HomeMy WebLinkAbout032-2107-90-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
430104 0
GER�RAC 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)I.
Permit Holder's Name: City Village X Township Parcel Tax No:
Moosai, Om P I Somerset Township 032 — Z /(,7 — ` (O — , , ,
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
7 - "7 1 07,30 9S 12.30.19. 11��
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
S ptic ' ' 1 ��� Benchmark
till J 1 t07.7�
D in Alt. BM
Aeration Bldg. Sewer '• 84 3
Holding §t/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION (/
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic � � � � / � r � Dt Bottom
Dosing t Header /Man.
Aeration Dist. Pipe
Holding Bot. System T I / /o •4
T L /O y. G f
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer Demand St Cover
G PM
Model Number '
TDH Lift
Fri c ' n Loss System Head TDH Ft
Forcemain Length D6 to Well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length [,1_2 a I No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 1 Lf S
SETBACK SYSTEM TO P/L JBLDG WELL LAKE /STREAM LEACHING anufacturer:
INFORMATION
Mo Type Of System: CHAMBER OR
f 1
' u ber
d
DISTRIBUTION SYSTEM
Header /Manif0!c Distribution x Hole Size x H Air Intake
1r Pipe(s) (
Length_ Dia_qL 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 F71
� Yes No ' :j Yes _ No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: CA / /0 Inspection #2:
Location: 811 165th Ave Somerset, WI 54025 SW 1/4 NW 1/4 1 T3 North Bass Lake Esta Parcel No: 12.30.19.
1.) Alt BM Description = S }' �f�ti� (vu" -n ��" a
2.) Bldg sewer length = 0 ( lt `� ya i
"'-
S� S�e�n^ k c, Au h
i
- amount of cover ='� 3 (`__ y sl
(I o
.Q,v��2�l.t.�n.•s�-C G� Q
red? es ��i -
O 1
- - 3
Use other ' side for additional information. No � Ens _ _ p or's Signature ert. No.
BD- 710 R.3/97
S 6 ( )
Jane Hansen °
Subject: Om P Moosai - N.Bass Lake Est - Lot 19 - B.Schumacher - 430104
Location: Somerset
Start: Thu 08/14/2003 2:30 PM
End: Thu 08/14/2003 4:00 PM
Recurrence: (none)
3, 4 do -
9 /
4
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Safety and Buildings Division Co t _
201 W. Washington Ave., P,O. Box 7162 S/ �Y` - , X
N v l' sconsin Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce (608) 266 -3151 Z I -1 .34' / �y
Sanitary Permit Application State Plan I.D. Number )
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide / ,, �' 4-
may be used for secondary purposes Privacy Law, s15.04(1)(m) Project Address (if different than mailing address)
I. Application Information - Please Print Ali Information ,>//
O
Property Owner's Na me Parcel # Lot t'! Block N
h /
Property Owner's M ailing Address Property Location
'A, ld,Section /a
City, State zip Code Phone Number
OD GL j J �Z/ R�E o le)
II. Type of Nuilding Icheck all that apply)
�1 or 2 Family Dwelling - Number of Bedrooms L: r Subdivision Name CSM Number
❑ Public /Commercial - Describe Use
❑ State Owned - Describe Use ❑City kfownship of Sd iLi CIr.5
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. kNew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B < ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. Type of POWTS System: (Check all that apply)
A Non - Pressurized In -Ground ❑ Mound > 24 in, of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter
❑ Constructed Wetland ❑ Pressurized In Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter
❑ Recirculating Sy nthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain)
V. Dis rsal/Treatment Area Information: b a <
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
73" 1 .0 7
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel giber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank �!' Ile
Aerobic Treatrnent Unit
Dosing Chamber
VII.' Responsibility Statement- I, the undersigned, assume responsibility for JaWation of the POWTS shown on the attached plans.
Plumber's Na me (Print) Plumber's Si gnature 7PRS Number Business Phone Number 57
Plumber's Addre ss (Street, City, State, Zip Code)
e - 1 1 7 a�� -ced _ZJ
VI Count, /De artment use Onl
Sani
VIII. C n ❑Disapprove! tary Permit Fee (includes Groundwater Da�e Issued Issuing Agent Signature (No Stamps)
Iq Surcharge Fee)
11 Owner Given Reason for Denial �(� v J
IX. Conditions of Approval/Reasons for Disapproval
C
Atum 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)
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Safety and Buildings Division County
201 W . Washington Ave., P.O. Box 7162
V sconsi n Madison, Wl 53707 - 7162 SaW7 ermit Num r (to be filled In by Co.)
Dep of Commerce (bog) 266-315] O
Sanitary Permit Application State Plan I.D. Number
In accord with Conan 83.21, Wis. Adm. Code, personal information you provide
may be used for secondary purposes Privacy Law, sl5.04(1)(m) Project Address (if different than Inailing address)
I. Application Information - Please Print All Infor 'on
Property Owner's Na me Parcel # Lot # Block #
Q P .SUN 0 3 2003 /F
Property Owner's M ailing Address Property Location
ZGf OFFS ( IF 'A, A)'A,Section
City, state / Zip Code PF01. e . u
ircle )
II. Type of Building (check all that apply) . 0 5 ,6 , T, N; R l y E o W1 1 or 2 Family Dwelling - Number of Bedrooms l ubdivision Name CSM Number
E1 PubliclCommercial - Describe Use V'v. taresL S� S
State Owned - Describe Use S \ ' ❑City_ ❑Village %wnshtp of yyi - e&i5 e
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. X New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New I List Previous Permit Number and Date Issued
Before Expiration Plumber Owner E
IV. TyW of POWTS System: Check all that apply)
Non - Pressurized In- Ground ❑ Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter
❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter
❑
Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (ex lain)
V. Dispersal/Treatment Area Information: 2 K $
Design Flow (gpd) Design Soil Application Rate(gpds0 Dispersal Area Reqdired Of) Dispersal Area Proposed (sf) System Elevation
Sly o 7
VI. Tank Info Capacity in Total Number Manufacturer Prefab I Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New usting �(
Tanks Tanks
Septic or Holding Tank
Aerobic Treatment Unit
Dosing Chamber QY
VU.'Responsibility Statement- I, the undersigned, assume responsibility for installation of the POW TS shown on the attached plans.
Plumber's Na me (Print) Plumber's Si gnature P MPRS Number Business Phone Number
4)/'1 /,`Q m 5C,4, - -a.zle Y � 9 �D
Plumber's Addre ss (Street, City, State, Zip Code)
VIII. Count /De artment Use Onl
Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing gent Signatur ( Stamps)
Surcharge Fee) I ,
❑ Owner Given Reason for Denial ZT3
IX. Conditions of Approval/Reasons for Disapproval _
V
ms s.
11 Attach c tplet� the County oWV for a system on paper not ess glen 81 x 11 inches in size
S10-634 - M 01/03)
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ST. CROIX COUNTY
,+ WISCONSIN
t ZONING OFFICE
- ST. CROIX COUNTY GOVERNMENT CENTER
t l
1101 Carmichael Road
Hudson, W1 54016 -7710
EROSION . CONTRO PLAN,,. X003 1 (715) 386 - 4680 • Fax (715) 386 - 4686
For Lot 19 811 165 A . S erset 'y' ner Om Prakash & Teelotama Devi Moosai
Under St. Croix County Zo 'ng Code: tj i e (Zoning) Administrator may attach reasonable erosion
prevention conditions to a p r&t approved for issuance." Wisconsin Admin. Code Comm. 21.125 requires the
building permit applicant and/or landowner to follow erosion control procedures and maintain them until the site
has been stabilized.
The Owner is responsible for notifying all contractors performing construction on this site that an
Erosion Control Plan is in effect and the following activities will be required in order to maintain
compliance with the plan:
1. The primary source for construction site runoff will be the house foundation excavation, driveway, and any
soil stockpiled until final grading and stabilization is complete. Septic system excavation/installation adds
to temporary disturbance, but establishing cover on exposed soils will prevent erosion. Plan to apply seed
and mulch as recommended in #5 below. Maintain existing vegetation wherever possible to minimize
sediment movement. A drainage easement is 50 ft. south of the proposed septic system on this lot, which
drains directly to Bass Lake.
2. Route contaminated runoff into stabilized vegetated buffer areas by creating temporary diversions graded
ALONG CONTOUR between excavation areas and any drainage ditches or waterways (see attached detail
for construction of diversions). Make sure no concentrated drainages or ditches can pick up runoff and/or
create erosion problems. There is approximately 300 feet between the septic system area and the 75 ft.
setback from the shore of Bass Lake.
3. If builder /excavator grades the site to create temporary diversions (see #2) to contain sediment and leaves
adequate vegetative cover to protect areas of concern, installation of silt fence MAY not be necessary. Silt
fence or other approved sediment control products will be required if sediment cannot be contained on
owner's property with the diversions and vegetative buffers. The Building Inspector or POWTS Inspector
will evaluate ESC plan effectiveness and make recommendations to owner and building inspector for any
action required to comply with applicable regulations.
4. Construction equipment and vehicles.must utilize a stabilized driveway access off public road for heavy
equipment; this includes cement trucks, well drillers, and other contractor's vehicles that access the property
during construction. This helps avoid muddy, rutted conditions that may allow contaminated runoff to reach
waterways and/or drainage ditches. Property owner must repair damage to ditches resulting from multiple
access points and sediment tracked on public roadways must be removed at the end of each workday.
5. Stabilize all disturbed areas with topsoil cover, seed and mulch immediately after final grading. If weather
does not permit seed germination, a heavy straw mulch cover will prevent erosion until grass /vegetation can
get established. On steep slopes or areas with little topsoil cover, erosion control matting can be applied any
time of year and if installed properly, will provide protection even if seed germination is delayed.
The owner of record during site construction will be responsible for compliance with the ESC Plan.
Please feel free to contact me with questions or ask for assistance with erosion & sediment control
installation. A copy of "Erosion Control for Home Builders" is included with this plan.
Prepared by: Pam Quinn, Soil Erosion Inspector #6650.54
Owner acknowled ement of ESC Plan requirements: - ��� //2003
�%t CrLC tS� />
VisconsinDepa'rn fIndustry SOIL AND SITE EVALUATIO REPORT Page 1 of
Labor and Human Relations
Division of Safety 8 Buildings in accord with ILHR 83.05, 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 St. Croix
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. d
APPLICANT INFORMATION— PLEASE PRINT ALL INFORMATION REVIE EDBY C�ry �
�a o
PROPERTY OWNER: PROPERTY LOCATION
Gerald J. Smith GOVT. LOT SW 1/4 NW 1/4,S 2 T 30 N,R 19 f W
PROPERTY OWNERS MAILING ADDRESS LOT # I BLOCK # I SUBD. NAME OR CSM #
11160 190th. Ave. N.W. 19 na N. Ba
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE XJOWN NEAREST ROAD
Elk River, ( - Somerset 85th. St.
[X] New Construction Use Ix ] Residential / Number of bedrooms 3 [ ] Additii6n to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate ._ bed, gpd /ft trench, gpd/ft
Absorption area required 643 bed, ft 563 trench, ft Maximum design loading rate _ bed, gpd /ft gpd /ft
Recommended infiltration surface elevation(s) 106.07 ft (as referred to site plan benchmark)
Additional design / site considerations alt. site system el.= 105.60'
Parent material outwash Flood plain elevation, if applicable na ft
L S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
=Unsuitable fors stem ® S El ® S El ® S El U ® S E] U ® S F7 U EIS ® U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ITrench
1 0 -9 10 r3 3 none
Uj sil 2msbk mfr aw 2f -9 -6
2 9 -38 10 r4/4 none sici lcsbk mfr
Ground 3 38 -84 7. r4 4
elev.
10 ft.
Depth to
limiting
factor r7 0
+84
Remarks: i3Z
Boring #
1 1 0-11 10 r3 3 none si
2 1 11-29 10 r4 4
Ground 3 29 82 7.5 \',
elev.
10 ft. 4
Depth to
limiting 5
factor
+82 1, s� ��
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715 - 246 -6200
Address: 1554 200 A ve., New Ric and WI 54017
Signature: 12,0 Date: 4 -17 -97 CST Number: m02298
PROPERTYOWNER Gerald J Smith SOIL DESCRIPTION REPORT Page of_�
PARCEL I.D. # C° 3 Z. Z V� S 0
Depth Dominant Color Mottles Texture Structure Consistence 'Ro GPD /ft
Boring # Horizon Y in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
._._3.. 1- 0-8 10yr3 none sil 2msbk mfr cs 2f .5 .6
2 8 -29 10yr4 /4 none sici 2msbk mfr gw if .4 .5
Ground 3 29 7. r4 4 none s 0scr ml na na .7 .8
elev.
109 ft.
Depth to
limiting
factor
+82
Remarks:
Boring #
1 0 -11 10 r3/3 none sil 2msbk mfr cs 2f .5 .6
sici lcsbk mfr 9w if .2 .3
Ground 3 21 -31 7.5 r4 4 none sl lcsbk mfr cw if .4 .5
elev. 4 31 -80 7.5 r4 4 none cos os ml na na .7 .8
57- 10 2 ft.
Depth to
S® 7 �I�% mot - cd s 05 ,�� - - 17 /�-4
limiting
factor
+80
Remarks: .6
Boring #
-14 10yr3/ 1 1
none sil lcsbk mfr cs 2f .4 .5
S 2 14 -25 10 r4/4 none sici lcsbk mfr gw if .2 .3
BEEN
Ground 3 25 -36 7.5 r4/4 none sl lcsbk mfr 9w na .4 .5
4 6 - 82 7.5 r4 4 none cos os ml na na .7 .8 �.
1 8 . Bt.
Depth to
limiting Lp
factor �5l
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Gerald Smith - 1554 200th Ave.
CSTM2298 SW4NW4 S12- T30N -R19W New Richmond, WI 54017
MPRSW 3254 town of Somerset (715) 246 -6200
lot #19 -N. Bass Lake Estates
N
1 =40'
BM.= top of SW lot stake C el. 100'
Alt. BM.= top of 2 pvc pipe C el. 107.70
3
b7v
)s7- 7d
2
Gary L. Steel
4 -17 -97
SEPTIC TANK & PUMP CHAMBER CROSS SECTION AND SPECTFICATYCNC
4" Cl VENT PIPE 12" MIN. ABOVE GRADE 8 WEATHERPROOF
>_ 25' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED
FRESH AIR INTAKE WITH CONDUIT M AN HO LE 1 ADDLOCKV &R
FINISHED GRADE WARNING LABEL 7 4" Cl RISER MIN.
MA
NLET
WATER TIGHT SEALS GAS-
TIGHT APPROVED
A SEAL JOINTS WITH
ALM APPROVED PIPE ZE--
PPROVED B ON 3 ONTO
IPE 3' 'i'" , SOLID SOIL
NTO SOLID OFF RISER EXIT
OIL PUMP OFF LEV . FT. PERMITTED ONLY
D IF TANK
ur MANUFACTURER
HAS APPROVAL
3" APPROVED. BEDDING UND TANK
CONCRETE PAD
SPtCIFIC TIONS
SEPTIC / DOSE
NUMBER DOSE5 PER DAY:
TANK MANUFACTURER:
TANK S : SEPTIC � GAL D EE VOLUME INCLUDING �
DOSE S'd GA FLOWBACK: �_ GAL
ALARM MANUFACTURER: � e!
CAPA ITIES: A = INCHES = �3�y GAL.
MODEL NUMBER: B z 2 INCHES = 32 GAL.
SWITCH TYPE: .._.... �--
C = $ INCHES =GAL.
PUMP MANUFACTURER: ��►��_,___�_
MODEL NUMBER: p ° �/ 'D = INCHES = _ L
SWITCH TYPE: �,
REQUIRED DISCHARGE R E GPM PUMP E ALARM WtRI NG AS PER
E _ c I LHR 16.23 WAC
__:�._. FEET
VERTICAL DIFFERENC BETWEEN PUMP OFF AND DISTRIBUTION P�P FEET
+ MINIMUM NETWORK SUPPLY PRESSURE ----
+ FEET f 0 CEMAIN X .&;� - FT! Ifl 0 F TATAL I DYNAMIC A HEAD = • FEET
; WIDTH ;
INTERNAL DIMENSIONS ENGTH DIAMETER
J �IONS OF PUMP TANK: LIQUID � „�--- G''..�����^
SIGNED: ,�'
�_ LICENSE NUMBER: - z?;?7944 DATE:
1/89
+.i. :Lii.1�
Submersible
C7
Effluent Pump
Epp
EP05
APFUU 711W Fasteners: 300 series • Fully submerged in high a M*; owing; Cast iron
$�gl, grade turbine oil f o r foj %went hot transfer,
sailowtnp M: ' Capable of running iutui oa and eftnt ft durability.
�t dry without damage to heat transfer. awe �owr: Thermoplas-
components, tic rsavor =1m=rd1,
Homes Available lor autemeoc aA and !tout
• F auns � Mandel opetmatice. AmomOc P
� Icy d* sump • EPO4 91: phase: 0.4 FOP, models lftde Mtah011"ll
+ 11S or V, 60 Hz, 1550 Flog $W1 dm w#nW#d and ■ Power Cable: Severe duty
RPM. built in overload with pMW It the hdory rated oil and water rosMant
automatic reset 0 Upper aril lower
• EP05 Single phas.0.5 HP, heavy du bat! bearing
115 V, 00 Hx,155 PM, !EAT com tru on.
Pump: FPO4 bush in overload with h , r I mp
Thermo-
• SoRds tudling uAllity: auka tk reset. plastic Se*pen design AGENCY L,I1MKG
ek" m it mum. • Pow cord: 10 toot with pump out wares for
,.� • Capecibes: up to 56 GPM. standard length, 16/3 SJTO ` mecharmjul seal protedio+t, t,�ned�rer
• Togtl heads: up to 24 feet, with times prong ground!ng w MWItet; The
rmrr
• DWftrge OW: I W NPT, plug, optional 20 foot p c eaalosa design for (CSA ill model numbers
• Mechaftl seal: mammon. Isiah, 1613 SJTW with end ir. 4 F o r AC',)
ro% y/c�amlc stationary, three prong grourmc#ing plug im roved performance.
BUNA -N 8lastomers. ,standard on EPOS) e
, +0asinp opl and and design Rugged
• Temperature: ll shluwof rmasesign provides
1O4 4 c) th) continuous ar ONO and
1401 J60• irzm m st �,d crrro�on ri ce.
• Fa l mars: 300 series uaERS FEET ,._ _...
stainless steal,
r Capable of namning
dry w�uwt damage to a so L ""'"""'
Puiltp: go e
• S handling capabilhy: 0 7 �
Ve maximum. --°
+ CalmillleB: up to 60 GPM. --
Total heads: ug to 31 feet.. $ sQ
• Glso" sire: l W NP T.
BU yy 4 T
N" etactamers.
+ T tai: 3
16 con"nuous
140°F (O+G) bmterndttent.
50 0
0 4 — t mz main
CAPACRY
s ton rsa& P UML tna. Y ta w ma togs
V 1497 PAGE 325 0
60041
STATE BAR OF WISCONSIN FORM 2 -199s KATHLEEN H. WALSH
Docum ntNuob r W D ED REGISTER OF DEEDS
—j ST. CROIX CO., WI
This Deed, made between Forest Oaks Condos Inc RECEIVED FOR RECORD
03 -23 -2000 9:30 AM
and Qm Prakash Moosai and Grantor, Teelotama Devi bloosai WARRANTY DEED
EXEMPT N
CERT COPY FEE:
Grantee. COPY FEE:
Grantor, for a valuable consideration, conveys and warrants to Grantee TRANSFER FEE: 125.70
the following described real estate in St. Croix County, State of Wisconsin RECORDING FEE: 10.00
(The "Property "): PAGES: 1
R —rdinv Area
DAVID J. ESTREEN
304 LOCUST ST.
HUDSON, WI 54016
032.2107.90000
Parcel Identification Number (PIN)
This is not homestead property.
Lot 19, North Bass Lake Estates, St. Croix County, Wisconsin.
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any
Dated this `� * day of March, 2000.
Forest Oaks Condos, Inc.
� ,President
s ,
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
ss.
authenticated this _ day of b County )
Personally came before me this day of _
' March, 2000, the above named Forest I rilbs Inc. b
Gerald J. Smith, President.
TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be th fson(s) whb e - ututed
(If not, the forego instrument and ac owl a dfe same.
authorized by 1 706.06, Wis. Stats.)
THIS INSTRUMENT WAS DRAFTED BY • l� .
nsin `
Attorney Kristina Ogland Notary Public, State of Wisco ,
Hudson, WI 54016 My Co mi ion is permanent. (If acfi�Sa expiration date:
(Signatures may be authenticated or acknowledged. Both are trot t l \"l ZvU� _) n.: )�+
necessary.) ,�'4.an...
*Names of persons signing in any capacity should be typed or printed below their signatures
WARRANTY DEED STATE BAR OF WISCONSIN
FORM No. 2.1990
INFORMATION PROFESSIONALS COMPANY FOND OU LAC, WI 5o0855.2021
I
May 27 03 09:43p Matthew Paulus 715 --246 -9737 P.1
05/2 5/03 WEU 13:b2 b'A3 d19 SUb 5004 eb�"`
Maw 27 - 03 09:43p Matthew Paulus 715 246 - 9 7 3 7 1D•
FR[�h/ Scl+u.�ake:r Piumben4
FAX MD. = 71.5386312L May. 19 2003 09:00W P2
ST CROIX COUSIN'
SEPTIC T MAINT AGPM,%MNT
AND
OWNER HV CEMPICATION FORM
Ow wNBu 1 rY` 22 O n w p1�ot+,► Aaat.l rlr. ,a�td bm fat am No C ParcO ldetstifnalian Nua�bat
'l , , / ? /� b 3 2 i v �- -CIO -ate
LEGALM P" Laaat . - Ya ts�' S.. �'�,.. 1� � 1` .K � W. Town of S'0'� e YS N�
Ceruftd sne+ey Maki 0 Valuate Pig@ #
1Famaty Decd * .� _ volume Peat # 3 2-
Spec boun O ymo no Lot )but kaeel:iftble Yes C nv
bnpmpw saesiomm "NumeofYamaepdosymm=Wdem"Iie dliltleetetlacalesactm rapersae�aaefsantie
o� e< a ae Igo wptk u& way dowl ~ ae.e.r I d =W&d W s li OWA wMpw. Wba ra: Flo im *s s�ncec+
aaoe atbact dw &&deal S t w ewe W* Y e rca: mc.A stale is fte "So dim O VAS•
I
?� pse/aety Oeras: ewes to sgtieait >r SL Cgoin Zosi1S Dowm� a laaeliexum 16m, eased by *0 ""W W and by
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner V�A obS�� Septic Tank Capacity Q'Q d g al
NA
Permit # 4 Septic Tank Manufacturer e ' 0 NA
DESIGN PARAMETERS Effluent Filter Manufacturer 0 NA
Number of Bedrooms 3 0 NA Effluent Filter Model ad 17 NA
Number of Public Facility Units 0 NA Pump Tank Capacity ga l O NA
Estimated flow (average) A V S g al/day Pump Tank Manufacturer Se 0 NA
Design flow (peak), (Estimated x 1,5) Q gal/day Pump Manufacturer a'ap j 4d 0 NA
Soil Application Rate gal/day/ft' Pump Model 0 NA
Standard Influent/Effluent Quality Monthly average' Pretreatment Unit 0 NA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter i7 Peat Filter
Biochemical Oxygen Demand {BOD 5220 mg /L 0 NA 0 Mechanical Aeration 0 Wetland
Total Suspended Solids (TSS) 5150 mg /L 0 Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) C3 NA
Biochemical Oxygen Demand (BOD 530 mg /L 0 In- Ground (gravity) 0 In- Ground (pressurized)
Total Suspended Solids (TSS! 530 mg /L ❑ NA Q At -Grade 0 Mound
Fecal Coliform (geometric mean) S10' cfu /100ml O Drip - Line ❑ Other:
Maximum Effluent Particle Size Y In dia. 0 NA Other ' 0 NA
Other: 0 NA
Other: ❑ NA
"Values typical for domestic wastewater and septic tank effluent. Other: (3 NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
nt s (Maximum 3 years) 0 NA
Inspect condition of tanklsl At least once every: ;no �(s)
Pump out Contents of tanks) When combined sludge and scum equals one -third {Y of tank volume 0 NA
dispersal call(s) At least once every:
month(s) (Maxlrrwm 3 years} ❑ NA
Inspect dia
p � �year(s1
Clean effluent filter At least once every: months) ❑ NA
ear(s)
Inspect pump, pump controls &alarm At feast once every: •-- 0 monthts! O NA 0 ear(s)
Flush laterals and pressure test At least once every: O month(s) 13 NA
'"'— E3 year(s)
❑ monthis) 0 NA
Other: At least once every: IO earls)
Other: 0 NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal califs) shall be visually inspected to check the effluent levels in the observation pipes and to
check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y3) or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence o products or other chemicals
f painting p
that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations ate detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing, and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
13 A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
site
0 T tank If nn 00610 e
O Mound and at -grade soil absorption systems may be reconstructed In place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
< <WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWYS INSTALLER POWTS MAINTAINER
Name (✓ � tl.' u ,,,,., �,,. r1fB L Name
Phone 7 l — _ ? _ S ,;2 Phone
SIEPTAOE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name �j'[ C(QA tK C"
Phone Phone (0 RD
This document was drafted in compliance with chapter Comm 83.22(2)(b)(11(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
ST. CROIX COUNTY
` WISCONSIN
ZONING OFFICE
T NNNRRNNN■ - nN. ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016 -7710
EROSION CONTROL PLAN (715) 386 -4680 - Fax (715) 386 -4686
For Lot 19, 811 165` Ave. (Somerset) — Owner(s) Om Prakash & Teelotama Devi Moosai
Under St. Croix County Zoning Code 17.70(3)(b) 5: "The (Zoning) Administrator may attach reasonable erosion
prevention conditions to a permit approved for issuance." Wisconsin Admin. Code Comm. 21.125 requires the
building permit applicant and/or landowner to follow erosion control procedures and maintain them until the site
has been stabilized.
The Owner is responsible for notifying all contractors performing construction on this site that an
Erosion Control Plan is in effect and the following activities will be required in order to maintain
compliance with the plan:
1. The primary source for construction site runoff will be the house foundation excavation, driveway, and any
soil stockpiled until final grading and stabilization is complete. Septic system excavation/installation adds
to temporary disturbance, but establishing cover on exposed soils will prevent erosion. Plan to apply seed
and mulch as recommended in #5 below. Maintain existing vegetation wherever possible to minimize
sediment movement. A drainage easement is 50 ft. south of the proposed septic system on this lot, which
drains directly to Bass Lake.
2. Route contaminated runoff into stabilized vegetated buffer areas by creating temporary diversions graded
ALONG CONTOUR between excavation areas and any drainage ditches or waterways (see attached detail
for construction of diversions). Make sure no concentrated drainages or ditches can pick up runoff and/or
create erosion problems. There is approximately 300 feet between the septic system area and the 75 ft.
setback from the shore of Bass Lake.
3. If builder /excavator grades the site to create temporary diversions (see #2) to contain sediment and leaves
adequate vegetative cover to protect areas of concern, installation of silt fence MAY not be necessary. Silt
fence or other approved sediment control products will be required if sediment cannot be contained on
owner's property with the diversions and vegetative buffers. The Building Inspector or POWTS Inspector
will evaluate ESC plan effectiveness and make recommendations to owner and building inspector for any
action required to comply with applicable regulations.
4. Construction equipment and vehicles must utilize a stabilized driveway access off public road for heavy
equipment; this includes cement trucks, well drillers, and other contractor's vehicles that access the property
during construction. This helps avoid muddy, rutted conditions that may allow contaminated runoff to reach
waterways and/or drainage ditches. Property owner must repair damage to ditches resulting from multiple
access points and sediment tracked on public roadways must be removed at the end of each workday.
5. Stabilize all disturbed areas with topsoil cover, seed and mulch immediately after final grading. If weather
does not permit seed germination, a heavy straw mulch cover will prevent erosion until grass /vegetation can
get established. On steep slopes or areas with little topsoil cover, erosion control matting can be applied any
time of year and if installed properly, will provide protection even if seed germination is delayed.
The owner of record during site construction will be responsible for compliance with the ESC Plan.
Please feel free to contact me with questions or ask for assistance with erosion & sediment control
installation. A copy of "Erosion Control for Home Builders" is included with this plan.
Prepared by: Pam Quinn, Soil Erosion Inspector #665054
Owner acknowledgement of ESC Plan requirements: _/_/2003
P
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