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'CG P 7) 44 /LO I� P !� Lti 1'1 PA
Wisconsin Departmentlof Cclnmerce PR1�/ SEWAGE SYSTEM County: St. Croix
Safety and Buildirl3 Division Sanitary Permit No:
(( #p t' > tOci' ac�� - INSPECTION REPORT 430206 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Pan ID No: �rl
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:
Koller, Jason Star Prairie Township 038 - 1067 -20 -000
CST BM f , ; K Q Z r Insp. BM Elev: BM Description: Sectionfrown /Range /Map No:
/z00 .vo /v a.oc, $ ; r � -, c e - 16.31.18.288B
TANK INFORMATION ELEVATION DATA
TYPE M U AC n CARACITY STATION BS HI FS ELEV.
Septic Benchmark !oo
' rley
Dosing Alt. BM /
fie. 5'rt:c �anrL aUi✓
Aeratio Bldg. Sewer J 1 5- � S•v� 3V
Holding � __. ___. St/Ht Inlet
St/Ht Outlet
TANK SETB CK INF MATION t.,. 7$ 9 3. (
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic r);� . I 7 b t 1 Dt ttov : !
Dosing Header /Man.
T 17
Aeration Dist. Pipe ' 7 . L a
13.1 qg.
a.
Holding Bot. System - . w 7 q t.1 I
3
PUMP /SIPHON INFORMATION Final Grade
�wih c.� +�f x•91 �y '/�
Manufacturer Demand St Cover i3 Q� 2- , m
Model ber
TDH Lift tion Loss System Head TDH Ft
Forcemain Length Di . Dist. to Well
SOIL ABSORPTION SYSTEM t 5 Z3 • ff
BEDITRENCH Width Length No. Trenches PIT DIMENSIONS Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 �i9. Z
SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM EACHING Manufacturer:
INFORMATION AMBER OR 'o
Ty e Of Syste ZoG , >` ( ' .7 6 / NI Model Number:
rrVBA(to'r � ld� S4c1-
DISTRIBUTION SYSTEM a �� c rl/ 71
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
Z 7 t 1
Length 1 ` Dia �-( 1 1-ength , r 9c' —W S Dia Spacing �gU
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over i Dep er epth of xx eded /Sodded xx Mulched
Bedf'rrench Center f . Bed/Trenc es Topsoi Lf -I
2 • L Yes j No Yes (r- No
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: ( /)7,10 � Inspection #2: / /
Location: 1028 210th Ave Somerset, WI 54025 (SE 1/4 SW 1/4 16 T31N R18W) NA Lot - 1 ;( arce No: 16.31.18.2886
1.) Alt BM Description = � (��- lG��COvt. -J
&X e
2.) Bldg sewer length = Ns ` d r* $ . Yo ; n4 6 n k f r 3S ire r
- amount of cover = J
6 P rar, loc a. d 'f k > O >1c : ri sti n/ �o
Plan revision Req uired. ? No
Use other side for addition in mation. to
v_L _v _J._ '_ _ _. _ _ __ _ L��iY✓h _ - �!` -- — L - - --
Date 2 �q IInnseeepccttor's qSinaturen Cert. No.
SBD -6710 (R.3/97) 1( ('� j !�. LS- �. ` _ „ - / /� J V ' t7� -�`'�} -��! %Z�`�V ���d �•� J .�1��
Safety and Buildings Division City �
201 W. Washington Ave., P.O. Box 7082 _5 - �- :� t✓ f
N via Con5in Madison, WI 53707 - 7082 Sanitary Permit Number (to be filled in b Co.)
Department of Commerce (608) 261 -6546 7 3 6 a) �
Sanit Permit App ation State Plan LD. / Number
Sani ic �
In accord with Comm 83.21, Wis. Adm. Code, person infotttyouprovide
may be used for secondary purposes Privacy I iw, s 15kOlt(t)(rr1)' Project Address (if di rent than mailing address)
�S
I. Application Information - Please Print All Information
Property Owner's Nam � Parcel # Lot # Block #
Property Owner's Mailing Address ` "" - ' ° Property Location q t�
Section
City, State Zip Code Phone Number
�f'�jr� r �° le one
I. Type of Building TAY N; K
YP g (check all that apply) L
M or 2 Family Dwelling - Number of Bedrooms Subdivision Name CSM Number
❑ Public/Commercial - Describe Use /-
❑ State Owned - Describe Use W1 E7 -L I k p ❑City ❑Village o ip of
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. ❑ New System ❑ Replacement System ys ep ys ❑ Treatment/Holding Tank Replacement Only 13 Other Modification to Existing System
B. ❑Permit Renewal ermit Revision ❑ Change of ❑Permit Transfer to New
List Previous Permit Number and Date Issued
Before Expiration 4 Plumber Owner
IV. Type of POWTS System: Check all that appl
on - Pressurized In -Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑
Constructed Wetland ❑ Pressuri In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter Leaching Chamber ❑Drip Li e, Gravel -less ❑ Pt4er (explain)
V. Dis ersal Treatment Area Information: ✓ 1 •
,,D esign Flow (gpd) Design Soil Applicati n Rate(gpds Dispersal Area Required (sf) Dis + Ar ro o ed (sf) S t Elevation Z /
'tea ✓ /S c.s� // 9
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fi lastic
Gallons Gallons of Units ncrete Constructed Glass
New Existing
Tanks Tanks
ptic or ok[ing Tank ` 1
rebic Treatment Unit X Irf le
Dosing Chamber
VII Responsibility Statement- I, the undersigned, assume responsibility for in stallation of the POWTS shown on the attached plans.
PI is Name (Print) Plums gnature e7 MP/MPRS Number Business Phone Number
<c� __ ,!mil' ��/
c
1 bedress (Street, City, SZip t
w
VIII. oun /De artment Use Onl
Approved ❑Disapproved Sanitary Permit Fee eludes Groundwater Date sued suing Age SignaWre mps)
Surcharge Fee) cro / 0/ l (J �3
❑ Owner Given Reason for Denial
IX. Conditions of Approval/Reasons for Disapproval _
-7 _ — torus did - 7 1 V
CIO
G 304- LZZ66 4aj-� Me ao n n e_<Y7 � l aet n" /;Z
4 0 _ AJtac compktc pass (to the County only) for the s rem on paper mot s than 81/1 i 11 Inches fit s /D ?
SBD -6398 (R. 08/02)
'I N
PLOT PLAN
PROJECT Jason Koller ADDRESS 1028 210th ave Somerset Wi. 54025
SE 1/4 SW 1 /41S 16 /T 31 /R 18 W TOWN Star P airie COUNTY ST. CROIX
7 -22 -03 BEDROOM
MPRS Byron Bird Jr. 220521 DATE
CONVENTIONAL XXXX A rade CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE Q LIFT TANK SIZE DOSE TANK SIZE
A
HOLDING TANK SIZE LOAD RATE •4 ABSORPTION ARE # of chambers If
IL BENCHMARK V.R.P nail in large Maple ASSUME ELEVATION 100'
❑ BOREHOLE (DWELL - n.R.p. Same as BM
Veut SYSTEM ELEVATION T -1 =92.3 T -2 =92.1
> 12" Standard Leaching
CC Chamber with 31.1
Cove ft ^2 per chamber
6"
— Grade. at Systern
Long 34" eva
Driveway
Garage
L4
3 bed house 1(t�'`
well
33' 18'
210th ave
ys,
Alt BM 10' 35' BM
st
25' 20'
O ob pipe B /
I / roc
100' ' 4 106.25'
B2
5'
l
S
B 1 95'
>200$
to PL
I'�
ST. CROIX COUNTY
WISCONSIN
ZONING DEPARTMENT
a ll N o I N I N g� R osati ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
JAM _ _ _' _-= Hudson, WI 54016 -7710
Phone: (715)386 -4680 Fax (715)386 -4686
September 24, 2003
Mr. Jason Koller
1028 210' Ave.
Somerset, WI 54025
RE: Septic installation — 4 BR replacement POWTS
Dear Mr. Koller:
This letter documents current status of the POWTS installed on 9117/03. With regard to insulation of
the building sewer, Byron Bird Jr. informed me that this connection to the septic tank is temporary
until the existing house is replaced by future construction. He said that the building sewer will
eventually be shortened to 30 feet or less as part of connecting to the new house's wastewater
plumbing. If the building sewer is not longer than 30 feet, insulation for frost protection will not be
necessary. Based on the information provided by your plumber, I will sign the inspection form for this
installation.
The original permit application was for a three bedroom, 450 gallon/day design wastewater flow. The
POWTS installed was changed to a 4 BR, 600 gpd sizing and Byron is required to submit a revised
application and $50.00 fee for these changes. He provided a new plot plan for the system at the time of
inspection.
When the new house is ready for connection to the existing POWTS, you will need to obtain a
reconnection permit and verify that the building sewer is either 30 ft. or less in length or that it has
been insulated to prevent freezing during the winter.
Please feel free to contact me at the Zoning Dept. office if you have any questions regarding this
matter.
incerely,
am Quinn, Zon g Technician
Cc: Byron Bird, Jr. — POWTS Installer
file
I
PLOT PLAN
PROJECT Jason Koller ADDRESS 1028 210th ave Somerset Wi. 54025
SE 1/4 SW 1/4S 16 /T 31 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX
j 9 -28 -03 BEDROOM 4
MPRS Byron Bird Jr. 2205 DATE
CONVENTIONAL XXXX -Grade NVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1260gal LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE 0 LOAD RATE •4 ABSORPTION AREA 1 500 # of chambers 49
BENCHMARK V.R.P nail in large Maple A SSUME ELEVATION 100'
❑ BOREHOLE O WELL +g,g,p, Same as BM
>12" _
Veui SXS'1'luM ELEVATION
T T
�
Of Standard Leaching
Cove Chamber with 31.1
ft^2 per chamber
6"
"
AN GrAdt at Sy*.tk*m
Long 34 ev
Driveway
Garage
t bed house
33' 18'
r
210th ave. `S s
50' 3 '� S
Alt BM 10'
O ob pi 3W pr�
100, 49 4 106.25'
B2
5'
BI 95'
>200
to PL
i
i
I
me �w4
loc r
Sanitary Permit Application /� Safety & Buildings Division
In accord with Comm 83.21, Wis. Adm. Code Pad 201 W. Washington Ave.
See reverse side for instructions for completing this applic 'on PO Box 7302
isconsin Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Su t completed form to coup
[Privacy Law, s. 15.04(1)(m)] ( p �'
Department of Commerce bmi if not
state owned.)
Attach complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x 11 inches in size.
County ` State Sanitary Permit Number ❑ Check if revision to previous application State Plan I. D. Number
ro r l0
I. Application Information - Please Print all Information Location:
Property Owner Name C Property Location
1/4
Property Owner's Mailing Address Lot Number Block Number
City, State Zip Code Phone Number ; Subdi sion Name or CSM N be
I. Type of Building: (check one) o p Sv.bwK` yes, City
1 or 2 Family Dwelling -No. of Bedrooms: ❑ Village
❑ Public /Commercial (describe use):_ Town of 1
r
❑ State -Owned
5 u
Nearest Road
2 zw "r Parcel Tax Number(s) / �
III. Type of Permif. (Chec on line A. Ch ck on line B if app ' able) , 28
A) 1. ❑ New 2 eplacement 3. ❑ Repla m t of 4. 5. 6. ❑ Addition to
System stem Tank Only Existing System
B) Permit . u ber Date Issued
❑ A Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
Non- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constru Pevatio etland
❑ Pressurized In- ground ❑ Holding TAent ❑ Single Pass ❑ Drip Li
❑ At -grade ❑ Aerobic Tt ❑ Re circulating ❑ Other:
V. Dispersal/Treatment Area Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Applicatio 5. Percolation ate 6. System Final Grade
Required Proposed 1� Rate (Gals. /day /sq. ) (Min. /inch) 7 __ levation
fir- a�
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallon Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks \
VIII. Responsibility Statement
I, the un dersign ed, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's a (print) Plumber's Si a (no stamps MP/MPRS No. Business Phone Number
Plum er's )(ddres (Street, City, State, rip Co da - c))
G
` ( .
IX. County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issui g Agent Signature (No stamps)
P(Approved ❑ Owner Given Initial Adverse Surcharge Fee)
Determination 1 $ 2
X. Conditions of Approval /Reasons for Disapproval:
{�
A
SBD -6398 (R. 0 /00)
PLOT PLAN
PROJECT JAson Koller ADDRESS 1028 210th ave So merset Wi. 54025
SE 114 SW 114S 16 /T 31 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX
`
MPRS Byron Bird Jr. 2205 DATE 7 -22 -03 BEDROOM 3
CONVENTIONAL XXXX rade CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000gal LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE a LOAD RATE .4 ABSORPTION AREA 1125 # of chambers, �-
IL BENCHMARK V.R.P nail in large Mapie ASSUME ELEVATION 100'
❑ BOREHOLE O WELL •n.R.P. Same as BM
Vent SY ELEVATION T -1 =92.3 T- 2 _92.1
Of 12" Standard Leaching `- ?
Chamber with 31.1
tM�
Cov ft ^2 per chamber
6" —Grade at Syqt
em
Long 34" eva
Driveway
Garage
3 bed house
well
33' 18' —
210th ave
50' 3 '
Alt BM 10' 35' BM
st
25' 20'
O ob pipe B3
l tg •�
4
112 s
Iff M B2
60'
B
Li 95'
>200 96 '
to P
" PLOT PLAN
PROJECT Mason Koller ADDRESS 1028 210th ave Somerset Wi. 54025
SE 114 SW 1145 16 /T 31 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX
7 -22 -03 BEDROOM 3
MPRS Byron Bird Jr. 220521 DATE
CONVENTIONAL XXXX rade CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000gal LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE a LOAD RATE .4 ABSORPTION AREA 1125 # of chambers,
,► BENCHMARK V.R.P nail in large Maple ASSUME ELEVATION 100'
Q BOREHOLE O WELL *H.R.P Same as BM
j2T, eui SYSTE ELEVATION T -1 =92.3 T -2 =92.1
Standard Leaching 4
Chamber with 31.1 `��
ft ^2 per chamber
Long 3 499 eva
Driveway
Garage
3 bed house
well
33' 18'
210th ave
50' 3 '
Alt BM 101' 35' BM
st
25' 20'
O ob pipe B3
1 lg •�
—� 6°' 4
Il 2,s
15r rh B2
60 9
B
95'
>200 96 '
to P
J
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must County 6-4 G �
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. !'f 3 �—
Please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
Govt. Lot 1/ /4 S` T N R /-g
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
41 — C - ) ! I -- ' Pe- City State Zip Code hone Number ❑ City El Village own Neare Road
�i (
1A New Construction Use: Residential / Number of bedrooms Code derived design flow rate GPD
❑ Replacement ❑ Public or commerci I - Describe:
Parent material Flood Plain elevati n if applicable ft.
General comments
and recommendations: r 91,A _ ? Q C � 1 5 2002
1 13 - 0 E�=
rr— ya- I
ST. Crtolx ����� ZZY
ZONING OFFICE
F —/1 Boring # ❑Boring G _
Pit Ground surface elev. / ' ft. Depth to limiting factor -'7 "� in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
Boring # ❑ Boring
L' 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 /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
.O b � J7,
* Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 _< 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L
CST Nam Please Print) / Signature CST Number
Address ate Evaluation Conducted Telephone Number
SBD -8330 (R07 /00)
L
Property Owner A y Ile Parcel ID # Page of
5 Boring # ❑ Boring
Iff Pit Ground surface elev. /S S ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color / Gr. Sz. Sh. *Eff#1 I *Eff#2
❑ Boring # ❑ Boring
❑ Pit Ground surface eiev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
❑ 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 /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 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 (R.07 /00)
Soil Test Plot Plan
Project Name Jason koller Byro ird Jr.
Address 102E 210th Ave, Somerset Wi. 54001
C #220527
Lot 1 Subdivision 11/3043 Date 9/17/2002 County
SE 1/4 SW 1/4S 1 6T 31 N /R W Townshi 210t
F] Boring Q Well PL Property Line# Alt. BM
,BM or VRP Assume Elevation 100 ft.nail in large Maple Tree
System Elv. T-1 =92.3T-2=92.1 H.R.P. same as BM
L
Driveway
Garage
3 bed house
well
33' 18'
210th ave
50'
Alt BM 10' 35' BM
P 25
B3
r
IQ 15'r I B2
60'
B
-- 6 R tn" PI
rn o
4
�`� 1996 12
N2 2 Jr
I o �
Sa38`�?�S VC+;plx�Vi►
-A CO
C ER T S E .I EO S CJR V �E Y MA
Located in the SE 1 /4 of the SW 1 /4 and the SW 1 /4 of the SW 1 /4 of Section 16, T3 IN.
R 18W. Town of Star Prairie, St. Croix County, Wisconsin.
Owned by: Merlin Halverson
1028 210 Th Ave.
Somerset, W1.
LEGEND
- Section corner monument
(as noted) L3npIELUed Inds_
0 1" X 24" iron pipe 5.5' North line of the SE 1 /4
weighing 1.68 lbs. / N "9.54' 22 "E
. of the SW 1/4.
ft. set. —6.5' 254. 10 { � {
'in' — _ — — — _ — _
LOT I OF I
R Previously recorded 3 GD C_S_M._IN_VOL 2,
w cv
information. ^ g - i
00 r- Fence �+N o NN 89 43 'E 1 33.00'
m o o In 414.59' 1 I
m Z 381.59 1
NOTE PIPE IS 47' WEST OF ( N89.55`12 "W 414.86') 1 I
THE WEST EDGE OF THE (D
GRAVEL ROAD. m i 6 `
Bearings referenced to the t` 1 1
South line of the SW 1/4, W
aasurned N89 °30100 "E. Q 1 I WI
3 1 1 Ci
NOTE: Parcel O �® T 1 I I—
recorded in Vol.465, p x 1 1
page 114 as document O 832, 100 square feet :41 number 302159. Z 0 (19. 102 Ac. ) �
including Right -of .way o a'
\ -W 0 n a1 � .I
w a o I w
772,175 square feet
_ 8 (17.727 Ac.) al w I
S89.59'05 "E ® >Iw
83.00' xcluding Right -of -way a1 NI CLI
Un LU
/ c 1 ' I
Qla w
tted lands 1
n \ 1 '� C> C wI w
'V 1 1 •
� O w' > I
In 1
1 U) 0 1
:j ci 1 1 approximate centerline of
U3 0 1 driveway. 1 { F-
I
• 1 Point of beginning 1 1
o I �
8.4' I
N89 °30'00 "E ,� S 89'30'00 "W 718.50' =669 75 0 _
1253.99' _ M _ _ — .- — — _ — � � � '.... �
— — — — — —S _S9_ 30_ 00 " W ,1 ", — — - 89�3QS o" W Y
SW Corner 210TH �
Section 16 % GO/VS' A VE.
Section
South line of the SW 1 /4 W. i�� T 31N, R 18W
(Berntsen cap) �`
HAR`1EY G. S`1 Z (Berntsen cap)
Scale in feet 1" =200' JOHL! ^ON
S S -1L39
� HtSL'.>O •
o' so' 100' 200' 400' 600' sk Y�IS o Q Ot �' Sheet 1 of 2
Drafted by: JWG- '1�<� Np Hsu J ;� x`+ ` 4952489
�
VOL. 11 PAGE 3043
Wisconsin Department of Commerce' SOIL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
'County `
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must S 4
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. ewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).(,, p 4. '2 n 3
Property Owner Property Location
�d
07 o Govt. Lot 1/4 S` T N R /-5
- Rroperty Owner's Mailing Address Lot # Block # Subd. Name or CSM#
City State ' Zip Code Phone Number ❑ City� ❑ Village W own Neare Road
New Construction Use: Residential / Number of bedrooms _3 Code derived design flow rate GPD
❑ Replacement ❑ Public or commercS I - Describe.
Parent material i� 1 , � �uJu Flood Plain elevation if applicable ft.
General comments
and recommendations: T)- - %Z - 3
1 Boring # Boring �J _
Pit Ground surface elev. ' ft. Depth to limiting factor -'7 yjt�' in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
a A� 9 2. 3 0
32 � 6�• �f
Boring ' #
❑ Boring
(3 pit Ground surface elev. 5 ft. Depth to limiting facto - in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
J.
OF
Z
' Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 _< 150 mg /L ' Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L
CST Nam Please Print) ` Signature CST Number
1 711
Address ate Evaluation Conducted Telephone Number
SRn -9330 (R07/M
i
Property Owner 10/1 /�/ y Parcel ID #,,- ?r+ . Page:' of
❑ Boring 3 +
Boring # 47.e e-
51 ZF r? n+i? rr r
Z Pit Ground surface elev. ___!_.L? ft. Depth to limiting factor '7�d in
„,f:, , , r + s• .�;I Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure,,, Consistence. Boundary Roots GPD/ft?
in. Munsell Qu. Sz. Cont. Color Gr; Sz. Sh. _ .. _. w_. *Eff#1 .�'Eff#2
A 4 !,
F -1 Boring # ❑ Boring ► ^i El 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/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh:' 'off #1
1+
1, V is ♦ b
❑ Boring
❑ Boring # Ground surface elev. ft. Depth to limiting factor in.
El pit - Soil Application Rate'
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
irt. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Efr#1 *Eff#2-
• Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 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 (R.07 /00)
i
I
Soil Test Plot Plan
Project Name Jason koller Byror Jr.
Address �
1028 210th Ave, Somerset Wi. 54001
CS #220527 �.�,,,� 7 ce )( .
Lot Subdivision 11/3043 Date /17 /200 Count
SE 1 /4 SW 1/43 T 31 N /R W Township 210th ave
?� 2 crt
[� Boring Q Well PL Property Line# t. BM �'�
`BM or VRP Assume Elevation 100 ft.nail in large Maple Tree - 1
System Hv. T- 1= 92.3T -2 =92.1 H.R.P. same as BM
.
Driveway
Garage
3 bed house
well
33' 18'
210th ave
L 50'
M M 10' 35' BM
25'
B3
15' 112
60'
B
95'
>200
to Pi
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner "� ' Septic Tank Capacity a l ❑ NA
Permit # 3D 2nl Septic Tank Manufacturer ee ❑ NA
DESIGN PARAMETERS -`'�P Effluent Filter Manufacturer �, �P 13 NA
Number of Bedrooms ❑ NA Effluent Filter Model 1p'd ❑ NA
Number of Public Facility Units A Pump Tank Capacity a l 'DNA
Estimated flow (average) al /da Pump Tank Manufacturer FPNA
Design flow (peak), (Estimated x 1.5) al /day Pump Manufacturer ?ZNA
Soil Application Rate r al /da /ft2 Pump Model A
Standard Influent/Effluent Quality Monthly erage* Pretreatment Unit t'Y-NA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg / L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD 530 mg /L In- Ground (gravity) ❑ In - Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) 51W cfu 1100m( ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other: ❑ NA
*Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tankis) At least once every: ❑ ea�t:h(s) (Maximum 3 years) ❑ NA
Pump out contents of tank(s) When combined sludge and scu equals one -third (Y of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: A mon 1(s) (Maximum 3 yearn 13 NA
E3 month(s) ❑ NA
Clean effluent filter At least once every: ear(s)
Inspect pump, pump controls & alarm At least once eve ❑ month(s) year(s)
13 NA
Ins
P every: ❑ years)
❑ month(s) ❑ NA
Flush laterals and pressure test At least once every: ❑ year(s)
Other: At least once eve ❑ month(s) [3 NA
every: ❑ year(s)
Other: ❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
GMW (4/01)
'Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tanks) for the presence of painting products or other chemicals
that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
'i The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the failed POWTS.
❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
< <WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
i
POWTS INSTALLER POWTS MAINTAINER Q�
Name �� r Name
1 E ® G
Phone Phone j)
i
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATOR AUTH ORITY
Name O 0--N Name Gf^p /7c
Phone Phone
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address --
Property Address s�
(Verification required from Planning Department for new construction)
City/State Parcel Identification Number ✓� g��D 6 7-� c�0
LEGAL DESCRIPTION
Property Location %4, ' /,, See . T�N -R W, Town of l
Subdivision . Lot # . .
Certified Survey Map # -S� 7C Volume Page # a
Warranty Deed # � 0 . Volume 1 l Page #
Spec house ❑ yes V� no Lot lines identifiable J M yes ❑ no
SYSTEM MAINTENANCE
Improper use and mamtenanceof 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, journeymanplumber, restrictedplumber 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 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 of the three year expiration date
SI OF APPLICANT EfAlt
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 owners) of
the property d bed abov , v' of a warranty deed recorded in Register of Deeds Office.
SI OF APPLICANT ATE
* ** * ** 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
UOCUMENT NO. TNi[ SRACC RCS[NVCO FOR RC/ ` RO nO OOATa
( � � � STATE; BAR OF WISCONSIN FOR 10 -198Z, I,
TRUSTEE'S DEED
11U4PA ,, :34= - -- -
---- ------- - - - - --
REGiSTEFrS 07Th_ -
Jos.ePh - D. Halves on.......... ..................... .• ST. CROIXCTI'.,w`1
.................................................................................. ............................... I Recd for Peo 'd
Trustee of
....-.. . .... ..... .
.......... .. •• • • • sa
Merlin F. Halverson . Fami ly:::Trus -..................... t and MAR Z 1996
.................... ....... .....n .......................
Ode. Halva -rson. 'F -t ..................
10.00 AM
• ... at
• .............................................•-•--............................... .............................._
for a valuable consideration conveys without warranty to ............ . .. ............... t
Jason M. Koller and Kristina R. ,_.,a•p........ i i. j
..................... ................Larson ............... Reg ister of
................................. ............................................
.................... ............................................................................................
............................................... ............................... .......................Grantee, �
the following described real estate in ....... ...................County, -- -- - - - --
State of Wisconsin:
.... �
WZ of SEk of SW -, Tax Parcel No: .........................
, Section 16, Township 31 I
North, Range 18 West, EXCEPT Lot 1 of II
Certified Survey Map recorded in Vol.' 2 of Certified Survey Maps,
page 309 as Doc. No. 336027.
Part of the SWk of SWk, Section 16, Township 31 North, Range 18 West,
described as follows: Commencing at the Southwest corner of the
WZ of SEk of SWk of said Section 16; thence North along the West
line of sad W2 of SEk of SW�, 525 feet; thence West at right angles
83 feet; thence South at right angles 525 feet to the South line
of said Section 16; thence East along the South line of said Section
16 to the point of beginning.
$
T4RN ER
I�
L -..ed this ........ 8 th...... ......................... day of ............. ... bua
rry ...... ............................... 19.-96-..
Fe
LIN F. HA / L V. V r ERSON FAMILY TRUST / ODELIE HALVERSON FAM / TRUST
I G ._... � :.I�!?C.i•�.�G:�:�{�4�s4(BLAL) � ,/ . ��.. �.. _��,e�G��G.!- .L�`.:t'•3.�(SEAL) 1
v
Joseph D. H al sun ................... • J.Qs .q.Ph ... Q. H. a...veragit.......--- ..........
Trustee) Trustee
I
I AUTHENTICATION ACKNOWLEDGMENT
4
I ,
Signature(s) ............................. ............................... STATE OF WISCONSIN 7
tp
as. 1 U
.. T—
..................................... ...............................
St. C roix w 0
................... V
authenticated this ........day of ........................... 19 ...... Personally came before me this Zfth.. day of n '
................................................
F.�P.>; tls).C.f......, 19.9.6 .. the above named
,?o.s ��h.._ P., __.H1xal:s.ali ............. . . ..
• ..... ........ ............. ---....... .....••- •...................... ........-••--•••-•••...._..--•••--•--•.......•--•-........-••••-•...........---- �O
I TITLE: MEMBER STATE BAR OY WISCONSIN
I ................................................. ............................... > Ku]
(If not, ........................•• ................................................. ...............................
- -•- ••...................... authorized by § 706.06, Wis. Stats.)
aut
to me known to be the person ............ w eeuted the J
-
II foregoing instrument and acknowled e.
THIS INSTRUMENT WAS DRAFTED BY
.........................
• l'Ykt ✓t +J
I Riv. r Falls WI 54022 S � .... ....X11, 1 ,; I ._..- ::
..._.....
C . . ............ 1_.................... ............._........_........ No ry Public ... ..� .....� .V.>~. r� :I... .:County, Wis,
(Signatures may be authenticated or acknowledged. Both My mission is permanent. 11o1; state 'expiration
are no necessary.) P, _ '• Z -
t date: ....... . .. .......................... t.�...........c�.19.q..)
• Name* of persons
`
afrnin[ in any capacity should be typed or printed below [hair *:r<nawre *.
STATE BAR ()F WISCONSIN
Kc Ie,COn,parygo FORM No. 111— 196 Stock No. 13016
�
�I1.E� �z
JAN
Si�B"��s.� � St,CcolxC
1
� w
CEP T I FI ED S UP VE Y MAP
Located in the SE 1 /4 of the SW 1/4 and the SW 1/4 of the SW 1/4 of Section 16, T 31N,
R 18W, Town of Star Prairie, St. Croix County, Wisconsin.
Owned by: Merlin Halverson
1028 210 Th Ave.
Somerset, W1.
LEGEND
- Section corner monument
(as noted) Unplatted lands-
0 1" X 24" iron pipe 5.5' North line of the SE 1 /4
2 4
weighing 1.68 lbs. / N . 10 22E of the SW 1/4. I I
lin.ft. set. —65 ---- - - -_��
LOT I OF
( R) Previously recorded 3 m C_S_M. IN_VOL_ 2-1 I
information. w_o° :a n PG,_ 309_
0 t4
k F, Fence ? ON 89'54' 43"E 1
.. o (U I 33.00
ip S N 414.59' f
CD Z
*NOTE: PIPE IS 47' WEST OF ( N89 °55' 2 "W 414.86') I I
THE WEST EDGE OF THE (D
GRAVEL ROAD. m 1 66
Bearings referenced to the n I I
South line of the SW 1/4, W
assumed N89 °30 "E.
U I 1
i
IA
W
NOTE: Parcel 00 w L® T 1 I I XI
recorded in Vol.465, p = I I V)
page 114 as document O 832, 100 square feet vl C1
number 302159. Z ° (19.102 Ac.)
including Right -of -way
_ W to I
to w Cr 772, 175 square � rou "I ��t
S89 °59'05 E _ ® _ (17.727 Ac. -5 `1 I 31 WI W I
83.00' �/ qxcluding Eight of- a CU QI a, (DI
n a
platted lands I w o1 ��
Un
n �z 01 0�
w 1 IT
I � , o Iw
N 1 3 I O W'0
L0 in I I u� >
(IJ
ru I I approximate centerline of i I
s _
M I driveway. I I X 1
Ln
I I 1
i I 1 01
I —I
' Point of beginning i 1
0 II I
0 8.4' I
N 89 °30'00 "E M S 89'30'00 "W 718.50' �(ci _ _
1253.99 — - ----------- - - - -- 668.50'....
�— —S 6 30 � 00 n W �� _ _ _ S 89° 300" W
SW Corner 210TH #0 Iryt�� A_VE S1 /4 Corner
Section 16 �� � Section 16
(Berntsen cap) South line of the SW 1/4 rX �1 We T31N,R 18W
} HARVEY G. * S (Berntsen cap)
do
Scale in feet 1" =200' JOHNSON
S -1099
HUDSO
o' 50' 100' 200' 400' 600' �1 WIS q �' Sheet 1 of 2
'o
Drafted by: J1✓G ,y �♦ suR ��� ` 4952489
VOL. 11 PAGE 3043
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
' INSPECTION REPORT Sanitary Permit No:
430206 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:
Koller, Jason I Star Prairie Township 038 - 1067 -20 -000
CST BM Elev: Insp. BM Elev: BM Description: SectionrTown /Range /Map No:
16.31.18.2886
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt, BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe
Holding Bot. System
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
Model Number
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKEISTREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: UNIT Model Number:
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia I Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth of Seeded /Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil xx
Yes Q No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 1028 210th Ave Somerset, WI 54025 (SE 1/4 SW 1/4 16 T31 R1 8W) NA Lot 1 Parcel No: 16.31.18.288B
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? ❑ Yes Q No
Use other side for additional information.
SBD -6710 (R.3/97) Date Insepctor's Signature Cart. No.