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HomeMy WebLinkAbout032-2141-60-000 Commerce ► County: Wisconsin Department of �►,,. PRIVATE SEWAGE SYSTEM St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 420704 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: P.C. Collova Builders, Inc. I Somerset Township 032 - 2141 -60 -000 CST BM Elev: Insp. BM Elev: Bs cription: Section/Town /Range /Map No: „ 03.31.19.1236 TANK INFORMATION U ELEVATION DAT TYPE MANUFACTURER CAPACITY STATION BS HI 1 FS ELEV. ^ h .6.,, lr = Mb ScA h.Jr4.a VA Septic Benchmark 9•114 • Sm y. 20 1-t.SD 0 3 . ::Vo Dosing �' Alt. BM Aeration Bldg. Sewer ! Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet `f 2. 9� • �s' TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic S v ` [ Dt Bottom Dosing '7C) Header /Man. fl Q2,3s Aeration Dist. Pipe tv.�o • Zo 2 -30 Holding Bot. System - d 9b bo 8. $o _ PUMP /SIPHON INFORMATION Final Grade 6eo.c.� vu Manufacture Demand St Cover r GPM 61' Model Numbe TDH Lift ion Loss System Head TD Ft Forcemain Length Dist. to w SOIL ABSORPTION SYSTEM 11111111100 Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIME NS / 6S- (12 1 SETBACK SYSTEM TO I P/L BLDG IWELL LAKE /STREAM LEACHING Manufactufer: INFORMATION CHAMBER OR ►,ed2 Type Of System: _ / 39 1` UNIT Model Number I f W n I DISTRIBUTION SYSTEM $. P /L) J uwo'eF Header /Manifool o Distribution x Hole Size x Hole Spacing Vent to Air Intake TV ' !I Pipe( 1 Length Dia_ Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes No r =,] COMMENTS: (Include code discreq� dh ncies, per pr e ) spection #1 c Z Inspec ion #2: ' 7 o 6s¢.,, rte•, G '` � be6 • A(( o6scwe,^ Location: 2376 53 d t Somerset, WI 54 5 (SE 1/4 NW 1/4 3 T31N R19W) Deer Trail Estates Lot 11 P rrcefNo: 03.31.19.1236 1.) Alt BM Description = AVA 2.) Bldg sewer length = (S - amount of cover = ($ 0 C. r tl�_� . Plan revision Required? [ .; Yes X No Use other side for additional information. SBD -6710 (R.3/97) Date Insepctor's Signature Cart. No. � 4 `1 e C w �I 1 I b� 1 L tl I c , S 1w�' t` fs�s v ,� Safety and Buildings Division Coun ` W ME 201 W. Washington Ave., P.O. Box 7082, �) iscons n Madison, WI 53707 — 7082 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 261 - 6546 �d o W Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.2 1, Wis. Adm. Code, personal information you provide I V may be used for secondary purposes Privacy s I ° Project Address (if di rent than mailing address) - f -23 I. Application Information — Please Print All Information 6 (a— Property Owner's Name �,' , _ U 0 v Parcel # Lot # Block # C- e f, l l rove.. — Property Owner's Mailing Address q IC" ti t Property Locatio�n� a )� x 1 __ %, YL /4, Section 3 ' City, State Zip Code Phone Number ecircle e �7 1 T3iN; Eo W ((i3(o • II. ype of Building (check all that apply) / j/� ✓ tX Subdivision Name CSM Number or 2 Family Dwelling - Number of Bedrooms I-- ❑ Public /Commercial - Describe Use�7 ❑ State Owned - Describe Use ❑City_ ❑Villagef�ownship of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A ' System ❑ Replacement System y ep ys ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System B List Previous Permit Number and Date Issued ❑ Permit Renewal Permit Revision ❑Change of ❑Permit Transfer to New Before Expiration Plumber Owner(L �C L IV. Type of POWTS System: Check all that appl on - 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 Ching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) :5 l 9 V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System El ti n , [' -� o 6' y 3 �� �a- 3 Q� (!' VI. Tank Info Capacity in Total Number Manufacturer Prefab Site 9teel Fiber Plastic Gallons Gallons of Units (� /� Concrete Constructed Glass New I Existing Tanks Tanks Septic or Holding Tank Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersi&A4ssume responsibility for installation of the POWTS shown on the attached plans. Plum is Name (Print) Plumb s azure MP/MPRS Number Business Phone Number Plumber's Address (Street, C , State, Kp e) z w ar VIII. un /De artment Use Only 01 pproved ❑Disapproved Sanitary Permit Fee (includes Groundwater Date sued Iss mt Signature ps) Surcharge Fee) /- ❑ Owner Given Reason for Denial 60, Z 6 Q IX. Conditions of Approval/Reasons for Disapproval v� Al CAL / ttach complete plans (to the County only) for the system on paper not less thso 81/2 x 11 inches in size SBD -6398 (R. 08/02) 431/R Test and System PLOT PLAN PROJECT P.C. Collova Bldrs. Inc. ADDRESS P.O. Box 489 Somerset Wi 54025 SE 1/4 NW 1/4s 3 / W TOWN Somerset COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 3 BEDROOM 3 CONVENTIONAL XXX IN-GROUW PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambers 22 BENCHMARK V.R.P. Top of Basement Foundation ASSUME ELEVATION 100' Filter Zabel A -100 ❑ BOREHOLE O WELL •H.R.P. Same as Benchmark 53rd St. SYSTEM ELEVATION 92.3/91.0 5' Below Grade Vent >6" Standard Biodiffuser of Cover Leaching Chamber with 31.1 ft2 of Area 1111 Plans Designed Using 6' Long Conventional Powts 34" Grade at System Elevation Manual Version 2.0 Alternate Benchmark is Top of Foundation main floor @ 103.7' Pro 3 Bedroom House 15, 2 -3' X 69' Cells with >3' Spacing B.M Alt. 10' T B -1 B-2 40' B.M. 70' 35' 15 Ven 97' 25' 95' 35' B -3 10% Slope a 0 150 Property Line 431 Test and System PLOT PLAN PROJECT P.C. Collova Bldrs. Inc. ADDRESS P.O. Box 489 Somerset Wi 54025 SE 1/4 NW 1/4s 3 /T W TOWN Somerset COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE3 /23/03 BEDROOM 3 CONVENTIONAL XXX IN-GROUW PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambers 22 BENCHMARK V.R.P. Top of Basement Foundation ASSUME ELEVATION 100' Filter Zabel A -100 ❑ BOREHOLE O WELL *H. R. P Same as Benchmark C 53rd St. SYSTEM ELEVATION 92.3/91.0 5' Below Grade Vent >6" Standard Biodiffuser of Cover Leaching Chamber with 3 1. 1 ft2 of Area 11 " Plans Designed Using 6' Long Conventional Powts Grade at System Elevation Manual Version 2.0 34" Alternate Benchmark is Top of Foundation main floor @ 103.7' Pro 3 Bedroom House 2 -3' X 69' Cells with >3' Spacing B M 15 Alt 10' T B -1 70 B -2 40 s ' 35' 15 Ven 97' 25' 95' a� 35' B -3 10 0 Slope a 0 150 Prop erty Line NO Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County � Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. P _ fy include, but not limited to: vertical and horizontal reference point (BM), direct n an El C t G / percent slope, scale or dimensions, north arrow, and location and distance t nearest road. b3 Z� �--� T — lam & 0-60 Please p rint all information. a by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). `V vV ✓+^- 3 7i (I �J Property Owner P operty4ocatton C' O l l0 G.� 1�c��v[.c1 7J - it/4°S T3 N R E (o W Property Owners Mailing Address Lot # Block # bd. Name or CS M# o�i3 k l/ v-P� T? 46g*n City State Zip Code Phone Number ❑ City ❑ Village X Town Nearest Ro d I 5 D w S`402r (7 1,r ) Sq 9 2 1 --5� S New Construction Use: Residential / Number of bedrooms Code derived design flow rate yea GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material a� u�-1 Flood P in elevation if applicable 4 General comments ) � and recommendations: e 1 G way lt:Y3 F —/1 Boring # W Boring 9, 7 Pit / Ground surface elev. ' ft. Depth to limiting factor in. Soil Appl ication Rate � Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. S `Eff #1 - E + 2 ---�� /% .3 �� s �✓> /►�/ - 7 , Boring # ❑ Boring FZ Pit Ground surface elev7ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 l o- 2 s ; - Cv o Effluent #1 = BOD > 30 1 220 mg& and T S 30 < 150 mg/L ' Effluent #2 = BOO < 30 mg/L and TSS < 30 mg/L CST [dame (Please ) Signature � CST N SA I.0 rN Address Date Evaluation Conducted Telephone Number Property Owner Parcel ID # Page _�Lof Z � © Boring # ❑Boring Pit Ground surface elev. ft. Depth to limiting factor in. F*Eff#1 Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots D/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#2 lo , .-S Z E sods # ❑ 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 F-1 Boring # E] Boring 11 Pit Ground surface elev. ft. Depth to limiting factor in. Sal 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 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.W00) Safety and Buildings Division County an an 201 W. Washington Ave., P.O. Box 7082 S - %x_ isconsin Madison, WI 53707 - 7082 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 261 -6546 ­% h OC 0 v Sanitary Permit Applicatio State Plan I.D. Num In accord with Comm 83.21, Wis. Adm. Code, personal informatio you pr�i tE C E I V E � ,T may be used for secondary purposes Privacy Law, s 15.04(1 (m) Projecl Address (if different than mailin address) 2 �(v 453 l� S I. Application Information - Please Print All Information FEB 2 3 0 , 3 d q Pro O Name arcel Lot # Block # ST. C ING OFIC FFIC 1P ,ZONING / Pro er's Mailing Address Property Locatio (D City, State Zip Code Phone Number Y. Section > l ✓ ° circl ne) II. ype of Building (check all that apply) -7— E r W Subdivision N e CSM Num 1 or 2 Family Dwelling - Number of Bedrooms �f � ❑ Public /Commercial - Describe Use ❑ State Owned - Describe Use /J A ?n / , ` _ ' l D/I l.!' 3 " X ❑City ❑Villagoownship III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. m ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B List Previous Permit Number and Date Issued ❑ Permit Renewal El Permit Revision El Change of ❑Permit Transfer to New Before Expiration Plumber Owner IV. T e of POWTS System: Check all that appl n - 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 ❑ Gr vel, ess Pipe ❑ Other (explain) V. Dispersal/Treatment Area Information: 1 Q>tit 6 G Design ( Design Soil Application Rate( Disp rsa ea RR ired (so Dispersal Ar Propose d 4 ysem lev on CJ i I VI. Tank Info Capacity in Total Number Manuf turer Prefab Site /Steel Fiber Plastic Gallons Gallons of Units �//j/ �-- !(( Concrete Constructed Glass New Existing / ,s Tanks Tanks *L Septic or Holding Tank Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersi ed sume responsibility for installation of the POWTS shown on the attached plans. Plumber's �Name (Print) Plumb ature MP/MPRS Business�h /� v Plumber's Address (Street, City, State Z ode) VIII. oun /De artment Use Onl pproved ❑ Disapproved Sanitary Permit Fee (includes Groundwater 4-1�t issue P IS ' uing Age) Signature ( a ps) Surcharge Fee) I � 'l f/ W ❑Owne r Given Reason for Denial oc O Cond:tiApproval/Reasons for Disapproval J �2Q�� V�1�S � !7f. ?�� . © Dk _ 7 1 Attach complete plans (to the County only) for the system on aper not less than gl/2 z 11 Inc es� size ;�5r 7Y6 �rhrr C�4 .&7� a4157;e 0-770 . SBD -6398 (R. 08/02) PLO PLAN PROJECT ` P.C. Collova Bldrs. Inc. DRESS P.O. Box 489 Somerset Wi 54025 SE 1/4 NW 1 /4S 3 /T 31 / 19 TOWN Somerset COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 2/19/03 BEDROOM 3 T 7 CONVENTIONAL X)OC IN -GROUN SSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TAN SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambe 22 BENCHMARK V.R.P. Top of Nail in 15" cotton Wood - ASSUME ELEVATION 100' Filte Za 1 A -100 ❑ BOREHOLE O WELL •H.R.P. Same as Benchmark Vent SYSTEM ELEVATION 92.0/91.8 4' Below Grade >6" Standard Biodiffuser Plans Designed Using Of Cover Leaching Chamber Conventional Powts with 31.1 ft2 of Area Manual Version 2.0 6' Long 11" 34" Grade at System Elevation COPY 2 -3' X 69' Cells with >3' Spacing r B.M. #2 1 — 40' � -3 35' Vents Vents csT 1 30 3 3- B92 75' B 20' 150' �L Pro 3 Bedroom House 53rd St. 375' Property Line 75' nIL PLO PLAN PROJECT P.C. Collova Bldrs. Inc. DRESS P.O. Box 489 Somerset Wi 54025 SE 1/4 NW 1/4s 3 /T 31 / 19 TOWN Somerset COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 2/19/03 BEDROOM 3 CONVENTIONAL XXX IN -GROUN SSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chamber 22 BENCHMARK V.R.P. Top of Nail in 15" cotton Wood ASSUME ELEVATION 100' Filte Za 1 A -100 ❑ BOREHOLE O WELL *H. R. P. Same as Benchmark SYSTEM ELEVATION 92.0/91.8 4' Below Grade jEft Standard Biodiffuser Plans Designed Using Leaching Chamber Conventional Powts with 31.1 ft2 of Area Manual Version 2.0 34" Grade at System Elevation 2 -3' X 69' Cells with >3' Spacing B.M. #2 B.M. #1 40' -3 35' Vents Vents 30 35' B -1 75' B -2 T 20' 150' Pro 3 Bedroom House 53rd St. 375' Property Line 75' Wisconsin Department of Commerce SOIL EVALUATION REPORT Page I of ' division =of Safety and Buildings in accordance with Comm 85, 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 not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. o , percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all in pp, r _ \ eviewed by Date 4 __� y U . Personal information you provide may be used fors AaBry ptxboses �Rvacy LRh( s. 15.04 (1) (m)).� Property Owner operty Location Go . Lot S 1A VW 1A S T 3 N R E (or) Property Owner's Mailing-Address Lot Block # Subd. Name or CSM# City State Zip Code hone N b Cqx City [I Village [RTown Nearest Road ® New Construction Use: 59 Residential / Nu e F Code derived design flow rate G,. O d GPD ❑ Replacement ❑ Public or commercial�ic Parent material S k Flood Plain elevation if applicable General comments y ,5 f-e 4e, e V - O C) and re mendations: 1ZL e V. q Z, p O �S J�, 5 Boring # Boring (/h.•S ® Pit Ground surface elev. • U d ft. Depth to limiting factor tom_ 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 I � l -- 5 i , 1 fir- C-5 1 4 • Z - Z -`t ! j _ 5i/ rte', c 5 B 3 - — m.5 rn -- _ /' 2Q.>LL (�iyc GAL a Boring # Boring ® Pit Ground surface elev. ZS' 90 ft. Depth to limiting factor / Q $ 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 0 - �� 2 Sit / c 1 V� . Z 2 /U 'Ve 'liq — / rncA aAi C- -ioa 1 6 yr-iho - -' 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) ignature CST Number 25,3 0 9 Address Date Evaluation Conducted Telephone Number 2113 - Z/ ,7- i 4 Property Owner r n u.rS Parcel ID # Page 2 of 3 _ F3-1 ❑ Boring Boring # ® pit Ground surfaceelev. 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 3 S 10 mS O and F F-1 Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil 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 ❑ Boring Boring # Ground surface elev. ft. Depth to limiting factor in. Pit Soil Applicabon 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 * Effluent #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg/- 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 (8.07100) PAGE 3 OF 3>' NAME _ LOT# ( LEGAL DESCRIPTIO ' /4N'v' /4 S T31 N R 11 E (or) SCALE: 1 "= B ION Jnr • O r BM I DESCRIPTION nu i + in ls� ( ppWoocQ BM 2 ELEVATION f Qd • C� BM 2 DESCRIPTIO (; r` l U t m SYSTEM ELEVATION I Z , 0 d ALTERNATE ELEVATION R Z . ()O CONTOUR ELEVATION AjIA Ot- -4� 5C i � I .0 t 90 P' w . m4�Y I _._.� 8Z . a a i1 s � bQ.e. j SIGNATURE DATE / — t I 3 -15 d r PAGE 3 OF 3 NAME LOT# LEGAL DESCRIPTION- T31 N R E or 40 QB E: I "_ ION ��� • I BM I DESCRIPTION t\u i + i A l ('n� roocQ BM 2 ELEVATION ICC) - C) BM 2 DESCRIPTIO (, n j j o" E ( m SYSTEM ELEVATION 1 Z , D 0 ALTERNATE ELEVATION ( Z. Q0 CONTOUR ELEVATION AL& YA,/ Ot, C-e�- -4" :5rc 4,, 1 I L 5y 1 .t issd 1� Z 6 O O � SIGNATURE DATE 9`13-0d ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer P. C. Collova Builders, Inc. Mailing Address P O Box 489 Somerset, Wl 54025 Property Address @3 4n ►^c (Verification required from Planning Department for new construction) City/State E�)'('MQA2 ' (/\- Identification Number 03 Z — 2 1 4 4 1 &D _Oc)o -3 . 3i. I°�• 123 LEGAL DESCRIPTION Property Locatior3 /., Sec. , T2� N -R W, Town of . Subdivision _ 0 0 �(� �u Lot #. Certified Survey Map # Volume �- , Page # Warranty Deed # Volume Page #., D Spec hoes ❑ no Lot lines identifia� 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 masterplumber, journeyman plumber, restrictedplumber or a licensedpumper verifying that (1) the on -site wastewaterdisposal system is is 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. A b SIGNATURE 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 wa my deed recorded in Register of Deeds Office. / 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 �m �T Maintenance and Contingency Plan for a Septic System 0 4:1- 7 4,20 � Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Effluent fitter is to be cleaned once a year. Please note: a larger fitter is being installed in order to extend the maintenance interval of the fitter. 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 Contingency Plan 1. if system faits, determine cause of failure, use alternate area and install new system or install system at a lower elevation. 2. 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\ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of ?' FILE INFORMATION Q ✓�D w ! v SYSTEM SPECIFICATIONS Owner 7?C.Ca &va Jy,7e6w,v t✓�— Septic Tank Capacity D al ❑ NA Permit # a� — 7� Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS T(/ Effluent Filter Manufacturer ❑ NA Number of Bedrooms 3 ❑ NA Effluent Filter Model — j ❑ NA Number of Public Facility Units iB Pump Tank Capacity a l "A Estimated flow (average) :30 gal/day Pump Tank Manufacturer L'Yh Design flow (peak), (Estimated x 1.5) s-D gal/day Pump Manufacturer CVNA Soil Application Rate Q , �7 gal/day /ft2 Pump Model 1;IA Standa Influent/Effluent Quality Monthly average` Pretreatment Unit A Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD _ <220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispers Cells) ❑ NA Biochemical Oxygen Demand (BOD :530 mg /L n- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) :530 mg /L '1 NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) :510' cfu /100m1 / ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size y in dia. ❑ NA Other: 13 NA Other: ❑ NA Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: 3 13 m ar( 1(s) (Maximum 3 years) ❑ A Pump out contents of tank(s) When combined sludge and scum equals one -third f tank vo ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA 3 ar(s) Clean effluent filter s p At least once every: / ❑ m nth(s) ❑ NA ( 0-fear(s) ❑ month(s) A Inspect pump, pump controls & alarm At least once every: ❑ year(s) ' ❑ month(s) A Flush laterals and pressure test At least once every: ❑ year(s) Other: ❑ month(s) ❑ NA At least once every: ❑ year(s) Other: ❑ 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 cell(s) 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 (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. 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 2 — 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. 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 replacem t system: 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. ❑ 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. Al � • The site ha not be n w alnat _oil and site _ r„ - -= -. :a - .:• -��� _ -_ �- _ - .Le nnu_ rrc e1 • --� - t ,_ _�-�. nnhnam area If nn ranla 11 I? ^- !'�mSl ta nk • 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 POWTS INSTALLER POWTS MAINTAINER Name s e jj Name Phone _ 2x1 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY " Name �r'1 7n(j7v.)or_... Name S - T AW �- V All � IbEP T. Phone 7/S-- Z to - Phone 1 - 71-c - 3 ( This document was drafted in compliance with chapter Comm 83.220Ib)(1)(d) &(f) and 83.5401, (2) & (3), Wisconsin Administrative Code. WARRANTY DEED k 645991 STATE pE W cC N A SIN — FORM 2 KATHLEEN H. WALSH OF DOCUMENT NO. V4L 1642FAGl STG CO., WI - RECEIVED FOR RECORD This indenture, Made this 18th day of MaY A.p „ 05- 21-2001 9:30 AM between - Kowski Farms Inc -- a Corporation duly WARRANTY DEED EXEMPT M organized and existing under and by virtue of the laws of the State of Wisconsin, located at CERT COPY FEE: Wisconsin, party of the first part, and COPY FEE: P.C. Collova Builders Inc., a Wisconsin corporation TRANSFER FEE: 1158.30 RECORDING FEE: 10.00 PAGES: I pan ieS of the second part. Witnesseth, That the said party of the first part, for and in consideration of the sum of $386 ,104.40 to it paid by the said part l es_ of the second part, the receipt whereof is hereby confessed THIS SPACE RESERVED FOR RECORDING DATA and acknowledged, has given, granted, bargained, sold, remised, released, aliened, conveyed NAME ANO RETURN ADDRESS and confirmed, and by these presents does give, grant, bargain, sell, remise, alien, convey and j confirm unto the said part 1 PR of the second part, _ their heirs OAKEY & OAKEY TITr E and assigns forever, the following described real estate, situated in the County of Box 126, Osceola, WI 54020 St. Croix State of Wisconsin, to -wit. I I i! Lots 8, 9, 10 11, 12, 17, 18, 19, 20, and 21 of the Plat of Deer T Estates, according to the recorded 032- 2i'4f -30 Qtf Plat on file and of record in the office of the 032 - 2141 -40 -00 Register of Deeds, St. Croix County, Wisconsin PARCEL IDENTIFt ATIONN MEER 032-2141-60-00 3. ? >/ -11, 1,736, - V32 - - 7141-70- 00 032-2142-20 -00 032= 2142 -30 -00 032- 2142 -40 -00 032- 2142 -50 -00 (IF NECESSARY, CONTINUE DESCRIPTION ON REVERSE SIDE) 032 - 2142 -60 -00 Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; and all the estate, right, ut1e, interest, claim or demand whatsoever, of the said party of the first part, either in law or equity, either in possession or expectancy of, In and to the above bargained premises, and their hereditaments and appurtenances. To have and to hold the said premises as above described with the hereditaments and appurtenances, unto the said part Jes of the second part, and to their heirs and assigns FOREVER. And the said Krjwn party of the first part, for itself and its successors, does covenant, grant, bargain and agree to and with the said pan i Pa of the second pan, their heirs and assigns, that at the time of the ensealing and delivery of these presents it is well seized of the premises above described, as of a good, sure, perfect, absolute and indefeasible estate of inheritance in the law, in fee simple, and that the same are free and clear from all incumbrances whatever, and that the above bargained premises to the quiet and peaceable possession of the said part les of the second pan, their heirs, and assigns, against all and every person or persons lawfully claiming the whole or any part thereof, it will forever WARRANT and DEFEND. In Witness Whereof, the said Kowski Farms, Inc party of (he first part, has caused these presents to be signed by Roger Kukowski _ its President, and countersigned by Norwytn Kukowski its Secretary, at Wisconsin, and its corporate seal to be. hereunto affixed this I Rth day of _ May A.D., kk 201. SIGNED AND SEALED IN PRESENCE OF Kowski Farms, Inc. ' Corporate Name G. r. >, President Roger Kukowski COUNTERSIGNED; We Secretary State of Wisconsin, Norman Kukowski 5S. Polk County. Personally came before me, this 18 th day of May A.D., j@e 2m 1 Roger Kukowski President, and Norman Kukowski Secretary of the above named Corporation, to me known to be the persons who executed the foregoing instrument, f ind Id tnaknown to be such President and Secretary of said Corporation, and acknowledged that they executed the Eoregoin sti ument as @tic olltc6i Rs tie deed of said Corporation, by Its authority ` THIS INSTRUMENT WAS DRAFfEU By Ronald L. Siler NOTARY B EVERT; MOORS VAN DYK, O'BOYLE & SILER, S.C. SEAL -- — - Post Office Box 118 Notary Public, �p_p1k County, Wis. New Richmond, �p'I 54017 My commission (expires) (al 9/2401 ts< ien 54 51 (I I f d w yonsn Sawn p u 'd s Char all umr I t hl er J d hall Karr Plaint) pow I p x u •n Ihereo , ,nab of h ,Mors; gr n I d wrap•. S•n an sY.SI) ,imtad/ nyuin. thm th. v ra ohh, pies +n wl , or bmun emal agency wh ch, dt wch nvrunmm, slwll be pn aJ. type nacn, Si mpyrl or written thereon in a legible manner) WARRANTY DEED — R Cur ration STATE OF WISCON51N Wiscd� Lapal Brook Co., In Y P° Form No. 2 MiNraukee Wig 4 / I j ........ N LOT 12 0 1� w. \ I ►°'v c°. 131, SO. 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