HomeMy WebLinkAbout030-1099-40-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No: 405131 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:
Kietlinski, Stanley & Laurie St. Joseph Township 030 - 1099 -40 -000
CST BM Elev: Insp. BM Elev: BM Description:
9T '70 GIs =90 R-1� /3^
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer � ✓ /
ii z." Ira d a ,'� 057 yS
Holding SVHt Inlet
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic - f J � / Dt Bottom v 1 ✓
Dosing eader/Man.
?. �•�3 •7 J D � 3
Aeration Dist. Pipe , g� Dl•
Holding Bot. System A 3 7
Final Grade
PUMP /SIPHON INFORMATION
�" d1e /a7 .d3 3.73 10 . 1
Manufacturer Demand St Cover
GP R ri
Model Number
TDH Lift Fric' Loss System Head TDH Ft
Forcemc-li Length T 13 - Dist. to We
SOIL ABSORPTION SYSTEM 3 JUn 3
BED/TRENCH Width / Length t No. Of Trenches I PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 /
SETBACK SYSTEM TO P/L JBLDG JWELL LAK E /STREAM LEACHING anufact ib
Ir5 r: V
INFORMATION CHAMBER OR
Typ Of System: 1 UNIT
/ odel u ber:
� I�b
DISTRIBUTION SYSTEM ( C.l
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
It Pipe(s)
Length P4 Dia / Length Dia ! 1 Spacin
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over I epth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center 3 3 ed/Trench Edges Topsoil Yes [�] No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: /� Inspection #2:
Location: 589 128th Ave Somerset, WI 54025 (NE 1/4 NE 1/4 33 T30N R19W) Perch Lae Estates Lot 6 Parcel No: 33.30.19.
1.) Alt BM Description S'a� -, �
2.) Bldg sewer length = f..f f r 3S /
- amount of cover = / ��✓ -�
Plan revision Required? L] Yes No /� ' oZ3 O Z � G ��Y✓4 --` �G�s - off
Use other side for additional information.
Date Insepcto S Signature Cart. No.
SBD -6710 (R.3/97)
f
Safety k Buildings Division
201 W. Washington Ave.
Ivi sconsin Sanitary Permit Application PO Box 7302 .
In accord with Comm 83.2 1. Wis. Adm. Code Madison, Wl 53707 -7302
oeportment of Commerce Personal information you provide may be used for secondary purposes (Submit completed form to county if not
Z [Privacy Law, s. 15.04(I)(m)) 6 (� state owned.
Attach com lete lane to the count co only) for the system on paper not less than 8 -1/2 x I I inches in size.
County' State Sanitary Pen it Number D fteck RE ion State Plan I. D. Number
/V fit'
I. Application Information - Please Print all Information Locati a
Property Owner Name MAY 3 1 2002 Property Location 3j1
S_ / 114/ �l /4,S 3T. N R�
Property Owner's M fling Add r ST. C 0IX COUNTY Lot Number Block Number
N G OFFICE
City, tale Zip Code Phone Number Su division Name or CSM Number
cls Lhe
Type of Building: (check one) O City
I or 2 Family Dwelling – No. of Bedrooms: —!� O village
Public/Commercial (describe use):_ JkTown of
O State -owned
III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road V
'1�4(9 6/ f ,GG� s �
A) I. 1Vew System 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Addition to Parcel Tax Numbers) lJ
System Tank Only Existing System e —
O G2�
� B) Permit Number Date Issued
A Sanity Permit was previously issued
Type of POWT System: (Check all that apply) .5f 1 1 w E/S
FcNon- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
0 Pressurized In- ground ❑ 1 loldingTank ❑ Single Pass ❑ Drip Line
❑ At -grade 3 ❑ Aerobic T eatim t Unit ❑ Recirculating ❑ Other:
5' Gd
V Dia ersabTreatment Area Information:
1. Design Flow (gpd) 2. DispersalArea . Dispersal Area 4. Soil Application 5. Percolation Rate 6. System El lion 7. Final Grade
Required Proposed ` Rate (Gals. /day /sq. It.) (Min. /inch) H – �Ob 0,
�•lW t) Elevation . IoY•S
01 VI Tank Capacity in Total q of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing jEZ A m, Crete strucled
Tanks Tanks
--,- -- J - "eks __ - - - -- - --
0 0 0
VII Responsibility Statement 0 0
1 the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (iywint) Plumber's Signs ;(no stmnVsV MP/MPRS No. Business Phone Number
l 0'11
Plumber's Address (Street, City, State, Zip Cod
sJ (S �4z) l
VIII County/Deparirdent Use Only
O Disapproved Sanitary Permit Fee Includes Groundwater Date Issued jss6mg A nt Si stun stamps)
Approved O Owner Given Initial Adverse Surcharge Fee)
Determination
d� 010 a.
IX. Conditions or Approval ason�,for Disapproval 1, �� , , 2 e/ 3 • ®l�f
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 _ of 3
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County S .
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. A49 — q? � J
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. g
Please print all information. Re ' wed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). S Q
Property Owner Property location
Del Ma. S
Govt. Lot NE 1/4 NE 1/4 S 33 T30 N R 19 3E (or) W
Property Owner's Mailing Address —Co—t# Block # Subd. Name or CSM#
950 N. Knowles Ave. 6 na Perch Lak
City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road
WI 154017 1 (71 ) St. Joseph - 60th- -St
EkNew Construction Use: ® Residential / Number of bedrooms 4 Code derived design flow rate F11��_' _ `. GPD
'a
❑ Replacement ❑ Public or commercial - Describe:
Parent material glacial drift 5 G C ' 2 - Flood Plain elevation if applicable rf '
General comments
and recommendations: �)
trenches @ el. 101.00', spaced to code 3.50' below grade V
Boring
Fil Borin # g pit Ground surface elev. 101 ft Depth to limiting factor _$4_ iJ --qoWApplication 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
1 0 -7 10yr3/3 none sicl 2msbk MfX cs 2f .4 .6
2 7 - 3 gw if 4 6 none mvfr
3 33 -50 75 4 4 none sl 2msbk mfr na 5 9
27 Boring # Boring
L23 Pit Ground surface elev. 101 .60 ft Depth to limiting factor 88 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
1 0 -10 10yr3/3 none sicl 2msbk mfr 9w 2f .4 .6
2 10 -38 7.5 4/4 none Os ml qw if .7 1.2
3 38 -88 7.5yr4/6 none fs /sl 2msbk mvfr na na .5 .9
Effluent #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg/L ' Effluent.#2= 92D < 30 mg /L and TSS < 30 mg/L
CST Name (Please Print) Signature . CST Number
Gary L. Steel 1 < ! 02298
Address n;3t6 Evaluation Conducted Telephone Number
1554 200th. Ave., New Richmond, WI. 54017 6 -12 -2001 715- 246 -6200
Property Owner Del Magsam Parcel ID # Pending Page 2 of 3
3 ] Boring # ❑ Boring
® Pit Ground surface elev. 1 05.00 Depth to limiting factor 84 in.
— §o 7 il - A — Pplication 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
1 0 -9 10yr3/3 none sicl 2msbk mfr
2 9 -19 75.yr4/4 none bk
3 19 -44 7.5yr4/4 none cos Osg ml gw na .7 1.2
4 44 -84 7.5yr4/6 none fs/sl 2msbk mvfr
D •
D Boring # ❑ Boring
Ground surface elev. 104.50 ft. Depth to limiting factor 84 in.
Pit 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
1 0 -10 10yr3/3 none sicl 2msbk
2 10- 7.5yr4/4 none s' 2msbk mf
1 -84 7.5yr4/4 none ms /sl 2msbk mvfr na na .7 1.2
78
❑ Boring Boring # Ground surface elev. ft. Depth to limiting factor in.
1:1 pit Soil A 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
' 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.6 /00)
I r
STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 Del Magsam New Richmond, WI 54017
MPRSW - 3254 NE4NE4 S33- T30N -R19W (715) 246 -6200
town of Somerset
lot #6 -Perch Lake Estates
This soil evaluation was conducted to satisfy a zoning requirement, it may or may
not be suitable for your use. The location of the test may or may not be as shown
as permanent lot lines were not established at the time the test was conducted.
N
1 11 =40'
BM.= to of 1" pvc pipe @ el. 100.00'
alt. BM.= top of mid o survey staKE @ el. 95.90'
` L
r
/
1� r I o'
�dt *1
Gary L. Steel
6 -12 -2001
S'1' CItO1X COONTX
SEPTIC 'TANK MAIN'TENANCP A(3RPIiMPN'I'
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer Ile 4- Q.i.{ r ! et ✓1 S K-L
Mailing Address SO(o Ki ye/L Rd --JJ t4d -sbY-1-
Property Address 5& f ,:� '6 xA-e . A , UOSD
04 (Verification required from Planning Department for new construction)
City /State t-+ SOn— 1n11 Parcel Identification Number 0 3Q /0 ? 416
LEGAL DESCRLPTION
Property L.ocation ' /,, k1C %, Sec. ,3 , '1' N -R. - ZY W, 'l'own of
Subdivision yell �ar Sfa�eS , Lot 0
Certified Survey Map # _ 1 7A JJ_ Volume , Page #
.1
Warranty Deed # _10 7 9'y/ Volume /� Page # & (�
Spec hou" 0 yes Eno Lot lines identifiable Wyes O no
Improper use and mdntemnecof your septic system could result in its premature failure to handle wastes. Proper maintenance
corutists 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
masterplumber, joumeymanplumber, restricted plumber or a licensed pumper verifying that (I) the on -site wastewaterdisposal system
is in proper operating condition and/or (2) S 10" don on and pumping (if necessary), the septic tank is lea thaw 113jhU of sludge.
Uwe, the undersigned have read the abov and agree to maintain the private sewage disposal
standards
set fbrW, Lecein, as set by the Department and the Department of Natural Resources, State of Wla:oaaie MIcatioo
stathrg that your septic system has been maintained Must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date,
SIGN TURB Op APPLICANT DATE
O R .RTIiFiC!ATrnty
�: •iT'.• . it
I (we) certifj► that all statements on�tb for PAM true to the best of my (our) knowledge. 1 (we) am (are) the owners) of
the Property described above, by virtue of aTwpnanty deed recorded in Register of Deeds Office.
t!,..
SIGNATURE OF APPLICANT DATE
is +'
Any information that is mis - re r
P }� ' ,Mult in the sanitary permit being revoked by the Zoning Department.
Include with this application: a stamped,�tan�ttgr deed from the Register of Deeds office
a copy of Ilse certified survey map if reference is made in the warranty deed
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-
P P
10567 -P (R.6/99).
Table 1: System Design Specifications
Sanitary Permit Number
Number of Bedrooms
Design Flow - Peak (gpd) �,UO
Estimated Flow - Average (gpd) y OU
Septic Tank Capacity (gal) a 6 (�
Soil Absorption Component Size (ft G 8
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
Table 3: Maintenance Schedule
Septic Tank Inspect and /or service once every 3 years
Outlet Filter Inspect once a year and clean at least once eve 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 component's 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.
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
more intense, and earlier, organic clogging of the soil.
2
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.
When system fails, we will replace with another system
at owner's expense. Alternate area must be left undisturbed.
St Croix County Zoning Office 386 -4680
Boumeester & Sons Excavating 386 -9020
Tri- County Sanitation 386 -2130
3
U 1896P 260 679741
STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. VALSH
Document Number WARRANTY DEED REGISTER OF DEEDS
ST. CROIX CO., VI
This Deed, made between Delwin R. Magsam RECEIVED FOR RECORD
05 -22 -2002 11:30 AN
Grantor, and Stanley M. Kietlinski and Laurie L. Kietlinski, husband EX � #
and wife
REC FEE.
11.00
TRANS
FEE. 209.70
COPY FEE:
CERT COPY FEE:
Grantee. PAGES: 1
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
Lot 6, Plat f Perch Lake Estates in the Town of St. Joseph, St. Croix Name and Return Address
County, Wis onsin.
LC-
030-1099-40-000
Parcel Identification Number (PIN)
This is not homestead property.
0() (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this ZO day of May 2002
' + Delwin R. Magsam
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Delwin R. Magsam STATE OF WISCONSIN )
) ss.
County )
authenticated this d of May 2002
Personally came before me this day.of
the above named
+ Kristina Ogland
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person(s) who executed the foregoing
authorized by § 706.06, Wis. Stars.) instrument and acknowledged the same.
THIS INSTRUMENT WAS DRAFTED BY +
Attorney Kristina Ogland Notary Public, State of Wisconsin
Hudson, WI 54016 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. Information Professionals c ompany, Fond du Lae. N
STATE BAR OF WISCONSIN 900-655'20211
WARRANTY DEED FORM No. 2 - 1999
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