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HomeMy WebLinkAbout032-2157-20-000 (3) Wisconsin Department of ComMerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 430081 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: Grand Properties L.P. Somerset Township 032 - 2157 -20 -000 CST BM Elev: In BM Elev: BM Description: Section/Town /Range /Map No: I V � : W o' L? 1 Yl(Gy WA k e (l i4 -, 12.30.19.1354 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic J(� f Benchmark ��� r vt ,y3 f� . loo Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet vi TANK SETBACK INFORMATION St/Ht outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet r /� Septic f � / / Dt Bottom Dosing Header /Man. .' TT 2 Aeration Dist. P+w FW014nitki N 1 7 � a 1-A / Holding Bot. System /e, 1/ • 34- �i i t -, , 2- . PUMP /SIPHON INFORMATION Final Grade ;3U 1 GG. / 3 Manufacturer Demand St Cover GPM IUD. Model Numb LL' 1 Y1 O S qv "at TDH Lift Fn Loss System Head TDH Ft Forc ain Length Dia. Well SOIL ABSORPTION SYSTEM der ,BED/TRENCH Width Length No. Of Tren hes ;? PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS �, j�c w _ l0 Y7 h � /�1 v' 1 Ft G '.I ��. - SETBACK SYSTEM TO P/L JBLDG ELL LAKE /STREAM LEACHING Manufacturer: r't INFORMATION CHAMBER OR Type Of System V4 y : / J �i UNIT Model Number: C - DISTRIBUTION SYSTEM Header /Manifold IDistribution x Hole Size x Hole Spacing Vent to Air Intake ,1 // Pipes Length �Ji'-^� Dia ` _ Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over I xx Depth of xx Seeded /Sodded jxx Mulched Bed/Trgnch Center Bed/Trench Edges Topsoil 1 Yes j No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: 0 1 Location: 1682 89th St New Richmond, WI 54017 (NE 1/4 NE 1/4 12 T30N R19W) The Highlands Lot 12 Parcel No: 12.30.19.1354 1.) Alt BM Description = 2.) Bldg sewer length = I \ e , - amount of cover Plan revision Required? ] Yes No ©'0Cj�j Use other side for additional Information. I V ��' Vim! _` ___� O _ J Date Insepctor's Signature Cert. No. SBD -6710 (R.3/97) �_ it VAI Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7082 Nv isconsin Madison, Wl 53707 - 7082 Lary Permit Number (to be filled in b Co.) Department of Commerce (608 9/ «t o a Sta Plan LD. Numbe Sanitary Permit Applicat' n I rs N I � In accord with Comm 83.2 1, Wis. Adm. Code, personal informs[ on yourvikle 6 ; may be used for secondary purposes Privacy Law, s 15. (1 xm) Pro ect Address (if different than mailing address) 1. Application Information - Please Print All Information - Property Owner's Name Parcel # Lot # Block # O - O Property Owner's Mailing Address F Property Location v 1 5 - Y ' /., %, Section City, State Zip Code Phone Number r O (circle II. Ty of Building _ T _ZO N; R�E oiW yp g (check all that apply) //�� � P Zd Subdivision Name CSM Number �/tmttil ®1 or 2 Family Dwelling - Number of Bedrooms 3 J'�C ❑ Public/Commercial - Describe U e r L El State Owned - Describe Use J D 1- p ❑City ❑Village Township of A & 7- III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. B New System ys ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System B • ❑ Permit Renewal 2 Perm Revision Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber er / 2 ^� / _ / D e� r CH!/>7r 7 J (/� (l� IV. Type of POWTS System: Check all that appl Non - Pressurized In -Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil 11 At-Grade 11 Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In round ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ching Chamber ❑ Drip Line ❑ Gravel-lqsi Pipq ❑ Other (explain V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdso Dispersal Area Required (sl) Dispersal Area Proposed (sf) System Elevation 6 Y3 6S -3, i , VI. Tank Info Capacity in Total Number �� Manufacturer Prefab Site Stocl Fiber Plastic Gallons Gallons of Units G/�J Concrete Constructed Glass New Existing Tanks I Tanks Septic or Holding Tank Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume responsibility for installs f the POWTS shown on the attached plans. Plumber's Name (Print) PI 's Signature MFjVEZS sue, Business Phone Number (_ /- 7j ZZ-1 2 Z:� Plumber's Address (Street, City, State, Zip Code) UIELU t v2 VIII oun /De artment Use Onl Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Daty Issued Issuing Agen )Sign fur o p Surcharge Fee) s) �l d (U Z � Owner Given Reason for Denial ` U b Q 3 IX. Conditions of Approval/Reasons for DisgQproval , /l %�� /) �� ¢��� �t 2Gc� l d/� ' (J S STE�EF�ry� -- 1 Septic tank, effluent filter and /►1 �h 3 • S� —�a �QLt/T� dispersal cell must all be irained j ,2��✓�j� as per management plan provided by plumber. syS�(j�y� / I v 2. All setback requirements must be maintained as per a licable code /ordinances. na H.. 01 3_ Attach complete plans (to the County only) for the system on paper not less than 81/2 it 11 Inches In size 1 SBD -6398 (R. 08/ - -- -- - -- C N J31 AV TE /- 2,1.1 /, /R E7V I - -- jp�o o F�'t,R -- -- -- -- --- g — - - - --- --- - - - -- LVA 3 BAD, W E LL . - -- __ - -- - -- --------- -__._- - _ -_ _ --- _— _�'__!3__1__'I__- Zef'__ o_F_ cow% c1t�T� _�Ca��c---- orc_.�Tr_or�._of SiQ�.v� __��•loa�_o_ ...__ - - �Q�L,QS_ET �i - r - - -- — _— - -, - - - -- -- -- - -� Pa o /.� -� w 1 -/ _- : -- WA 3 8 S 4!1). -- - _ --� 8 - �'__!3/"I___7aP !_Q F_ co./%6C.R& c - _ �CO K o2 Lfral -of Sfa�.v _ / r -- . UACIc.A E !11ezv- --� - -- - -- -- - _- _ Qt: ,�ST -i. :- 5 ��` 0 z� c�O�� sue- - �- S- - -- _ - i _.___ ______ __ _._ ___ _. __- ___._ .___ _ _ ._ __ _._ __.. _.__ _... _.. -_ __ 1173 Wisconsin Department of Commerce SOIL EVALUATION REPORT page 1 of 3 Division of Safety and Buildings Tom Schmitt in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8%2 x 11 inches in size. Plan Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and parcel I.D. percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Please print all information. Revi y Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). I� Z3 Property Owner Property Location 13 Grand Properties, LP Govt. Lot NE 1/4 NE 19 S 12 T 30 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 712 Rivard Streeet, Suite 300 12 The Highlands City State Zip Code Phone Number J City _ I Village 10 Town Nearest Road Somerset I WI 1 54025 715 - 247 -5900 Somerset I 89Th St. ✓1 New Construction Use: 0 Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD J Replacement Public or commercial - Describe: Parent material Outwash Flood plain elevation, if applicable na General comments and recommendations: Area is suitable for a conventional system with a 0.7 gpd/sgft rating. Possible system elevation for Area I is96.90' a Boring # J Boring vi Pit Ground Surface elev. 100.39 ft. Depth to limiting factor 100+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF *Eff#1 *Eff#2 1 0 -7 1Oyr3 /4 none sl 2msbk mfr a 2m,2f .5 .9 2 7 -100 1Oyr5 /6 none ms Osg ml — 7 1.2 7 a Boring # Boring 1/ Pit Ground Surface elev. 101.39 ft. Depth to limiting factor 101+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft *Eff#1 *Eff#2 1 0 -10 1Oyr3/3 none I 2msbk mfr cs 2m,2f .5 .8 2 10 -17 1Oyr5/3 none sl 2msbk mfr gw 2m .5 .9 i 3 17 -31 1 Oyr5 /4 none Is 1 msbk mvfr gw — .7 1.2 4 31 -101 10yr5/6 none ms Osg ml — .7 1.2 t3d Vo `� .►. * Effluent #1 = BOD ? 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD <30 mg/L and TSS <,30 mg/L CST Name (Please Print) Signature: CST Number Thomas J. Schmitt 227429 Address Tom Schmitt Date Evaluation Conducted Telephone Number 1595 72nd St., New Richmond, WI 54017 8/16/03 715- 247 -2941 Property Owner Grand Properties, LP Parcel ID # Page 2 of 3 F3� Boring # J Boring N_J Pit Ground Surface elev. 98.09 ft. Depth to limiting factor 100+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots 2 *Eff#1 *Eff#2 1 0 -13 10yr3 /4 none sl 2msbk mfr cs 2m,2f .5 .9 2 13 -100 10yr5/6 none ms Osg ml ---- ---- .7 1.2 ❑ Boring # Boring J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *Ef1#1 *Eff#2 F-1 Boring # Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *Eff#1 *Eff#2 * Effluent #1 = BOD ? 30 < 220 mg/L and TSS >30 < 150 mg /L * Effluent #2 = BOD -i 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. v f3Y�t- o c� fcgo Gw+c,re 4 e' b � s ar �-' � � O � a tea+ -� s b o y 16D cz) r / l o,;a e ('/ "s e - 703. -2,' A lt yo �r r �4 e w PA 51" f Y,w`t �hy Parr V !'Ow� �/'Oy0 8/ fief OrCc. -J j 4Y 7th d y 4-1/// csTwi X 7.2 7 S/af Sw la I ^41 5/, �avr. er tai "/,Z AL ,� 'c �r..� /� G✓+� sy-o/ � f?ts') - 461L EVALUATION REPORT 11 73 Wisconsin Department of Commerce Page 1 of 3 Division of Safety and Buildings in ac¢ordaaae with Comm�85, Wis. Adm. Code Tom Schmitt Attach complete site plan on pape no is in size. must County St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel I.D. Please print all information. Reviewed By Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Grand Properties, LP Govt. Lot NE 114 NE 19 S 12 T 30 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 712 Rivard Streeet, Suite 300 12 The Highlands City State Zip Code Phone Number J City J Village IIS Town Nearest Road Somerset I WI 1 54025 715 - 247 - 5900 Somerset I 89Th St. 0 New Construction Use: Yr Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD J Replacement Public or commercial - Describe: Parent material Outwash Flood plain elevation, if applicable na General comments and recommendations: Area is suitable for a conventional system with a 0.7 gpd/sqft rating. Possible system elevation for Area( is96.90' Boring # Boring 1/ Pit Ground Surface elev. 100.39 ft. Depth to limiting factor 100+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fF *Eff#1 I *Eff#2 1 0 -7 1Oyr3/4 none sl 2msbk mfr cs 2m,2f .5 .9 2 7 -100 10yr5/6 none ms Osg ml -- -- .7 1.2 Boring # Boring iI Pit Ground Surface elev. 101.39 ft. Depth to limiting factor 1 0 1 + in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft *Eff#1 *Eff#2 1 0 -10 1Oyr3/3 none I 2msbk mfr cs 2m,2f .5 .8 2 10 -17 1Oyr5/3 none 61 2msbk mfr gw 2m .5 .9 3 17 -31 1 Oyr5 /4 none Is 1 msbk mvfr gw .7 1.2 4 31 -101 10yr5/6 none ms Osg ml — -- .7 1.2 Effluent #1 = BOD ? 30 < 220 mg /L and TSS >30 < 150 mg/L ` Effluent #2 = BOD <30 mg/L and TSS <_W mg/L CST Name (Please Print) Signature: CST Number Thomas J. Schmitt :. Z1-- 227429 Address Tom Schmitt Date Evaluation Conducted Telephone Number 1595 72nd St., New Richmond, WI 54017 8/16/03 715- 247 -2941 Property Owner Grand Properties, LID Parcel ID # Page 2 of 3 3 ] Boring # Boring 1/ Pit Ground Surface elev. 98.09 ft. Depth to limiting factor 100+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP 'Eff#1 •Eff#2 1 0 -13 1Oyr3/4 none sl 2msbk mfr cs 2m,2f .5 .9 2 13 -100 1Oyr5/6 none ms Osg ml -- --- .7 1.2 F f Pit Boring # Boring _ Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD •Eff#1 `Eff#2 F—I Boring # Boring Pit Ground Surface elev. ft. Depth to limiting factor in. F Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM *Eff#1 'Eff#2 * Effluent #1 = BOD ? 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD -i_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. l2e r✓, l ? e ` � o � /.1 �,/, y �► lames sm z - o`F Gcr -+ e d't 4 b loeks ov 6, #c, og A X . (j3'✓t = NIA) �/� 3r 3br 39r �r �( 1 _y ^� 0 SIB 1 �p� O tYrn.a,+�►y Poem; G rc �,j erV er 1 t ie1 �+'rw.�e � iy 4""Jooe 70) ,+ gi ucwa ( 5 Ski �d S> l / C i c,,z rw,2-s / 'ems✓ ' e, - C, oyo/ ,.�w -% G - 7� s,4 ,y Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit 430081 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID 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: Grand Properties L.P. I Somerset Township 032 - 2157 -20 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 12.30.19.1354 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover 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. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT 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 Yes [] No 0 Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 1682 89th St New Richmond, WI 54017 (NE 1/4 NE 1/4 12 T30N R19W) Highlands Lot 12 Parcel No: 12.30.19.1354 1.) Alt BM Description = 2.) Bldg sewer length = - amount of r ov = c e 1- Use other revision side for lu 1 No additional information SBD -6710 (R.3/97) Date Insepctor's Signature Cart. No. Safety and Buildings Division Count N visconsin 201 W. Washin ton Ave., P.O. Box 7162 g s' /. Madison, WI 53707 — 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 266 -3151 4'3008 Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.2 1, Wis. Adm. Code, personal information you provide (R may be used for secondary purposes Privacy Law, s1 5.04(1)(m) Project Address (if different than mailing address) I. Application Information — Please Print All Informati I n KLGEIVED —4— !// 6 2- QQ Property Owner's Name Parcel# 0 Ot #' Block # ,!UN 1 1 2003 13�`f Iv 0 oeo E / /ES L, , Property Owner's Mailing Address C;u;��i ( Property Locati ST. ;;FzOfX y 7/ ?- R ✓/+Aev S 1. <5G/ /7 /D �,ING OFFICE IV C_ ��4, V VV4 ,Sectl o /a City, State ZipCooddle Phone Num er �e// /CGS T S , 7 Vat .� 71S z `l - yy / II. Type of Building (check all that a L _-.- _ T N; R pply) N 1 or 2 Family Dwelling - Number of Bedrooms /) SubdivisioZw CSM Number El Public /Commercial - Describe Use TH J ❑ State Owned- Describe Use ��L ❑City illage Township of .To/)IE ,eS III. Type of Permit: (Chec my one box online A. Complete line B if applic ble) A. X New System y ❑Rep ment System ❑ Treatment/Holding Tank Replacement Only t her Modification to Existing System B. ❑ Permit Renewal El Permit Re vis El Change of El Permit Transfer to Ne List Previ VrEl it Numbe d to d w Before Expiration Plumber Owner IV. Type of POWTS System: Check all that a Non - Pressurized In- Ground El Mound > 24 in. of sut le soil El Mound < 24 in. of suita soil 11 At-Grade ngle Pa ss Sand Filter El Constructed Wetland El Pressurized In- Ground [I Holdin ank El Peat Filter ❑ A is Treatment Unit ❑Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter El Leaching Chamber ip Line L1 Gravel -I Pipe ❑ Other (explain) V. Dispersal/Treat ent Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Disper ea Require f) Dispersal Area Proposed (sf) Sys em El yation yQ ��� 47 ys0 C .,o VI. Tank Info Capacity in Total Numbe ufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units 7_,+6 4_100 Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank 1 l�AO / Do c) ' X V{l cC,cs C. P. Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume r onsibility for installation of th OWTS shown on the attached plans. Plumber's Name (Print) Plum er's ignature f MP/MPRS Number Business Phone Number � tX) S cy irli t Wa;Z3 71 5 �(9' -1 ,6,5 l Plumber's Address (Street, City, State, Zi ode) 64 /j /} yr S 16,e sue: 1,r>I s 1/o VIII. County/Department Use Onl X Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing A ent Signature (N tamps) Surcharge Fee) ❑ Owner Given Reason for Denial G L-5 !3 2Qr7 IX. Conditions of Approval /Reasons for Disapproval 0,4 r x- Attach 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) E H I � LAA Lo - 7 Z-� -- _ PP Pa S S _ Zo¢EE7" -- -_ _. -. - - -- - - - - - -- - -- -- _A IM 1_ - TO E r fY PVC 0 0,00 6mi. TOP 9e o� A- -3X-A6 - -- 1 l A r ar -- - r - - - — - -- - - -- -- . - - -- q- -- . - -- -- WTI 1H j= I LaJ L�S Lo �z d ' Avc [ti1sPEC .( -ll . ro:'- . PI 0 5 S - EL, 90. 10 '' 3 eOP6 �,- �L,_ /00,00 - dma Gov 3 /q QvC BoAE_ Hoccs - / W ZAA,6L A -100 f - r . t - o - -- - - 5 ees i Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Cr w % Attach complete site plan on papeY 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. P. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. w by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 6 D 3 Property Owner Property Locatio �I C r 34 6 u4 Govt. Lot NE 1/4 ivE 114 S 1 T 30 N R ( E (or) Property Owner's Mailing Address Lot # I Block # Subd. Name or CSM# ► 5 ,T4wq+ukee - Tr. ► 2- - TF,e High lands City State Zip Code Phone Number ❑ City ❑ Village WoWY Nearest Road 4 —New Construction User Residential / Number of bedrooms 3 "`f Code derived design flow rate GPt� ❑ Replacement ❑ Public or commercial - Describe: G ` Parent material Flood P ain elevati c n ifjppli ble ff ft. General comments 3 a U a� and recommendations: 5¢etY1 'elev. f Ojo l0 W ty - �l' 3.op I h 1 JA X1 -e l ev. +0 P _ - (� my ❑ Boring # ❑ Boring '�� *d'� SI�S /G�� Z MAA ® Pit Ground surface elev. ft. Depth to limiting factor iQ in. . SoH - Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2 6-1 10 Y 312 ~ SL r C s i VI .9 g�lw 1 0 r 1 — SL. Z � r cs . 9 164 Y'4 1�(.0 O _ — - 1 1. eJ ",a � Fil Boring # ❑Boring cp� ® pit Ground surface elev. q _7-30 ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0- l0 31Z Si I Zmcxbc. rn c Z 13.31 1b Si 2 mab r c. r 1-Z * Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L CST Name (Please Print) ,Signature CST AdA Scl1 ,rte ker Address Date Evaluation Conducted Telephone Number 1 t1 96 73 54. So ►nc►Ir&e- - i - W1 SY62 /0 -30 07 Zif7 - - - 1QO8' 1 SBD -8330 (R07 /00) 1 Property Owner �� Parcel ID # Page 2 of Boring # ❑ Boring y[�� F- �� Ej} Pit Ground surface elev. `7�- ft. Depth to limiting factor ` q in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 6 -9 10 r Sit 2 c5 27- IU y ILD mS t F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ❑ Boring # ❑ Boring El Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application' Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft 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 Peed material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 - 264 -8777. SBD -8330 (R.07 100) AP • PAGE 3 OF NAME LOT# / Z LEGAL DESCRIPTION lzE YNa X,S iZ T 3 ,N,R, 1 E(or)10 SCALE: I"= BM 1 ELEVATION /C7O d BM 1 DESCRIPTION <j e o -� /� QT �— BM 2 ELEVATION 79.0 U BM 2 DESCRIPTION jog cs %� ! �ttc- SYSTEM ELEVATION p I' ,0 0 � ?3.0 V ALTERNATE ELEVATION doe ZZ , Oo CONTOUR ELEVATION g3,00, 9s, oG" T77 00 q �a3 SIGNATURE — ATE PAGE_OF IS NAME S 7 D J LOT# J Z LEGAL DESCRIPTION dzE Y,yF— 1 4 ,S IZ 1.50 ,N,R, I q E(or)� SCALE: I"= !f () I BM I ELEVATION 16 0. 0 BM I DESCRIPTION 4j p o � �/t( " Qj! c. BM 2 ELEVATION Tx. o C) I BM 2 DESCRIPTION jo Q cs-� %y f (J U c_ SYSTEM ELEVATION 9`��o o Mo c.) 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I t. i , I � I ....... , � _ .. ems- _ ! �� I` :...- ___ ... � --- +-- • -� - -, I i/ �- � -� k I I i jl l i 1 I , I : I �-t i I I i � ! �.. t I : 1 �R,?��?._._ ...... , _ _fir• _ .:.._ .. . - .. �. _ � - -- - - - _ _ _ i _ ( i �- POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION S'f STEM SPECIFIC.3 MNS Owner Septic Tank Capacity 1000 al [3 NA Grand Properties L.P. Permit # Septic Tank Manufacturer Week's C.P. ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer Zabe1 13 NA Number of Bedrooms 3 [3 NA Effluent Filter Model A -100 ❑ NA Number of Public Facility Units IN NA Pump Tank Capacity gal ®Np` Estimated flow (average) 300 gallday Pump Tank Manufacturer ■ NA Design flow (peak), (Estimated x 1.5) al /da Pump Manufacturer NA Soil Application Rate 0 gal/day/ft2 Pump Model 0 NA Standard Influent /Effluent Quality Monthly average" Pretreatment Unit ®NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L M In- Ground (gravity) 13 In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ® NA ❑ At -Grade [3 Mound Fecal Coliform (geometric mean) 510 cfu /100ml ❑ Drip -Line ❑ Other: Other: 13 NA Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ NA Other: ❑ NA ❑ NA "Values typical for domestic wastewater and septic tank effluent. Other. MAINTENANCE SCHEDULE Service Event Service Frequency ❑ month(s) (Maximum 3 years) ❑ NA Inspect condition of tank(s) At least once every: 3 ® ear(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA ❑ month(s) (Maximum 3 years) ❑ NA Inspect dispersal cell(s) At least once every: 3 ® year(s) ❑ month(s) ❑ NA Clean effluent filter At least once every: 1 I year(s) y; ❑ month(s) 9 NA I. Inspect pump, pump controls & alarm At least once every: ❑ year(s) ❑ month(s) ■ NA F' Flush laterals and pressure test At least once every: ❑ year(s)% ❑ month(s) p NA_ Other. At least once every: ❑ year(s) >u ❑ NA f Other: 3 b MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications iner; Se Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Mainta are, Servicing Operator identify any cracks or leaks inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, , measure the volume of combined sludge and scum and to check for any back up or ponding of a$ a to heck for any ponding The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes - of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a fairing 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 (Y 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. eft vk 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. fR ays of completion of any service event. A service report shall be provided to the local regulatory authority within 10 d } Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are 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. Dur ing P g in p ower outages p ump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be u 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. ' urb or compact, the area and di cells. Do not drive or park over, or otherwise disturb p • les over tanks p Do not drive or park vehicles 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, r 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 wdl result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the in effect at that time. o setback and /or soil limitations. Barring advances in POWT E3 A suitable replacement area is not available due t S r, technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding ,tank may be installed as a last resort to replace the failed POWTS. ❑ 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. RESGUE OF A`` PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. r ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER �.x T , Name John Schmitt Name Owners choice P hone Phone ( 715)-549-6651 P SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY ' Name Owners choice Name St. Croix Ct Zonin Phone Phone (715)-386-4680 This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code i ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer GR Mailing Address _ 2 14 17 i /1,Q R 0 s Property Address -#- tcos Z 22 (Verification required from Planning Department for new construction) City /State A (6W /t c #/W /VU CV/' Parcel Identification Number ®3 " v - 0 1 -0 &D LEGAL DESCRIPTION Property Location %,, A - V4, Sec. . T -10_ N -R--49—W, Town of Subdivision _ 'T /{C /�� " c nr �� . Lot #. Certified Survey Map # Volume , Page # Warranty Deed # - /,2166- l , Volume 0 9,1- y3 , Page # IS Y Spec house S yes ❑ no Lot lines identifiable B yes ❑ no SYSTEM MAINTENANCE Improper use and 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. 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 mastorplumber, journeymanplumber, restrictedplumber or a licensedpumper verifying that (1) the on-site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, 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 Commerce 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 Zoning Office within 30 days of the three year expiration date. _ / /O §iGNATURff OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. " (- / 9 / O SIGNATURE OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed I J 2293P 15`{ 721651 G � a STATE BAR OF WISCONSIN FORM 2 - 1998 Ij KATHLEEN H. MALSH WARRANTY DEED jI REGISTER OF DEEDS ST. CROIX CO., WI Document Number __,jl RECEIVED FOR RECORD I ff I i This Deed, made between 05/15/2003 01:001"M ICHARD O STOUT and JANET P_ STOITT j WARRANTY DEED !! husband and wife, EXEMPT M j Grantor, I and GRANT) PROPF.RTTES, T.P REC FEE: 11.00 TRANS FEE: 176.70 ( I COPY FEE: CC FEE: ii Grantee. PAGES: I 'I Grantor, for a valuable consideration, conveys and warrants to Grantee the following 1 described real estate in St.,, rrpix County. State of Wisconsin: Hocurrinij :rqG Lot 1 Plat of The Highlands, Town of - -- - - merset, St, Croix Coun , isconsin, I 'NamaendReturnAddress /_ ' - 71d �j /vo c al T '; 032- 2157 -20 -000 I Parcel Identification Number (PIN) This is not homestead property. (is) (is not) I i f 1. j' I i I! I I i Exceptions to warranties: easements, restrictions, rights -of -way and covenants of record. Ij Dated this 1 5th day of May 2 003 ,I j (SEAL) (SEAL) iI . Richard 0. Stout Janet P. Stout it (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT (i Signature(s) ��/�, a�� 9"V 4 State of Wisconsin, St. Croix County. 1 authenticated this da of t �' `� ' 3 Personally came before me this 1 5th day o! May ,2 the above named Richard O_ Stout and Janet P_ S V o 6%A. wio Stout i i �. TITLE: MEMBER STATE BAR OF WISCONSIN to (If not, me known to be the person S.S who executed the foregoing authorized by §706.06, Wis. Stats.) instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Janet P. Stout 1353 Awatukee Tr. u SOri, Notary Public, State of Wisconsin I My commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not ) ji necessary.) ' Names of persons signing in any capacity mum be typed or printed below their signature. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc. WARRANTY DEED FORM No. 2 — 1998 Milwaukee, Wis. i' � tl u z� asp a o aloe a o � N = N4I 60O Gli;rl O�]G�i 10O OOO f?UGTIi ��G�fnl N . 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