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HomeMy WebLinkAbout038-1181-30-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix S2rety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 538735 0 GENERAL INFORMATION 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: Flod, Todd Star Prairie, Town of 038 - 1181 -30 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: Dt G ST 15.31.18.908 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark mar 3 qq. ? / az-S QQ64> Alt. BA, 14c, -. C11- Aeration Bldg. Sewer --- Holding SUHt Inlet - TANK SETBACK INFORMATION St/Ht Outlet TANK TO PiL WELL BLDG. Vent to Air Intake ROAD sHrdet' S 3 Gvt.'S 3• Septic i Dt Bottom r.�s 7 S� 5 5d 34 3. , 2 DO&M 5 75 � / 3 r Header /Man. C nI , 2 U 7 �J Aeration Dist. Pipe q , Z 7 32.7 Holding Bot. System 9 , Z Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover M F,'6J. Ca - �/ti Model Num r ve__ TDH Li Friction Loss System H Ft t/ / atv� Forcemain i [Dist. to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width I Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS -3 C� / �� J 7 C %-- SETBACK SYSTEM TO P/L JBLDG WELL LAKE /STREAM LEACHING Manufacturer: — INFORMATION CHAMBER OR ,L ^ ( — i ' Type Of System , ' a 54 36 i 7` UNIT Model Number: DISTRIBUTION SYSTEM d Z 3 }' Z 3 Header /Manifold ! / Distribution x Hole Size x Hole Spacing Vent,to Air take Pipe(s) Length Dia Length Dia \ Spacing 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 A. � ? Bed/Trench Edges Topsoil Yes No Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / ! Inspection #2: / / Location: 1104 212th Avenue New Richmond, WI 54017 (NW 1/4 SW 114 15 T31 N RI 8W) Apple River Bend 1 Add L Parcel No: 15.31.18.908 Ja� L �C C/ 1.) Alt BM Description �e — = 2.) Bldg sewer length = .7� — U (o S 3 - amount of cover = �k�� lT � S Plan revision Required? Yes ° No / Use other side for additional inform on. / (� SBD -6710 (R.3/97) Date Insepctor' Signal Cert. No. _ _ V� � � r �� � �� � � � x � � �� � �, l tA_ I D cammeme,1111A,gpv Safety and Buildings Division County r 201 W. Washington Ave., P.O. Box 7162 10 'W i sconsin Madison, WI 53707 -7162 Sanitary Permit Number Number (to be filled in by Co.) eparbnent of commerce p Sanitary Permit Application State Transaction umber In accordance with s. Comm. 83.21(2), Wis. Adm_ Code, submission of this form to the appropriate governmental r� unit is required prior to obtaining a sanitary permit. Note: Application f Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information yo E-D cond purpo in accordance with the Privacy Law, s. 15.04 1 m , Stats. , R` s4,.• �*/r .F� 2 I. Application Information -Please Print Information Property Owne 's Na f Parcel # o f- 6 DEC 0 3 ZO10 3 �. Property Owne Mailing Address S I . (;KUiX L Property Location PLANNING & ZONING OFFICE , 96$ P / Govt. Lot _ ' l (� City, State r Zip Code Phone Number y CC/ Vi, Section /`� i I l / acircle one II. T pe of Building (check all apply) Lot �✓ or 2 Family Dwelling - Number of Bedrooms Subdivision Name n (oc l.G� ❑ PublicJCommercial - Describe Use City of CSM Number ❑ Village of ❑ State Owned — Describe Use Z � i *4- f � � W Z3 'r7i G�>l .'� own of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System Replacement System ❑ Treatment/Hoiding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. El El Permit Renewal ❑ Permit Revision Change of Plumber List Previous Permit Number ❑ Permit Transfer W New Before Expiration Owner IV. T e of POWTS System/Component/Device: (Check all that apply) (.' on- Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound> 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank Other Dispersal Component (explain)_ _ ❑ Pretreatment Device (explain) V. Dis ersaUTre tment Area Information: - Design Flow (gpd Design Soil Application dsf) Diagelsa Require so Dispersal Area Prop d ( �te� kv t� S YY , VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units g U n New Tanks Existin g Tanks til / 1 V I o k U v] I Septic or Holding Ta»k � Dosing Chamber VII. Responsibility Statement - 1, the undersigned, responsibility for installation of the POWTS shown on the attached plans. Plu 's Name (Print) uTWSignature MP /MPRS Number Business Phone Number d Plumber's Address (Street, City, State, Zip VI . CouA/De rtment Use Onl Approve Permit Fee Datb I ued / Issuing cut Signature en Reason for nial $ . / /5 171 /b IX. Condit' aeons for Disapproval r r p e� 1. Septic tank, effluent filter and �J, P` v vK•+�J[.b. dispersal cell must all be services / maintained as per management plan provided by plumber. J �t •5o t QGe.� 2. AN sebAck requirements must be maintained J ord inances. Attach to complete plans for the system and submit to the County only on paper not leas than a 112 x I t Inches In size SBD -6398 (R. 01/07) Valid thm 01/09 PLOT PLAN PROJECT Todd Flod ADDRESS 1104 212th Ave New Richmond WI 54017 NW 1/4 SW 1 /4S 15 /T 31 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 11/30/10 BEDROOM 3 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 .5 ABSORPTION AREA 931 # of chambers 46 IL BENCHMARK V.R.P. Top of observation pipe ASSUME ELEVATION 100' Filter BEST Filter ❑ BOREHOLE O WELL *H. R. P. Same as Benchmark SYSTEM ELEVATION 92.0/91.0 5' below qrade Property Line Plans Designed Using Conventional Powts Manual Version 2.0 Well Existing 3 99' 100' 10' Bedroom House Vents 95' 20' 60' B -2 40' Scale is 1" = 40' unless otherwise 70' noted B -3 18% Slope 3 80' B.M.* T ' A valve is to e installed 0 t 20' ST B -1 1 3 �� J � Vent Vents Failed system >6„ Quick4 Standard -W 2-3' x 57' cells ?4'Lolng Leaching Chamber with 20.0 ft2 of Area " 5.8ft^2 /pair of end caps 34" Grade at System Elevation 212th Ave Cover Page I Shaun Bird Bird Plumbing Inc. 1008 192nd Ave New Richmond Wi 54017 715- 246 -4516 Date: 11/30/10 Owner: Todd Flod Location:NW1 /4 SW1 /4 S15 T31 N,R18W 1104 212th Ave Star Prairie System type: In- ground absorbtion system(conventional) Manuals Used: In- ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cross Section 4 -5. Maintanance and Continge y Plan i 6. Filter Specifications Shee 7. Utilization of Existing S t' nk Signature License numb 4r Coo I PLOT PLAN PROJECT Todd Flod ADDRESS 1104 212th Ave New Richmond WI 54017 NW 1/4 SW 1/4S 15 /T 31 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 11/30/10 BEDROOM 3 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 .5 ABSORPTION AREA 931 # of chambers 46 IL BENCHMARK V.R.P. Top of observation pipe ASSUME ELEVATION 100' Filter BEST Filter ❑ BOREHOLE O WELL *H. R. P. Same as Benchmark SYSTEM ELEVATION 92.0/91.0 5' below qrade Property Line Plans Designed Using Conventional Powts Manual Version 2.0 Well Existing 3 99' 100' 10' Bedroom House Vents 95' 20' 60' B -2 40' Scale is 1" = 40' unless otherwise 70' B -3 18% Slope noted 3 80' B.M.* T ' A valve is to be installed —� 0 20' ST B -1 I Vent Vents Failed system >699 Quick4 Standard -W 2 -3' x 57' cells of Cover Leaching Chamber with 20.0 ft2 of Area 4' Long 1291 5.8ftA2 /pair of end caps 34 Grade at System Elevation 212th Ave Cross Section of Quick 4 Standard -W Leaching Chamber Typical cross section for 2 of 2 cells Quick 4 Standard -W Leaching Chamber with 20.0 ft2 of Area per Chamber 5.8ft ^2 pair of end plates To be >1' above grade Finish grade elevation Typical Installation 98.0 Vent AC I Grade Vent 4' 4" 4' X30/34 Septic Tank 4' Long 1 15 5' 4' Long 1 59 I 34" Grade at System Elevation 3 4" Grade at System Elevation I i Spacing 5' i 2 -3' x 88' Cells Observation tubeNent Same on other end Located at ends of Cell A B 23 chambers per cell System elevations: A--9 1. 0 B 92.0 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AQRI� AND OWNMtSHW CERTMCATION FORM owner/Buyer property Add Pymeias Zomas D �°" Pic.1 yd a na Number (qty /Sta�c� Of / T 3� N Towa Fropa v L� oat - S tv toaa Vob=O Page # ,� pie wed Survey' MUP C Volume # WNT aub9 Deed # J Lot He" y yeG� no _ trace t D bsa& P�oQ aar u iabo me aaaad ° ° Y o � yms or ioamw ifunded, by a OWAN mal*m saG6 WM go= o f sqyw tank as 6 tr stifle � ' - tltt system is $C�ummo. 83.52(1) and is C iz - St. C a c o'a foarm, dped t}�dt (i} tba o a awns to saber to i2bunber at s (if a�ec Y)� � �� � is owW and b a a oom, a�/aac (2) a& sya = W tha sad qFW tc of Wboons 8t w ant IFS, b` y of ,mud cc°m` cac'°°�ty pta got Jbfijo k bas bow C MMS tbil 7 30 og m d' . ywe mine * o�wa+es(s) of ft ZonmB Ions know VWO �fy Cheat all M this m oiD°°d° Offico- �,�t d,e�sibmd 430M bY�° cf a wanwAY Number of b DATE S`IGNAT[3RE OF AprPLIC`ANp(S) revobod by *0 PbaaM & Zon:ba8 DvKtl1Mt' * **Any iafoarmslw s teoaa+aied, deed $"°� X10 R °f Deeds MOM and a �' °Etta ode with this gp des is a W in the waraveq doe& 0MV• 0&" Maintenance and Contingency Plan for a Septic System Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Eff luent 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 Option #1. If system fails, determine cause of failure, use alternate area and install new s n tested replacement area. Qa on #2 Install system at a lower elevation, by removing chambers, removing biomat, all 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 uj Cl 0 0 0 Q � iL -v- uL. 0, - - - - -- - Z Q C9 0 z = U � o �nz � � ti m ° Ck- � �rl _t-t Ott ti N J { � �LL N N Q rj }j N ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK `li:i.s is to certify that I h ve inspected the septic tank presently serving the � reside e located at: Section �J TN, R / W, Town a r /7 Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. bast time serviced: Az �U`� _ Pid flow back occur from absorption system? Yes _�_ No (If no, skip next line) Approximate volume or length of time: gallons minutes, - apacity: lz7rl o Construction: Prefab Concrete Steel Other manufacturer: (If known) : - - -- Age of Ta (If known).: r (S' ure) (Name) - Please print i (Title) (License Number) Tate 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 th st of my knowledge will conform to the requirements of ILHR 83 s. Adm. Code (except for inspection opening outlet baffl 2z� Name ��� 61 Signat MP /MPRS �s �� P .iii Wisconsin Department of Commerce SOIL EVALUATION REPORT """""■++.a of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code n County j l Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must ry include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D ,,x�, percent slope, scale or dimensions, north arrow, and location and distance to nearest road. L ,9 33 -/ _ Q /�vt/ Please print all information. Revie by Date Personal information you provide may be used for seconda u P 'v (1) (m)). Property Owner _ Pro rty Location A AV Go Lot "" 1/ 1/4 /� T 3l N Rl E (or W Property Owners Mailing Addr 2010 Lot Block # Subd. Name CSM# o �� DEC 0 3 City State Zip Code hone Nynkw-;ln C SUN TY n ❑ Villag Town Nearest Road -'YD/ 7 ( PLA NING & ZONING OF ❑ New Construction Use: Residential / Number of bedrooms Code derived design flow rate _ � GPD eplacement ❑ Pu or commercial - Describe: Parent material Flo elevation if applicable A2 l General comments x /..t . it L' i,' v�^� u-� - ,S • and recommendations: 5' t l - -J Pr� System Type System Elevation Q F � # E] ring Pit Ground surface elev. .S • 4 ft. Depth to limiting factor - �- /� - -' n. 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 t �o Boring # ❑ Boring 9 V. Pit Ground surface elev( : c ' a - - 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 —e/ XZ, 3/L G —7 r- V,2 sc t ►c Effluent #1 = BOD > 30 < 220 rtg& and TSS >30 < 150 ' Effluent #2 = BOD < 30 mg& and TSS < 30 mg/L CST Dame (Please Print) Sig CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 540 _ 715- 246 -4516 Property Owner _ Parcel ID # Page of Boring # ❑ Boring !a� ® pit Ground surface elev. � ft. Depth to limiting factor � 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 _ t o 4 - 2 0= i C D Y d :; 5 0 - /Y? F-1 Boring # E] 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 E Boring Boring # Ground surface elev. ft. Depth to limiting factor in. El Pit Soil ication Rate Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/fl= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 1150 mgA- ' Effluent #2 = BOD, 130 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. seD -9330 Wfift) Property Owner _ Parcel ID # Page of ❑ Boring # ❑ Boring ® Pit Ground surface elev. ft. Depth to limiting factor Ldl 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 - /D /,v F Z/ - z o$ l z ----� v lol E vil F-1 Boring # ❑ Boring [] Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Y 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 I I I F71 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Sal Application Rate Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 1150 mg/L ' 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. SBD -8330 (RANG) Soil Test Plot Plan Project Name Todd Flod Shaun ' d Address 1104 212th Ave New Richmond Wi 54017 #226900 Lot 42 Subdivision Apple River Bend Date � 11 130/10 NW 1/4 SW 1/4S 15 T 31 N /R W Township StarPrairie [ Boring 0 Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of Septic tank observation pipe System Elevation 92.0/91.0 *HRpSame as Benchmark Property Line Scale is 1" = 40' unless otherwise noted Well Existing 3 99' 100' 10' Bedroom House 95' 20' 60' B -2 40' 70' B -3 18% Slope 30' 80' B.M.* T ' 10' 20' B -1 Vents Failed system 2 -3' x 57' cells 212th Ave T P ' ATT'D A i � 8 '*48' " 2788. 234.E 2081 . 3 2 LO 42 L 2. 14 AC i FT. 93,4 SO, FT. €x.82 1.34 AC. EXC. 'ESMT. 35, 744 67, 233 SCE. FT. Go In 8 o 71,4or R 04 WA% " _ Wm. . i ,3+ce '' 13. \R OF \\ �:CO :38y FC -MV - .482 t \ARR,4i3fiM DEED acrCz. L - CWT F O mZICHXRV U. - 137 S4. C 3 w(J,, WI TODD E . FL40D and JENNIFER M. I STA -- 1.0:30 A a -- rk O.J.au ?� Ce Mods cw,> std Cz� ���ID r� �'•i ,uRCrav: Ln -�. �- nPAt7� R;:S: FSr.,,Fi7+ mnnrax l!'7: rtm8as9rtb` �escrrbn,3 a'rs9 diet aT St. C ro i X C; y - Su,r ai \Fmscoasstrt Lot 42, Plat of Apple River Bend First Addition, Ts►um of Star Prairie, St- Croix Caunty, Wisconsin. / T RA NSFER FEE is not This r�rsarxs! Pr�'R*c�! toy 4"s nm o F�eR�r/tnFOrt +u+. ?r -w�ors easements, restrictions, rights-of-way and covenants of record, if any, D 1tlr,�_ 3 rd__ O L � —jL'.j F+ebru y �P - - -r. �►is.1�$_ *� :sue) (SEAS.) Richard O. Stott _ T„w MAU s (SEAL) e _ AUTHE NTT CATIQk%.' ACKNOWLEDGMENT Stgnatweis) _ Stme of Wisconsin, -- — — St. Croix County 1 authenticated this — day 19 -- perso»aliy earta berom the ttus _ 3rd , day of Feb ruary i9 4£3 - ,t s; .w ,. == a -- R O. Stout I l rl E MEgll)ER STATE BAR Or WISCONSIN - - -�— _ -- -- — 0i net. authon.ed by g t Oi , i \'ts �:au) to -ne known to b: kh.: persc n �\ v ese" utsatt -neru and z '• :stt.lgr t Sa. ('9O ARY THtS w-IS'rkoAEmT iCJAS DH9kFTC0 BY r Janet P. S tout 1353 Acwatur Tr. — - D/HNA Hl3EI56i1 -► — �i- .- 4��f>— ^'otsry Fublcc..a. �/t� (Signatures .may be aud.- tuteated or ackna.,tedg.t! Kith are no My ommtsscnn u oertnan.at {If` ` f) a ,4:y5t�6 n; date ^;: -e..d s:r. -_ •- sc•. ,;rm .. rsa @e r•. • -..•.t �- pr:•d 5, r!•, . �u..:..r -. SIATF. tt.AR OF %VISC.ONM% A°,C.l.r^-A9M — •r K'tRR \NTY DEED Fnrm Nn 2 - t9Rl tf+twzu.� '•- 9 9 l�<� ST. CROIX COUNTY ZONING DEPARTMEN � � A ~' t AS BUILT SANITARY REPORT Owner ) =I r a Address 104 ?.y ,r COUNT City/State — � � �� e r �• ZC3NVNGOFFICE / Legal Description: Lot _'Z Block -&4- Subdivision/CSM # t/. AW '/4 SIV Sec. ,L�., T..3LN -RAW, Town of ST i4/2 � Gp PIN /5=3�. ►�. °10l 038- ltg ►'3c� — �ov SEPTIC TANK -- DOSE CHAMBER — HOLDING TANK INFORMATION: Tank manufacturer &Z&uE A�X Size ST/PC " Setback from: House 4, q Well 25:! P/L ya ` Pump manufacturer _ &A Model AM Alarm location �_ .tr (HOLDING TANKS ONLY) Setbacks: Service road VenAto, ir take Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: T j:F&c « Width �_ Length 16, Setback from: House � ` Well d � ---�— Number of Trenches � _ P/L X0,2 � Vent to fresh air intake _ a ELEVATIONS f b Description of �,o ©,�_ p � � 7�/ �11,4i� Elevation a Description of alternate benchmark To o Elevation CO1?NER �y 6­42Aee EC. Building Sewer - LD S ST/HT met ST Outlet PC Inlet PC Bottom -- ;I(Q Header/Manifold Top of ST/PC Manhole Cover © Distribution Lines ( /) 1NF i , 4 r1jA (2) _iA(,pij T/t4 70� ) Bottom of System Final Grade (1) /D 4. Date of installation 61,ql Permit number 4 R tate plan number Plumber's ' ature _ License number .2417 �f�_ Date P l , / Inspector Complete plot plan or • NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show altemate benchmark, if applicable. PLAN VIEW I,f�E�L oR7 P1 4(- fit. �a9./2 s rAa'&cties Q INDICATE NORTH ARROW 1 NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW Cf9E�L o e T ip x �fe a- a-re CAP Ardam �Z t a i- B /oae mac. s• % - Q INDICATE NORTH ARROW r t ' Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division ST. CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarys r[��t.fj(p,: Personal information you provice may be used for secondary purposes [Privacy La s.15.04 (1)(m)j. 33 U / / V 1 P rmO�Hold �Qla e: ❑Lis.�c w yl x n of: State Plan ID No.: CST BM Elev.: UUlll, Insp. BM Elev.: BM Description: �'lAK t'KA Parcel Tfc,Na._1181- 30_000 A t e. . _ 3Z5 TANK INFORMATION ELEVATIO ATA A9800090 TYPE MANUFACTURER ,_ [- CAPACITY STATION BS HI FS ELEV. Septic �- - BeTRtfP`n r 1� °I ? "LAp Dosin g A-ct. ZM •/ Aeration Bldg. Sewer . 10q Holding DJInlet o I!- 3 TANK SETBACK INFORMATION OW Outlet TANK TO P/ L WELL BLDG. Air Intake ROAD Dt Inlet Sep "ti l � t 60 ` NA Dt Bottom Dosing Header / Man. I I •�Z Low T r ( .9 q ; pa_ Aerati NA Dist. Pipe , , , I eJ Holding Bot. System -r �5. qV -37 PUMP/ SIPHON INFORMATION Final Grade 10 .67 Manufacturer Dem d S{ Z • 3 (,� 2. (o Model Number GPM TDH Li Friction System TDH Ft Forcem in Length la. Ii Dist. To Well SOIL ABSORPTION SYSTEM BED / NC W idth No. Of Trenches PIT No.O Dia. Liquid D pth DIMEN Length S4.2 oZ DIMENSION SETBACK SYSTEM TO P/ L I BLDG WELL LAKE / STRE M LEACHING facturer: INFORMATION Type Of 2 CHAMBER o e Numb System 00 DISTRIBUTION SYSTEMS _ S ; 14,0��,�� Header/Manifold �, ' A Distribution Pi a {s x Hole Size ent To Air Intake Length � Dia. Length �� Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over tl < Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center 3(0— 4 Bed /Trench Edges opsoP ❑Yes o ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STAR PRAIRIE 15.31.18 NW,SW 1104 212TH AVENUE �Sfn 1, IA(f 49 t./&V— — (, D C+. 3) "��z ' 4� &u Plan revisi n required. ❑ Yes )6, No ,v JA, 12PA Use other side for additional information. & y I Ri��7 SBD -6710 (8.3/97) Date Inspector's gn ure SANITARY PERMIT APPLICATION S afety 01 E. Washin n Ave sion V6onsin P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County �� Cho than 81rz'x 11 inches in size. /A • See reverse side for instructions for completing this application State Sanitary Permi The information you provide may be used by other government agency programs ❑ Check if revision applicItion (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Property Owner Name o ation Prperty Loc 7_0 ,a 5 W 114, S / ;SS T , N, R 1 E (Or Property Owner's Mailing Address Lot Number Block Number 3 g1 1 7A City, State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE F BUILDING: (check one) ❑ State Owned It Nearest Road Public 1 or 2 Family Dwelling - No_ of bedrooms TownOF .� /� L`' III. BUILDING USE (If building type is public, check all that apply) rcel Tax Number(s) 1 ❑ Apartment/ Condo 638•- 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ 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. ❑ 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 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 IX Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill 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 /sq. ft.) (Min. /inch) V ElyatW Feet n � Feet Capacit VII. TANK in Ca allo s Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks r- Septic Ta Q �� /f °„S R ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ I ❑ I ❑ I ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibiliUtfor installation of the onsite sewage s stem shown on the attached plans. Plumber's Name: (Print) Pt be 's Signature: (No s) M SW N � Business Phone Number: LIM( 77r Plumber's Ac dress (Street, City, State, Zip Cod-e-)": d _ o IX. COUNTY / USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuin gg. ent Signature (No Stamps) , of roved © � / Su rcharge Fee) pp ❑ Owner Given initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 IRA 1/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 4. A sanitary permit is valid-for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 1 > 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 be installed. ll. 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. �L�DO. S ct�► PVL Vvil �K Rb)(/M t7- E j NjSPECT,(oA PI PE CP4 oz Z (o FL, 97.5 f�p+PaXr . G�Rtl S /OfW,NQ E � � ZO E 97 D _ s�dew,N0 j 3 3� F f oP qty �N_ PR w ELL Pwoep lf045C 18 z- Z53 1p00 GAL 5•T 3 `U 8� Cl gs - i E � � � g� � a•� Bm � Z p SZ �3X S6. ZJ N Kitre4rok ♦� �� �S�o SiDtwiNOER TkEiVCEFES 3 1,$f7 z J'r�Tionl I •S'C44 � "_ yp • Bfil4l TOP of ��„ Pee _F L. IDO.DO k Z T oP g NG Foe TODD F40 D NeW 1?/c,#/ - ` , c)1 !D , CV l ' So m t5e ICJ - r 5-YDA;5�- Wisconsih Department of Industry SOIL AND SITE EVALUATION REPORT Page of 3 -Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Co UNTY t1C� J sT; cR0 c K Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan mu I but not limited to vertical and horizontal reference point (BM), direction and % of slo or� P dimensioned, north arrow, and location and distance to nearest road. � l; � APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION r vG REVIE j Y DATE PROPERTY OWNER: P TY LOCA7)0p k G h A RD S"r'o V T GO T ( ;,,Lj4 1 /4,S 3� ,N,R �� E (o Wo PROPERTY OWNER':S MAILING ADDRESS k0 �8B@ifVA ff 35'3 /f W,4 T•U A TiP. , CITY, STATE ZIP CODE PHONE NUMBER []CITY G NEAREST ROAD r�� Sow /��5. 54or� (715) 5 �Ywy. CC [l,�ew Construction Use [ �iesidential / Number of b6drooms 3 to 4 [ j Addition to existing building [ ) Replacement () Public or commerdal describe Code derived daily Bow y �� gpd Recommended design loading rate 111,e bed, gpd/ft ' F trench, gpW Absorption area required bed, ft2 ?SO trench. 112 Maximum design loading rate N�iQ bed, gpd/ft2 trench, gpd/(t2 Recommended infiltration surface elevation(s) SEA 3 ft (as referred to site plan benchmark) Additional design / site cons rations NSE Go.v G- 'TRF $ C u PUL C, fio e"o-'3 F o v Q S . Parent material $CS I 1 130teh mn— t e ,yllAil A ' Flood plain elevation, if applicable &Z± ft S = Suitable for system C MOUND IN -GBOM PRESSURE AT-GS DE SYSTEM � H0 SING TANK El = Unsuitable fors stem 21 U O S C� �1 [TS 1:1 0 Sloft-Cs - 2- - ' SOIL DESCRIPTION REPORT / V'R = N 071 Boring # Horizon Depth Dominant Color Mottles Texture Structure��y Roots GPD /ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed mnch ( 0 - 10 /O yR y / 2s 3f . 7 2- o - i7 io yi2 3/z t she .4 c f , Lt , S Ground 3 /7- 3 J /o ye 3 2 fJ �rl �� Q - S /vf • S . G elev. /o D. 38 ft. 3 7 4 /4 I S/ �i»I S�i� �►►� V�' 12 Q Lo — . �{ , S Depth to 5 _ ' limiting factor F-1 >� Remarks: Boring # I 1 0-o / �Q Ground elev. `r 7• S ft. Depth to limiting taco i Remarks: CST Name:—Please Print R d Q t R T ZA L Q R I T Phone. 7is Address: 2 — Signature: Ulbrlcht a R isociate. Date: CST Number: Private Sewage Consultants �p�'y� y "Q,, � ` 655 O'N eil ls. t'TJ� �f�°4 Hudson, Wls. 54016 ORIGINA - 1 PROPERTYOWNER Rl?-44,P1 S���T SOIL DESCRIPTION REPORT Pap Z of 3 PARCEL I.D. tl ,� 0 T - 4q hE ! f1 E"R- SL'. J f. Boring # Horizon Depth Dominant Color Motes Texture Structure Consistence GPD /ft In. Munsell Qu. Sz. ConL Color Gr. Sz. Sh. R00 Bed ierxl� 10 ,04, 3/z s /7,T 7 ,1t - SA CS 17c- . q , S Z �a' 1 � io Yk 31f s/ /f's6� dS! cs /vf , q , S Ground 3 O vie -- elev. /os ft. Depth to limiting f actor r Remarks: Boring # p -// /a yiP 342- y s v y l -F 5h k- - ,eS-A cs l f 1 4 _ , S E .- I // /6 YA 31� -- s /�shw d5 cs 1 cf • `f . S 3 /o Y2 Y/6- - , s, O s a21L, 7 , Ground elev. /Od • Sao ft. Depth to s limiting factor it i Remarks: Boring # ���� .. I � /o /oy,P 3l� y l -f Sbk � 54 CS / S.. Z 0 -2T /o p `F •q • S Ground 3 y- f �e �/� — s . o s j t 1 4 elev. /oS 6 � ft. i i Depth to i limiting 'facttoor� r I Remarks: Boring # 13 i Ground } elev. ft. Depth to limiting factor Remarks: eon 000nio nc inm K PROPEWYOWM 6�44 5-(v07— SOIL DESCRIPTION REPORT Page Z of 3 PARCEL I.D. # 407 — Boring # Horizon Depth Dominant Color Moo" Texture Structure Roots GPD /ft In. Munseli Qu. Sz. ConL Color Gr. Sz. Sh. Bed Tmnch o - /Z /0Y,c° 3/;?_ S /fs Sti �5 / f . 4j , S 2- io v 3111 s/ /fs6� dS4 Ground 3 O ye elev. /OS it. Depth to limiting i factor rr ! Remarks: Boring # /d �P 3/1. y y -F c - i � 10-// Y s l sb,� .�sti , q; , s Ground elev. s 106 tt. i Depth to 1 = Nmiting factor it Remarks: Boring# o- 1�iP /d d 31.;?— ' rgdd/ y f Sbk 1 54 CS / :` 5 ... I � zq /o R f shy SGT cs l of • q � • S Ground 3 / IQ 7 /Ce . S . elev. } /OS (o (G ft. Depth to i limiting :. factor i Remarks: Boring # 13 i ................. Ground elev. Depth to limiting factor I Remarks: ' cen oeenro ncrnrn i I e ll -� m m - -� J o O a� I N c ° _ o ( O 1 L _ W O � O I • a ,p w N I, w O W � � W ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer r© Q D p Malllug Addraau 3.3 /L/ OA +7 �A 13 �E &zy OA s pr Property Address (Verification required from Planning Department for new construction) �/ City /State _FLU &&1 9 ` Parcel Identification Number � O " / W1 - 3 a LEGAL DESCRIPTION Property Location )V&) '/4, 50 '/4, Sec. /5�, T_ LN -R-1 W, Town of .5 f Subdivision f PG j df U e-2 )&LVe2 . Lot # �z_ Certified Survey Map # , Volume , Page # Warranty Deed # ,5 71 AJ , Volume 3 A Page # 52 2 Spec house ❑ yes K no Lot lines identifiable W yes ❑ 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 (1) 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 113 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 II I days of the three year expiration date. ff SIGNATURE OF APPLICANT Ali TE j 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 the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT 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 04/02/98 19:38 it MCK MINNEAPOLIS 001 /001 STA B AR o f WISCONSINE&UM 2 —1982 WARRANTY D 1 � DOCUmF-NT NO. REO Pitt ST. CR fX CO., WI Rpg'd !sr Raot+►d } MAID 18 1998 J NNIF R p A conveys arud warrants tla TOpD E PLOD end I 4.3 � � I 7M19 9PACG R66rRJED FOR RECORDING DATAJ„ NAME AND RLfURN ADDREEGS I I $ t . Croix __ County, ,I, �c�C1C�l the follo%xing described rcal estate in Y�Lt I - J . State of WYaconsin: �l � S �N 1� App Lot 42r Plat 4f le River bend First I I 1/adr� rs�� Addition, Town of Star Prairie, St. Croix l county, Wisconsin. PARCEL IDENTIFICATION NUMBER �y TRANSFER 1 V FIEE �} �. 11 } 4 is not homestead property. I I This 1 its) (is not) 1. E to warranties: easements, restrictions, rights - of - way and covenants II of record, if any, 1 A.D, 19_��.• 3rd day of ebruar :{ Dated this (Sl. At) (SEAL) I ` Richard 0. Stout (yLAL) (SEAL) If w r 1 I w !,I AUTHENTICATION I ll. _ _ •_ _. ..- 5�trt:e -0f Wisaa•T►s#n: -- _. Fs. 1' St. Croix County. y I I da of _ , 14_� peraonsk came before me this _ -- clay o authenticated this Y Febr art 19 9 8 the 2WIC darned �` Richard o. Sto — p. I I �t �jM tn,, , TITLE: 1AEbIBER Sl'ATE BAR nr W15CON51N r<•uer. K�f`A II Ul mm. to me mown To im 1"'a gu thorize.,3 by 6706,0C Wis. Stitts.) jr%21rurACnt and gc k no ll7 r 4l"'t NO)rAPY THIS INSTRUMENT WAS DRAFTED By P JaWCt P. Stout R Dt ly Ls rM Notary Pubuc, dat r A - r, -4-0 M commission ts PCTTftfmcfLt• He&�' — — . —-- - Both are riot (Si F ratty be authentw2t or acknowledged. necessary.) oc pemf%s Mintnt Rl any cPpdcjLy h 6 typed or prinLM qviow ther sigmitirm STATE BAR Or W13CONS' Form No, I — 1982 WARRANTY DEED