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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
453293 0
GENERAL INFORMATION (ATTACH TO PERMIT)
State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.1 5.U4 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
P.C. Collova Builders, Inc. I Star Prairie Township 038 - 1221 -29 -000
CST BM Elev: Insp. BM Elev: IBM Description: Section/Town /Range /Map No:
q 5 s
— 1 0 p V07 .31.18.1229
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
l.t
Aeration Bldg. Sewer {
�.5
Holding St/Ht Inlet
Kr- Io �•`�
NK SETBACK INFORMATION St/Ht outlet
TANK TO P/L WE BLDG. [Vent to Air Intake ROAD Dt Inlet
Septic S t 'JG? 33 Dt Bottom \
Dosing Header /Man. \
Aeration Dist. Pipe •r- t $.I
r -2- -Ct<
Holding Bot. System T- I 7 -7
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer Demand St Co r
Model Nu ber
TDH Lift tion Loss System Head TDH F
rcemain Length Dia. Dist. to well
SOIL ABSORPTION SYST /
BED/TRENCH Width ength . Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 9 3 ? j - 7
SETBACK SYSTEM TO BLDG W LAKE /STREAM LEACHING Manufacturer. cc
INFORMATION HA BER OR
Type Of System: Model Number:
cono - : c� �. 2 2 -►-So nl °�; ►. N lA 5ti
DISTRIBUTION SYSTEM ZZ prop°
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake s
Pipe(s) I
Length LO' Dia L4 Length Dia Spacing �" 8
s
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over (M 0 . W "�`� Depth Over xx Depth of xx Seeded /Sodded xx Mulched t
Bed/Trench Center • V> Bed/Trench Edges Topsoil
Yes L-] No � ''� Yes '� No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 9 / I2. 04 Inspection #2:
Ivt w
Location: 929 189th Ave Unknown (SE 1/4 NE 1/4 31 T31 R1 8W) Prairie Pond Breaks Lot 29 Parcel No: 31.31.18.1229
L 3 S b. � w � v �d b �-•- -8 �'b � � s w...P w � � c� � � � j (
1.) Alt BM Description = Te 3 o� a f +�• co.....c %hT r) C w R t5� - 'rG�t .c y S F e /✓� Q r Q,ti4x P4�
2.) Bldg sewer length = �j'� �� O,. g . �, :„� 13. M . C1 s +r. -7 --+Q_ 1 AlA . 0 5
amount of cover = e % 4" O s- r
Plan revision Required? Yes k o
Use other side for additional informati __-L L L A____ 1-- ._.J___
Date aR 3 kr�� Insepctor' Sign e - / art. o.
SBD -6710 (R.3/97) 6 J M v "" �p�� «v �j P d
Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162
Vsconsi Madison, WI 53707 - 7,162 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce (608) 266 -3151 S3
Sanitary Permit Application State Plan I.D. Number
In accord with Comm 83.21, Wis. Aden Code. personal information ou
tray be used for secondary purposes Privacy La , s E I V F Project Address (f differertr than mailing address) _ ,r e
I. Application Information - Please Print All I or T�
property
owne 71 C.
E Parcel # Lot # Block #
i,
Property Owner's Mailing Address �r _ Property Location
City, State Zip Code Phone Number K M Section _
S [ O -5 T ! N. R�fi
II. Type of Building (check all that apply) PQr S tM t
2 Family Dwelling - Number of Bedrooms el , Subd ision Name Numbs
Public/Conmercial — Describe Use C �!
State Owned - Describe use 2 3 k b i J Croy— V ownslrip °P r
U G
III. Type of Permit: (Check only one box on line A. Comp ere 'ne B if appli ble) 3�) `
A ' ew System Replacement System TreatmetiMolding 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
$cfote Expiration Plumber Owner
IV. Type of POWTS System: (Check all that apply)
A= - Pressurized In- Ground Mound 2t 24 in. of suitable soil Mound < 24 in. of suitable soil At -Grade Single Pass Sand Filter
Constructed Wedand Pressurized in Ground Holding Talc Peat Filter Aerobic Treatment Unit Recir sting " �Fdterr
Recirculating Synthetic Media Filter g Chamber Drip Lute Gravel -less Pi Other (ex lain) . J t
V. DispersaVrreatment Area Information:
Design Flow (gpd) Design Soil Application Rate(gpdst) Dispersal Am Required (sf) Dispersal Areas proposed (st) yste oy,
O JC / ./ Y�
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Ateel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank
Aerobic Tmatmem Unit V
Dosing Chamber
VII. R onsbili Statement - 1, the undersi ed, assume respe risibility for installa of the POWT shown on the attached plans.
Plu s Name (Print) Plu mbffl Signature MP/NIPRS Number Business Phone Number
Plumber's Address (Street, City, State, )
rev $ q te.� l� b r ?
VIII. Coun /De artment Use Onl
Sanitary Permit Fee (includes Groundwater Date Issued Its ' Agent Signature (No Stamps)
Appm Disapproved
Yen Reason for Denial 2
IX. Conditio ppro
SYSTEM OWNER:
1 Septic tank, effluent filter and
dispersal cell must all be service t maintained
as per management plan provided by plumber.
2. All setback requirements must be maintained
as per applicable codelordinances.
Attach complete plans (to the County only) for the system oa paper not less than &In x 11 inches in size
PLOT PLAN
PROJECT P.C. Collova Bldrs. Inc ADDRESS P.O.Box 489 Somerset Wi 54025
SE 1/4 NE 1 /4s 31 /T 31 /R 18 W TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 6/2/04 BEDROOM 3
CONVENTIONAL XXX IN -GROUN RESSURE 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
0�BENCHMARK .R.P Top of Wood Corner Post ;::: o'� ASSUME ELEVATION 100 F Zabel A -100
r
❑ BOREHOLE O WELL *H. R. P Same as Benchmark
SYSTEM ELEVATION 91.7/91.4 4.5' below qrade
Alt. BM Top of Survey Iron C& 99.5'
Pro Town Road
W ell is to meet all Plans Designed Using
setbacks required by Conventional Powts
WDNR Manual Version 2.0
350'
B -2 30' 30'
22' S
Pro 3
�►��� Bedroom
-� B -3 House
70' �
35'
2 -3' X 69' Cells
B -1 0 = >3' Spacing
Vents
(;0
80'
Vent
>6 „ Standard Biodiffuser
Leaching Chamber
20' B.M. Cover with 3 1. 1 ft2 of Area
6, Long 11
34" Grade at System Elevation
Alt. v 197'
PLOT PLAN
PROJECT P.C. Collova Bldrs. Inc ADDRESS P.O.Box 489 Somerset Wi 54025
SE 1/4 NE 1/4s 31 /T 31 /R 18 'W TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 226900 3
BEDROOM
CONVENTIONAL XXX IN -GROUN RESSURE 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 .R.P. Top of Wood Corner Post BO= ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL *H. R. P. Same as Benchmark
SYSTEM ELEVATION 91.7/91.4 4.5' below grade
Alt. BM Top of Survey Iron @ 99.5'
Pro Town Road
W ell is to meet all Plans Designed Using
setbacks required by Conventional Powts
WDNR Manual Version 2.0
350'
B -2 30' S 30'
4% Pro 3
,;Innf Bedroom
B -3 House
70'
35'
2 -3' X 69' Cells
B -1 t-00 with >3' Spacing
Vents
80'
Vent
>6„ Standard Biodiffuser
Leaching Chamber
20' B.M. of Cover with 3 1. 1 ft2 of Area
6' Long 11 "
34" Grade at System Elevation
Alt. 197'
J3 M
/
1
Wm mm Deparbnent of Commerce Sol EVALUATION REPORT Page of
Dihtsion �sai;etymhd Btu ,
l accordance wlth thy, vAs. Adm. code 5
AQach complete aita Pon on pepw not lass than 8112 x 11 kxihes in aim Plan must ` r o h
Mckx , fiat not invited toc wwftal and horjaontal mfwwm post (Brig, direction and Parcel I D.
pwcent slope scale ordknerAlons. north arrow and location and distance to nearest road
Please pint an lnforrnalon. by Date
Personal idorendion you pride NY be and for secondary purposes (Privet Low. s. 15.04 (
Location T Property
Property Owner A // / "^ (r Govt. Lct L^ 1/414 j N R E ( W
G D !3[/Gc/
a9' Bl ock Subd Namear
� 0 , S --
state Cow ❑ aty L7 VOW Town Neared Road
New Coristuction use Residential / m irriber of bedroorns —_ Code demred design now rate ' (� (3PD
❑ Raplaoement ❑ Pubic or con ordal - Describe: _
Parent material c , L Flood Plain if applicable N //} R
Clenwamew eral hnheridatiahs s� �, 91, 7 9�' 3
and zcajf:�
F -11 # 0 soft 0 a pt hound SUrrBCe elev. s R Depth to tktiigng factor k, R lc�
Hatt Depth Dontrherht Now Oescl4w n TehrMConsistence e Smxb" Co B nifty Rotes our
In. Mhnsei C1u. SO- Carr<. Color Gr. Sz Shh. `EtJ#1
z , 3 am . s
- r S /r1 1 - - �, Z
ir off 90.S -off
pt Ground atsiane ahev. Si 3 R Depth to imi6ng faclar in sa Appliddion Rate
Hwiton Depth Dominer t Redox Description Tgxb" Sbucb" Cary Boundary Routs GPM
in. Mtneel C1u. SL cant. Color Gr. Sz Sh. TIM
G
3 — 5 2 rn r r i✓S Z n- °l
r `1 LS r'vi✓JC�r e V0 I z 7 1, 2
go .90
EMum t #1 = BOD > 30 <_ 220 - and TMW >30 < 1 / , ' Etiluant #2 - h30D <_ 30 mgL and TSS c 30 mgit.
CST (Please P" Numilm
as
Address _ Dale Evakialion Conducted Telephone WOW
Ae AVI .5-�/O/
. i
t2�
Parcel ID# Pa of
Borin # , � pit Ground arios elev / l b ' z a D t 6.ah g for �- sou Applicallm Rate
Horimn Depth Doruiirwt Color Redox Desaiplim Texture Stru ckm Cormislarice Botmdary Roots GPDAF
Im Mrrrsl Qu. Sz Corti. Color Gr. Sz Sh. •Etffil
la 3 /Z 5 L 2 F c 2 �
L s rVIv r 1 IF ( Z
1,Z-
F ear# O
(] pit Ground surface elev ft. Depth to mow factor iR sofa Rafe
Horizon Depth Domm t Color Radox DescripBon Texture Stnr:Oure COMISIlence Barxtay Roots GPM
in. murad CU Sz Cont Color Gr. SL Sh. M
a # ❑ Pi Gnxrd srrEaoe etev, IL Depth fo *A" factor ir.
Sou Applicaliort Rate
Horhm Depth Dom mt Color Retim nesaipf'an• Texture structure Consist nce Borrrdary Roots GPDff
kL IMu nsa9 Qu. Sz Cod Odor Gr. SL Sh *M •Efllf2
• EMUart #1 BOD > 30 <_ 220 mgit. and TSS >30 <_ 150 mglL ' Effluent d2 = BM, _< 30 mglL and TSS 1 30 nv&
The Deparmunt of Commerce is an equal opportunity service provider and employer. If you need assistance fo access services or
need material in an alternate format, please contact the depardnent at 608- 266 -3151 or TTY 608- 264 -8777.
sansMOW"
Soil Test Plot Plan
Project Name P.C.Collova Bldrs. Inc. Shaun Bird
Address P.O. Box 489
Somerset Wi 54025 CSTM #226900
Lot 29 Subdivision Prairie Pond Breaks Date 4/9/03
E 1/2 NE 1 /4S 31 T 31 N /13 W Township Star Prairie
NW 1 /4 W 32
Boring 0 Well PL Property Line County ST. CROIX
BM r VRP Assume Elevation 100 ft. --Top of Wood Corner Post
System Elevation 91 *HRPSame as Benchmark
Alt. BM ; Top of Survey Iron @ 99.5'
Pro Town Road
50'
95' B-2 96'
4%
Slo
-3
70'
35'
1 30'
80'
20' F B.M.
0'
LRn4 197 '
'�j
Maintenance and Contingency Plan for a Septic System
Maintenance Plan e d once every 3 years.
1. Septic Tank is to be pump installed in
2. Effluent latter is to be cleaned once a year. Please note: a larger filter is being
order to extend the maintenance interval of the filter; the inspections pipes at the ends of
3. Once evt:ry $ years, cells are to be inspected via P
the COOS.
4.Owner I 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. Watershod is to be diverted away from system. omm. 83
8. Discharge into system is not exceed those required as per C
C Plan
O ion #1..j If system fails, determine cause of failure, use alternate area and install new
Pt
system in tested replacement area.
r elevation, by removing chambers, removing biomat,
option #2. Install system at a lowe
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 -468
Pumper Tom Mondor 715 - 246 -5 148
Shaun Bird #226900
i
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 Q dM A
(Verification required from Planning Department for new construction)
Cit y /State New Richmond WI
ty Parcel Identification Number
LEGAL DESCRIPTION
Property Location SE %, NE y,, Sec. 3 �". T 31 N -R 18 W, Town of J" 4z�,r
Subdivision Prairie Pond Breaks Lot # l� l
Certified Survey Map # . Volume , Page #
695417 2021 27
Warranty Deed # 695419 . Volume 2021 , Page # _ 29
Spec house ❑ yes ❑ 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.
Ile property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner. and by a
masterplumber, jourueymanplumber, 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.
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
4A4 (7 15) ree year x Lion date.
R C. COLLOVA BUILDERS, INC. /
O APPLICANT 247 -2742 DA
P.O. Box 489
OWNER CERTIFICATION SOMERSET, WISCONSIN 54025
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the property describ jb, by virtue of a warranty deed recorded in Register of Deeds Office.
A PI:ICANT
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.
KATHLEEN H. WALSH
WARRANTY DEED
Document Number REGISTER OF DEEDS
ST. CROIX Co., WI
This Deed, made between Douglas A. Strohbeen and Eileen RECEIVED FOR RECORD
Strohbeen, husband and wife,
10 - 23 -2002 11:00 Alf
WARRaVTY 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 NE 1/4 ofNE1 /4 and part of SE 1/4 of NE 1/4 of Section 31, Name and Return Address
Township 31 North, Range 18 West, St. Croix County, Wisconsin, described
as follows: Lot I 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) NXdQ
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this y of September 2002
+ + Douglas A. Strohbeen
' + Eileen Strohbeen
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
) ss.
St. Croix County }
authenticated this day of
Personally came before me this y of
s}`�l� <,!''.•, September 2002 the above named
f X, Douglas A. Strohbeen and Eileen Strohbeen, husband and wife,
TITLE: MEMBER STATE BAR OF' I � t
(If not, to me known to be the rson(s) who executed the foregoing
authorized by § 706.06, Wis. Stets. �
instru nd a ged the same.
11 OF WISt,;10'
THIS INSTRUMENT WAS DRAFT�D�Y''
Attorney Kristine Ogland Notary Public, State of Wisconsin
Hudson, WI 54016 ommission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.) , /�D 6!!� •)
Names of persons signing in any capacity must be typed or printed below their sig% ture. Information Profassionals Company, Fond du Lae, WI
STATE BAR OF WISCONSIN 800-655-2021 WARRANTY DEED FORM No. 2 - 1999
U 2021P 029
STATE BAR OF WISCONSIN FORM 2- 1999 6 9 5 4 1 9
WARRANTY DEED KATHLEEN H. WALSH
Document Number REGISTER OF DEEDS
ST. CROIX CO., MI
This Deed, made between Cecil Brighton and Cleo Brighton, RECEIVED FOR RECORD
husband and wife,
10 - 23 -2002 11:00 AM
WARRANTY DEED
Grantor, and P. C. Collova Builders, Inc. EXEWT #
REC FEE: 11.00
TRANS FEE: 720.00
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): ��� £ � 4
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.
A
038 - 1131 -60
Parcel Identification Number (PIN)
This is not homestead property.
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. (M) (is not)
Dated this day of September 2002
* * Cecil Brighton v
' * Cleo Brighton
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
ss.
�'., =;•fr St. Croix County )
authenticated this day of
Personally came before me this day of
September 2002 the above named
+ Z 0 Cecil Brighton and Cleo Brighton, husband and wife,
t OF 11SC��,
TITLE: MEMBER STATE BAR OF WISCONSIN.. v:..,;�_
(If not, to me krigmon to be a on(s) who executed the foregoing
authorized by § 706.06, Wis. Stats.) instru o&led2ed the same.
THIS INSTRUMENT WAS DRAFTED BY * ,
Attorney Kristina Ogland
Hudson, WI 54016 Notary Public, State of Wisconsin
MY Commiss' n is permanent (If not state exp (Signatures may be authenticated or acknowledged. Both are not necessary.)
' Names of persons signing in any capacity must be typed or printed below their si lure, information p rofessionals c ompany. Fora au sec +nn
STATE BAR OF WISCONSIN 800455f 21
WARRANTY DEED FORM No. 2 -1999
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239.48' 197.45 202.62' 66 00'
S 00 0 20'52" E 1323.28'
E4STLBWOFTMNwI/4OF 80' RADIUS TEMPORA
CUL -DE -SAC EASEMI
THEIVW 114 OF SEC 32 TO BE EXTINGUISHED
UNPLA TTED LANDS EXTENSION OF THE R