HomeMy WebLinkAbout038-1221-25-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 479415 0
GENERAL INFORMATION State Plan ID No:
Personal information you providb 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. I Star Prairie, Town of 038- 1221 -25 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
V ' � — 32.31.18.1225
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 3 �1T Benchmark ` I 1 1
(� n
Alt. BM
lJO Fao _I -' a 2.
Aeration _____. Bldg. Sewer
3, Z
Holding St/Ht Inlet 14.
T
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P /L11\\ WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic / I / / Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe / I -7
Holding Bot. System �
Final Grade
PUMP /SIPHON INFORMATION k- B- 5 3 '115' -7
Manufacturer - Demand St Cover ` 2 , q�
J I
Mode Number q f c3
TDH U Friction Loss System Head TDH Ft ; 7 'T/ G
Forcemain Le Dia. ' . to well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length r No. Of Tren PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer.
INFORMATION CHAMBER OR d
Type Of System: r ! _ / V l_ UNIT Model Number.
n
DISTRIBUTION SYSTEM l( P-C-CAr
Header /Manifold Distrib ion x Hole Size x Hole Spacing Vent to Air I ak,
Pipe(s)
Length
Di i Length Dia \ Spacing e v
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over I Depth Over xx Depth f xx Seeded /S ded xx Mulched
Bed/Trench Center �. 7 Bed/Trench Edges Topsoil Yes No Yes U No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 930 189th Avenue Star Prai ie, WI 54026 W /4 NW 1/4 32 T31 RI 8W) Prairie Pond Breaks Lot 25 Parcel No: 32.31.18.1225
1.) Alt BM Description = a �� V--\ YS
2.) Bldg sewer length =
- amount of cover
Plan revision Required? j j Yes No /(�
Use other side for additional information. (J jre / c � J i Date Insep s Sign Cert. No.
SBD -6710 (R.3/97)
Safety and Buildings 'vision l County C t
201 W. Washington Ave., P.O :fox 1 U �.
� Madison, WI 53707 - 716 Sanitary Permit Number (to be filled in by Co.)
Nv is c onsin O 608 266 -315I t
Department of Commerce
Sanitary Permit Application RE( �Plan [. .Number
In accord with Comm 83.21, Wis. Adm. Code, personal information you ovide
may be used for secondary purposes Privacy Law, sI5.04(l)(m) AU �a Add ss (if different than mailing
I. Application Information - Please Print All Information y�
t:
T. CROIX C UNTY 130 I g9 T1V•
Property Owner's me ZONING Lot# Block #
Property Owner's Mailing Address Property Location
P , 0 ,) 1- K� /<, � , A, Section Z
City, State Zip Code Phone Number
T om/ N; R E rW
II. ype of Building (check all that apply) ter S N^^
3 1 Subdivision Name CSM D
r 2 Family Dwelling - Number of Bedrooms
❑ Public/Commercial - Describe Use
❑ State Owned - Describe Use ❑City_ ❑Village ship o `
III. Type of Permit: (Check only one box on line A. Complete line B if applicable) 0 30 12,2 - ZS coo ( 225-
A ' ystem ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New
List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV a of POWTS System: Check all that app 1
PI;-Nor-Pr essurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑
Constructed Wetland ❑ Pressurized In round 11 Holding Tank El Peat Filter 11 Aerobic Treatment Unit El Recirculating Sand Filter
Recirculating Synthetic Media Filte ching Ch r ❑ Drip Line ❑ Gravel -less Pipe ❑ Oth r ( xplain)
V. Dispersal/Treatment Ar nformation: Z 3 S
D Flow (gpd) Design Soil Application Rate(gp sf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) ,Stem Eleva ' n
e YJ 6
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site teel Fiber Plastic
Gallons Gallons of Units ��(�� s( -Io0 E oncrete Constructed Glass
New Existing
Tanks I Tanks oil
Septic or Holding Tank
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement- I, the undersigned ume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) ZPIumber's a ture MP/MPRS Number Business Phone Number
Plumber's Address (Street, City, State, Zi
J obi
VIII. Coun /De artment Use Onl
Sanitary Permit Fee ( cludes Groundwater Date Issued ssuing A nt Signature (No Stamps)
Approved ❑ Disapproved Surcharge Fee)
Owner Given Reason or e ' • 2s 2C�
IX. Conditions o pprov .�
SYSTEM OWNER:
1 Septic tank, effluent filter and
dispersal cell must all be serviced / maintained — ' as per management plan provided by plumber. (� S �p� /l9- � C.;r? - S 1 't�•�
2. All setback requirements must be maintained k t
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)
PLOT PLAN
PROJECT P.C. Collova Bldrs. Inc. ADDRESS P.O.Box 489 Somerset Wi 54025
1/4 I, /4S L 1 /T 1 18 W TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 8/17/05 BEDROOM 3
CONVENTIONAL XXX I G UND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1 000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambers 22
ENCHMARK 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 94.6/94.0
lt. BM Top of 2" Pipe (Lb 100.2'
Well is to meet all
setbacks required by Plans Designed Using
WDNR Conventional Powts
Vent Manual Version 2.0
>6 „ Standard Biodiffuser
of Cover Leaching Chamber
L, 3 1. 1 ft2 of Area
6' Long 11 " Pro wn Roa
34" Grade at System Elevation
Pro 3
Bedroom
House
7% 25'
Slope ST I
20 j
4 / I
287
Vents
2 -3' X 69' Cells with >3' Spacing I
0' I
B.M. 154'
Q� B.M.
PLOT PLAN
PROJECT P.C. Collova Bl9GUND ADDRESS P.O.Box 489 Somerset Wi 54025
1/4 1 /4S 1 18 W TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 2269 DATE 8 BEDROOM 3
CONVENTIONAL XXX I 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
ENCHMARK V.R.P. Top of Survey Iron ASSUME ELEVATION 100' Filter Zabel A -100
BOREHOLE O WELL * H.R.P. Same as Benchmark
"Alt. BM SYSTEM ELEVATION 94.6/94.0
Top of 2" Pipe @ 100.2'
Well is to meet all
setbacks required by Plans Designed Using
WDNR Conventional Powts
Vent Manual Version 2.0
ALo Standard Biodiffuser
Leaching Chamber
with 3 1. 1 ft2 of Area
Pro
34 wn Roa
Grade at System Elevation
"
Pro 3
Bedroom
House
7%
25'
Slope
ST
B:3 65, 20 r
I
B -2
40' I
287
Vents
2 -3' X 69' Cells with >3' Spacing
0 ,
B.M. 154' j
B.M.
I
Wisotxtsin Department of Commerce SOIL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with Comm 85. Wfs. Adm. Code
_ Cro►
Attach complete site plan on paper riot less than 81/2 x 11 inches in size. Plan must 1
Include. txd not limited to: vertical and horizontal reference pant (BM). direction and Panel I.D.
percent slom scale or dimensions. north arrow. and location and distance to nearest road.
Please print all information. I R;e7 by Date
Personal information You Provide may be used for secondary purposes (Privacy taro, s. 15.04 (1) (m)). '
Property Owner A Property Location Aza� T
/. z4 /� . Govt. LDt �4� 1/4 3 N R / (y E { W
Property Owr>ees Melling Address Lot # Block # Name or
City State Code Phone Number
❑ City ❑ Village JaTown Nearest Road
New Construction UsrRaesidential / Number of bedrooms .,3_ Code derived design flow rate ' GPD
❑ Replacement ❑ PuNic or =Tvnwclal - Describe: _. _
Parent material _ f,� Gr /n S Flood Plain tion if appticabie
General comments SG ���.� Q 1 / — Q
and �' I`t 'G / .J
1 .
F I # °. Pit Ground surface also. l I ft. Depth to fanning factor l i in.
Sot Application Rate
Horizon Depot Dom1nantColor Redoc DescrOon Texture ShKA ure Consistence Boundary Roots G PQff
in. Mtmsell Qu. Sz. Cord. Color Gr. Sz. Sh. �^ TIM I *E=
N
,,t- qy.(
qg
a soft# ° B
y �
Pit Ground surface Nev. U , � ft. Depth to Cimlb'r►g facto Q� in. son �
Horbw Depth Domir>ertt Redox Descr"on Texture Stru Consist�e
Boundary Roots GPDAF
in. Munsefl Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Efr#2
i 1 44 z
Effluent #1= BOD > 30 1220 mg& and TSS >30 < 15 f ✓ ' Effluent #2 = BOD 130 mg& and TSS < 30 mg&
CST memo Prirrt) ; ` 2 CST Nvrb
6V
Address Addy Date Evaluation Conducted Telephone
I
•
Property owner Parcel ID # Page of
eorin9 #
®
Pit surface elev. J ft. Depth to limiti� factor �. sou Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Cansistence Boundary Roots GPD/fF
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Etf#2
2
Borkv # ❑
❑ Pit Ground surface elev. ft. Depth to Canift factor in. Sod Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDlfF
in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 `01#2
F-1 B.V # O Boft ft ❑ Pit C'". surface �' Depth to iirnittr►g facto in.
Sol Application Rate
Horizon Depth Dominant Color Redox Description Texture Stnxture Consistence Boundary Roots GPM
in. Munsel Ou. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Effluent #1 = BOD > 30:E 220 nV& and TSS >30.150 mgk ' Effluent #2 = BOD, 1 30 Trot and TSS <_ 30 rng&
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- 2648777.
i
. r
Soil Test Plot Plan
Project Name P.C:Collova Mrs. Inc. Shaun Bii
Address
P.O. Box 489
Somerset Wi 54025 CS #226900
Lot 2 5 Subdivision Prairie Pond Breaks Date 4/9/03
E 1/2 NE 1/4S 31 T 31 N /1318 W Township Star Prairie
N W 1/4 W 32
E] Boring Q Well PL Property Line County ST. CROIX
�B r VRP Assume Elevation 100 ft. ; Top of Survey Iron
System Elevation 94.6/92.5 *HRPSame as Benchmark
Alt. BM ` Top of 2" Pipe @ 100.2'
r
0
0
0
7% 97'
Slope 98 ,
B -3 65 9 B -2 99'
40'
287
B -1
0'
154'
M.
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
5 ptio cy Plan
. If system fails, determine cause of failure, use alternate area and install new
n 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
Property Address l $� \-t-9—
(Verification required from Planning Department for new construction)
City /State New Richmond WI
tY Parcel Identification Number X3' — I a a ► — a5 -- oo(}
LEGAL DESCRIPTION
32
Property Location SE V NE 1 /4, Sec., T 31 N -R 18 W, Town of CO h , ,,r
Subdivision Prairie Pond Breaks Lot #.
Certified Survey Map # Volume , Page #
695417 2021 27
Warranty Deed # 695419 . Volume 2021 Page # ` 29
Spec house ❑ yes V no Lot lines identifiable )� yes ❑ no
SYSTEM MAINTENANCE
Improper use and ma intenanec of your septic stem could result in its remature.failure to
P system p 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 liccnsedpumper 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 Iess 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
of the three year expiration date.
T), rM A, P. C. COLLOVA BUILDERS, INC.
(715) 247 -2742
P.O. Box 489 /J()/ Q
SIGNATURE OF APPLICANT SOMERSET, WISCONSIN 54025 DATE
OWNER CER
TIFICATION
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
th p perry described above, by virtue of a warrantAe(o,rcWc fi g8ifl EUM, ;
U p dh k fio (715) 247 -2742
P.O. Box 489 g , ,a, aS
SIGNATURE OF APP tICANT SOMERSET, WISCONSIN 54025 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
U 2021P 027
STATE BAR OF WISCONSIN FORM 2- 1999 6 9 5 4 1 7.
WARRANTY DEED KATHLEEN H. YALSH
Document Number REGISTER OF DEEDS
ST. CROIX CO., MI
This Deed, made between Douglas A. Strohbeen and Eileen RECEIVED FOR RECORD
Strohbeen, husband and wife,
10 -23 -2002 11 :00 AM
WARRAVIY DEED
Grantor, and P. C. Collova Builders, Inc. EXEMPT #
REC FEE: 11.00
TRANS FEE: 1260.00
COPY FEE:
Grantee.
CERT COPY FEE:
1
Grantor, for a valuable consideration, conveys to Grantee the PAGES:
following described real estate in St. Croix County,
State of Wisconsin (if more space is needed, please attach addendum):
Recording Area
Part of the NE1/4 ofNEl/4 and part of SE1 /4 ofNEI /4 of Section 31, Name and Return Address
Township 31 North, Range 18 West, St. Croix County, Wisconsin, described
as follows: Lot 1 of Certified Survey Map filed September 17, 1993, in
Vol. 9, Page 2686, Doc. No. 505678, St. Croix County, Wisconsin.
038 - 1125 -10 -100 & 038 - 1127 -70 -000
Parcel Identification Number (PIN)
This is homestead property.
(is) NXdt)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this y of September 2002
+ * Douglas A. Strrohhbeen
* + Eileen Strohbeen
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
) ss.
St. Croix County )
authenticated this day of
Personally came before me this y of
,`� V ��,'•', September 2002 the above named
j Douglas A. Strohbeen and Eileen Strohbeen, husband and wife,
ID
TITLE: MEMBER STATE BAR OF- ($ • s.
(If not, to me known to be the rson(s) who executed the foregoing
authorized by § 706.06, W is. Stats. �� _
instru nd a ged the same.
11 OF WISE,, ., J� _
THIS INSTRUMENT WAS DRAFT6D +
Attorney Kristine Ogland Notary Public, State of Wisconsin
Hudson, WI 54016 Commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.)
* Names of persons signing in any capacity must be typed or printed below their sig9 ture. Information professionals Company Fong du t.ac, wt
STATE BAR OF WISCONSIN e00.655.2021
WARRANTY DEED FORM No. 2 - 1999
U 2021P 029
STATE BAR OF WISCONSIN FORM 2- 1999 6 9 5 4 1 9
Document Number
WARRANTY DEED REGISTER OF DEEDS
ST. CROI% co., MI
This Deed, made between Cecil Brighton and Cleo Brighton, RECEIVED FOR RECORD
husband and wife,
10 - 23 -2002 11:00 AN
WARRANTY DM
Grantor, and P. C. Collova Builders, Inc. EYEMPT i
REC FE: TRANS 720000
COPY FEE:
Grantee,
CERT COPY FEE:
1
Grantor, for a valuable consideration, conveys to Grantee the PAGES:
following described real estate in St. Croix County,
State of Wisconsin (if more space is needed, please attach addendum): ACA' let f /01VJ k,5
Recording Area
NW 1/4 of NW 1/4 of Section 32, Township 31 North, Range 18 West, St. Name and Return Address
Croix County, Wisconsin.
038 - 1131 -60
Parcel Identification Number (PIN)
This is not homestead property.
N) (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this ,day of September 2002
* • Cecil Brighton v
I
' + Cleo Brighton
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
ss.
St. Croix County )
authenticated this day of
ROM
Personally came before me this day of
September 2002 the above named
Cecil Brighton and Cleo Brighton, husband and wife,
N . g g
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me kn to be a on(s) who executed the foregoing
authorized by § 706.06, Wis. Stats.) instru ed le ed the same.
THIS INSTRUMENT WAS DRAFTED BY s ,
Attorney Kristina Ogland Notary Public, State of Wisconsin
Hudson, WI 54016 M Commiss' n is permanent (If not, state expirapon date:
(Signatures may be authenticated or acknowledged. Both are not necessary.)
a Names of persons signing in any capacity must be typed or printed below their si ture. information Professionals company. Fond d, Ur, wt
STATE BAR OF WISCONSIN
WARRANTY DEED FORM No. 2 - 19992f
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