HomeMy WebLinkAbout032-1072-90-000 Wisconsln,Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT sanitary Permit No:
453180 0
GENERAL INFORMATION (ATTAV H TOE ERMIT) 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:
Polzin, Douglas I Somerset Township 032 - 1072 -90 -000
CST BM Elev: Insp. BM Elev:, BM Description: Section/Town/Range/Map No:
t7p .rJ` lSa .o 1 &P M,- �, 26.31.19.355B
TANK INFORMATION U ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Otte Benchmark e
Dosing 11..'��• -S Z� 1 Alt. BM
Aeration Bldg. Sewer
Holding SUHt Inlet
SUHt utlet
TANK SETBACK INFORMATION t �a ��¢ •°�
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD D
Septic S r 7 IG / '4 5
Dosing a i �r Header /Man.
Aeration Dist. Pipe �D
O
Holding Bot. System , 3S' gS.2Jj'
Final Grade S O
PUMP /SI ON INFORMATION g. 0
Manufacturer Demand S over�� ?i S5� t90 • O S
GPM wr
Model Number i1 2. 7D CD . :1O r
TDH Lift F ' ion s System Head T H Ft tw 6 }� q�
(JI .
Forcemain ength Dia. '
F I 7 *_11111 � 1 � ` ( e• ( vJ
SOIL ORPTION SYSTEM
.@@kfcrRENCHJ Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIM 2 1 87- S/L SETBACK SYSTEM TO P/L l BLDG WELL LAKE /STREAM LEACHING Manuf tyrer: A
INFORMATION CHAMBER OR Tjltal
Type Of System I I L , r UNIT Model Number.
II'�
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size Ix Hole Spacing Vent to Air Intake
Lengt is " L ngth Dia Spacing CD ,
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
C Depth Over Depth Over xx Depth of 1 xx Seeded /Sodded xx Mulched
Bed /Trench Center Bed/Trench Edges Topsoil
� � ,Yes I No 'Yes No
COMMENTS' (In clude c screpe 4cie p r q son present, etc.) Inspections #1: Insp�ectiioon_ #2::_��{�oc4u 627 200th A a Unknwn (N 1/ /4 4 2 T31N R19W) NA Lot
1
1.) Alt BM Description= J 5 T, vu��..r.P FceTNo`26.3i.19 35�56�
}.ngMN.CCA_. 111�5 ru� C . r` -6
�.f //
2.) Bldg sewer length = LL S f 1. n 1 9 "'�`C ( c L '�4�✓ per{ Q� • e ,
Plan re t
- amount of cover = ? �¢ cZ-r+�+'l, f a t 5 S Q� C �e 1..3 1*"
�tiision Required? Ye No
[ .', s
Use other side for additional information.
SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No.
's
�v Couory � I
Safety and Buildings Division 7082 �z
__• Permit Number {to 5lled in by Ca)
201 W. Sanitary v
s>>�n d ► � �`
(�g) State Plan LD. NumDet
,
Department of Camm erc e Pe rmit App e adall 1 0 2004 7
5 anit � formation You provide i project Address (if differeat than mailing gddrers)
accord ith Comm 83.2 Wis. Adm Coda >
. s] 5.0 )(T) .
Privacy
f � may be used for scoondarY P urposea e Z( -
uu �- a
"A Lot 3a - 6 � •-
Information — Please Print All Information parcel # re BlockM
Property Owner s lame ' r' Property S.aeatio
property pwner's Mailing Address
%. v., section
Zip Code Phone Number
cit y, Staatte/�
V V l� i� ��✓ CSM N bet
� Subdivisiaa Namt � n
IL of Rullding (cheek all that aPp1Y) fS
Yp a
1 -1 2 Fa,nilr Dwelling - Number of Hodroatas _ r Yilla o i of
❑City a 8e
❑ idCortunercisl - Describe U b i S _
�-DescribeUse ^
DS rate Own lies ble
)
e $
111. Type of permit (Check o y one boz on line A. Complete lie if app
>ue0!19at System ❑ TreatmeocHoldiag
TaOk gep(aCetnent OaIY [D Other Modification to Existing System
A. ❑New System � List Previous Permit Number and Dare Issued
[] peratit Transfer ta'he`*'
[3 Change of Owner
Uri �wh
B. D p Renewal
I] Permit Revision plumber
Before Expiration Filter 0
I ❑ At.�rade ❑Single Pass Sand
IV T e Of PC?s S stem: Check all ;#M- a Mound 24 in. ofsuitable soil [] gee;reulating Sand Filter
> 24 in. of suitable $ ❑ [D Aerobic Treatmen t unit
-pressur in ❑ d Moun _
Non -Frees Iding -rte ❑Feat Filter er ( lain)
urizod In round IJ Ho Q Crra,el.less Pipe
Constructed Wet _ be [J D Line Eleyapo
g rsal ed (sf) Symm
Reeirwl]aDtt Synthcoc Media Filter t D 1 Area Required (sf) repos
Di
v. Dis ersal/Tresta°e0t Area I orma 'on: Dispe� y O i
Flaw (gpd) Design Soil APPll eatlon Rate(gPdsf) J -,l • I-- Site S Fiber P1LStiC
Design '? (, Manufacturer Con te Constructed Glass
Total ua�Q
Capacity in N
VL Tank Info Gallop Gallons o o f Units
New Existing I f
Tanks Tanks !f^ 7
Septic at Ho Iding Tank
Aerobic Traarmmt Una j
VV'TS sbawn oa the ansehed plant
Doa�g�r i tion of the 1'O g.usiness PhoneN tuber
sume reaponaibillty for M FIM
the undenlBae MPIMPRS Numbu
,VU. Rea onaibiUty Statement- I, pitcrrtber's f
Plumbs'
Plumber's Address (Stree4 CitY, S>A Z'P
Issuing Agent S" a e (No )
Date sued � �
oun /I1 actment Use Saait� permit Fee (includes Gr °"ndwater ��O
Approved D Disapproved Sureharge Fee) , 0 �ca� I
Q awacr Given Reason far Denial a!J (J s � % I
ens for 1)isgpproval Q ea- ,
dons of Approv,lfReas
IX. Conde � J
S OWNER.
I Septic tank,
etflu nt filter and � l
dispersal cell must all be serviced mallumberr. , —p� F '
as per management plan provided by p �r�h�d (/W �vt
2, All setback requireme must b
es. aintained r n ✓��
as per applicable cod
t�-
Attach to late pla
u (to the Couoly only) for the system ea piper not less than :11 lactus in sirs
08102)
*31/R AN
PROJECT Doua Pol SS 2468 30th Ave Osceola Wi 54020
NE 1/4 NW 1 /4S 26 /W'TOIVI l Somerset COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 5/7/04 BEDROOM 4
CONVENTIONAL )00( IN- GROUND SSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000/261 LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 872 # of chambers 28
BENCHMARK V.R.P. Top of Walkout foundation ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL *H.R.P. Sameasl3enchmark
SYSTEM ELEVATION 96.4/95.4' 3' below qrade @ B -2
Alternate Benchmark Top of Septic Tank manhole @ 9 9.5' Scale is 1" = 40'
unless otherwise
noted
Vent
Well is to meet all Standard Biodiffuser
setbacks required by >6" Leaching Chamber
WDNR of Cover with 3 1. 1 ft2 of Area
11"
Existing 4 6 Long Grade at System Elevation
Plans Designed Using Bedroom 34"
Conventional Powts House
Manual Version 2.0
0 200th Ave
B.M. Z61
20'
Alt. !JO
WEII 120' 30' A � B. M . 40' B -1
40'
Old drainfield has failed, a 98'
valve may be installed if
possible
0'
2 -3' X 88' cells with Vent 35' g %
>3' Spacing B- 3Slope
0
100' 15' B -2
Property Line 100'
*31/R N
PROJECT Doua Polzin s 2468 30th Ave Osceola Wi 54020
NE 1/4 NW 1 /4s 26 /W TOWN Somerset COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 5/7/04 BEDROOM 4
CONVENTIONAL XXX IN- GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000/261 LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 872 # of chambers 28
BENCHMARK V.R.P. Top of Walkout foundation ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
SYSTEM ELEVATION 96.4/95.4'3' below qrade @ B -2
Alternate Benchmark Top of Septic Tank manhole @ 9 9.5' Scale is 1" = 40'
unless otherwise
noted
Vent
Well is to meet all Standard Biodiffuser
setbacks required by >6 " Leaching Chamber
WDNR of Cover with 31.1 ft2 of Area
Existing 6' Long 11 "
g Grade at System Elevation
Plans Designed Using Bedroom 34"
Conventional Powts House
Manual Version 2.0
B.M.
o - 200th Ave
61
2
20'
Alt. d
WEII 120' 30' B M 409 B -1
40'
Old drainfield has failed, a 98
valve may be installed if
possible
0 '
2 -3' X 88' cells with Vent 35 ' 8%
>3' Spacing B- 3Slope
0
15' B -2
Property Line 100 100'
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page // of-3-
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
Y
Attach complete site plan on paper not less than 8 1/2 x 11 inches in si e. PI ��� f
include, but not limited to: vertical and horizontal reference point (BM), iredion d 'Parcel IT
percent slope, scale or dimensions, north arrow, and location and dista ice to nearest road. rin A 11
Please print all information. MAY 1 ew 1 Date
Personal Personal information you provide maybe used for secondary purposes (Privacy w, s. 15.04 (1) (m)). ` J ��
Pro
Property Owner be L
CNiNG 0 �E: /l� ��
J E (or
4 S T N R
Property Owner's ailing ess Lot # Block # Subd. Name or CSM#
_ � i � ._. ' / r
City State , Zip Code Phone Number ❑ City C] Village 6 Nearest Road
❑ ew Construction Use Residential I Number of bedrooms Code derived design flow rate GPD
Replacement ❑ Public r commercial - Describe: _
t material __—
Fl Plain elevation if applicable
Parent
�/�f%7�2� _ _ _ _ Flo of L e
General comments
and recommendations: �J `�`� � ✓ 'P� <� b / � ,� ' y
Boring # Boring
i /� '' ,
Pit Ground surface elev. v 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
30 CAS - h
AL
2° J 6 ! s ' /v/
F�] Boring # Boring
it Ground surface elev.� ft. Depth to limiting factor - �== in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIfF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - Eff#1 'Eff#2
f
Effluent #1 = BOO > 30 < 220 mg/L and TSS >30 1 150 ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Si CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date Evaluation Co�O ucted Telephone Number
1008 192nd Ave, New Richmond, WI 54017 J� 715- 246 -4516
Property Owner _ Parcel ID # Page of
F3_1 Boring # ❑Boring ` [
Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
r* a r
'Z, 0-5
F-1 Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 - Eff#2
F-1 Bodng # ° Bo Pit Boring ng
❑ 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 mg1L and TSS >30 < 150 mgA_ ' 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 (RAM)
Soil Test Plot Plan
Project Name Doug Polzin
Shia i d
Address 2468 30th Ave
Osceola Wi 54020 C M #226900
Lot 1 Subdivision - -- -- -- Date 5/7/04
NE 1/4 NW 1/4S 26 T 31 N /R W Township Somerset
❑ Boring 0 Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of Walkout Slab
System Elevation 96.4/95.4 *HRpSame as Benchmark
Alternate Benchmark Top of Septic Tank manhole C 9 9.5'
Scale is 1" = 40'
unless otherwise
noted
200th Ave
Existing 4
Bedroom
House
20' Alt.
WEII 120' 30' B.M. 40' B -1
T
Old drainfield has failed, a 98
valve may be installed if
possible
0 '
Slope
Vent 35'
B -3
20'
15' B -2
Property Line 100' 100,
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to ce 'fy that I have inspected the septic tank presently
serving the %� iin/ resid ce located at:
f✓ ;, N Section , f T5_N, R� W, Town of
Upon inspection, I certify that I have found
the tank and baffles to be in good condition, and it appears to be
functioning properly. ,
Last time serviced: -)--UV
Did flow back occur f om absorption system?
Yes No (If no, skip next line)
Approximate volume or length of time: gallons minutes
Capacity:
Construc u tion: Prefab Concrete Steel Other
Manufacturer: (If known) :10
Age of Ta (If known).: `
(Si ature) (Name) Please print
'c� 9
(T� (License Number)
Date
Form to be completed by licensed plumber (s.145.06, Wisconsin
Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative
Code)
- -- — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the b st of my knowledge will
conform to the requirements of ILHR 83, W' . Adm. Code (except for
inspection openi over outlet baffle).
X90
Name Signature MP /MPRS
ST CROIX COUNTY
SEPTIC -TANK MAINTENANCE AOREENiENT
AND
OWNERSHIP CERTIFICATION FORM
l �(
Owner/BuYer J l 17 o
Mailing Address a e ,
Property Address
'o? 7 b .o�� /awe e�c
(Verification required from Planning Department for new constcucrion)
Parcel Identification Number a 02
City /State
LEGAL DESCRIPTION
T , Town of
' 355
N w,
r '/,,,� , Sec.
Property Locatio
�- Lot #
Subdivision
Volume Page #
Certified Survey Map # o
Volume 1 Page # _L1 —�—•.
Warranty Deed
Lot lines identifiableX ❑ no
Spec house F-1 yes
lyj MAINTENANCE salt in its premature failure to handle wastes. Proper maintenance
SYSTE sys could re into the sum
septic s s t you put S7'
of our ep Y pumper. wha Y P
Improper use and maintenance you a licensed pump
consists of pumping out the septic tank eve three years or sooner, if needed di sposal system.
can affect the function of the septic tank as a treatment stage in the waste disp ed by the owner and by a
owner agrees to submit to St. Croix Zoning Department a certification form, sign
The property or a licensed pumper verifying that (1) the on -site wastewater disposal system
masterplumber, journeymanplumber, restrictedp lumber in necessary), the septic tank is less than 1/3 full of sludge.
if
is in proper operating condition and/or (2) after insp ection and pump g C
sal system with the standards
requirements and agree to maintain the Private sewage dispo Y
Uwe, the undersigned have read the above artment of Natural Resources, State of t i fi thin 30
set forth, herein, as set by the Department of Commerce and the Dep to the St. Croix County Zoning Office
stating that Your septic system has been maintained must be completed and returned
ear ex imtion date.
oft eg p - l L
/ - -- DATE
J i L�jRE OF APPLICANT
OWNER CERTIFICATION our) knowledge. I (we) am (are) the o wner(s) of
I (we) certify that all deed
statements on this formr ecorded to Register of Deeds Office.
the roperty des ed above, by virtue of a warranty � 17 ,� L
DATE
SIG ATURE OF APPLICANT
Zon ing De artment.
* *** **
Any information that is mis- represented maY result in the sanitary permit being revoked by the Zon g p
** Include with this application: a stamped warranty deed from the Register of Ds e d fin the warranty deed
a copy of the certified survey map if referenc
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. Watershod is to be diverted away from system.
8. Discharge into system is not exceed those required as per Comm. 83
Contingency Plan
Option #1. If system fails, determine cause of failure, use alternate area and install new
sy 7installn i
sted replacement area.
Opnstall system at a lower elevation, by removing chambers, removing biomat,
n ew 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
• f , Y
GENERAL ST. CROIX COUNTY, WISCONSIN OLD TXSCR01
REAL ESTATE TOWN OF SOMERSET
COMPUTER NUMBER 032 - 1072 -90 -000 Parcel Number 26.31.19.355B
Claimed 1 Date Re- certified / / Relate Number:
OWNER NAME: First DOUGLAS M & THEA L Last POLZIN
CO -OWNER
Mailing Address 627 200TH ST
City SOMERSET State WI Zip 54025 - J
Type Vol Page Doc # Rec.Date Type Vol Page Doc # Rec.Date 1
HISTORY WD 1784/ 192 664447 12/07/2001 LC 919/ 18 474680 10/15/1991 ^
PROPERTY ADDRESS: �V
Hse # 1/2 PD -- Street Name- Type SD Apartment Post Office
627 200TH ST
School District: 5432 - SCH D OF SOMERSET
Special District: (1) 1700 - (2) - (3)
W ITC Zl
Plat Code: Last Changed on: 01/02/2002 Book Number: 1 �S
SECTION 26 TOWN 31N RANGE 19W %160 1 /440 Map Number: 00 - Sales Area:
Parcel Control 0 TAXABLE
Number of Units:
ZONING: Permit Number: Type:
Bank Numbers:
F4 -Prev, F5 -Next, F6- Legal, F7- Value, F8- History, F10 -Exit, F12 -More
A,
449,9%
CERTIFIED SURVEY MAP
Located In part of the NE; of the NW; of section 26, T31N, R19W,
4 4
Town of Somerset, St. Croix County, Wisconsin.
LEGEND OWNER
• 1" Iron pipe found. Richard Newman
Box 393
St. Croix County Section corner monument, Somerset, Wi. 54025
aluminum cap In concrete.
0 Set 1 x 24 Iron pipe weighing 1.68 pounds
per linear foot. FILED
X existing fencellne
JUL 2 41989o-
JAMES O'CONNELL
Rooster of Deeds
St. Croix CO., WI
unplatted lands owned by others
NW corner N' corner
4
Section 26-31-19 Section 26-31-19
N88 250.01, north l of NW = ,
30
-
069 1
200 Avenue
pt I
S88 250.00;
k-4
co
co C) 0 0 Q
01
=r
z —
00 (0
00 (P
Q 0
0
06930
0 0
existing
-t 41
T �
ho use Z =
0 0
I
M C) Q =3 z M
.1- 0 0 I'D ze :1
0 0 1 0
1 C 0 C) 1 0) (D
I) IQ (A
:a. r- 0
0 M
+
M 0.
Id I 17 Q
-+
11) � 10
1 LA 0
co LOT I co V,
10
1 0 10.
�.n I SCALE IN FEET
%.n i a-
I Q %J1 139,767 sq. ft.) INCLUDING co -<
10. %.n
1 3.21 acres ROAD R/W oo 1-0 100 50 0 100
'o 130,680 sq. ft.) EXCLUDING
+ 10
(D
in 3.00 acres ROAD R/W
i to
ALLE
N y
07
I `fie Ku m,
A S88 790.001
unplatted - lands - owned - by - platter
----------------------------
JUL 24 1,489
nstrument was drafted by Douglas Zahler job no. 82-15-189
VOLUI
8
11111h1h PAGE 2128 ANDMIN!"r.