HomeMy WebLinkAbout032-2118-00-000 Wlsconsiri r(epartment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
uafety and Building Division
` INSPECTION REPORT Sanitary Permit No:
430220 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:
Szulim, Derrick I Somerset Township 032 - 2118 -00 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range/Map No:
0 4 , yy 1 4Z.e_a — 15.31.19.1080
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic _ / / � � Benchmark„
k
Dosing / Alt. BM
Aeration Bldg. Sewer
_541 , S
Holding St/Ht Inlet Q G�
TANK SETBACK INFORMATION St/Ht Outlet u, S-r -
TANK TO P/L WELD BLDG. Vent to Air Intake ROAD Dt Inlet
Septic i 3 Dt Bottom
Dosing Header /Man.
` ter O�
Aeration Dist. Pipe
Holding Bot. System g`
Final Grade
PUMP /SIPHON INFORMATION 2 Z
Manufacturer Demand St Cover �i q
GPM 1-
Model Number
TDH Lift Fric ' s System Head JTDH
Forcemain ength Dia. Dist. to Well
SOIL ABSORPTION SYSTEM G(ZQ,,, G Pity
BEDITRENCH Width Length No. Of Trenches PIT DIMENSI NS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L JBLDG WEL LAKE /ST EA M LEACHING an rer:
INFORMATION CHAMBER OR r
Typ Of System: UNI
/• ► r J I Model Number:
BUTION SYSTEM Hw U 5 ,s A'
Header/ / �nifold Distributi x Hole Size x Hole Spacing Vent to Air Intake
Len th Dia Length Dia cin l
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over epth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
Yes No j Yes -?1 No
COMMENTS: (Include core discrepencies, persons present, etc.) Inspection #1:q11'91 d 3 Inspection #2:
Location: 2177 59th Street Somerset WI 54025 NW 1/4 NE 1/4 15 T31 N R15W Shadow Pines Lot 2 Parcel No: 15.31.19.1080
1.) Alt BM Description .C4V"k :Z QPdq.
2.) Bldg sewer length
- amount of cover =
Use other side for additional information.
Plan revision Required? Yes No
Ff
SBD -6710 (R.3/97) Date Insepctor's Sign ture Cert. No.
L
` 4
Soil Test and System PLOT PLAN
ROJECT Derrick Szulim RESS 6375 Bailv Rd Woodbury Mn 55125
01 1 NW 1/4 NE 1/4S 15 /T 31 N 9 W "TOWN Somerset COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 9 BEDROOM 4
CONVENTIONAL XXX IN- GROUND #SSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1260 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 870 # of chamb (s
BENCHMARK V.R.P. Top of nail in tree ASSUME ELEVATION loo' Filter Zabel A -100
❑ BOREHOLE O WELL H. R. P Same as Benchmark
59th St. SYSTEM ELEVATION 93.0/92.2' 3 Below grade
200'
Alt. B.M., top 2-3'X
of footing @ 88' Cells
98.0' with >3'
Spacing
10 ' 20 , B -1 80 , B -2 P�
Pro 4 T 10
Bedroom 5 15, Ve
House ,
35 B -3
0
% /
B.M. * lope
a�
10'
0
2 -3' X 88' Cells with >3' spacing
Vent
>6„ Standard Biodiffuser
of Cover Leaching Chamber
with 31.1 ft2 of Area
6' Long 11 "
34 Grade at System Elevation
Safety and Buildings Division col'oty �/ / / ( t/ I
201 W. Washington Ave., P.O. Box 7112 � - ` .
l Vi s con s in Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in C, )
(608} 266.3151 3 b Z
De artment of Commerce
State Plan T.A. tau
Sanitary Permit Applic /,,_)
in accord with Comm 83.21, Wis. Adm. Code. per8onal info ation tZ^GE' VE D
ruay be used for secondary purposes Prig Uw, s 5.04(1x-) T jeer Address (if difl`eretrt than mailing , address)
1 . Applicati Information - Please Print All information S E P r 0 2003 �2 11
sae► M Lot d
Property Owner's u
L �zo T CROIX COONTY NIN
Property ex's Mailing Address ropeety Location
Section
7ZII Zip Code Phone Number
SS (nre
T � N; �£ W
Il. Type of Bull (check all that apply) L CC "
I I, Imo. Subdiviat Nam CSM ';umber
or 2 Family Dwelling - Number of Bedroo — C
El PubiiclCommercial - Describe Use Q Yl ! kv� _ -- �
❑ State Owned - Describe Use f1r:iry_ 0vilhasc ownship of
M. Type of Permit: (Check onl one box on Hue A. Comple line B If applicable)
A ' 'yetem ❑ Replacement S ❑ I'reatment/HoldiagTank Replacement C I11y ❑ Other Modification to Existing Systei i
List Previous Previous Permit Number and Date ). sued
❑ Pcttnit Renewal 't Revision ❑ Cb mge of D Permit Transfer to New
Before Expirad Plumber owner
IV. Type of POWTS System- Check all that 1 -- IN
on - Presmuired (n- Ground C' Mound ? 24 M. of suitable soil ❑ Mound < 24 in, of suitable: oil ❑ At -Grade 0 Simple Pass Sand Filter ❑
Constructed Wetland ❑ Pressurized In ad ❑ Holding Tank ❑ Peat Filter ❑ Aerobic 1'reatmeut Unit 11 Recircul�ing Sand Fitter ❑
Recirculating ' Synthetic Media Filter hbrg Ch _ qaLber ❑ Drip Line ❑ Gravel -lnas Pipe ❑ Other (0x lain) 1 3 t /tom ,
V. DispersaVEreatment Arttlt ndorm oa:
Des' Flow (gpd) Design Soil Application Rate(gpdsQ Dlspetsal Area mired (st) Disp Area Pro (sf) System Vdvatt
o b j e2 � <-
V1. Tank Info Cepecityin Total Number Manufawt prefab Site Fib:' Plastic
Gallon Gallons of Units ir?�/Tfl Concrete Gona -rctrd Glans
Now FAistiag �'✓
Tar" I Tanirs
Septic w Holding Taek
Aerobic Tn:Naeem Unit
DD64 Chamber
VIT. Responsiblltty Statement- 1, the eadersigne e neepmaaihil "rty for iastalladou of the POWTS shown on the attached plane.
Plurr�bbct' (print) Plumber' re `dpi Nu�M r � Bu siness � � r orn b er J
Pturnber's Address (Street, City, S
Y oua /D a nt Use Only
Approved (] Disapproved Sanitary Permit Fee (includes Groundwater Dot Issu ssuing A cnt Si tamps)
Surcharge Fee �- G) /�
❑ Owner Given ami for Denial l " / D
Rc
IX. Conditions of App %� sons far Disapproval � <
C urn �-G�:�l -t�► -- 2� �� �
Attseb eompleao plane (ta musty rely) r#tbeastm r set k u teas 81R s 11 incbn is sine TIV
SBD -6
Soil Test and System PLOT PLAN
"ROJECT Derrick Szulim PRES 375 Bailv Rd Woodbury Mn 55125
NW 1 / 4 NE 1 /4 S 15 /T 31 "TOWN Somerset COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 9 /9/03 BEDROOM 4
CONVENTIONAL X)(X IN- GROUND #SSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1260 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 870 # of chamb s 28
BENCHMARK V.R.P. Top of nail in tree ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL H. R. P Same as Benchmark
�a
59th St. SYSTEM ELEVATION 93.0/92.2' 3' Below grade
�l
I
200'
Alt. B. top 2-3'X
of footin 88' Cells
98.0' with >3'
Spacing
B -1
Pro 5 , Ve
10
oom d,
ouse 6YA
\° B -3
%
B.M. * 0 Slope
��" D
a�
1 0' S ��s
�b
2 -3' X 88' Cells with >3' spacing
Vent
>6 „ Standard Biodiffuser
of Cover Leaching Chamber
with 3 1. 1 ft2 of Area
6' Long 11 "
3411 Grade at System Elevation
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of 3
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County G',1 �
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.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. Vwed Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). N
Properly Owner Property Location
Govt. Lot 1/4�Z1/4 V� N E ( r) W
Property Owner's Mailing Addre � n L t# I Block # � JJa� CSM#
l/I �!9'ctJ
City State Zip C Phone Number ❑ city C) Village Town Nearest Road
New Construction Use Residential I Number of bedrooms —>) Code derived design flow rate �-�^ U GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material Flood Plain elevation if applicable
General comments /J
and recommendations:
flr2� ,6ej-.- �G��r —f 3 ✓ � �w � J�
/ Boring # Boring
W pit Ground surface elev. � Oft. Depth to limiting facto 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 I `Eff#2
21 /X1
__--- -- c
q fZ .a -5-
Boring # ❑ Boring
® Pit Ground surface ele &� ft. Depth to limiting factor 71 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. `Eff1#1 `Eff#2
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) CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date Evaluation Conducted Telephone Number
1008 192nd Ave, New Richmond, WI 54017 715 - 246 -4516
1A '
Property Owner _ Parcel ID # Page of
®Boring # ❑ Boring Q
AL Pit Ground surface elev ft. Depth to limiting factor /o in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDKf
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
a E] 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
F-1 Boring # E] 1:1 Pit 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/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Effluent #1 = BOD. > 30 < 220 nVL and TSS >30 < 150 mg/_ ' 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.
SOD -8330 (RAW)
i
Property Owner _ Parcel ID # Page of
❑ # ° Boring //
p a- � Pit Ground surface elev ft. Depth to limiting factor in. Soil Applicatiort Rate
Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPEW
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. O*Effff#1 'Eff#2
F Boring # C) Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in. Sal 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
❑ 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/11F
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2
Effluent #1 = BOD > 30 < 220 mglL and TSS >30 1150 mgA_ ' Efliuerd #2 = BOD 130 mglL and TSS 130 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.
SOD4330 (R.6(00)
Safety and Buildings ll UUU lvtslon y '
201 W. Washington Ave., P.O. Box 7162 �T • 0 c V ) 7`
Madison, WI 53707 - 7162 Sanitary Permit Number (to be led in by Co.)
iseonsin
(608) 266 -3151 ZZ 0
Department of Commerce
State Plan 1. D. Number
S anitary Permit Application in accord with Comm 83.21, Wis. Adm. Code, personal information you provide ect Address (if different than mailing address)
may be used for secondary purposes Privacy Law, s15.04(l)(m) l
I. Application Information - Please Print All Information s'g. sr
Parcel Lot J! Block #
Property Owner's Na me
44 Property Owner's M ailing Address _ Props ty Location
23 c , /a,Z i �A, Section
� �
City, State �p Zip C hone Number _ _F
ir
(ccl e
T � N E6
II1 Type of Building 06eck al hat ap ly) (W S `" Subdivision N e CSM Number
for 2 Family Dwelling - Numbof Bedro s w � s • —
Public /Commercial — Describe Use /
State Owned - Describe Use
❑City — ❑Villag>W_wnship of
L:!
III. Type of Permit: (Check only one box on a A. Complete line B if licable) Q
A. System ❑ Replacement System ❑ Treatment/Holding T Replacement Only ❑ Other Modification to Existing System
B. ❑ Permit Renewal ❑Permit Revision hange of ❑Permit Transfer to ew
List Pr I zippe t ate Issued
Before Expiration Plu ber Owner
IV. Type of POWTS System: (Check all that apply)
- Pressurized In- Ground ❑ Mound > 24 in. of suitable s ❑ Mound < 24 in. of suitable soil - rade ❑ Single Pass Sand Filter
❑ Constructed Wetland ❑ Pressurized In- round ❑ Hold" g T ❑ Peat Filter ❑ A is Treatment Unit ❑ Recirculating Sand Filter
❑ Recirculating Synthetic Media Filter ing Chamb ❑ Line ❑ Gravel -less Pipe ❑ Other (explain)
V. Dispersal /Treatment Area In mation:
De ign Flow (gpd) Design Soil Application Rate(gpds Dispersal Are e i ispersal Area Proposed (sf) System Elevation
VI. Tank Into Capacity to Total Number M Prefab Site teel Fiber Plastic
Gallons Gallo of Units Concrete Constructed Glass
New Exis[ing
Tanks Tanks
Septic or Holding Tank
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement- 1, t undersi , assume responsibility for installation of e POWTS shown on the attached plans.
Plumber's Na me (Print) Plumber' gnature MP /MPRS Numb Business Phone Numb
Z - /
2Ij � �j
Plumber's Addre ss (Street, ty, S e, Zip e) A (� 2
VIII. County /De artment Usi Only
Approved Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing A ent Signature ( tamps)
Surcharge Fee) ,
11 Owner Given Reason for Denial 2� /��
IX. Conditions of Approval /Reasons for Disapproval
Attach complete plans (to the County only) for the system on paper not less than 81 /2 x 11 inches in sue
SBD -6398 (R. 01/03)
PLOT PLAN
PROJECT Derrick Szulim ADD S 234 4th Ave N. St. Paul Mn 55075
NW 1/4 NE 1/4S 15 /T 31 N/R 1 W TO Somerset COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 7/31/03 BEDROOM 4
CONVENTIONAL
XXX IN- GROUND PRE HOLDING TANK
RE CONVENTIONAL LIFT HO
MOUND SEPTIC TANK SIZE 1260 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 870 # of chambers 28
BENCHMARK V.R.P. Top of nail in birch tree ASSUME ELEVATION 100° Filter Zabel A -100
❑ BOREHOLE O WELL - H.R.P. Same as Benchmark
59th St. SYSTEM ELEVATION 93.0/92.7' 3' Below grade
Plans Designed Using
Conventional Powts
120' Manual Version 2.0
3%
B-4 90' Slope B -1
15' 45' B -3
15' Vents
Vents 2 -3' X 88' Cells with >3' spacing
B- B -2
90' 15'
B.M. * 0
B.M. Alt. T
15' 15'
40' 30'
Pro 4
Bedroom
House
Vent
ALong Standard Biodiffuser
Leaching Chamber
with 3 1. 1 ft2 of Area
1 "
3499 Grade at System Elevation
PLOT PLAN
PROJECT Derrick Szulim ADD S 234 4th Ave N. St. Paul Mn 55075
NW 1/4 NE 1/4S 15 /T 31 N/R 1 W TO Somerset COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 7/31/03 BEDROOM 4
CONVENTIONAL )00( IN- GROUND PRE RE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1260 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 870 # of chambers 28
BENCHMARK V.R.P. Top of nail in birch tree ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
59th St. SYSTEM ELEVATION 93.0/92.7' 3' Below qrade
Plans Designed Using
Conventional Powts
120' Manual Version 2.0
3%
B -4 90' Slope B -1
15' 45' B -3
15
Vents
Vents 2 -3' X 88' Cells with >3' spacing
B- B -2
90' 15'
B.M. * 30'
B.M. Alt. T
15 15'
40' 30'
Pro 4
Bedroom
House
Vent
>6 „ Standard Biodiffuser
of Cover Leaching Chamber
with 3 1. 1 ft2 of Area
6' Long 11 "
Grade at System Elevation
34"
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Divisir ,,1�f'Safety and Buildings Page 1 of 3
Bureau of Integrated Services in accordance with s. ILHR 83,09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size'" Plan must County
include, but not limited to: vertical and horizontal reference point (BM) difOption qnd St. Croix
percent slope, scale or dimensions, north arrow, and location and di ance, to neare$"l 'd`
.. .. Parcel #
APPLICANT INFORMATION - Please print all inform � a ew¢ by Date
Personal information you provide may be used for secondary purposes (Privacy, Law; s. 15.04 (1) (mNf "'
12 Z 3
Property Owner �Ppjgn
Richard Stout Govt. Lot NW 1/ NE 1 /4,s 15 T31 N,R1 9 E (o
Property Owner's Mailing Address L of # Slock# `Subd. Name or CSM#
1353 Awatukee Trail S w P'nes —
City State Zip Code Phone Number Villa e Town Bares oa
Hudson Wi 4016 715 5 -6731
Somerset I 60th Street
New Construction Use: [3j Residential / Number of bedrooms 4 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 600 gpd Recommended design loading rate • 7 bed, gpd /ft 8 trench, gpd/ft
Absorption area required R 5 R bed, ft 7 5 0 trench, ft 2 Maximum design loading rate • 7 bed, gpd /ft - trench, gpd/ft
Recommended infiltration surface elevation(s) See plot plan ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material Ger 2 Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system s U El S ❑ U Q S ❑ U [J S❑ U ❑ S ® U ❑ S U
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
9 Texture Consistence Boundary Roots
in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
1 0 -3 1 0yr2 /1 -- is 1 Ir A,6r, mvfr cs if . 7�. 8
2 3-24 1 0yr3 /3 -- is 1 rn4br, mvfr cs -- . 7 ' .8
Ground 3 24-SO 1 0yr4 /6 -- ms osg ml cs -- . 7 ' .8
elev.
93 _Rn ft.
Depth to
limiting
factor
9 in.
Remarks:
Boring #
- 1 1 m --
ir 2 2 3 -2 10yr3/3 -- is 1 m4 mvfr cs -- .7 ; . 8
3 25-E9 10yr4/6 -- ms osg ml cs -- .7-.8
Ground
elev.
9 6 � — ,
o f �j3.o
Depth to
limiting I _ 2
factor
8 g in. Remarks:
CST N me (Please Print) Signetur > Telephone No.
Address Date CST Number
PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Pa
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
0 -3 10 r2 1 --
. 2 3 -24 1 0 r3/3 1S 1 MAl
Ground 3 24 -88 10yr4/6 Ms
elev. — —
9 5 .
Depth to
limiting
factor
8 in.
Remarks:
Boring #
1 -3 10 r2
4 -1-24 p (�
3 24 -90 10yr4/6 Ms os
Ground
elev.
96 ft.
Depth to
limiting
factor
9 0 in.
Remarks:
F23-26 Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
Boring # - 3 1
--
5 1 0yr3 /3 Is 1 rhA / mvfr CS
3 26-89 10yr4/6 -- s osg ml Cs
Ground
elev.
94. ft.
Depth to
limiting S - (v tt t
factor I? u C
8 9 in. Remarks: a �
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R. 07/96)
JlArkMark I Bleu too' tall ,n ,9�1 'M�
Qe nchy%at-K e-lev IW' nail i'r c ec x r4ro e
` N
f a
oa
Cj$ r
I �j�n1 i
•
I
1
Maintenance and Contingency Plan for a Septic System
Maintenance Plan
1. Septic Tank is to be pumped once every 3 years.
2. Effluent 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
Contingency Plan
1. If system fails, 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
.Aug •2,1 03 01:22p Don Stickney (651) 501 -2409 p.1
! f
Attention: Zoning Date' _ 81 1103
Company: St. Croix County Number of Pages: 2
Fax Number: 17153864686
Voice Number:
From: Don Stickney
Company: Don Stickney
Fax Number: (651) 501 -2409
Voice Number: (651) 501 -2409
Subject: Szulim Property Septic Permit
Comments:
To Whom It May Concern:
Attached please find the St. Coix County Septic Tank Maintenance
Agreement and Ownership Certification Form for Derrick Szulim's
home to be built at 2177 59th St. Lot 23, Shadow Pines, Town of
Somerset. Please let me know if you need anything or have any
questions.
Don Stickney
Home Building Equity, Inc.
651.248.3517
, Rug - 2l 03 01:22p Don Stickne!:j (651) 501 -2409 p.2
FROM : PC COLLOVA BLDR &BROTHERS EXC FAX NO. : 7152943632 Jan. 21 1996 03:35AM P1
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer. t'L C,tL 2a `
Mailing Address 3 4 .
Property Address
(Vesitication required from Planning Department for new construction)
'1 ��3c�2 1 �j� f
City/State - - V(nef' �(,� _ Parcel Identification Number
L EGAL DESCRIPTION
Pro taty Location lvW y.,. N �' /•, Sere. T�N - R�W� Town of ��" "«
P �- �,�
Subdivision � ti Q y &o Lot # 73
Certified Survey Map # , Volume . Page #
Warranty Deed # — 7 3 !�) I , Volume 2 3 (,P d . Page # Q Z
Spec house 0 yes W no Lot lines identifiable yet, 0 no
SYSTEM MAINTENANCE
Impt+oparuse sad maintenanceof your septic systemaould result in itspromatum.fiilum to bandit wastes. Proper ...•intmm•..c e
consists of pttmpmg out the septic tads every three years or sootaer, if needed by a licensed pumper. What you put into the system
can affect the function of the septic ank as a treatment stage irk the waste disposal system
property owner agrees to submit to St 06,lx 7,m qo Department a ecrtM adon form, signed by the ounaff and by a
emssterplomber, journeyman plumber, restricted plumber or a licmu d pumper verifyiU4 that (1) the 010-site .va Wwaocrdisposal system
is is proper operating condition and/or (2) alter inspection and pamplo6 (if necessary), the septic tank is less rhea 1/3 full of sludge.
undersigned have mad the above tequutments and agtce to maim0ria the private Sewage di sposa l system with the sdadard+
set hcm as sex by the Dqw memr of Co mte- = e and the Department of Natural lKswueeea, Stan or Wiseo 'e"L Cerafrestion
t syst has been mai�ined must be completed and rctumd to the St_ Qkoix CouatY Zoning office within 30
days. the a intio C.
2 ,2, 0
"A A V-1WPLICANT DA
OWNER
N
1(w o y that all statements on this foray are true to the best of nq (our) imowledge. 1 (we) am (are) the owncr(s) or
the above, by virtue ore warranty deed reeorded in Register of Decds Office.
2 ,21 03
IGNA O
DATE —�
a•••es My mfor —don tbat is misaepresented may result in the sanitary pesmit being mvokedby the Zoning Depamwmt. ••••••
•• Inelude with this application: a stamped waeaasy deed horn the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
J 2.3 6 0,P 0 2 5 735172
I STATE BAR OF WISCONSIN FORM 3 - 1998 I! KATHLEEN H. WALSH
i QUIT CLAIM DEED REGISTER OF DEEDS
I ST. CROIX CO., WI
Document Number RECEIVED FOR R
�! 08/12/2003 11:30AM
This Deed, made between
William J Tennis and Linda D. Tennis, husband and !' GUIT CLAIM DEED
wife i EXEMPT i 8
u
Grantor, REC FEE: 11.00
and Derrick Szulim and Tammy Tennis, both single it TRANS FEE:
persons ii COPY FEE:
CC FEE:
PAGES: 1
Grantee.
Grantor quit claims to Grantee the following described real estate In p
St. Croix County, State of Wisconsin: I!
I' Recording Area
Lot 23 at of Shadow Pines, Town of Somerset, St.
I Name and Return Address y _
County, Wisconsin. �I
Foundation Title, LLC
!I 5701 Shingle Creek Parkway, #520
Brooklyn Center, MN 55430
II
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�� II
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032 - 2118 - 00-00 i l
�i Parcel Identification Number (PIN)
This is::notE homestead property.
(is) (is not) II
it
1
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II II
I !
Together with all appurtenant rights, title and Interests. ;!
li
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Dated this day of LA 2003
VA r
(SEAL) (SEAL)
William J. Te s D. Tennis II
i ♦ II
(SEAL)
WAN (SEAL) II
Notary Publ'�c N o t ary Public y
Mb it esft
Jan. 31,2005 3
Signature(s)
State of 1t44MMn, II
I I
I ss. If
County.
authenticated this day of PetsRRrally came before me this d�Y of 1
F 1 v Q 2003 , the above nd it
William J. Tennis and Linda D. Tema_
husband and wife ;I
TITLE: MEMBER STATE BAR OF WISCONSIN to
II
Of not, the known to be the person IS who executed the foregoing Il
authorized by §706.06, Wis. Stats.) Instrument and acknowledge the same.
, n
THIS INSTRUMENT WAS DRAFTED BY
i, Notary Public, State of Wisconsin Ij
,I Q // My commission is permanent. Of not, state expiration date:
(Signatures m be authenticated ok acknowledged. Both are not
i necessary.) II
Names of persons signing In any upacity must be typed w printed below their signature.
STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.,
QUIT CLAIM DEED FORM No. 3 - 1998
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