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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
463109 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:
P.C. Collova Builders, Inc. Star Prairie Township 038 - 1221 -22 -000
CST BM Elev: Insp. BM Elev: BM Description: ' Section/Town /Range /Map No:
`Iq L. r t rro 31.18.1222
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark � 9 /C?I• � /��•ej
Dosing - _ Alt. BM
Aeration Bldg. Sewer x
Holding St/Ht Inlet . 7 q5
2
TANK SETBACK INFORMATION St/Ht Outlet to.5 C l y 91 `I
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet �\
Septic y � ,, . Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe �► yl- 8 - u 93 t
Holding - Bot. System - !�, r iA
PUMP /SIPHON INFORMATION Final Grade 2 7 -
Manufacturer Demand St Cover
GPMf'i
Model Num
6 °y (tn Ce a {
TDH Lift tion Loss System Head TDH Ft / 3IoN
Forcemain Length Dla. Dist. to Well
SOIL ABSORPTION SYSTEM �/ (�
BED /TRENCH Width Length No. Of Trenche PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS /
SETBACK SYSTEM TO (� P/L BLDG ELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR (3 : u A .-�-✓
Type Of System: 4 System: °
1-- f , ) M UNIT Model Numberyr 7
DISTRIBUTION SYSTEM a
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
Length 1 �* Dia L11 v 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 B Edges Topsoil
Gj� 0 Yes No � Yes 7[�]N.
I
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: /.;?- / 2 /� Inspection #2:
,y i
Location: 904 189th Avenue Star Prairie, WI 54026 (SE 1/4 NE 1/4 31 T31 R1 8W) Prairie Pond Breaks Lot 22 Parcel No: 31.31.18.1222
1.) Alt BM Description = v t et-
2.) Bldg sewer length -
- amount of cover = y f hu (1 316C�
Plan revision Required? Yes [] No j
-7
Use other side for additional information. Z D
SBD -6710 (R.3/97) Date sepctor's Signature Cert. No.
P OT PLAN
PROJECT P.C. Collova Bldrs. Inc. ADDRESS P.O.. Box 489 Somerset Wi 54025
SE 1/4 NE 1 /4S 31 /T 3 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX
12/2/04 BEDROOM 3
MPRS Shaun Bird 226900 DATE
CONVENTIONAL XXX IN -GR D PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambers 22
BENCHMARK V.R.P. Top of Survey Iron ASSUME ELEVATION 100° Filter Zabel A -100
❑BOREHOLE O WELL *H. R. P. Same as Benchmark RECEIVED
SYSTEM ELEVATION 92.3 6' below qrade RECEIVED
Alt. BM Top of survey iron @ 997 Alt DEC 0 3 2004
B.M.
Plans Designed Using ST.CROJXCOUNi_ti.
Conventional Powts 80' 15 BONING OFFICE
Manual Version 2.0 201'
Well is to meet all 35' B -4
setbacks required by
WDNR
30'
1% Slope /not enough
slope to establish B -2 70 ' B -1 B.M.
contours 75'
30'
04—, 2 -3' X 69' Cells
B -3 with >3' spacing
90
Vent
348' ST >6„ Standard Biodiffuser
O of Cover Leaching Chamber
with 31.1 ft2 of Area
30' 6' Long 11 )9
34" Grade at System Elevati
Pro 3
Bedroom
House
343'
Pro Town Road
Property Owner _ Parcel ID # Page of
Boring # ❑ 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 I •Eff#2
i
a 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/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Eff#1 •Eff#2
F-1 Boring # E] Boring
11 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/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 •Eff#2
I
Effluent #1 = BOD > 30 < 220 mg1L and TSS >30 < 150 mg/L ` Effluent #2 = BOD < 30 mg& 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.
sen -6330 (8.6/00)
G
Safety af�i ings D, 'sion Counry�� �j J
201 W_ VVi4dngton P.O. ox 7162 '
� �0���� �)Midiso 1� 787 62 Sanitary Permit Number (to be filled in by Co.)
i
Dep artment of Commerce
� 1 `3109
State Plan I.D. Number
Sanitary Permit
In accord with Comm 83.21, Wu. Adm. Code, personal info [ Ppaj 6ct Address (f different than mailing address)
may be used for secondary purposes Privacy Law, s U
L Application Information - Please Print All Information
Proputy Otvner's
l # Lot Block #
/6z
Property Owls Mailing Address R1D
�(, J � /f/
ys Section
City, State .Tap Code Phone Number
,
T �; av
II. Type of Building (check all that apply) ,S ' u sio n No 1 Family Dwelling - Number of Bedrooms � -
✓ Atftideorometdal - Dcscnu Use city Wisp AwnsiliP of f
State owned - Describe Use
IQ. Type permit: (Check only one box on line A. Complete line B N appUcable) 03 - ) 2Z (- 22 - MV 1222
A- System Replacement system Treatment/Holding Tank Replacement Only Other Modification to L:xisting System
— �; B. Permit Renewal Permit Revision Change of Permit Transfer to New .
List Previous Pemnit Number and Date issued
Before Expiration Plumber owner
IV. T e of I'OWTS S Check all that a L) 3 K
Pressurized in-citound Mound _t 24 in. of suitable soil Mound < 24 in. of suitable soil At -Grade Single Pass Sand Filter
Constrcted Welland Pressurized
Filter d in and Holding Tank Peat Filter Aerobic Treatment Unit Recis culating Sand Filter
Recirculating Synthetic Me" Chamber Drip Line Gravel -less Pipe Oder (explain) 0
V. Di ecsallTreatment Area Information:
Design now (gpd) Design Soil Application Ratr(gpdsf) Dispersal Area Required (sfl Dispetital� �Pruposed (st) System
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site S PI
Gallons Gallons of Units Concrete Constructed
Gf
New Existing
Tanks Tanks
septic or Holding Tank
Aerobic Trestamt Unit
Dosing t'kamber
VII. Res ondbili Statement- I, U►e and astanne resposisilillity for installs of shown on the attached ZIEM
Plumber's Nano (Print) Plumber's Signature Business Phone Number
Q'Ut�is
J
ees Address (Scree,[. CitL State, m
zo U-,)) 3Y D/ - 2
VIII. Courst]/De paftrnent use Only Date issued Signature (No Stamps)
Sanitary Permit Fee ( ud ter
es Groundwa
ppmved Di Surcharge Fee) 'z 5 � . ' 3
Reason r `
17C. Conditions of ApprovaMemons fee Disapproval
SYSTEM OWNER: .� -���. S -+y��-
t^
1 Septic tank, effluent filter and 1
dispersal cell must all be serviced / maintained SiT2
as per management plan provided by plumber.
2. All setback requirements must be maintained
as per applicable code /ordinances.
Attaeh cougdete plans (to the county only) for the system on paper ' not less than sta x ti incbes in size
III - I
OT PLAN
PROJECT P.C. Collova Bldrs. Inc. T ADD ESS P.O.. Box 489 Somerset Wi 54025
SE 1/4 NE 1145 31 /T 3 N/R 1 W TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 10/7/04 BEDROOM 3
CONVENTIONAL XXX IN -G D PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambers 22
BENCHMARK V.R.P. Top of Survey Iron ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL * H. R. P. Same as Benchmark
SYSTEM ELEVATION 95.0/95.1 grade Alt
Alt. BM Top of survey iron C& 99.7' M.
201' lans Designed Using 150'
Conventional Powts
Manual Version 2.0
Well is to meet all
setbacks required by. - -,: ^ ------
WDNR
1% Slope /not eno h - B_1
slope to establish 70 B.M.
contours 5'
30 — •,n,n -1 t..s�
2 -3' X 69' Cells
35 with >3' spacing
B-
c Vent
348' > 691 Standard Biodiffuser
of Cover Leaching Chamber
with 31.1 ft2 of Area
11"
30' 6 Ong 3 4„ Grade at System Elevation
Pro 3
Bedroom
House
C ()Vol 343'
Pro Town Road
I,
jR1 N
PROJECT P.C. Coilova Bldrs. Inc. 13N S P.O.. Box 489 Somerset Wi 54025
SE 1/4 NE 1/4S '31 /W TOWN Star Prai rie COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 10/7/04 BEDROOM 3
CONVENTIONAL XXX 1N -G D PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambers 22
BENCHMARK V.R.P. Top of Survey Iron ASSUME ELEVATION 100° Filter Zabel A -100
❑BOREHOLE O WELL *H. R. P. Same as Benchmark
SYSTEM ELEVATION 95. 0/95.1 grade
Alt. BM Top of survey iron @ 99.7' B M
201' lans Designed Using 150'
Conventional Powts
Manual Version 2.0
Well is to meet all
setbacks required by 80'
WDNR
1% Slope /not enough B -2
slope to establish 70 ' B -1 B.M.
contours 5'
30'
35' 2 -3' X 69' Cells
z. with >3' spacing
40' Vent
348' /�j >6„ Standard Biodiffuser
U of Cover Leaching Chamber
with 3 1. 1 ft2 of Area
6' Long 11 "
30' Grade at System Elevation
34"
Pro 3
Bedroom
House
343'
Pro Town Road
E
oDepartrmtlydof Commerce SOIL EVALVATION REPORT Page of in accordance vet► . •Code -...
arse,00rrrpeiesfa&non pa l otkw#M a Inxl, kwhssinskB. Pbnff*M
imch,de.
but mot irrdted b: vertical and horbaontat reference post (13". direction and Parcel ED.
pmn o t slope scale ordimermiom north arrow. and looaaon erd dlstenoa t0 r road.
Please prat as hrlora dm. wied by Date
Personal kftnwri m yo pcv maybe wad for eecordwy a•noem (Pdv8g7 M w. r~ fs a (f) (m)). FE$ . l2 c ?.6i)
Location A Zca=--
CAWLtAt 114 1/4 S N R f E( W
propertyOwno'sMaRVAddrm Lot# t k0Kc* tad Nwm
f� i fJX ! �' 1> 1 s
I C 1 1Y Cly ❑ Tam Road
G�Ji SAO S S - l a /
New Construction U ai I Number of bedrooms _ _.� code derived design low rate
O commercial - Describe: —• _
PwW moEedai .��e[l�..s.� Rood Plain dwAden applicable
Gerreralcormrerrts
and 9=Bvrta4 dations
M soft# o
Pit Grocad surfaoa rev. J _ R Dept a fac�or -/ v gqi Application Race
Hoiaon Depth dim-Color Redox Desalrlon Tedue Struck" Cornsislence Boundary Roots GPOW
it liArnsel COLL Sz. Cont Cater Gr. Sz Sh. - EW *131112 �" 0 2 S
3.6 93•
® Bwft # pd Gmxatd surbce (' tt Deptl► t -�= in g Rate
Hod= Depth Dom Color Redac Dsscr%*w Texture Structure Car�temce Bcu vWwy Roots GPOW
in. tiAume d ChL Sz. Coat. Color Gr. Sz. Sh. •tSY#1 'Eta
67lL n C YYl ► r a 1, z.
• tBlm+x in = t > 30 = 220 mglL and TSS >30 -` 15 " 417, • Elluemt #2 = Bop <_ 90 mgil. and TSS c 90 mglL CSTNUmber
r
Dade Evaluation Condrxied Telephone Number
Address -
T
properly Owner Parcel ID # - Page of
131 #. Ug pft Gnmdsauceelev. , � Q Deplhtob -'K factor in
Sod Apokallon Rate
Horizon Depth Dw*=tCokx Redox Desatplim Texture Sbucbae Cormblance Baardary Roots GPDAF
in. Mursed Qu. SX Cont Color Gr. Sz. Sh. `EM I `EW
1
6 -11 16 3h �- 2
13 6 ° 2 l r S ol h 4. f 7 /- Z
= YO
E te# 0 BOFkV
Pit G ound ustmos elev. ft. Depth b favor im Sod Rate
Horizon Depth Dw*w*Calor Redox Dasalpdon Texture S9uckne Cansiskom Boundary Roots GPDN
in. Mural Qu. Sz. Cont. Color Gr. Sz. Sh. `Eti#1 `EM2
D soft# 0 Ommi mhos esev. ft. Dept, to tmidrhg tabor in.
SA Rase
Hm mn Depth Dm*wtCdm Redox Destdptort. Text" Structure Conswerm Boundary Roots GPM
h Musel Qu. Sz Cork Color Gr. Sr- Sh. `M `EM
• Ef&mt #1 a SM 30 5 220 mgft. and TSS >30 <_ 150 rngL ` Eflhm t 112 - BCI 6 < 30 nhgil. and TSS S 30 nVIL
The Departotertt of Commerce is an equal oppoMmIty service provider and ooployer. If yon need assismaw to access services or
need material in an alternate format, please contact the dVubnmt at 609- 266 -3151 or TTY 608 -264 -8777.
seauro(aserrl
i
Soil Test Plot Plan
Project Name P.C.Collova Bldrs. Inc. Shaun rd
Address P.O. Box 489 :,,
Somerset Wi 54025 cfrm #226900
Lot 22 Subdivision Prairie Pond Breaks Date 4/9/03
E 1/2 NE 1/4S 31 T 31 N /R18 W Township Star Prairie
N W 1 /4 W 32
F1 Bor'ng ()Well PL Property Line County S T. CROIX
r VRP
Assume Elevation loo ft.= Top of Survey Iron
System Elevation 94.7/95.5 *HRpSame as Benchmark
/Alt. BM ` It
C : Top of survey iron Qa 99.7' M
150'
201'
1 % Slope /not enough
slope to establish
contours 80
B -2
�— 70' ro, M.
75'
35'
B -3
348'
343'
Pro Town Road
�I
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
C cy Plan
Op n #1. system fails, determine cause of failure, use <^`aernate area and install new
sys in tested replacement area.
Option #2. Install system at a lower elevation, by removing chambers, removing biomat,
and install new system.
Option#3. No adequate area is suitable for replacement area, and system elevation
cannont be lowered. Install holding tank as last resort.
3. Replace any other failing components as needed.
Plumber: Shaun Bird 715 - 246 -4516
St. Croix County Zoning 715 -386 -4680
Pumper Tom Mondor 715- 246 -5148
Shaun Bird #226900
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer P• C . Collova Builders, Inc
Mailing Address P O Box 489 Somerset, WI 54025
(� 4s Property Address - 1 —q I
(Verification required from Planning Department for new construction)
City /State New Richmond WI Parcel Identification Number c>M - (ZZ 1 - Z Z - acre (ZZ 2)
LEGAL DESCRIPTION /
Property Location SE %, N E V,, Sec. 3 P T 31 N -R 18 W, Town of 3 ,r"
Subdivision Prairie Pond Breaks Lot #
Certified Survey Map # . Volume , Page # "-
695417 2021 27
Warranty Deed # 695419 . Volume 2021 Page # _ 29
Spec house ❑ yes 3 no Lot lines identifiable ❑ 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
masterplumber, journeyman plumber, restricted plumber or a licensedpumper verifying that (1) the on -site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
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 Zoning Office within 30
-u of the three year expiration date. P. C. COLLOVA BUILDERS, INC.
V-An �" n (715) 247 -2742
'LZA�g P.O. Box 489 / /
SIGNATURE OF APPLICANT SOMERSET, WISCONSIN 54025 DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) kaowledge. I (we) am (are) the owners) of
th property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
LLk
Q lt �" - _" - c P. C. COLLOVA BUILDERS, INC. V.
SIGNATURE OF APPLICANT (715) 247 -2742 DATE
P.O. Box 489
Any information that is mis- representedmay r �t CO nr permitting 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
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