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Wisconsin Department of Commerce P RIVATE SEWAGE SYSTEM Count
Safety and Buildings Division Jt. Croix
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit
81it No.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: []City ❑ Village ❑ Thn of: State Plan ID No.:
P. C. Collova Builders, Star Prairie Township
CST BM Elev. Insp. BM Elev.: BM Description: Parcel Tax No.:
d O,,00 t v D, a Z" 038- 1194 -10 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
Se C-ej / 0 0 U Benchmark (? 1 00
Dosing O 0 Alt. BM O �
n Bldg. Sewer a
__,f olding / Ht Inlet D f5 r
TANK SETBACK INFORMATION t Ht Outlet /U. e 95_. 2- 2-
TANK TO P/L WELL BLDG. Vent to AirIntake ROAD Dt Inlet
I
Septic ysp' �� ` (Z NA Dt Bottom , I q , 75—
Dosing �S'�'6 ' Z/ 7 Z/ ' NA Header / Man.
A Dist. Pipe � ,/ a.
9
2 d
Ho Bot. System
PUMP/ SIPHON INFORMATION Final Grade S. /O p0, ?
Manufacturer �;O Demand St cover
Model Number f pel GPM
TDH Lift Friction System TDH Ft
Forcemain Length ��' Dia. Z Dist. To Well
SOIL AB PTION SYSTEM G� t7Gr S �,c
BED / Width- Len th No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIM -'s Z. DI EN I N
WELL LAKE /STREAM STREAM LEACHING Manufa urer.
SETBACK SYSTEM TO Pl L BLDG -
INFORMATION Type O , Moe Number:
System: 3 30 f-S'
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length
A
Dia. y Length �• _ s Dia. 4,M_ Spacing A)
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
P P P
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No Cl Yes ❑ No
COMMENTS (Include code discrepancies, persons present, etc.)
Inspection #1: 3 /Zf /U/ Inspection #2:
Location: 1346 218th Avgr�re, Sta�Prairi , WI 54026 (NE 1/4 NW 1/4 13 T3 IN RI 8W) - 1331181006 Pine Acres -Lot 11
1.) Alt BM Description = s,' ' 3 / �e�W�en
2.) Bldg sewer length = // f Y
amount of cover= .> 3b // f
s)Pt �aewb was a4v; 't��d -
Plan V on uired? Yes []No
'
Use other side for additiorW information.
SBD -6710 (R.3/97) Date Inspector's Signature
Cert. No.
�
Sanitary Permit Application Safety & Buildings Division
In accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave.
See reverse side for instructions for completing this application PO Box 7302
Wisconsin Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302
Department of Commerce [Privacy Law, s. 15.04(I)(m)] (Submit completed form to county if not
state owned.)
Attach com lete plans (to the county co only) for the system, on paper not less than 8 -1/2 x 1 I inches in size.
County State Sanitary Number ❑ Check if revision to previous application Stat Plan 1. D. N umber
ST. CSI �
j -
1. Application Information - Please Print all Information Location:
Property Owner Name ((�� ^ Pr r operty Location 18
IJ( I ' Vr 1/4 # IA, S 15 T N, R E or W
Property Owner's Mailing Address ` . ! Lot Number Block Number
1 �
City, State Zip Code Pkoqp umbe p , Subdivision Name or CSM Number
E&
II Type of Building: (check one) — 0 (, T )� �c� �- city
I or 2 Family Dwelling — No. of Bedrooms: 3 r Village
Public /Commercial (describe use): 5T ,qry ` Town of
q State -owned / 3TA '
III Type of Permit: (Check only one box on line A. Check box on applicable} Near e a
N
A) 1. New System 2. ❑ Replacement 3. OR Replacement of '4! r U di ' to Parcel Tax Number(s)
System Tank Only xtstin S stem WD —
B) Permit Number B "mo
❑ A Sanitary Permit was previously issued ! 3 31 • t g
IV. Type of POWT System: (Check all that apply)
Ion- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
O At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
V Dispersal/Treatment Area Information: — 145 0 7
1. Design Flow (gpd) 2. DispersaWea 3. Dispersal Area 4. Soil Application 5, Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed Rate (Gals. /day /sq. R.) (Min. /inch) Elevation
1 456 3 -15 .7- Ct - 2) g4- 7
VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks
Se K I C_ 1 06b l
VII Responsibility Statement
1, the undersigned, assume res n ibility for install tion of the POW shown on th e attached plans.
Plumber's Name (print) I Plu is Signa re (n s MP/MPRS No. Business Phone Number
T Q Q013 5 17 L
Plumber's Address (Street, City, State, Zip Code)
I i CA- 5_i&6
VIII County/Department Use Only I2 -46 co — 4,v ,0 c .,m kAd
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a Issued Issuing Agent Sig azure (No stamps)
Approved ❑ Owner Given Initial Adverse S harge Fee)
Determination
IX. Conditions of Approval /Reasons fo ID applrova
�t oc AA aL s
SBD -6348 (R. 07/00)
S`
sy
4isconsin Department of commerce SOIL AND SITE EVALUATION Page 1 of
Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
Attach complete site plan on paper not less than 8'h x 11 in §jze, Plan must County
include, but not limited to: vertical and horizontal refere poipfM y,"d ection and _Y/_ ��D X
percent slope, scale or dimensions, north arrow, a IbcApdn and distandk,to nearest road. parcel LDI
APPLICANT INFORMATION - Plea t l *r' lion. X \ _ Pen —
ep,�trn
Personal information you provide may be used for purpo (i!eVyww, s. 1�.d4 6) jm)). vleWed By Da
Property Owner Proper Location
Lakes & Hills Develoment
GavCL t 114 NW 1/4,S 13 T 31 ,N,R 18
Property. wners Mailing Address Block # Subd. Name or CSM#
Pine Acres -- - --
Ity / State Zip Cc "PhoneNumber „ ' ity illage FATown Nearest Road
.✓ ,1J" v P ' ��c .Cd , C 218 TH. Ave.
❑ New Construction Use: ❑ Residential 1 Num edrooms 3 ❑Addition to existing building - - - - --
❑ Replacement ❑ Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/fF 8 trench, gpolfF
Absorption area required 643 bed, fF 562 trench, ftz Maximum design loading rate .7 bed, gpoltts .8 tr ench, gpdff
Recommended infiltration surface elevation(s) 963 ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material- - - - - -- 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 M S❑ U I E S❑ U ❑ S❑ U ❑ S U ❑ S U ❑ S ® U
SOIL DESCRIPTION RE R
Horizon Depth Dominant Color Mottles Texture Structure Consistent Boundary Roots GPD/ft2
Boring# in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 1 0 -12 10YR3/3 -----------------
1 1 m sbk mvfr as if .4 .5
2 12 -21 l 0YR4 /4 ---- -------- - - - - - - I 1 msbk m vfr gw 1 of .4 .5 . T
Ground — — --- -- — � -- ---- - - - - - --
3 21 -5 0 7.5Y R4/4 - c ps g ml as - - -- .7 .8
elev — -- -- - -- - --
101 0 ft 4 50 -94 10YR4 /6 ---------- - - - - -- s osg ml - - -- ---- 7 .8 5
Depth to
limiting c& • 40
factor
>94 $ (4 $
Remarks: - -- - - - - -- — - -- - - --
1 0 -12 10YR3 /3 ------------ - - - - -- I lms mvfr as if .4 .5 `f
- 2 12 -25 10YR414 --------- - - - - - - 1 lmsbk mvfr as lvf .4 .5 `f
Ground 3 25 -48 7.5 ------------ - - - - -- cs osg ml gw - - -- .7 .8
elev
Ol 1.0 ft 4 48 -94 10YR4/6 ------ - - - - - - s osg ml - - -- - - -- 7 S
Depth to
limiting ,
factor
>94"
Remarks: - -- -------------- _.-- _ - ____ —
CST Name (Please Print) Signature. Telephone No.
Jacque Hawkins . _ l % ?_ � _ j ` N Iii t -r)17 Addr -r U � Date CST Number Ref#
/ 0 v u c , ►/ 8J 3 4/8/00 Z 383
PPPERTY OWNER: Lakes & Hills Develoment S OIL DESCRIPTION REPORT Page 2 of
PARCEL I.D.# Pending
Depth Dominant Color Mottles Structure GP DR
Horizon Texture onsistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ;Trench
3
1 0 -12 IOYR3 /3 ------------ - - - - -- I Imsbk mvfr as If .4 .5
2 12 -23 10YR4/3 - - -- gw 1 of 4 .5
-------- - - - - -- 1 Imsbk m vfr
Ground — — - —
elev
3 23 -46 7.5YR4/4 ------------ - - - - -- C osg ml gw - - -• .7 8 •�
l O1.O ft. 4 46 -95 10YR4 /6 ------------ - - - - -- s osg ml . . }
Depth to
limiting
factor —
>95 11 t - -- - - -- - - - - --
Remarks:
1 0 -11 10YR3/3 - -- l Im sbk mvfr as If .4 .5 ,' f
2 11 -26 10YR4/3 ------------ - - - - -- I Imsbk mv fr gw 1 of .4 .5
Ground
3 26 -51 7.5YR4/4 ---- - - - - - - cs os ml gw - - -- .7 .8
elev _ —
100.4 4 51 -84 1 0YR4/6 - ----------- - - - - -- s osg ml - - -- - - -- .7 .8 •�-
Depth to
limiting - - -- - - - -- -- -- - - --
factor
>84" - -- --
Remarks:
5 1 0 -12 10YR3/3 ------- - - - - - - I Im mvfr as if 4 .5
2 12 -23 10Y ----------- - - - - -- I Im mvfr g 1 of .4 .5 f
Ground
3 23 -50 7.5YR4/4 - - -- Cs osg ml gw - - -- .7 .8
elev - - - - -- -- - - - - -- -- - —
lO1.O 4 50 -93 10YR4 /6 ------------ - - - - -- s osg ml - - -- - - -- .7 .8 �}
Depth to
limiting -- — - - - -- -- -- -- —
factor
>93 —
Remarks:
Ground - -- - - - -_ - - -- -
elev
ft.
Depth to
limiting -- - - -- - -- -- -- - -- - -- --
factor
Remarks:
l i -
.� dff� f /3
�r
-- 7 - ,;w ash ' t O
f it
d
f � �
114-
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
Number of Bedrooms
Design Flow - Peak (gpd) 5�
Est imated Flow - Average (gpd)
Septic Tank Capacity (gal) — <<
Soil Absorption Component Size (ft) C
Type of Wastewater Domestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absor ton Component
Design Flow - Peak (gpd) 3 s —QS ZQUQL 0"
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 septIpApokand outlet filter shall be assessed at least
once every y ears 3 b inspection. The outlet felt shall be cleaned as necessary to ensure
Y
p o er o era 'on. The filter cartridge should not be removed unless provisions are ma a to
re lain 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 1/3 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
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
nn OWNERSHIP CERTIFICATION FORM
Owner/Buyer i', ( U oVA rt S - T ti c,._.
Mailing Address — 70� �v . �t d : it /�v�su.v LU :L
Property Address 1 3 V�
(Verification required from Planning Department for new construction)
City /State �) ,cu Parcel Identification Number _ 0 3 S, --
13. 31.1 8, I �o(
LEGAL DESCRIPTION
Property Location ' /,, 'l,, Sec. i , T-3
LN -R 1 b W, Town of s AoAai
Subdivision _ Lot It
Certified Survey Map # — . Volume Page #
r r----r7
Warranty Deed # Volume Page #
Spec house X yes O no Lot lines id y
4 bl� es 0 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
master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (t) the on -site wastewater disposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
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 �eeyear on date.
S NA OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) l mowledg6. I (we) am (are) the owner(s) of
the 7pr ndescribeda by virtue of a warranty deed recorded in Register of Deeds Office.
00
SI i OF A PLI DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * **
** Include wltlr this applicatlow a stamped warranty deed from the Register of Deeds office
a copy of tine certificd survey map if reference is made in the warranty deed
FROM : C COLLOVA BLDRS, INC. PHONE NO. : 715 549 5911 Dec. 01 2000 12:29PM P1
FUN-pit IVn. M— wp1tRAN'1'Y 1)101'91) M 1j11A COl1VC ancin 111,1%cx 19713
— l lulstad & L m on, PJ C.
Corporation or Prtrtnership to Corporation or I)artnership
oQ 15 7PAGE 2 2 �qL
Y.AT'HLEChI ��1. WAZSN
No delinquent taxes and transfer entered; Certificate of REGISTER OF DEEPS
Real Estate Value ( ) filed ( ) not required ST_ CROIX C0.. WI
Ce�cate O f Real Estate Value No. RECEIVED FOR RECORD
�
,19
06 -07 -2000 4:00 PM
VSRRAHTY DEED
County Auditor EXEMPT A
CERT CORY FEE
COPY FEE:
TR914SFER FEE: 304,90
RECORDING FEE:
i by PAGES: 7.
Deputy ,
N �UIN
STATE DEED TAX DUE HEREON: $ Recording Area
Date: - May 31, 20 00
FOR VALUABLE CONSIDERATION, Lakes and Hills Inc.
a Corporation under the laws of
,Minnesota , Grantor, hereby conveys and warrants to P.C. Collova Builders, Inc.
,Grantee, a
Corporation under the laws of Minnesota
.real pro rty in St Croix County, 'Wisconsin, described as follows:
Lots , 1 5, and 17 Pine Acres, St. Croix County, Wisconsin
"The seller certifies that the seller does not know of any wells on the described real property:
I
together with all hereditaments and appurtenances belonging thereto, subject to the following exccptions:
Easements, covenants and restrictions of record.
4 o f NW 1/4 of Sec. 13, T31N, R18W - - -- UN PLA ; JOHNSON & Ass"E!S
_ _ - _ T TED L ANDS FIRST ADDI110N
I � 864.99'
ENUE
_ — — — - 864.57' 8 S89 "E 462.00 _ r to z N)
_ _ _ cp s
233.00' — 200.00' — — — _ A \
0
Gr
� n
y O
N y LOT Z�
n CERTIFIED_ SURVEY MAP
o c0 �T VOLUME 9 PAGE 2494
2 O Et C. -- - 1 0 — A j yo
DOCUMENT NO. 484994
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