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HomeMy WebLinkAbout040-1310-00-013Wisconsin Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)J. Permit Holder's Name: City Village Township STEPHEN & ANDREA TOMLINSON TOWN OF TROY CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding relUK SFTRA(:K 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 BED/TRENCH Width Length No. DIMENSIONS �L INFORMATION Type Of System: v c�Tn1�1ITil1A1 eveTenn FI_EVATION DATA County: St. CI"OIX Sanitary Permit No: 617871 State Plan ID No: Parcel Tax No: 040-1310-00-013 Sectionlfown/Range/Map No: 17.28.19.2000 STATION BS HI FS ELEV. Benchmark Alt. BM Bldg. Sewer SUHt Inlet SUHt Outlet Dt Inlet Dt Bottom Header/Man. Dist. Pipe Bot. System Final Grade St Cover No. Of Pits LEACHING CHAMBER OR UNIT Inside Dia. Manufacturer: Model via r r�rou � w�. v � v � ��.� Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipes) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx mouna ur HZ-c�raae ayscems piny Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Bed/Trench Center Bed/Trench Edges Topsoil �;t Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Location: 488 MEADOW RIDGE LN 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Inspection #1: Inspection #2: Yes � No Plan revision Required? � Yes � No ��� Use other side for additional information. Date can_av� n �R '3�q7� Insepctor's Signature �.�..�� Cert. No. _ o �,�:.: _ :.,. `,T„`�r Industry Services Division County s \� 1400 E Washingto ve �� be filled in by Co.) ,1\ � = , ,1 t0 P.O. Box 716 i APR .0 � � ` itary Permit Num er (to Madison, WI 5370 — Y �Sps�' ; �' �,]� I ''��F �� �wnxrr/ St. �r,>�x w unt - State Trans etion Number Co I ' Application �_,. In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate goverrunental unit POWTS are submitted to Project Address (if different than mailing address) is required prior to obtaining a sanitary permit. Note: Application forms for state-o�med be for secondary the Department of Safety and Professional Services. Personal information you provide may used Privac Law, s. 15.04 1)(m Stats. (~} � �� /'t�a�s� /� � LN u oses in accordance with the , I. A lication Information —Please Print All Information Parcel # � �. , Zg (q Z ppo Property Owner's Name ✓ Q) .v � � e � - �_ _ ., ,3 Property Location Property Owner's Mailing dress � � - / Govt. Lot �_ y, �_ %,, Section City, State Zip Code Phone Number circle one II. Type of Building (check all that apply) Lot # ✓ - Subdivision Name 1 or 2 Family Dwelling -Number of Bedro s s�4.�! et� / � /.O = '� � Block# ❑ Ci of ty - De cribe Use S ❑ Public/Commercial s ��) ❑Village of CSM Number ❑ State Owned -Describe Use tvl Town of�SS Gi III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑Replacement System Ne�v System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System (explain) List Previous Permit Number and Date Issued S. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New Before Expiration Owner IV. T e of POWTS S stem/Com onent/Devicc: Check all that a 1 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. Dis ersal/I'reatment Area Information: Plow Design Soil Applicatior�,Rate( dsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation Design (gpd) r� �: � S� ��Ur VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units � /ns /� �� ) � 4 � V 0 � U U _ � � .. � New Tanks Existing Tanks ( /' i / � � y �n � � `� w C7 a+ P;,/U -S /� Septic or Holding Tan}: B _� � Dosing Chamber VII. Resp nsibility Statement- I, the undersigned, assume r ponsibility for installation of the POWTS shown on the attacfted plans. Plum is �gna MP/MPRS Number Business Phone Number Plumb r' ame ( int ,� ' � s 7 ` --3� Plumber's Address (Street, City, State, Zip Code �°� — � D VIII. Coun /De artment Use Onl Permit ee Date Issued Issui Agent Signature Approved ❑Disapproved $ !�{ � "� �_ �y Zow ❑ Owner Given Reason for Denial I��S�TEMOWNEpproval/ReasonsforDisapproval 3, Q,,,�/„.I-.��__-������ I 1, Septic tank, efflRuent filter and u'�'r��"�"`f� / dispersal cell must be serviced /maintained �{') ���/'� u� o�.s � f� � as per management plan provided by plumber, � R����►-� ��.r' � 2, All setback requirements must be maintained s per app ica e CO rclir>�n, plans for the system and submit to the County only on paper nat less than S 12 s 11 inches in size i1 SBD-6398 (R 08/14) �il Coro Ad/I • . , Residential APPkagm 1t_DE! PAGE :'reject NamE Township_ County_ Subdivision Name: Lai Nnmtrer_ DesignerJPtumber. Signature .. c, . Filter Specs page 6 AftvagementPian pag- 7 SL cwK Cfy 22pLc Tank Maintenance Form sage 8 a , Dead P:Rge CSM or Plat Lkmm Nuffr -- i � � 9 i" 1 1 — 1\ F .d — i \ 7 a � - i t J r S W it bmiber H ,�. � $ v f it ft i i�i :. • � li 1 FMR � ! �. !• _ 1 ' i 1 ! s 7 i :,, Is/ � .: ice. ! i. is � t. Y .v. i25 �i�Vf�ei eii�J ■ Polylok, tnc is pleased to add its n ,w commercial filter to its existing line of quality effluent filters.The P6525 is rated for over 1o,000 GPD (gallons per day! making it one of the largest commercial filters in its class. It has 525 linear feet of 3116" filtration slots. Like the Polylok PLA22, the new Polylok P6525 has an automatic shut off ball installed with every fitter. Men the filter is removed for cleaning, the ball will float up and temporarily shut off the system so the effluent won't leave the tantc No other filler On the market can make that dlairril The PL525 Effluent Fitter should operate efficiently for several years under normat conditions before requiring cleaning& it is recom- mended that the fi[ter be cleaned every time the tank is pumped or at least every three years. If the installed fitter contains an optional alarm, the owner will be notified by an alarm when the fitter needs servicing. Servicing should be done by a certified septic tank pumper or installer. i .Locate the Dull et of the septic tank. L%Remove tank cover and pump tank if necessary. 3. Do not use plumbing when fitter is removed. 4.. Pull PL-525 out of the housing. S. Hose off fitter over the septic tank. Make sure all solids fall back into septic tank. 6. Insert the fitter cartridge back -into the housing making sure the filter.is property aligned and completely inserted. 7 4-- Alarn. accP eeihil�ttF � 5�5 iinearfeet of 1116-- filtration slots S%#"U. 40 PiPe`� U �_ Pai4nt Nay 6A'i5 �,o^7t,6�30 Ideal for residential and com- mercial waste flows up to 10,000 Gallons Per Day (GPD). „�--------,—�,y Accepts PVC extension handle Toted far aver 10,000 GPD Gas deflector Automatic shut-off ball when filter is removed 9. Locate the outlet of the septic tank. 2. Remove the tank cover and pump tank if necessary. 3. Glue the filter housing to the r or 6° outlet pipe. if the filter is not centered under the access opening use a Polylok -:xtend & Lok or piece of pipe to center filter. 4. Insert the PL-525 filter into its housing. 5. Replace the septic tank cover. . Replace septic tank cover. O WTIer/B U}per Mailing Address Property :4ddress ST, CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT ANT OWNERSHIP CERTIFICATION FORM (Verification Cite/State hi .. -t-- LEGAL DESCRIPTION Property Location . Subdivision Plat: Parcel Identification Numbers 1/4 , See. ,/3 : Tc _NT R , Town of !•! Certified Sur�e�Map # Warranty Deed # � 09 L — Spec house ? yesno n Volume (before 2007)Volume Lot lines identifiable yes � no Improper use aid 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_ lidhat you put into the system can affect the function of the septic tank as a treatment stague in the waste disposal system. Owner maintenance responsibilities are specified in §SPS. 353.52(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 Yank 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 Safety And Professional Services 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. Uwe certify that all statements on this form are true to the best of my/our knowledge. 1/we am/are the owner(s) of the property described above; by irtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms APPLICAI�ST(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revolved by the Planning R: Zoning Department. '""* A 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. (RDV. 04/12) POWTS OWNER'S MANUAL & MANAGEMENT PLAN MAINTENANCE SCHEDULE Page�of MAINTENANCE INSTRUCTIONS one of the following licenses or certifi mtior�s: fnspections of tanks and soil absorption systems shall be made by an individual carrying erator (p p )• Master Plumber, Master Plumber lRestricted sewer, of the ar k(s) t pid identify any missing norlbroken hardware, delntify a0ny"cracks or leaks, Tank inspections must include a v P onding of efFluent on the ground surface. The soil onding of effluent measure the volume of combined sludge and scum and a check for any back up or p condition and requires the immediate absorption system shall be visually inspected nsp cted tocheck the effluent on the ground Isurface may evels in the observation .fail ngand to check for any p on the ground surface. Thep 9 notification of the local regulatory authority. icin operator (pumper) and disposed of in accordance with chapter NR 113, When the combined accumulation of sludge and sce Sin ervany treatment tank equals one-third (%s) or more of the tank volume, the entire contents of the tank shall be removed by a Septag 9 Wisconsin Administrative Code. All other services, including but not limited to the servicing e Ie'rnformed by a celrtified POWTS Maintainers ters, mechanical or urized components, pretreatment units and any servicing at intervals of <12 months, shall p A service report shall be provided to the local regulatory authority within 30 days of completion of any service event. GMW 005 (02105) Page yoE of START UP AND OPERATION products solvents or other im ede the treatment process and/or damage the soil absorption system. If high concentrations are For new construction, prior to use of the POINTS check treatment tank(s) for the presence of painting p chemicals or sediment that may p operator (pumper) prior to use. detected have the contents of the tank(s) removed by a Septage Servicing Op failures. Start up or restoration of power under these an Pump tanks may fill above normal highwater levels prior to startup or due to pump of effluent and damage to the system. To'avoid p or contact a Plumber conditions s not recommended, as the excess wastewater will be discharged to the soil absorption system in one large dose causing he over) or surface dischargeower to th p p overload that may result in the backupriot to restoring p contents of the pump tank removed by a Septage Servicing Operator (pumper) pal WTS Maintainer to assist in manually operating the pump controls until norm surfacefluent levels are restored within the pump tank. or PO System start up shall not occur when soil conditions are frozen at the infiltrative or ark vehicles over tanks or the soil absorption system* aDe not drive or park over, or otherwise disturb or compact, the Do not drive p area within 15 feet down slope of any mound or at -grade soil absorption im rove the performance and prolong the degreasers, thetreatment floss, Reduction or elimination of the following from the wastewater stream may ' pcondoms, cotton teases, herbicides, meat tanks and soil absorption system: aciddraiantibiotics, ump) di dischargpes e cigarette and vegetable p and watersoftener ,.grew brine discharge. diapers, disinfectants, fats, foundation esticides, sanitary napkins, solvents, tampon scraps, medications, oils, painting products, p 'ABANDONMENT When the POINTS fails and/or is permanently taken out of s'scice the follO onsin AdministrativeCode. Il betaken to insure that the system is properly and safely abandoned in compliance with s. Comm 83.33, i openings sealed. All piping to tanks, pits a • nd other soil absorption systems shall be disconnected and the abandoned pipe p A;, n Cori of by a Septage Servicing Operator (pum er p )& Th • e contents of all tanks and pits shall be removea aU i IN] UN�. air �•-�- - in ,all tanks and pits shall be excavated and removed or their covers removed d the void space filled with soil, an ~ • After pum p g gravel or another inert solid materialt rovide a code compliant CONTINGENCY PLAN fails and cannot be repaired the following measures have been, or must be taken, to p Ifathe POINTS replacement system: disturbance and compaction and should not be infringedal resultbiy the need A suitable replacement area has been evaluated and may be utilized for the location of a replace ent soil absorption required sys e . The replacement area should be protected from with the rules in setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacemen fora new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply system cannot be effect at the time of their permit issuance. ❑ OWTS technology, a holding tank may be installed as a last resort. site evaluation A suitable replacement area is not aPvailable due to setback and/or soil limitations. If the soil absorption sya rehabilitated and barring advances in ❑ The site has not been evaluated asleelbarea replacement no replacement area islavail available a holding tank may be installed as a must be performed to locate a suitreplacement last resort to replace the failed POWTS. in ❑ Mound and at -grade soil absorption systems may be reconstructed rules in ffremoval of the biomat at the infiltrative ect at that time. surface. Reconstructions. of such systems must comply with the WAS GASSES OR LACK RNING TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY TER ANY TANK UNDERIANY CIRCUMSTANCE MAY T.R SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE. ADDITIONAL INSTRUCTIONS: POINTS MAINTAINER POINTS IN t LCK � j Name Name � J Phone Phone JS� — F LOCAL REGULA ORYAUTHORITY SEPTAGE SERVICING OPERATOR(PUMPER) Names n i Name Phone Phone r document was drafted by the staffs of Lite Green Lake, arng'inisfrat ve Code shara County POWI'S regulatory agencies in compliance with sections This docum d & and 83.54(1), (2) & (3), Wisconsin A Comm 83.22(2)(b)(1)() (f) l 4 S Document Number State B�ofAR iANTY DE D 1-2003 Document Name THIS DEED, made between DCCI Land Planners Inc., a Wisconsin corporation ( hereinafter "Grantor," whether one or more), conveys and Warrants to Stephen P. Tomlinson and Andrea M. Tomlinson Revocable Trust (hereinafter "Grantee," whether one or more), the following described real estate in St. Croix County, State of Wisconsin: Lot 1 ,Plat of Meadow Ridge of Troy in the Town of Troy, St. Croix County, Wisconsin. Exception to warranties: easements, restrictions and covenants of record; highway and street rights of way; and Municipal and zoning ordinances and agreements entered under them; and further except real estate taxes accruing in the year of this conveyance. Dated ��8 � �� AUTHENTICATION Signatuce(s) authenticated on *TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by Wis. Stat. § 706.06) THIS INSTRUMENT DRAFTED BY: St. Croix County Abstract &Title Co., Inc. by Lexie Leslie at the direction of the Grantor. 20-517660 ViYIIBIIII�idV�llili�l� 1097907 BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI 02/27/2020 12:04 PM EXEMPT#: REC FEE 30.00 TRANS FEE 223.50 PAGES: 1 Recording Area Name and Return Address St. Croix County Abstract &Title Co„ lna 575 N. Knowles Ave., Suite #B New Richmond, WI 54017 040-1310-00-013 Parcel Identification Number (PIN) This IS NOT homestead property. � (SEAL) CC Land Planners Inc., a Wisconsin corporation By: Ronald L. Derrick, President ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. St. Croix COiJNTY ) Personally came before me on �� 2� �' the above -named DCCI Land Planners Inc. a Wisconsin cor oration b Ronald L. Derrick as President to me known to be the persons) who executed the foregoing Notary Public, State of Wisconsm � My Commission (is permanent) (expires: 5 Z (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY ID FORM NO. I-2003 © 2003 STATE BAR OF WISCONSIN WARRANTY DEED * Type name below signatures. '. a _ L i cn ? w �' ~¢ �8� oDom� �?� c�� �Woz �pz m�� pm(�3 �-,m ��ow D=w Wp �(nZ OZ nm�N ��(J1 �NmNm A=� p02 D'TJ fv Ap X � m D m W p W p -mip m�� ��Z n<� m0 <(pj yr^ �z mD+ mT� m=� ZW `<—��c Wit+ Z—� pap ^�< wcm ^j 0D ^-aon A'^Z ov zoz mF' Szz pzo Am NZL] pm p � {Zj�'n 3� cmo ci �� � � m V � O w D 1ST FLOOR LAYOUT SCALE: 1/8' = 1'-0" IcroR: C & E WURZER DATE.' 07-2619 /� _� 1.21.2020 H rWNERr ROLLING HILLS MODEL 1.23.2020 2.19.2020 1�g„ c 1=0" PNCNE.' W.T. 1&309 it X 17 PAPER LYMAN LUMBER COMPANY THE PROFESSIONAL BUILDERS SUPPLY CENTER 1700 WESTERN AVE. EAU CLAIRE WIS. 54702 DRAWN BY.' CVH CCURTNEY_VANNAREN®LYMANLUMBER.CCM 7268383383 Elf Ail; Ell mitj ir r a r, 41 OF `- NNE JEW ZEN _T. ZEE �y NE NINE �1 � >' s i.... c � �� � b' �� i //�� .°� � s - o sz '1 _,E z a= �� m � yo.5y !V Iwo I ° W y t3 1.1. 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HODS+ PREP BENCH MARK: Totem DCCI 1 9E t' IRON PINE, 15051 ELEVA110N 925.5' �7ss� NEW t' s N88'54'49'E 334,BB' 20.53'-� '`� ti�f 147.-- 485r� 152.03 . y�i 6 \ •a• �� r � LOT 11LOT 12 Apo t �, PSI Yo lop CAPP AIDOW maconsin Department of Commerce Division of Safety and Buildings ref Includeibutnotlifflitaidto:venju—percent slope, smile 1 ♦.: or dirruNetsionS, north { { {. Please print OU infOrTne 1505 HWY 65 CLO (CA EVALUATION REPORT Page 1 Of 3 YWs. AArYt. Code County St. Croix in size. Plan must 7 Are, Parcel I.D. „i / _ lei All ton All in / [I riff, i' _ '�'• _ m or CSW 11 ! RidgeOf 'Nearest Road onlity eVillage I East Cove Road 1 . M •D Q ,a - ., Replacementedi 3 to 4 Code derived design flow rate New CiOrkstn)i E3 Public or oommerclalDescribe: Flood Plain elevationapplicable commentslaarent material conventional syStOM General recommendations:and a Boring # !o Rmi6ng factor >i00 in. + Pit Oroundsurfaceelev. 928.13 1t. Depth on Texture Structure Consistence Boundary Roots Horiton Depth Dominant Color Redox Description Gr. Sze Sh. in. Munsell Qua Sz. Cont. Color dsh ass 2f 1 0-8 1Oyr3/2 - sil 2msbkII _ sit IMghk dsh cw if 2 849 7.5 r4/4 dl _ 7.Syr6/4 - is Osg - 3 19-32 dl - 4 32-100 7.5yr6/4 s Os 3 29-100 23.E J �or;ng 928.2s 3 pit Ground surface etev. —�- Dominamt Cola Redox Description Texture Munseli Qua Sz. Cont. Cola 10yr3/2 sit - - - is Ti I - a z3 5100 Depth to limiting factor In. SV,dm Consistence Boundaly Rooms Gr. St. She 2msbk dsh as 2f s Etltuerd #1 = BDD > 30 _< 220 mgA- arxi TSS >30 � 15D mg1L CST Name (P{ease print) .• Signature WI 1432 120th Street, New Richmond, Efifuent #z = - •Etf#1 `Eff#2 6 .8 .4 .6 7 11.6 7 1.6 • and Tss < 30 CST Number 2273 715-246-2454 e � '� t �� t ..- � .. , :.- «- . � ' II i �® � r. •.. :.: r� w. ft. Death to Ilmiting factor __-- in. • { ��r�rr�r���r �r�■■� ■ '� :, , ®®� �_ •. ._ ► .. ... Effluaht #2 = BOD, a 30 rngA. and TSS ? � �::� u: SBD•E330Teq (R07Ab} DCCI LAND PLANNERS, INC. Ldt � 13 -MEADOW RIDGE OF TROY NE 7/4 OF THE SE i/4 OF SECi'10N 17, T28N. R19W. TOWN OF TROY, ST. CROIX COUNTY. WISCONSIN. - • • - • _ c -� • � •.� • :1• • 1' 1 . � ♦ ] M 1' 1 1 i � � r• �; �. � � � � a � � � �� � � �� � .�