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Home My WebLink About038-1197-60-000 /* Wisconsin Depaitment of Commerce PRIVATE SEWAGE SYSTEM Count and Buildiks Division Count §t. Croix INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitarX o.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. SS Permit Holder's Name: ❑ City ❑ Village T . n of: State Plan ID No.: P.C. Collova Builders, Inc., Star Prairie Township CST BM Elev. - - , Insp. BM Elev.: ' BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA (� 3 1 • ( 9v f ( TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark S ,2.q la K 2 1 0D f o r Dosing Alt. BM 2 -5 Aeration Bldg. Sewer A m, tm , / Holding St /Ht Inlet �p r TANK SETBACK INFORMATION St/ Ht Outlet �, 75 &D .2- r TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic '>50 - NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System /0"00 CH4,1f PUMP / SIPHON INFORMATION Final Grade Ma cturer St cover Zo 0, 0 q , Model Numbe GPM TDH Lift Fri System TDH Ft Forcemai n ngth Lia. : Dist. To well SOILAgSPRIPTION SYSTEM BENCH Width i Len th ( N . Of ren hes PIT No. Of Pits Inside Dia. Liquid Depth DIMEN 3 •?�Pe�. DIMENSION SETBACK SYSTEM TO P / I� BLDG WELL LAKE /STREAM LEACHING �M4anu acturer: f ( INFORMATION Type O s CHAMBER a Number: System: C t g' )} OR UNIT - caet DISTRIBUTION SYSTEM Header / nifold 'L 4 Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Leng Dia. T S ? 8 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 discre persons etc.) nspection 2r oa n - nec ion Location: , ( 13 T31N R18W) - Pine Acres -Lot 45 1.) Alt BM Description 2.) Bldg sewer length= 1 7.0 - amount of cover = `� 2`� (4 `� I C M,r 3) At ;4 l _ - - ' j- , e„� �,p�R L k ",:C a ►ti u c� . �jer�t .Qav�`Qt S Plan revision required? ❑ Yes No _ Use other side for additional information- 4 ) SBD -6710 (R.3/97) L--)? a C��s Inspector's Signature Cert. No. i ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: T4__ 4_ 1 f i { 5 S E Safety and Buildings Division SANITARY PERMIT fLKAMQN 2 01 W. Washington Avenue V rsconsin P o Box 7162 Department of Commerce In accord with Comm 83.05, o - M1 Madison, WI 53707 -7162 • Attach complete plans (to the county copy only) forth sys pap j�odess C u ty� than 81/2 x 11 inches in size. tCF /�/�~/) • See reverse side for instructions for completing this applid �/ U St fe nitary Permit Number Personal information you provide may be used for secondary purposes "�`, ST �� , ❑fir` if revision to previous application [Privacy Law, s. 15.04 (1) (m)). G'��f!/y�, S n Review Transaction Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL I M c Prop Owner Name o j- Property Lo L yl ' 1 3 T 3 � .N -RJ or� Property Owner's Mailing Address Lot �� Block Number City, State Zip Code Phone Number Subdivisi Npme or CSM Number (,c �� Yo /G ( 71,5 -)S s' II. T YPE OF MIMING: (check one) ❑ State Owned ❑ it Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms I Town o L III BUILDING USE (If building type is public, check all that applyy) Parcel T Number(s) 1 [] Apartment /, Condo �' � ' g 10 �� 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 1 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. New 2 E] Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ____System -------- System _____________ Tank Only -------------- Existing System - --------- Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 []Seepage Bed 21 C] Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12XSeepage Trench �.- /d 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit ��'`~ r 43 E] Vault Privy 14 E] System -In -Fill — /� X = X31., t�= P. VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day q. ft.) (Min. /inch) Elevation � l , Feet Feet Capacit VII. FORMATION in gallo Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. New Existin Gallons Tanks Concrete strutted glass App- Tanks Tanks Septic Tank or Holding Tank 1600 000 El 11 11 1:1 1:1 Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Na ep( - n t) Plumber' ignatur : (N /MPRSW No.: Business Phone Number: G/ iPd r o3.�;_7 e ;?,,6 - 6��s Plumber's Address (Street, City, Stat . ode): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps) (Approved []Owner Given Initial Surcharge Fee) Adverse Determination as UD 6 -12- X. CONDITIONS OF APPR VAL / RE SONS FOR DISAPPROVAL: Uk r SBD -6398 ( . 99) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS j 1- A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 -3151 To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to oe installed. II- Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII- Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX- County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ------ - ---------- ----- ------ ----- ----- - -- -------- ----- - --------- ------- --------------------- --------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. O GIN 0 7#-F � o \1 S-�j o Q � � y Y Wisconsin 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 '/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimemsions, north arrow, and IQlierrndtance to nearest road. Patel I.D.# t ` Pendin APPLICANT INFORMATION - Plea pry �a information. R viewed By Date Personal information you provide may be used for 'purposese�k'rivacy Law, s. 15.04 (1) (m)). "I 7i �l7 Properly Owner - Property Location Lakes & Hills Development �' Govt., Lot 1/4 NW 1 /4 ,S 13 T 31 N,R 18 �W❑ 4 t �:.i1.1 Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# c .E- 114 ;4 -Z_ 5 -- Pine Acres Nearest Road ity State Zip Code . PhoneNtrT4er City ❑ e [Town ❑ New Construction ❑ Use: Residet3tipl / Number of f e oms 3 ❑Addition to existing building - ❑ Replacement ❑ Public or commer&a "describe Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/f 2 8 trench, gpd/fF Absorption area required 643 bed, ftz 562 trench, ft Maximum design loading rate .7 bed, gpdffl? .8 tr ench, gpd/fF Recommended infiltration surface elevation(s) 97.6 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 N S U M S U ❑ S❑ U M S❑ U ❑ S ®U [I S Z U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Borin Horizon Texture Consistent Boundary Roots 9# in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 1 0 -10 10YR3/3 ------------ - - - - -- 1 lmsbk mvfr as if 4 .5 2 10 -18 10Y /4 ------ - - - - -- 1 lms mvfr gw lvf .4 .5 Ground 3 18 -35 10YR4 ----------- - - - - -- cl lm sbk mfr as - - -- 2 .3 elev — — — — -- 102.1 ft. 4 35 -56 7.5YR4/4 --- --------- - - - - -- cs osg ml gw ---- 7 .8 5 56 -96 10YR5/6 --------- - - - - -- s osg ml - - -- - - -- 7 8 Depth to - - — - - - -- - - - - -- — -- —— -- - limiting R factor — >96° t7 Remarks: 2 1 0 -11 10 YR3 /3 ----------- - - - - -- 1 lmsbk mvfr as if 4 .5 2 11 -20 l 0YR4 /4 ------------ - - - - -- 1 1 msbk mvfr gw 1 of .4 .5 Ground 3 20 -30 10YR4 /6 cl lmsbk mfr as - - -- .2 .3 elev 101.1 ft 4 30 -59 7.5YR4/4 ------------ - - - - -- cs osg ml cw - - -- 7 8 5 59 -84 10YR5 /6 ------------ - - - - -- s osg ml - - -- - - -- 7 8 Depth to — -- limiting factor >84" Remarks: CST Name (Please Print) Signature: Telephone No. Jacque Hawkins V 7 Z - -� - ` y b Ad ress Date CST Number Ref# S d Gv ti t le Sy 8S3 4/12/00 a D e 7 7 — 418 PROPERTY OIAMER: Lakes & Hills Development SOIL DESCRIPTION REPORT Page 2 of PARCEL I.D.# Pending Depth Dominant Color Mottles Structure GPD/ff? Horizon in Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. onsistence Boundary Roots Bed Trench 3 1 0 -10 10YR3 /3 ------------ - - - - -- 1 lmsbk mvfr as if 4 .5 2 10 -21 10YR4 /4 ------------ - - - - -- I lmsbk mvfr gw 1vf .4 .5 Ground elev 3 21 -31 10YR4 /6 ------------ - - - - -- cl lmsbk mfr as - - -- 2 3 101.1 4 31 -53 7.5YR4/4 ------------ - - - - -- cs osg ml cw - - -- .7 .8 Depth to 5 53 -85 10YR5/6 ------------ - - - - -- cs osg ml - -- - - -- 7 8 limiting factor >8511 — -- - Remarks: 4 1 0 -10 10YR3/3 ------------ - - - - -- 1 lmsbk mvfr as if .4 .5 2 10 -19 10YR4 /4 ------------ - - - - -- 1 Imsbk mvfr gw lvf .4 .5 Ground 3 19 -29 10YR4/4 ------------ - - - - -- cl lmsbk mfr as - - -- .2 .3 elev - — - - -— -- - - 100.2 4 29 -50 7.5YR4/4 ------------ - - - - -- cs osg ml gw - - -- .7 .8 Depth to 5 50 -75 10 YR5/6 ---- - - - - -- cs osg ml - - -- - - -- 7 8 limiting - - factor >7511 - - — Remarks: 5 1 0 -10 10YR3/3 --------- -- - - -- 1 1 msbk mvfr as if .4 .5 - 2 10 -17 10YR4 /4 ----- - - - - -- - - - - - -- 1 lmsbk mvfr gw lvf .4 .5 Ground elev 3 17 -30 10YR4 /6 ----- ------- - - - - -- cl l m sb k mfr as - - -- 2 3 100.4 4 30 -50 7.5YR4/4 - - - - -- cs osg ml cw - - -- .7 .8 Depth to 5 50 -79 10YR5 /6 ------------ - - - - -- cs osg ml - - -- - - -- .7 .8 limiting factor >79" Remarks: _ Ground elev __ -- -- -- — ft. Depth to limiting factor Remarks: k G, 2 o e e � I vt I 4 � � � Z L W iT <1 0 Clhius ' ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer //a 0�w 4/ Mailing Address _ _ 7o� C /� �u�aso,� CtcZ S�c� l (P Property Address C O . 1�lt N c c w t I �- (Verification required from Planning Department for new construction) City/State Parcel Identification Number o-3b - /6 5V LEGAL DESCRIPTION Property Location %,, N W %,, Sec. / 3 , T 2_LN -R�W, Town of s A C I /K/ C Subdivision rl NE ACitu Lot # Certified Survey Map # Volume - _ . Page # "- Warranty Deed # _ �� o� �{ - 3 Volume /6 . Page # 7 Spec house yes ❑ no Lot lines identifiable s ❑ 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 masterplumber, journeymanplumber, restricted plumber or a licensedpumper verifying that (1) the on -site wastewaterdisposal 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 da a year exp' tion date. G A 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 ;G;A11MKF rry scribed abo , by virtue of a warranty deed recorded in Register of Deeds Office. APPI: CANT 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 r Vol. KATHLEEN H. WALSH REGISTER OF DEEDS Document Number Document Title ST. CRO I X CO., WI Q") N t , N �.� D C. d RECEIVED FOR RECORD " - 06 - O7 2000 4.00 PH WARRANTY DEED EXEMPT I CERT COPY FEE: COPY FEE: TRANSFER FEE: 74.70 RECORDING FEE: 12.00 PAGES: 2 Recording Area Name and Return Address r00 f U ; Kd � Scf o 47 3 5. 3 !;— UGC oj g,s MA q „fi o 4 OTCs ^ Io ovo 05S- tort' -cfd ^0 Parcel Identification Number (PIIN) 0 0 nl - f.0 -O 0 0 Form N.4-Ni— WARRANTY DEED Minnesota Uniform Conve ancin g Blanks 1978 Holstad & Larson, P.L.C. Corporation or Partnership to Corporation or Partnership yo 5 pa 20 No delinquent taxes and transfer entered; Certificate of Real Estate Value ( ) filed( ) not required Certificate of Real Estate Value No. 1 19 County Auditor by Deputy STATE DEED TAX DUE HEREON: $ (reserved for recording data) 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 property in St Croix County, Wisconsin, described as follows: Lot 45, Pine Acres, St. Croix County, Wisconsin "The seller certifies that the seller does not know of any wells on the described real property: together with all hereditaments and appurtenances belonging thereto, subject to the following exceptions: Easements, covenants and restrictions of record. Lakes and Hills, Inc.. By: Richard S Ne son Affix Deed Tax Stamp Here Its: President STATE OF MINNESOTA Ss. COUNTY OF Ramsey The foregoing instrument was acknowledged before me this 31st day of May 1 19 99 by Richard S Nelson, President and the and of Lakes and Hills, Inc. a Corporation under the laws of Minnesota o behalf of the Corporation NOTARIAL STAMP OR SEAL (OR OTHER TITLE OR RANK) C � �� j�j�j►�� IGNATURE OF PERSON ` TAAKING ACKNOWLEDGMENT DEBORAH L. DNNESOTA NOTARY PUBLIC - MI Tax Statements for the real property described in this instrument MY COMMIS should be sent to (Include name and address of Grantee): EXPIRES JAN. 3 THIS INSTRUMENT WAS DRAFTED BY (NAME AND ADDRESS): P.C. COIIOVa Builders, I n c. Northwest Title &Escrow Corp. 705 County Road E Suite #120 Hudson, Wisc. 54016 3535 Vadnais Center Drive Vadnais Heights, MN 55110 59443