtures and other appurtenant interests, in s C ro i e
County, State of Wisconsin ("Property") (if more space is needed, please attach
addendum):
�f.
/ ors /'5
Ella 4- 0�-
AUTHENTICATION
Signatures)
authenticated
on
'TITLE: MEMBER 51'ATE BAR OF WISCONSIN
(If not,
authorized by Wis. Stat. § 706.06)
THIS INSTRUMENT DRAFTED BY:
:3
KATHLEEK H. WALSH
REGISTER OF DEEDS
5T. CRO I X CO. , WI
RECEIVED FOR RECORD
02/23/2007 04:15PM
SUIT CLAI1! DEED
EXEMPT #
REG FEE: 11.00
TRANS FEE:
GOPY FEE:
GG FEE:
PAGES: i
Recording Area
Name and Relurn Address
�s 7L Lr
This
� � -- CJOO
(PM)
Parcel identification Number
homestead property.
(is) (is not)
ACKNOWLEDGMENT.
STATE OF
WISCONSM
• O t
�+ � )ss.
Personally came before me on a ja3 �a(Do7
to me known to be the persons) who executed the foregoing
instrument and acknowledged the same.
es
Notary Public, State of Wisconsin
My Commission (is permanent) (expires: � 3
THIS
(Signatures may be authenticated or acknowledged. Both are not necessary.)
NOTE: TINS IS A STANDARD FORM. ANti` i\tODIFICATION5 TO
FORM SHOULD BE CLEARLY IDENTIFIED.
QUIT CLAlni DEED !9 2003 S"rATE BAR OF WISCONSIN FORM NO. 3-2003
* I %pe name below signatures.
42 �
39
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Joe
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l 34 \\
�1.51ACRES
\� S
59717 SQ. FT./ n
/ % I I I I 1
( ( I I I
I ACRES I 36 I �� 1 1' o� z
WOO
?6,019 SQ. FT. �1.65 ACRES 11.54 ACRES V zs
W 71 SQ. FT. 66,853 SQ. F� 5 oe
SBA E ; 1 t/ ,g�► SNg (°3D
a 3B7.84 84.33. 1
I c
o
Z m
N
I C
I "
O UTLOT 3
OPEN ACRES
9.13 ACRES
397,511 SQ. FT.
NOTE THIS OUTLOT IS TO BE OWNED BY _
TROY WOOD ASSOCIATION, INC. FURTHER
$UBDM$ION PROHIBITED AND BUILDING
DEVELOPMENT PROHIBITED IN ACCORDANCE
WRH ST. CROIX COUNTY ZONING
ORDINANCE SECTION 17.09.