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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division Sanitary Permit No:
INSPECTION REPORT 395202
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 Township Parcel Tax No:
Sicard, Michael Somerset Township 032 - 1025 -60 -000
CST BM Elev: Insp. BM Elev: BM Description:
f
T 6' L
TANK INFORMATION ELEVATION DATA
MANUFACTURER CAPACITY STATION BS HI FS ELEV.
T Y PE
Septic / / s
Benchmark
143 4
Dosing Alt. BM
Ae Bldg. Sewer
Holding t Inlet
S Ht Outlet
TANK SETBACK INFORMATION 9. 9
[AeNK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
ptic / --- Dt Bottom
- 7 S'
le
srn Header/Man. _ /� 2
ration Dist. Pipe L
lding Bot. System 4 1Y,3S
- sS 9 3- 9 S
Final Grade
PUMP /SIPHON INFORMATION 3
M ufacturer Demand St Cover
M
Model Number <�
T Friction Loss Syste ad I T DH Ft
Forcemain Length Dia. Dist. to Well
SOIL SORPTION SYSTEM
BED/T C Width Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSI 3 Q
SETBACK SYSTEM TO v P/L JBLDG IWELL LAKE/STREAM O Manufact er
INFORMATION CHA B OR v
Type Of System: S Z :r T M elNu er:
- G
DISTRIBUTION SYSTEM
HeaderlManifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
ry I q ti Pipe(s)
Length Dia 7 Length Dia Spacing -
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of ] 77e7de — dISodded - Mulched
Bedrrrench Center Bed/Trench Edges Topsoil , ❑ Yes ❑ No I ❑ Yes [] No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: /� ❑ Inspection #2:
Location: 462 222nd Avenue Somerset, W 54025 (SW 1/4 SE 1/4 9 T31N 1 R19W) NA Lot 6 A Parcel No: 09.31.19.1266
1.) Alt BM Description =' 0 .4 °01S y � )� 5 ` " o il le-,4 Was A e - , c� eea
2.) Bldg sewer length = q b t 0 c (' - 2s Ktkv
amount of cover = 1{ tea C S��(�W4+ Spq� p .r pl u)
--
Plan revision Required? �Yes ❑ No
Use other side for additional Information.
Date Insepctoes Signature Cert. No.
SBD -6710 (R.3/97)
J
, e
tv
3i'
Safety and Buildings Division' County
201 W. Washington Ave., P.O. Box 7162
z�
Madiso n ,
WI 53707 707 - 7162 Site Address �vC011s/'ifI
De artment of Commerce — i& - W i 6ry Permit Number
Sanitary Permit Application a _
in accord with Comm 83.21, Wis. Adm. Code, personal informatiogyaa p�o ❑ Check if Revision 3 7,5 _ Z
ma be used for second--- ses Privac Law, s15. L r
I. Application Information �- ease Please Print All Information ` �` State Plain I.D. Number
PP
r ,,, Parcel Number oq . 3
Property Owner's Name Q�C,C.
Property Owner's - 'a , Mailing Address �� roperty Location
W A;S 9 T N,R A
City, State Zip Code ne N /
q
Lot Ntun r Block N r
i 2
/ \ Subdivision Name
7��
�A 1A )Z:
3
n Type of Building (check all that apply) ❑City
J9 1 or 2 Family Dwelling - Number of Bedrooms ` -0 Zownship age
❑ Public/Commercial - Describe Use
❑ State Owned Nearest Road
III. Type of Permit: (Check only one box on tine A (numbering scheme for internal use). Complete line B if applicable)
A. Replacement of 6 ❑Addition to For County use
I�New 2 ❑ Replacement System 3 ❑ Repla me
system Tank Onl Ezis ' S stem
B. ❑ Check if Sanitary Permit Previously Issued --J
Permit Number Date Issued
1 numberin scheme is for internal use)
i Iv. Type of Permit: (Check all that aPP Y)( g r
4444)1 Non Pressurized I r acrd 210
Mound 47 ❑ Sand Filter 50 ❑ Constricted Wetland
22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Linea` t
45 11 At-Grade 46 ❑ Aerobic Treatment Unit 49 ❑ irculating 30 0 Other � x �� 7 S
V. D' ersal/Treatment Area Information - -
Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade
Required Proposed Rate (Gals. /Days/Sq.Ft.) (Min.Meh) 99�5� Elevation
7�
Site Steel Fiber Plastic
i i Total Number Manufacturer Prefab i
.Tank Info Capac ut
Gallons Gallons of Tanks Concrete Constricted Glass
New Existing
Tanks ranks
okling Tank
z
Dosing Chamber
VII. R bility Statement- Y, the undersigned, a responsibility for installation of the POWTS shown on the attached plans.
Plumber's e ) Plumber' Si MP/MPRS Number Business Phone Number
Pl is Address (Street, City, State, Zip Code)
VIII. County /De artment Use Onl
�
( A roved ❑ Disapproved �� Permit Fee (includes Groundwater Date Issued nt Signature (No Stamps)
t� PP Surcharge Fee)
Owner Given Initial Adverse
❑Own G c, f
Determination
x . % of Approval/Reasons for D' ap roval Si 1w� CanVC0ltk
`�' '''(�D � � �'r's0°drr1� �' �r!/ls�k.fl�NCtssG/ �s�f�'��''¢�l�.c�w�„��� ✓�i -lie 4 04 u��F� -! S
Attach complete p (to the Camq oa ) ror the on p pW e �ot 1w than a1/2 x rl loch« In size
`l ~sti 4,." vkeA� a,,kmtt ` �cQZ
SBD -6398 (R. 05101)
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Wisconsin Dep R I of In SOIL AND SITE EVALUATION REPORT` Page I of 3
Division Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
4 _ 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.
[j�
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION I BY D TE
Is"
PROPERTY OWNER: PROPERTY LOCATION
Paul Anderson GOVT. LOT Sjq 114 S N,R 19 E (or) W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # IFID. NAME OR CSM # 7
Box 242 6 n/a na
CITY, STATE ZIP CODE PHONE NUMBER OCITY OVILLAGE
T3ixdson, WI. 54016 ( rl /a
222- Ave,
[ New Construction Use f ] Residential / Number of bedrooms 3 [) Addition ttlexisting building
I ] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd /ft . trench, gpd /ft
Absorption area required 643 bed, ft 563 trench, ft Maximum design loading rate • 7 bed, gpd /ft • S trench, gpd /ft
Recommended infiltration surface elevation(s) 99.85 -97.75 ft (as referred to site plan benchmark)
Additional design / site considerations step down trench system
Parent material outwash Flood plain elevation, if applicable n a ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem a- O U ia O U faS El xF0 S❑ U O S CCU O S E?U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundry Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trer>ch
U 1 0 -6 10 r2 /1 none ls. 0 /sg 7mvtfr c/s /m .5 .6
2 6 -21 10yr4/4 none Is. 0 / ml g/w 1/m .7
Ground 3 21 -80 10yr4/6 non S 0 /sg n/a /a .7
elev.
1
Depth to Z
limiting
factor
i0
Remarks:
Boring #
1 0 -7 10yr2/1 none Is. 0 /sg nnrfr c/s 2/m .5
2 7 -30 10yr4 /4 none 1_s. 0 /sg mvf_r g/w 1/m .7
3 0 -80 10yr4 /6 none S_ 01sg ml na/ n/a .7
Ground
elev.
10 - al t.
al t.
Depth to
limiting
factor
>80
Remarks:
CST Name: — Please Print Phone:
G 1 715- 246 -6200
Address:
1554. .0th. A e? Ri.c}mlond T%TI.54017
Signature. Date: CST Number:
5 -14 -93 229£3
PROPERTYOWNER Paul Anderson SOIL DESCRIPTION REPORT Page of 3
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trerch
1 0 -4 10yr2/1 none ls. Qsg mvfr c/s 2/m .5 .6
2 4 -2.4 10yrZ none S. sil 2 In, /sh?c mvfr g /uT 1/m .5 .6
Ground 3 24 - 10yr4/4 none 1_s. 0 /sg rill. g/w 1/m .7 .8
elev.
1 4 38Y-92 10yr4 /6 none S 0 /sg ml n/a n/a .7 i.8
Depth to
limiting
factor
>
Remarks:
Boring #
1 0 -6 10yr2 /1 none ls. 0 1sg mvfr c/s 2/m .5 .6
z 4 2 6 -26 10yr4/4 none ls. 0 /sg mvfr g/w 1/m .7 .8
3 26 -80 10yr4 /6 none S 0 /sg ml n/a n/a .7 .8
Ground
elev.
1 ���•
Depth to
limiting
factor
>80
Remarks:
Boring #
1 0 -6 10yr2 /1 none Is. 0 /sg mvfr c/s 2/m .5 .6
5 `< 2 6 -36 10yr4 /4 none ls. 0 /sg ml_ g/w 1/m .7 8
3 36 -80 10yr4 /6 none S. 0 /sg ml na/ n/a .7 .8
Ground
elev.
10 S ft.
Depth to
limiting
factor
X 110
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(R.05/92)
STEEL'S SOIL SERVICE t554 26001. tve.
Gary L. Steel OmmacDcive
C.S.T. 2298 Paul Anderson New Richmond, WI 54017
MPRSW -3254 SW 'S S9 - T31N - R19[J (715) 246 -6200
tol-m of Somerset
lot #
1<<<to"
goo
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�ANO t� N
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2
Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In- Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWTS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
10567-P (R.6/99).
Table 1: System Design Specifications
Sanitary Permit Number S9 5�C%
Number of Bedrooms
Design Flow - Peak (gpd)
Estimated Flow - Average (gpd)
Septic Tank Capacity (gal) ,
Soil Absorption Component Size (ft
Type of Wastewater Domestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Comp
Design Flow - Peak (gpd) 3 77o
Maximum Influent Particle Size (in) 1/8
Maximum BOD (mg /L) 220
Maximum TSS (mg /L) 150
Table 3: Maintenance Schedule
Septic Tank Inspect and /or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the septic tank and outlet filter shall be assessed at least
once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure
proper operation. The filter cartridge should not be removed unless provisions are made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
I
• �` Management Plan for a Septic Tank and Soil Absorption Component
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 113 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, defective, or subject to failure must
be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
r
Management Plan for a Septic Tank and Soil Absorption Component
Plantings of deep- rooted trees and shrubs directly over or within ten feet of the
component should be avoided since root intrusion into the component may obstruct wastewater
flow. -
. � 6'och��
r
3
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer fil IC_ 11 d,i 1 I . )
Mailing Address !] 9 T tS
Property Address �� t
(Verification required from Planning Department for new construction)
City /State ,1,o m r' yr gr-7" W l i Parcel Identification Number
LE GAL DESCRIPTION
Property Location SW ' / _ Y4, Sec, , T_I N- R_J_q_W, Town of S�DM£ r s T_
Subdivision - "'—"� , Lot # A u
Certified Survey Map # Volume ,Page #
Warranty Deed # 1 070 �� , Volume, Page #
Spec house ❑ yes �Qo Lot lines identifiable ), yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenanceof 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
master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposa I 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 Zoning Office within 30
days of the` hree ye r ex iration date.
IGNATURE 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 owner(s) of
the property described above, l cz by virtue of a warranty deed recorded in Register of Deeds Office. al
IGNATURE � 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
STATE BAR OF WISCONSIN FORM 2 - 1999 652ZS2
KATHLEEN H. WALSH
WARRANTY DEED
Document Number REGISTER OF DEEDS
ST. CROIX CO., WI
This Deed, made between George E. Belisle, RECEIVED FOR RECORD
07 -27 -2001 11:00 AN
WfMNTY DEED
Grantor, and Michael S. Sicard, a single person EXEMPT I
CERT COPY FEE:
COPY FEE:
TRfD{SFER FEE: 165.00
RECORDING FEE: 10.00
Grantee. PAGES: 1
Grantor, for a valuable consideration, conveys to Grantee the
following described real estate in St. Croix County,
State of Wisconsin (if more space is needed, please attach addendum):
Recording Area
f
Lot 6 of Certified Survey Map filed April 18, 1975 in Vol. 1, Page 119, Doc. Name and Return Address
No. 326443, being part of the SW '/4 of SE '/4 of Section 9, Township 31
North, Range 19 West, St. Croix County, Wisconsin.
Together With a non - exclusive easement for ingress and egress across the
existing roadway as described as Lot 9 of Certified Survey Map filed April
18, 1975 in Vol. 1, Page 116, Doc. No. 326440.
032 - 1025 -60
Parcel Identification Number (PIN)
This /.j AA' 1- homestead property.
(is) (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this !i day of July 2001
« • George E. Belisle
AUTHENTICATION PAY PV9 ACKNOWLEDGMENT
Signature(s) p'� �j STATE OF WISCONSIN }
) ss.
ROGE
J?` � County )
* ( authenticated this day of i �� - , f Personally came before me this 3 AOday of
�/ J'f July , 2001 the above named
# II George E. Belisle,
TITLE: MEMBER STATE BAR OF WV6VW48Wn dos.
(If not, to me kngWn t person(s) who executed the foregoing
authorized by § 706.06, Wis. Stats.)
instru owledged the same.
THIS INSTRUMENT WAS DRAFTED BY
Attorney Kristina Ogland Notary lic, State of Wisconsin
Hudson, WI 54016 Mv Cn�m�miss' n is pe ent. (If not state expiration da .
(Signatures may be authenticated or acknowledged. Both are not necessary.)
•Names of persons signing in any capacity must be typed or printed below their si ture. irdormetion Pmfeuior Compeny, Fong du Loc. W
STATE BAR OF WISCONSIN
WARRANTY DEED FORM No. 2 - 1999
Q�
3 43
T43
, ,
269. 0528 9.59'OO'E 912.03'
N 8 278
300.00 612.03
NOR LINE
w OF S 1/2 OFSE 1/4
.N -N
't A 6�, - z N
No 6 a 0 S 7 (D CD M
� _8_
)z 5.01 ACRES e'.'� &, 5.02ACRES o SCALE TRUE BEARING
C to N N OF BEGINNING ao
o SW- (/) 200 0 100 200
M p ? N � 2 `32 � S86°50'01 "W
m PO 3 0 ��, �, 134. 30
o ' S- �• �, 20 9° oc� \
WE ST _ I . .INE OF 4 O SS ?
Z1/4 SE I/4 ? ea
240
P'
0 RNER, 9
° S57 °08'55.5"'W
SECTION 9,T 31 N, R 19W R =80� , ��
p' 79.24
A = 59 °22' 1 i
LEGEND L = 82.90'
TANGENT BEARING= S27* 27 @ 30 "W
SECTION CORNER MONUMENT
p 1" X 24" IRON PIPE
WEIGHING 1.68 # /LINEAL FOOT.
SURVEYED FOR EDWARD GERMAIN, Box 66A, Somerset, Wi. 54025
DESCRIPTION:
Apaarcel o land located in the SW1 /4 of the SE1 /4 of Section 9, T31N, R19W,
Town of Somerset, St. Croix County, Wisconsin, described as follows: Commencing
at the S1 /4 corner of said Section 9; thence NO °53'32 "E (true bearing) 1025.90'
along the West line of said SE1 /4 to the point of beginning; thence N0 "E
302.12' along said West line; thence N89 ° 59 1 E 912.03' along the North line of
the S1 /2 of the SE1 /4; thence S8 ° 08'34 "W 586.86 thence S86 ° 50 1 01 "W 134.30
thence Southwesterly 82.90' along an 80' radius curve concave Southeasterly
whose chord bears S57 0 08 1 55.5 "W 79.24 thence N62 °32 "W 713.34' to the point
of beginning.
I certify that the above description and map are correct and that I have fully
complied with the provisions of Sec. 236.34 of the Wisconsin Statutes.
DATE: April 3, 1975
FRANCIS H. G EN S-81r2 Map No. 74-
326443
��1�YtiN�M
FRANCIS H.
s _
RIVER FALLS,
� x �NIS.
U N Volume 1 Page 119