HomeMy WebLinkAbout038-1195-40-000 Wisconsin Departnfent of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
453017 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:
Marek, Darin Star Prairie Township 038 - 1195 -40 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
U . 6 1/ 0 0 -0 1 c t/-A" 13.31.18.1019
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Bench ma k
(� 4
/oXD 8Z 2.� �v�• hod . b
Dosing K/ A / Alt. BM kIA" w
Aeration i! Bldg. Sewer
Holding St/Ht Inlet
BSc -t-� Y0 R 1
TANK SETBACK INFORMATION St/Ht Outle/ O t SGF-( 4 Z
�a .a
TANK TO P /L �VyEl-t BLDG. Vent to Air Intake ROAD Dt Inlet —
Septic / Dt Bottom
ew
S
$� 2f
Dosing Hea r /Man. I (, 9 ow
C
Aeration Dist. Pipe L
Holding Bot. System
PUMP /SIPHON INFORMATION F' de t A r
Manufacturer Demand St Cover /
GPM Z hT5 1 4
Model Number
1 i1
TDH Lift Friction Los em Head TDH _ Ft
Forcemain a Dia. Dist. to Well [)
,f-� II /t'ew�'►
SOIL ABSORPTION SYSTEM 6ALx y ,3[/t,a 0 R �,� ,
BED /TRENCH Width Length No. Of Trenches PIT DIMENSI NS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS '1 /
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM EACHING Manuf rer:
INFORMATION CHAMBER O rp /1�1
Typ Of System: +�, � , / �-� � I � / / Model Number:
DISTRIBUTION SYSTEM GZ pr�� ` (jam akC4
Hea anifold Distribution x Hole Size x Hole Spacing Vent to Air Intakes
-7/ P pe(s) ) 0 /�A - -�- ,
Length Dia Length Dia pacing_ I i i
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 Yes No
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1 T / /Pyx Inspection #2: / /
Location: 1326 218th Avenue Star Prairie, WI 54026 (SE (SE 1/4 NW 1/4 13 T31 R1 8W) PinepAckes Lot 24 Parcel �N,/o: 13.31.18.1019
1.) Alt BM Description ap 6Yb�pc�w INUAw't (� f �" , /�U�- F'`�,5�
2.) Bldg sewer length = Z21 ( �X �,flQ� X 720 �i �M e <
- amount of cover = � n �� , ,._ p�1' 0 0- /
Plan revision Required? Yes /No S
Use other side for additional information. Date Insepctor's natur (! CeJr rt`
SBD -6710 (R.3/97) . No.
■
' ty
Safety and Buildings /-
201 W Wsshingt 537 �i San tart Permit Number (to be filled in by Co.)
(608) 61X546
consin Mad1 m be
M n state plan LID. Number
00 3artment of Commerce ilC t�
Sanitary Permit App
in accord with Comm $3.21, VAs. Adm. Code, Porsonal taforttta:ion ou proS1 c G � Address (of different than lia address)\
maybe used for secondary purposes Privacy Law, s l 5.04(1) ) ZE N N
I. Application Information - Please Print All Information Lot # H1ock s
Parcel
Property O s Name a
PrOt7CG(y Location
r's Mailing Address
Property Own- C -. ' f/� ' //��/ / /`] /
/� /�, Section /
Zip Code Phone Number
� City, State irde o
N- 1t /2E o
4 5 ✓ Subdivision Name CSM Number
X _ �, ypeof Bulldiag (cheek all that apply) _ _ r , V p r 2 Family Dwelling - Number of Hodrix r _ 4 ul licjCxrnmercial - Describe Use ❑City Cvilla owasbip
o
❑ Seam Owned - Describe Use
III, Type of permit: (Cbeek only one boz on line A. Complete line B If applicable) O other modification to Existing System
A [j Treatment/Holding Tank Replacement Only
System ❑ Replacement System
❑ Permit Transfer to New
List Previous Permit Number sad Date Issued
B. ED Permit of Permit Renewal ❑ Permit Revision plumber Owner
Before Expiration 11
e of POWT3 S rem: Check ail that a 1
• on - Pressurized In -Ground E] Mound >_ 24 in. of suitable soil ❑Mound < 24 in. of suitable soil 13 At.Gtade 12 S ingle p
d Filter
Hold Tank ❑ Peat Filter C u
Aerobic Treatment Unit C larin Sso
g i
Constructed Wetland C1 Pressurized la and la ❑ Gravel - less Pipe ❑Other (explai
Itecirculstia S yr
shetic Media Filter bier Chamber [) Drip Line
V. DIs trsalrPreatment Art aformatioa: Dispersal As Propos i) S 00
L
Dig 1 Required (st) i
Design Soil Application Ra e(gp
D es i gn Flow (god) , �
Y� Prefab iu Steel
,s a it i?oral Manufacturer
YL Tank Info Capacy s Number Concrete Constructed Glass
Gallons Gallons of Units
New Existing
Tanks Tanks
Septic or Holding Tank
Aerobic Trsument UNA
Dosing t:aamher
VII. Res onsibili Stateme - 1, the unders assume responsibility for installation of the pOWTS s h ow n on the attached plans
MP/MpRS N tuber Eusinas Phone Number
Pt Plumb is
nature Name (Print) trature Jam✓ J
t
Plumber' Address Street, City Stare, Z' 0i
VIII. Court /D artment Use Onl
Sanitary Permit Fee (includes Groundwater Date Issued l su' g Agent Signature Stamps
Approved 0 Disapproved Surcharge Fee)
0 Owner Given Reason for Denial
IX. Conditions of Approval/Ressons for Disapproval 5) C�M a
SYSTEM OWNER: l
1 Septic tank, effluent filter and S S
dispersal cell must all be serviced / maintained
as per management plan provided by plumber.
2. All setback requirements must be maintained
as per applicable code /ordinances
less than SO 2 z 11 lathes la site
Attach Complete P4625 (ter the County only) for the system an paper sot
SBD -6398 (IL 08102)
PLOT PLAN
PROJECT Darin Mare A ADDRESS 1306 210th Ave New Richmond Wi 54017
114 NW 1/4S 13 /T 1 /R 18 W TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE3/6/04 BEDROOM 3
CONVENTIONAL XXX IN-GRAND , 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 2" Pipe ASSUME ELEVATION 100 Filter Zabel A -100
❑ BOREHOLE O WELL * H. R. P. Same as Benchmark
SYSTEM ELEVATION 90.0/90.5 4' below qr
Vent
>6 „ Standard Biodiffuser 218th Ave
of Cover Leaching Chamber
with 3 1. 1 ft2 of Area
1"
6' Long 1 B. M. * \
34" Grade at System Elevation
Pro 3
Bedroom
House
Plans Designed Using
Conventional Powts
Manual Version 2.0
2 160' T
Well is to meet all �{ c
setbacks required by
'
WDNR ''are ✓�
B -5 3 t B -1 50 ,
L�
%
Vents
5 '
6 B -2
Slope
5 '
2 -3' X 69' Cells with >3' Spacing
35'
370' operty Line
30' - 3 e =�
B -4 r B -3 Vents
O V11
250'Property Line
PLOT PLAN
PROJECT Darin Marek ADDRESS 1306 210th Ave New Richmond Wi 54017
1/4 NW 1/4S 13 /T 1 '/R 18 W TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 3/6/04 BEDROOM 3 '
CONVENTIONAL XXX IN -GR ND PRESSURE CONVENTIONAL LIFT HOLDING TANK 4 '
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 2" Pipe PV ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL * H. R. P. Same as Benchmark
SYSTEM ELEVATION 90.0/90.5 4' below qrade
Vent
>6 „ Standard Biodiffuser 218th Ave
of Cover Leaching Chamber
with 31.1 ft2 of Area el(Ae-Ia
11"
6' Long B. M.
3 4" Grade at System Elevation
Pro 3
Bedroom
House
Plans Designed Using
Conventional Powts
Manual Version 2.0
20' 160'
Well is to meet all T
setbacks required by
WDNR
30'
B -5 3 B -1 50
Od
Vents
5 '
6% J35'
Slope
2 -3' X 69' Cells with >3' Spacing
370' operty Line
30'
B -4 B -3 Vents
4
250'Property Line
Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3
-1 Nision of Safety and Buildings in accord with Comm 83.06, Wis. Adm. Code
Attach complete site plan on paper not less than 8 x 11 i Plan must County 7 L
include, but not limited to: vertical and horizontal refer �gpoirytKB�vl), dttt�tion and
percent slope, scale or dimensions, north arrow, d 1dFation and `distAnce f"earest road. parcel I.D.#
` P din
APPLICANT INFORMATION - PI 4 egrint I,1 � anon: ev' d e Date p
Personal information you provide may be used for 8ry purE> (1?tiwdel~Law s. 15.04 (() (m))• y yj, /
Property Owner Propel Location ❑)
Lakes &Hills Development Govt: t 1/4 NW vo 1 T 31 N,R 18 W
Property Owner's Mailing Address TY hod# Block # Subd. Name or CSM#
GO tC
Pine Acres
�ur� e own Nearest Road
State Zip Co ` ' FhoneNumber C' 9
C' e p C ity
t, 218 TH. Ave.
❑ New Construction Use: ❑ Residential / Number of bedrooms 3 [:]Addition to existing building - --
❑ Replacement ❑ Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpdtW .8 trench, gpd/ftz
Absorption area required 643 bed, T 562 trench, it' Maximum design loading rate .7 bed, gpd/ft .8 tr ench, gpd/fF
Recommended infiltration surface elevation(s) 90.6 ft (as referred to site plan benchmark)
Additional design / site considerations
t Parent material- -- - - -- Flood plain elevation, if applicable - ---- ft ble for system Conventional Mound In - Ground Pressure AT - Grade System in
Fill Holding Tank
itable for system ® S ❑ U ❑ S ❑ U ❑ S ❑ u ❑ S ❑ U ❑ S ❑ U ❑ S LE U
SOIL DESCRIPTION REPORT
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ftz
Boring# in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
1 0 -10 10YR3 /3 ------------ - - - - -- t lmsbk mvfr as if 4 .5
1 —
2 10 -19 10YR4 /4 ------------ - - - - -- 1 lm mvfr gw lvf .4 .5
Ground ____ 7 .8
3 19 - 49 7.5YR4/6 --------- - - - - -- cs osg ml gw
elev -- -- -
95.1 ft. 4 49 -94 10YR4/6 ------------ - - - - -- s osg ml - - -- - - -- 7 8
Depth to - -- —
limiting sq i D'j
factor
>94"
Remarks:
1 0 -11 10 YR3 /3 --- I 1 msbk mvfr as i f .4 .5
Z- -- -- ------ - --- - - - - -- - - -- -- - - - - - -- - -- -- - – —
2 11 -25 10YR4/4 ------------ - - - - -- I 1 msbk mvfr as 1 of .4 .5
Ground 3 25 -5 7.5YR4/4 ----------- - - - - -- cs osg ml gw - - -- .7 .8
elev — 95.1 ft 4 51 -94 10YR4/6 ------------ - - - - -- cs osg ml - - -- - - --
Depth to
limiting 5 Amp mf
factor
„ J&V !i
>94 S A 7A 74
Remarks: __ -- —- -- -- --
CST Name (Please Print) Si ature: Telephone No.
— Jacqu Hawkins - -- - -- ❑ - -- - -- y 7 z
Address Date CST Number Ref #
a v �e ' Gam,' y ,� 4/9/00 z z a1— 38
PROPERTY OWNER: Lakes &Hills Development SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D.# Pending
Depth Dominant Color Mottles Structure GPD/ft?
Horizon I in Munsell Qu. Sz. Cont Color I Texture Gr. Sz. Sh. onsistencel Boundary I Roots
Bed ! Trench
3 1 0 -11 10YR3 /3 ------------ - - - - -- I I lmsbk mvfr as If .4 5
- —
2 11 -23 10YR4 /4 I ------------ - - - - -- I I lmsbk mvfr I as lvf .4 .5
Ground
3 23 -53 7.5YR4/4 I ------------ - - - - -- /Cs osg ml gw - - -- .7 .8
elev __-
94.0 ft. 4 -82 10YR5 /6 c osg ml - - -- - - -- .7 .8
Depth to I I
limiting
factor
>82 -
-
Remarks: t l , , 7 47 S `
4 1 ( 0 -10 10 YR3 /3 ------------ - - - - -- , 1 1 msbk I mvfr I as I if 4 .5
- 2 10 -25 10YR4 /3 ------------ - - - - -- I lmsbk mvfr as lvf .4 5
Ground
elev 3 25 -50 7.SYR4/4 ------------ - - - - -- cs I osg ml gw - - -- 7 8
93.3 ft- 4 50-74 10YR5 /6 ------------------ osg ml] _ -_- ____ 7 8
Depth to
limiting
factor
>74
Remarks: d y 5�
5 1 0 -9 10YR3 /3 - - - - -- 0 ---- - - - - -- 1 lmsbk mvfr as if 4 .5
2 9 -25 10YR4 /4 ------------ - - - - -- 1 lmsbk mvfi gw lvf 4 .5
Ground
elev 3 25 -50 7.5YR4/6 - - -- - -- --------- I osg I ml gw .8
93.3 ft. 4 50 -73 I I OYRS /6 ------ - - - - -- cs osg I ml I -- -- - - -- I .7 .8
Depth to �—
limiting
factor
>73"
Remarks: .Slv1. , �,e cam
l l 1 I I
Ground
elev
Depth to
limiting - --
factor
Remarks:
/7/,W-5
jo Z.Z.
T s N M i
-TwtiZ5 �,; p
7� aY
T b Y; 0Is3
A -6-M
d)e L7
O 7
J"
87
s M Z �� z�
System
S tic
Maintenance and Contingency Plan for a Septic Y
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
Contitency Plan
Option #1) If system fails, determine cause of failure, use altemate area and install new
in tested replacement area.
Option #2. Install system at a lower elevation, by removing chambers, removing biomat,
and install new 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
ST CROIX COUNTY
SEPTIC TAN MAINTENANCE AGREEMENT`
AND
OWNERSHIP CERTIFICATION FORM
o r
Mailing Address
o? /D 4
Property Address Dep artment for new construction)
(Verification required from Planning � � �✓
Parcel Identification Number 03 $ . !�
City /State C. �0 (q)
LEGAL DESCRIPTION /
. N
Location 1 /,, u/ ` /•, Sec.
3
. T _� � W, Town of
Property F �
Lot#
Subdivision ______� �
, Volume —, Page #
Certified Survey Map #
Warranty Deed # Volume �' Page #
ty
S housY� no Lot lines identifiable`` es O no
P /
SYSTEM %lAINTENANC
m could re
Improper use and maintenance of your septic systesult in its premature failure to handle wastes. Proper maintenance
m g out the septic tank every three Years or sooner, if needed by a licensed pumper. What you put into the system
consists of pumping
can affect the function. of the septic tank as a treatment stage in the waste disposal system
s i g n ed b the owner and by a
The ro rty owner agrees to submit to St. Croix Zoning Department a certification �� site w by t to owner
sal system
Pe ve O
P lumber restrictedplumber or a l icensed a fytng
masterplumber, journeymanP
and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
is in proper operating condition
i/we, 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
tics stem has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
stating that your sep Y
da s of the three year expiration date.
DATE
IZ G A' APPLICANT
OWNER CERTIFICATION
ed a to t
d b Register of Deeds Office I (we) am (are) the owner(s) of
I (we) certify that all statements on this form a
property described above, by virtue of a warranty
---- ---- -- DATE
SIGNATURE OF APPLICANT
Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department."""
** Include with this application: a stamped warran d eed stove ma o ffi ce the warranty deed
a copy of the certif Y P
U. 2622P 236 -7!5!5 �
STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH
Document Number WARRANTY DEED REGISTER OF DEEDS
ST. CROIX CO. WI
RECEIVED FOR RECORD
This Deed, made between Jeffrey C. Kemp,
Grantor, 03/05/2004 11: 00A1'[
I and Darin H. Marek, WARRANTY DEED
Grantee.
EXEMPT #
I Grantor, for a valuable consideration, conveys and warrants to Grantee
r ix County, Wisconsin
REC FEE: 11.00
scribed real estate in St. C o Co t State of lsco
the followin de ,
g y TRANS FEE: 98.40
e spa ce is needed lease attach addendum): >P ) COPY FEE:
Lot 24 lat of Pine Acres in the Town of Star Prairie, St. Croix County, CG FEE :
Wisconsin. PAGES: 1
Recording Area
Name and Return Address
-"tcb r
038- 119540 -000
Parcel Identification Number (PIN)
This is not homestead property
(is) (is not)
Exce to warranties: Easements, restrictions and rights -of -way of record, if any. l�i
Dated this \ day of March 2004
* * J ' re . Ke
* *
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Tracy L. Tu rner STATE OF (/l— )
Notary( Public ) ss.
C Ii� COl�SIrl County )
authenticated this day of State Of V V
Personally came before me this day of
M arch , 2004 the above named
Jeffrey C. Kemp,
*
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me own to be the person(s) who executed the foregoing
authorized by § 706.06, Wis. Stats.) instr 4andack wl d e same.
THIS INSTRUMENT WAS DRAFTED BY
Attorney Kristina Ogland
Hudson, WI 54016 Notary of
My Commissio s rmanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.) P� )
* Names of persons signing in any capacity must be'typed or printed below their signature. Information Professionals Co., Fond du Lac, WI
STATE BAR OF WISCONSIN 800- 655 -2021
WARRANTY DEED FORM No. 2 -1999
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