HomeMy WebLinkAbout038-1125-90-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Divisidn.
INSPECTION REPORT Sanitary Permit No:
488172 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:
Tilsen, Janie I Star Prairie, Town of 038 - 1125 -90 -000
CST BM Elev: Insp. BM Elev: BM Description: Sectionf town /Range /Map No:
c, 31.31.18.516G
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic - Benchmark
4
Dosing A Alt. BM
Aeration Bldg. Sewer `
Holding t Inlet
TANK SETBACK INFORMATION St/H O utlet
TANK TO P/L WELL LDG. v ent to Air IntaKe ROAD Dt In
ep Ic > ZS 3 / B ottom
osmg Header/Man. -rx- J, . f �f
T `77 • 3
era wn
Dist. P ipe ; �j , 't 7tv 5
o ing
Bo t. system
�j . �pL✓
PUMP /SIPHON INFORMATION F inal ra e
m anufacturer GPM n over _ \ 3 -' /6/, z
M odel um er
i ric ion LOSS syste m rieaa i
9(n
r eng 1 131a.
Sol SORPTION 5YSTF=M
DIMENSIONS
CHAMBER OR 7 i �
INFORMATION • � � - � J`-►Q�
� t
RAF z - d-
4 i Pipes)
Length O Dia Length \ Dia \ Spacing \
x Pressure Systems Only xx Mound Or At - Grade Systems Only
Bed /Trench Center Bed/Trench Edge Topsoil Ye
�` � No s No � \ j�Yes I
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2:
Location: 1891 County Road CC Somerset, WI 54025 (NW 1/4 NE 1/4 31 T31 R1 8W) NA Lot Parcel No: 31.31.18.516G
1.) Alt BM Description=
2.) Bldg sewer length=
- amount of cover
Plan revision Required? Yes No
Use other side for additional information. - I ��-
- -- Date-t---J — -/ F hisepct igna - - - -- -- - -- -
SBD -6710 (R.3/97)
fet and Buildings ivision Cou
RECI Washi gton Ave .,P.O. Box 7162 I
1 Iadiso WI 53707 — 7162 Sanitary Permit Number (to be filled in by Co.)
( 08) 266 -3151 7 0 $"/ 7
Department of Comm rce MF tate Plan I.D. Number
Sanit ry Permit A In tion
In accord with Co 83.21,�is.Cf(�iti)C ft1pp1rpa1 inf ation you provide
may be used or secondary purposes Privacy Law, 11 5.04(1) Project Address (if different than mailing address)
1. Application Information — Please Print All Information
n-
Property Owner's Name Parcel # Lot # Block #
Property Owner's Mailing Address Property Location LA i
Section
`b /
City, State t C ip Code Phone Number
(.n„/ ' J l� I - � e� N; / E W e
111 •
II. Type of Building (check all that apply) / L;
Subdivision Name CSM Number
r 2 Family Dwelling — Number of Bedrooms a rv��
Xt 57 /�
❑ Public /Commercial — Describe Use
El State Owned — Describe Use Z s GQ I� I2.. 1 Z G e fS pCity_ ❑Villa wnshi f.�
111. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A ' ❑ New System lacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. ❑ Permit Renewal ED] Permit Revision El Change of El Permit Transfer to New
List Previous Permit Number and Date Issued
Before Expiration Plumber Owner i n�
A
IV. T I e of POW TS S stem: Check all that apply)
on — Pressurized In- Ground 11 Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil El A -Grade Single Pass Sand Filter ❑
Constructed Wetland ❑ Pressurized In -G and ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑
i
❑ Drip Line ❑ Gravel -less Pi Dtt/ r
Recirculating Synthetic Media Filte Leaching Chamber p P e ❑ Other (explain) S
V. Dis ersaUTreatment Area nformation: 6 Dispersal Area Proposed (sf) System Elevati n
Design Flow (gpd) Design S\1 Applicayon Rate(gpdsf) Dispersal Area wired (jf) p _ / s � , �
CrZD VI. Tan Capacity in ✓/ Total Number Manufacturer 6 Prefab ✓ Site teel Fiber Plastic
Gallons Gallons of Units L Concrete Constructed Glass
New Existing L / f 6e5` ` 1 �•��
Tanks Tanks
Septic or Holding Tank
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement- I, the undersign ume responsibility for installation of the POWTS shown on the attached plans.
Plu s m i Name (Print) Plumb gnature MP/MPRS Number Business Phone Number
, r_ 0 Plumber's Address (Street City, Statde
VHL1CountV /De artment Use Onl
Sanitary Permit Fee (includes Groundwater Dat Is d Issuin ent Signa re o S p
pproved ❑ ra pp rove Surcharge Fee) j \ rj �Z Q(o El n rven Reason Denial — [ C �
IX. Conditions of Approval/Reasons for Disapproval
SYSTEM OWNER: .3) OJ 1
C 6y64v� V 6f_ ito 0 V
1. Septic tank, effkwtt Mar end lJ
dispersal cell must all be services /
as per management plan provided by plumber.
2. All setback requirements must be maintained
as per applicable code / ord 4inances. J
Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size
SBD -6398 (R. 01/03)
P OT PLAN
PROJECT Janie Tilsen ADDRESS 1891 Ctv RD CC Somerset Wi 54025
NW 1/4 NE 1/4s 31 /T 31 R 18 W TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE5 /10/06 BEDROOM 2
CONVENTIONAL XXX IN-GROV E 1URE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 800 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 600 # of chambers 24
BENCHMARK V.R.P. Bottom of Siding ASSUME ELEVATION loo' Filter BEST Filter
❑ BOREHOLE O WELL * H. R. P. Same as Benchmark
SYSTEM ELEVATION 95.3/95.2 5' below grade
Vent
Well is to meet all
setbacks required by >6 „ Standard Biodiffuser
WDNR of Cover Leaching Chamber
Plans Designed Using with 25.0 ft2 of Area
Conventional Powts 11 "
Manual Version 2.0 5' Long
Grade at System Elevation
35"
Cty Rd CC
Scale is 1" = 40'
unless otherwise 2 -3' X 60' Cells with >3' Spacing
35'
noted B - 45'
10, Vents 12'
Old System is to be Property
pumped and buried B -1 tB.. 60, B -2 10' Line
Driveway 20'
No Conflict with * 30'
neighboring wells!
Existing 2
Bedroom 30'
House Well
5 '
Apple River
P OT PLAN
PROJECT Janie Tilsen ADDRESS 1891 Ctv RD CC Somerset Wi 54025
NW 1/4 NE 1/4s 31 /T 31 R 18 W TOWN Star Prairie COUNTY ST. CROIX
5/10/06 2
BEDROOM
MPRS Shaun Bird 226900 DATE
CONVENTIONAL XXX IN -GRO P E SURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 800 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 600 # of chambers 24
BENCHMARK V.R.P. Bottom of Siding ASSUME ELEVATION 100° Filter BEST Filt
❑ BOREHOLE O WELL *H. R. P. Same as Benchmark
SYSTEM ELEVATION 95.3/95.2 5' below qrade
Vent
Well is to meet all
setbacks required by >6 „ Standard Biodiffuser
WDNR of Cover Leaching Chamber
Plans Designed Using with 25.0 ft2 of Area
Conventional Po w „
is
5' Long 11
Manual Version 2.0 Grade at System Elevation
35"
Cty Rd CC
Scale is 1" = 40'
unless otherwise 2 -3' X 60' Cells with >3' Spacing
35'
noted B -3 45'
Vents 12'
Old System is to be 10 Property
and buried _ 8 60 - Line
pumped B 1 ST B 2 10
Driveway 20
No Conflict with B 30'
neighboring wells!
Existing 2
Bedroom 30'
House Well
5 '
Apple River
RECEIVEED
MAY 1 0 � 0j
WiisconsinDepa fCommerce SOIL EVAL &TIO REPORT Page of
Division of Safety uild' s t 1�; ��)) II accord nce h'�omiY ii A6m. C de
County Attach complet�llspi� on paper no ss than 8 1/2 x inches In size.
include, but not limited to: villISiQLadhorizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, n arrow, and location and distance to nearest road. �/ 3 ' �� j • D — MI
Please print all information. Revie d by Dat
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner _ Property Location
_
I I t/�`� Govt. Lot AJL J 1/4N� 1/4 S ( T 3 N R E (or CW
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
jot I
City State Zi ode Phone Number ❑ City ❑ Village ATown Nearest Road
(A ) 3$ ;-- 7
New Construction Use esidential I Number of bedrooms Code derived design flow rate GPD
08 epiacement ❑ Public or commercial - Describe:
Parent material Ou t Flood Plain elevation if applicable
General comments
and reoonwriendadons:
System Type System Elevation Alt �S `�� 5 �—
I Ong # rpitd ng J
G round surface elev. ft. Depth to limiting factor 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
3/z
IL I AZIX //a b
,I
®Boring # ❑ Boring �✓
Pit Ground surface elev. ft. Depth to limiting factor) in.
Soil licetion 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 I •Eff#2
0 - 9 311- J
7- Z a 16.. 5 1 p
1 01
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Nam (Please Print) a CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date Evaluation Conducted Telephone Number
1008 192nd Ave, New Richmond, WI 54017 �f� 715 - 246 -4516
Property Owner _ Parcel ID # Page of
/ _�.,•-
Boring # Boring
� .
N it Ground surface elev. / Z& 3 ft. Depth to limiting factor 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
7 2 L
_ 0,51
in / �✓ '-?
I,o
Boring #
F
❑ 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
El Boring
ng # Ground surface elev. ft. Depth to limiting factor in.
❑ Pit Soil Application Rate
Horizon 7epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff
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.
SBD4330 (RV00)
Soil Test Plot Plan
Project Name JanieTilsen Shaun Bir
Address 1891 Cty RD CC
Somerset Wi 54025 CSTM 226900
Lot ------ Subdivision -------- Date 5/10/06
NW 1/4 NE 1/4S 31 T 31 N /R W Township StarPrairie
Boring Q Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Bottom of House Siding
System Elevation 95.3/95.2 *HRpSame as Benchmark
Cty Rd CC
Scale is 1" = 40'
unless otherwise 35'
noted B -3
45'
10'. 12'
Property
B -1 60' B -2 10' Line
Driveway 20'
*
B.M. 30'
Existing 2
Bedroom 30'
House well
5 '
Apple River
I
Maintenance and Contingency Plan for a Septic System
Maintenance Plan
1. Septic Tank is to be pumped once every 3 years.
2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in
order to extend the maintenance interval of the filter.
3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of
the cells.
4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system.
5. The owner agrees to save this plan.
6. Do not plant trees nor park nor drive over system.
7. Watershed is to be diverted away from system.
8. Discharge into system is not exceed those required as per Comm. 83
Contingency Plan
Option #1. If system fails, determine cause of failure, use alternate area and install new
system in tested replacement area.
Option #2. Install system at a lower elevation, by removing chambers, removing biomat,
and install new system.
ption #3.yo 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 L': d i' 15 -24G -4516
St. Croix County c" Dning 715 -386 -4680
Pumper Tom Mor, -or, 715 - 246 -5148
Shaun Bird #22Eu
�f 2 849P 085 a � �:
KATHLEEN H. YALS9
State Bar of Wisconsin Form 2 -2003 REGISTER OF DEEDS
WARRANTY DEED
ST. CROIX CO., MI
RECEIVED FOR RECORD
Document Number Document Name 07/22/2005 10:29AH
WARRANTTY DEED
THIS DEED, made between Daniel A. Muzzy and Patricia L. Muzzy, husband and REC FEE: 13.09
wife TRANS FEE: 476.40
( "Grantor," whether one or more), COPY FEE:
and Janie B. Tilsen CC FEE:
PAGES: 2
( "Grantee," whether one or more).
Recording Area
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate, together with the rents, profits, fixtures and other appurtenant
interests, in St. Croix County, State of Wisconsin ( "Property") (if more space Estreen & Ogland (�
is needed, please attach addendum): 304 Locust Street , 5 (y'3 9,
See Attached Exhibit "A" Hudson, WI 54016
038 - 1125 - 90-000
Parcel Identification Number (PW)
This is homestead property.
(is) (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated rl r
(SEAM,) (SEAL)
* aniel . Muzzy
(SEAL) (SEAL)
* *Patricia L. Muzzy
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Daniel A. Muzzy and
husband and wife ' STATE OF A )
authenticated on I ) ss.
12AI)SE'Y COUNTY )
*Kristl a dilani Personally came before me on .1iil 15, 7fY15
TITLE: MEMBER TATE BAR OF WISCONSIN the above -named Patricia L. Hizzy
(If not, to me known to be the person(s) who exe TL>1gM�
authorized by Wis. Stat. § 706.06) instrum d ac ged the same.
THIS INSTRUMENT DRAFTED BY: know MlOnnr - 10 1 1 ay>tl
Attorney Kristine Ogland No Public, State of
Hudson. WI 54016 M Co fission (is pe ent) (expires:
(Signatures may be authenticated or acknowledged. Both are not necessary.)
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED.
WARRANTY DEED 0 2003 STATE BAR OF WISCONSIN FORM NO. 2-2003
• Type name below signatures. INFO -PROTM Legal Forms 800- 655 -2021 www.intoproforrns.com
• U, 2849P 086
EXHIBIT "A"
All that part of the NWI/. of NE% of Section 31, Township 31 North, Range 18 West, St. Croix County, Wisconsin
described as follows: The point of beginning is a point on the Ely line of County Highway C 965.1 feet North and
339.0 feet East of the SW comer of said NW% of NE' /• of Section 31 -31 -n; thence East and parallel to the
South line of said NW% of NE% of Section 31 for 65.8 feet; thence N21 °17'E for 100.0 feet, thence West and
parallel to the said South line of the NW% of NE% of Section 31 for 69,2 feet to its intersection with said Ely line
of County Highway C; thence Sly along said Ely line of County Highway C for 98.85 feet to the point of
beginning. Also that strip of land lying between the Ely line of the above described tract and the Wiy shoreline of
Apple River and between the North and South lines of said tract each extended Ely to the Wly shoreline of Apple
River.
St. Croix. County, Wisconsin.
I
+ ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer I (�
Mailing Address
Property Address s--�
(Verification required from Planning & Zoning Department for new construction.) Q
City /State
Parcel Identification Number
LEGAL DESCRIPTION ,v
Property Location � % ,`, 1 /a , Sec. 3 1 , T N R�W, Town of 5 7 4 1 -
Subdivision , Lot #
Certified Survey Map # , Volume / , Page #
ty
Warran Deed # < 1 ) , Volume 2 7 / 9 , Page ## 0
Spec house yes no Lot lines identifiable P no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
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 Owner maintenance
responsibilities are specified in §Comm_ 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & 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 1/3 full of sludge.
I/we, 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 Planning &
Zoning Department within 30 days of the three year expiration date.
Uwe certify that all statements on this form are true to the best of my /our knowledge. I/we amlare the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE OF APPLICANTS) DATE
** Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * **
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 08105)
Parcel #: 038 - 1125 -90 -000 05/12/2006 10:39 AM
* PAGE 1 OF 1
Alt. earcel #: 31.31.18.516G 038 - TOWN OF STAR PRAIRIE
Current C' ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner
O - TILSEN, JANIE B
JANIE B TILSEN
1891 CTY RD C
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description ' 1891 CTY RD C
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: N/A -NOT AVAILABLE
SEC 31 T31 N R1 8W PRT NW NE BEG E LN HWY Block/Condo Bldg:
"C" 965.1 FT N & 339 FT E OF SW COR; E
65.8 FT, NLY 100 FT, W 69.2 FT TO HWY, Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4)
SLY 98.85 FT TO POB 31 -31 N-1 8W
Notes: Parcel History:
Date Doc # Vol /Page Type
07/22/2005 801137 2849/085 WD
02/10/2000 618179 1489/367 WD
07/23/1997 819/411
2006 SUMMARY Bill #: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/15/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 48,700 44,800 93,500 NO
Totals for 2006:
General Property 0.000 48,700 44,800 93,500
Woodland 0.000 0 0
Totals for 2005:
General Property 0.000 48,700 44,800 93,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch #:
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel #: 038 - 1125 -90 -000 06/10/2005 08:34 AM
PAGE 1 OF 1
Alt. Parcel #: 31.31.18.516G 038 - TOWN OF STAR PRAIRIE
Current X, ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): • = Current Owner
MUZZY, DANIEL A & PATRICIA L
DANIEL A & PATRICIA L MUZZY
1889 W CTY RD C2 �C� ✓Y''�^' �1 �S� '� l�
ROSEVILLE MN 55113
Districts: SC = School SP = Special Property Address(es): ' = Primary
Type Dist # Description ' 1891 CTY RD C
SC 5432 SCH D OF SOMERSET , /�
SP 1700 WITC U� '�&
d- - Aj° C-
Legal Description: Acres: 0.000 Plat: N/A -NOT AVAILABLE
SEC 31 T31 R1 8W PRT NW NE BEG E LN HWY Block/Condo Bldg: (,L
C' 965.1 FT N & 339 FT E OF SW COR; E
65.8 FT, NLY 100 FT, W 69.2 FT TO HWY, Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4)
SLY 98.85 FT TO POB 31 -31 N-1 8W
Notes: Parcel History:
Date Doc # Vol /Page Type
02/10/2000 618179 1489/367 WD
07/23/1997 819/411
2005 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations Last Changed: 10/15/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 48,700 44,800 93,500 NO
Totals for 2005:
General Property 0.000 48,700 44,800 93,500
Woodland 0.000 0 0
Totals for 2004:
General Property 0.000 48,700 44,800 93,500
Woodland 0.000 0 0
Lottery Credit Claim Count: 0 Certification Date: Batch M
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00