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HomeMy WebLinkAbout032-1000-60-100 Wisconsin Department of Commerce '� , PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 488113 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)J. Permit Holder's Name: City Village X Township Parcel Tax No: Dollery, Wes I Somerset, Town of (532 - IftO - GO- Im CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 91 �? -3 S� 01.31.19. TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic '} Benchmark ��� N0 9.7 ��,— Q. /om Alt. BM 2 . 1 Aeration Bldg. Sewer 3_ 1 J ✓ fit Ho Ing St /Ht Inlet 5. TANK SETBACK INFORMATION t t ut et TANK TO P/L WELL BLDG. Vent o Air Inlet p o om e Ic 7 5� > 5d / ea er an. — 7. Z osmg era Ion is . P ipe . Z5 9 (. • to 5 �•Sf 7 •bs o Ing o . System � / - ) Final ra a t..�/ PUMP /SIPHON INFORMATION L -) S 3 . S anu ac urer Demand st Cover I 1 X GPM 63, $ �,'\ cti� m odel Number i ric Ion LOSS ea g g 0 �- �IS It- i KNZI SOIL A SORPTION SYSTEM DIMENSIONS 3 Q i1 _z_ � `\ _ w 11 INFORMATION / V `\3 CHAMBER OR �ra� ype 01 System. UNIT IV. /6 9 � > 166 � N A- 4 Pipe(s) \ Z Length Dia Length Dia_ Spacing �_ x Pressure Systems Only xx Mound Or At - Grade Systems Only Bed /Trench Center Bed/Trench Edge Topsoil ` , Yes No Yes No COMMENTS: ( Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 721 Polk /St. Croix Road Somerset, WI 5402 (NE 1/4 NW 1/4 1 T31N R19W) NA Lot 1 Parcel No: 01.31.19. 1.) Alt BM Description= wckmk C)vd— �Q.1 'per_ G �— S '� L 2.) Bldg sewer length = 5 7 - amount of cover = Plan revision Required? Yes No 3" G� Use other side for additional information. `�' C _ 7 !! — Insepcto ignatu -68 - -- - - -- - - -- SBD -6710 (R.3/97) A Air Safety and Building ision County r �O��l,� t 201 W. Washington Ave., .0. Bo 162 `f ' -1. Madison, WI 5310 - 716 Sanitary Permit Number (to be filled in by Co.) (608) 266 -3151 Department of Commerce 1 $, 3 Sanitary Permit App State Plan I.D. Number A In accord with Comm 83.21, Wis. Adm. Code, personal i forma may be used for secondary purposes Privacy s]5. W ED Projec Address (if different than mailing address) I. Application Information - Please Print All Information M 3 1 2006 7 64, Property Owner's Name ST Parcel !� r Blk # �� / u CRO T IX COUNY a Pa 4k # oc � A Property Owner's Mailing Address Property ion C� 7-3 � ��r AXE %, AA/ ?14, Section City, State Zip Code Phone Number I l circle II. Type of Building (check all that apply) a K ec S s� w. {} N; 1�E W Subdivision Name CSM Num r or2 Family Dwelling - Number ofBedrooms f�as� t'gti Z_6 `-j5 (O I� El Public /Commercial - Describe Use ❑ State Owned - Describe Use Z 1J , 6� - CQ « 5 t ,) I IS + 1,5 ❑City ❑Village wnship of 1II. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ew ystem ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. 11 Permit Renewal ❑ Permit Revision 11 Change of El Permit Transfer to New ,List Previous Permit Number and Date Issued Before Expiration Plumber Owner i IV. Type 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 -G ound 11 Holding Tank ❑ Peat Filter 11 Aerobic Treatment Unit 11 Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter Ching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) 5 S V. Dis ersabTreatmei Area ormation: Design F'lo (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevatio VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Stiel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank / Aerobic Treatment Unit ✓ Dosing Chamber VII. Responsibility Statement 1, the undersigns. a ume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Printl Plumber's ure MP/MPRS Number Business Phone Number Plumber's Address (S r t, City, SA, , Zip o VIII oun /De artment Use Onl Approved ❑ Di pro Sanitary Permit Fee (includes Groundwater Date u-4 Issui gent Si o s Surcharge Fee) r () C) ,l ❑ ven Reason for Denial 6� '' e) E' IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER: 3, ` J e e,t t. Septic tank, Mklatlt tiger and b CST •. diapefsal cell must as "PW Mwagwn" plan provkW by plumber. 2 AN salback requkartlaMs mt»t be maintsined Z 5 ' Ero 5 o ` as per appkWe coda ! aldilmlces. r ^�- f ✓� d' , ,,-1 e Attach complete plans (to the County only) for the system on paper not less than 8112 x 11 inches in sift 66 1) SBD -6348 (R. 01/03) :I130W4 M.ITRYZ br• ist Inwftl-j Yvrf nk"Z . t , % e wwn isq as r so jftirT efrmmoit,"i Aosdf" OA obo: skWAqq* *a as PL Q PLAN PROJECT Wes Dollery i DDRESs 737 Polk /St.Croix Rd New Richmond Wi 54017 NE 1/4 NW 1/4S 1 /T 31 19 W TOWN Somerset COUNTY ST. CROIX 3/28/06 BEDROOM 3 MPRS Shaun Bird 226900 '� ' DATE CONVENTIONAL XXX IN- GROUND` P URE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 933 # of chambers 30 , BENCHMARK V.R.P. Top of 1/2" pipe ASSUME ELEVATION 100' Filter Zabel A -100 ❑BOREHOLE O WELL *H. R. P. Same as Benchmark SYSTEM ELEVATION 95.7/95.2 Alternate Benchmark Top of 1/2 pipe C 100.5 Polk/St.croix Rd. Well is to meet all 6 „(� Scale is 1 = 40' setbacks required by WDNR � unless otherwise noted Pro 3 Bedroom House Tree Line 30' Test hole, ST Marginal soils, on flat top of hill! At1.B.M. 80' 300' 2 -3' X 94' Cells with >3' Spacing 30' * B -1 B -2 B.M. 90' 350' 101' Vents 30' Plans Designed Using Conventional Powts 99 ' Manual Version 2.0 45' 9% Slope - Property Line /40 Line Vent > 6» Standard Biodiffuser of Cover Leaching Chamber Please note: Survey was not completed with 31.1 ft2 of Area at time of testing, all lot lines must be 1 1 " verified before system can 6' Long be installed 3 4" Grade at System Elevation Eess CEIVED u Wisconsin Department of Commerce SOIL EV LU N R Pa of 3 ` Division of Safety and Buildings ROIX COUNTY aj�J A(S511 1 � pWm85, is. Adm. Code /J my Attach complete site plan on paper 1/2 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. n percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. evie ed by \ Datg__ Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ba Property Owner Property Location A 1 Govt. Lot /� 1/4/�•I�114 S T 3� N R / E (or W Property Owner's Mailing Address Lot Block # Subd. Name or CSM# 7 / City Sta Zip Code Phone Number ❑ City ❑Village Town Nearest Roa ew Construction U 4 Residential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - D �¢ cribe: Parent material a�zl'J i 1� r t.�t. Fl ilevatio if applicable General co -S l` - e /E' ✓ cc.��y. / `� ' � and reco ons: / r? f� n-.. ,�..P,� `JY`if`��.tl ���� /�✓ � OG�i/I� -fi (fir o-r. L Boring # ❑ E C S t Pit Ground surface elev. ft. Depth to limiting factor - in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 vc _Z s_ q 5 fi4 �6 0 Boring # Boring ®it Ground surface elev. Depth to limiting factor 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 Aw �C , 0- (06 (aZ Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) a CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 54017 j ..-- 715- 246 -4516 1 Property Owner _ Parcel ID # Page of a Boring # ❑] Boring it Ground surface elev. Iq I V ft. Depth to limiting factor in. FE Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots D/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. n 'Eff#2 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/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ❑ Boring # E] 1:1 Pit Boring Ground surface elev. ft. Depth to limiting factor in. Soil ication 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 (8.6/00) 1 Soil Test Plot Plan Project Name Blair and Eleanor Dollery Shaun Bird --� Address 737 Polk /St.croix Rd. New Richmond Wi 54017 CSTM #226900 Lot Subdivision -------- Date 11/8/05 NE 1/4 N W 1 /4S 1 T 31 N /R W Township Somerset i ❑ Boring Q Well PL Property Line County ST. CROIX IL BM or VRP Assume Elevation 100 ft. Top of 1/2" pipe System Elevation 95.7 /95.2 *HRpSameasBenchmark Alternate Benchmark Top of 1/2" pipe @ 100.5 Polk/St.croix Rd. Scale is 1" = 40' unless otherwise Tree Line noted Test hole, Marginal soils, on flat top of hill! O 45' AtI.B.M. 300' 30' 10 B -1 B.M. 90' 350' 40' 101' -2 13 9% Slope B -3 45 Property Line /40 Line Please note: Survey was not completed at time of testing, all lot lines must be verified before system can be installed 62��+56 M -4 __ _ K L 20 PAGE__ -5173 05 �!' p v Q REGISTER OF DEEDS m z u'i ST. CROIX CO. MI o cn N Z RECEIVED FOR hECORD D v 03/10/2006 10:05AN tp CERTIFIED SURVEY NAP v m n 1 Z REC FEE: 15.00 ° COPY FEE: p Z z m PAGES: 3 m m t _ �m M_GvJ__PC�GQ44GD �_n[vJ__D� I I �I O D Q l OO 4GO C G3� 1 I p i __________ ____________________ ___________ _ 1 I BEARINGS ARE REFERENCED TO THE ST. WEST LINE OF THE NE1 /4 OF I I I CROIX COUNTY COORDINATE SYSTEM O i _ _ THE NW1 /4 OF SECTION 1 _ _ 4 - x r o I �n C 00 4 $ mc�i -�+ ga r� i y 8 p �° CS 401.98' 32 00' Z r °° A m n " m( rn (is ° of O C" � Cm O Z� ............► ......... ................. Z D X71 ( Z 0 oo en l z Z a m w o ° ^' m8 o . ow ;cs �8 g rt1 ol� c ► WAD On y w S ml v, � Z z� �-1 O mC 0� N _ m a I m i�° m a � m 77 O"' m C C11 1 _ I co z m PRDRIVEE33 _ I O G) m m 401 - ' Nl O S 00 0 30'08" W 434.98' I I N rn v i I 3 w „pauuu rr,rp I 1 ' 0 1 O y ma y. .... 9� O T _ Tm Ns p,� I ��'� g OO i� v s 4 Ko Z m ED - -- I I p A II 10;� N 00 18'09” E 579.94' 1 . ;Q to N ► 546.94' 33.00' ° Z O Z 10- CO i(OD o D o � c D i cgg O '°°_ 0 rc F, c m 0 m j s r�ii N f0 r- �► GCj� c/) W O Z \ 4 S i 109 m 111 -^ 46.94' 33.00' ° o0 S 00R 8'O " W 579.94' I � a , � �` _ I 1 ca DEC st] �J o M� -- G�D� dQMnDD�� j N�ZT< _5oZ -- - - - - -- OC�r Ii G] y UDL &VU[PE g Z ' ° rr� �, m m l,� ------- - - - - -- -- ------- - - -� -- --- - - - - -- I 1 _ O Z 80TH STREET i I Z Z � Q 5z J m NORTH -SOUTH 114 LINE OF SECTION 1 _7) 2 z ------------------------------------------------------------------------------------ Vol 20 Page 5173 1 of 3 EROSION & SEDIMENT CONTROL PLAN Parcel # 1.31.19. Site: Polk/St. Croix Rd, NE '/a of NW ' / a Sec. 1, Somerset Twp. — Owner(s) Wes Dollery 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. Erosion control is a requirement of the conservation easement recorded for this lot. The property Owner is responsible for notifying all contractors performing construction on this site that an Erosion & Sediment 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 installation adds to temporary disturbance, but establishing cover on exposed soils will prevent erosion. Apply seed and mulch cover as recommended in #5 below. Maintain existing vegetation wherever possible to minimize erosion and sediment movement. Surface drainage flows toward a swale located on the southeast corner of the property. 2. Intercept and route contaminated runoff into stabilized vegetated buffer areas b creating temporary g Y g p rY diversions graded ALONG CONTOUR between construction areas and any potential receiving waters (includes drainage ditches). Do not allow diverted runoff to be directed into surface water conveyances. (See specification sheet for temporary diversions provided by Zoning Dept.) 3. If 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 other products may not be necessary. However, silt fence, straw wattles, or other approved sediment control products will be required if sediment cannot be contained on owner's property with diversions and vegetative buffers. The POWTS or Building inspector may evaluate ESC plan effectiveness and make recommendations to owner 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 new topsoil cover over septic system with seed and mulch immediately after installation - do not wait for final stabilization and/or landscaping of entire site to cover exposed soils on the POWTS. p g p If late - season weather will not permit seed germination, a heavy straw mulch cover will prevent erosion until vegetation can get established. 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 regarding erosion & sediment control product installation. Prepared by: Ryan Yarrington POWTS Inspector #683475 Owner acknowledgement of ESC Plan requirements: ' _/_/2006 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND I 1��0 OWNERSHIP CERTIFICATION FORM OwnerBuyer UJL6 D O Mailing Address Property Address , 64 I (Verification requited from Pl g & Zoning Departme w construction.) C City /State Parcel Identification Number r LEGAL DESCRIPTION Property Location / 1 /4 , A✓W ' /4 , Sec. ' T 3 1 N R L L W, Town of .-5-010_ - n Subdivision , Lot # / Certified Survey Map # �d J� , Volume 7- , Page # cj l - 2 3 . Warranty Deed # a / , Volume , Page # Spec house yes no Lot lines identifiabl yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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 Owner maintenance responsibilities are specified in §Comm. 83.52(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 tank 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 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 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. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms 3 I LICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** 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. (REV. 08105) li r 8 KATHLEEN H. WALSH REGISTER OF DEEDS State Bar of Wisconsin Form 1 -2003 ST. CROIR Co., MI WARRANTY DEED RECEIVED FOR RECORD 03/30/2006 10:30A1I Document Number Document Name WARRANTY DEED EXEWT # 9 THIS DEED, made between Blair Collingwood Dollery and Eleanor Lucille REC FEE: 11.00 Dolle a/k/a Blair C. Dollery and Eleanor L. Dol husband and wife TRANS FEE: rv ry ry, COPY ( "Grantor," whether one or more), FEE: CC FEE and Wesley C. Dollery and Tatyana V. Dollery, husband and wife, as survivorship PAGES: 1 marital property ( "Grantee," whether one or more). Grantor, for a valuable consideration, conveys to Grantee the following described real Recording Area estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ( "Property") (if more space is Name and Return Address needed, please attach addendum): The RiverBank Attn: Val Memmer Part of the NE '/4 of the NW %4 of Section 1, Township 31 North, Range 19 West, Post Office Box 188 Town of Somerset, St. Croix County, Wisconsin described as follows: Lot 1 of Osceola, Wisconsin 54020 Certified Survey Map recorded March 10, 2006 in Volume 20, Page 5173, Document No. 820456. Part of 032 -1000- 60-000 Parcel Identification Number (PIN) This is not homestead property. (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except: Easements, Restrictions and Ordinances of record and will warrant and defend the same. Dated ?/ 2006. (SEAL) (SEAL) * * Blair C. Dolle (SEAL) (SEAL) b * * Eleanor L. Dollery AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN authenticated on ) ss. POLK COUNTY ) 4 * Personally came before me on 2006 , TITLE: MEMBER STATE BAR OF WISCONSIN the ab ve -named Blai C. Dolle f and E L. Dolle (If not, terson(s) who executed t6 foregoing authorized by Wis. Stat. § 706.06) thpsame. , L r THIS INSTRUMENT DRAFTED BY: ` Priscilla Dorn Cutler Notary Public, State of Wisconsin ,1 U Lattx Cutler, S.C. My Commission (is pe�rrent) (expires: V U b ) (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED ® 2003 STATE BAR OF WISCONSIN FORM NO. 1-2003 *1Tgipt name below signatures. i • a r Maintenance and Contingency Plan for a Septic S stem Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Eff luent filter is to be cleaned once a year. Please note: a larger filter is being installed in order to extend the maintenance interval of the filter. 3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of the cells. 4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system. 5. The owner agrees to save this plan. 6. Do not plant trees nor park nor drive over system. 7. Watershed is to be diverted away from system. 8. Discharge into system is not exceed those required as per Comm. 83 ncy Plan ption #1. j'system fails, determine cause of failure, use alternate area and install new in tested replacement area. Option #2. Install system at a lower elevation, by removing chambers, removing biomat, and install new system. Option#3. No adequate area is suitable for replacement area, and system elevation cannont be lowered. Install holding tank as last resort. 3. Replace any other failing components as needed. Plumber: Shaun Bird 715 - 246 -4516 St. Croix County Zoning 715 - 386 -4680 Pumper Tom Mondor 715-246-5148 Shaun Bird #226900 AFT - ry • r -i`�'� - Y � err S h �• -- � - + - i �� { - ��" F -lam - � ,k rip t � d � _