HomeMy WebLinkAbout040-1265-90-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
453478 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:
Bell, George Troy Township 040 - 1265 -90 -000
CST BM Elev: Insp. BM Elev: T Description: Section/Town /Range /Map No:
7 n add FMV\ C. S., 16.28.19.1441
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
0. 413 roc 'i3 /Z:C
Septic Benchmark
Dosing Alt. BM
A Bldg. Sewer
X30
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic 7 Dt Bottom I ' 0 � 9� < 3
Dosing 7 / 1 1 ' I 3 a j Header /Man. ` \ 1 �
Aeration Dist. Pipe ` 1 5 1 -
Holding Bot. System
PUMP /SIPHON INFORMATION Final Grade 1 `- • (0 '7 5/
Manufacturer Demand St Cover
G a 7 �. u �o
Model Number - /1T
TDH Lift Friction Loss System Head TDH Ft .
7 ZI Z.�l
Forcemain Length ; Dia. i/ Dist. to Well .
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length r No Trenc s PIT DIMENSION No. Of Inside Dia Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO ICJ P/L JBLDG WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION Ty Qf� stem: ` CHAMBER OR
yp M z q ? /Loo A ! „ I UNIT Model Number: \
DISTRIBUTION SYSTEM !\, J �
Header /Manifold , Distribution x Hole Size ; I x Hole Spacing Vent to Air Intake
P() )
Lengt Di a Z Length 5� ( � Dia ) Spacing_ (� �e�-
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 // Bed/Trench Edges Topsoil
No s No
i
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2:
Location: 338 Soo Line Rd Unknown (SE 1/4 SW 1/4 16 T28N R19W) Glover Station Add V Lot 80 P cel No: 16.28.19.1441
1.) Alt BM Description = f ` ` r E L b w J `�C�
2.) Bldg sewer length = � zb
- amount of cover = c • .,
3.) Contour
Plan revision Required? Yes _^ No ) I �� Z 1 �
Use other side for additional information. 1 ` ((( L�
Date Insebors at ure Cert. No.
SBD -6710 (R.3/97)
Safety and Buildings Divlsi n Coun
201 W. Washington Ave., P. .Box 162
Madison, WI 53707 7152 Sanitary Permit Number (to be filled in by Co.)
/ sin
Department of Commerce () 266 3151���
State
an I.D. Number
Permit A iheatim
to
Sanitary _
In accord with Coman 83.21, Wis. Adm. Code, personal information you provide
l 0 - mss /
may be used for secondary purposes Privacy Law, s15.04(lX;n) Inroject :Address (if different than mailing address)
1 t 10
I, Application Information - Please Print AD Information SOO 1 (►Vl 1) Q.
;' Earcel # Lot qo BI4c #
Property Owner's Na me
P" A I M Lyfy 0
r etqerty O 's M ailing Address ' `i 9 ov�0 l u el Property Location
C) BO 44S - �
14 if ,Section
City, State Zip Code Phone Number
i 5 ` OI -7 1S � t0 a � T N, R $o W }
II. Type of Building (check all that apply)
Subdivision Name CSM Number <
1 or 2 Family Dwelling - Number of Bedrooms Ste) 40
�
❑ Public /Commercial - Describe se
State Owned - D O Z Cit ❑Villa a ownshi of
❑ escxibe Use / vD — � Y_ g � P
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. New System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only 0 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. Type of POWTS S em: (Check all that a ply)
❑ Non - Pressurized In- Ground Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter
❑ Constructed Wetland 11 Pressurized In- Ground El Holding Tank ❑Peat Filter ❑ Aerobic
Treatment Unit ❑ Recirculating Sand Filter
❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ O r (explain)
V. Dis xeatnnent Area Information: .
Design Flow (gpd) Design Soil Application Rate(gpdsf) ispersal Area Required (sf) ispersal Area Proposed (sf) ystem Elev��
o � T P VI. Tank Info Capacity in Total Number anufacturer refab Site Steel Fiber Plastic
Gallons Gallons of Units ncrete Constructed Glass
New Existing
Tanks Tanks
ptic r Holding Tank p` Sid
Aerobic Treatment Unit
ping Qtamber C jq t
VII. Responsibility Statement- I, the umdersign responsibility for " of the POV►"15 spawn on the attached plans.
Plumber's Na me ( P tier's Si lure P umber Business Phone Number
O .N L I VA O - 7 -S ,S!
Plumber's Addre ss (Street, City, State, Zip Code) YVN niA t
VIII. Coon /De ent Use Onl
Sanitary Permit Fee (i udes Groundwater Date Issued Issuing gent Signature o Stamps}
Approved ❑ Disapproved Surcharge Fee) 7
❑ Owner Given Reason for Decrial
IX. Conditions of Approval/Reasons for Disapproval
SYSTEM OWNER:
1 Septic tank, effluent filter and
dispersal cell must all be serviced / maintained
as per management plan provided by plumber.
2. All setback requirements must be maintained
as per applicable code /ordinances.
Attach complete plans (to tits County only) for the syateat oo paper not Im than 81/1 x 11 itches in sire
Plot plav
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Safety and Buildings
N
4003 N KIN Y COULEE RD E
commerce LA CROSSE WI 54601 -1831
TDD #: (608) 264 -8777
,t sco n s i n www•commerce.state.wi.us /sb
Department of Commerce www.wisconsin.gov
Jim Doyle, Governor
Cory L. Nettles, Secretary
August 09, 2004
CUST ID No.220537 ATTN: POWTS Inspector
ZONING OFFICE
CALVIN W POWERS ST CROIX COUNTY SPIA
1969 185TH AVE 1101 CARMICHAEL RD
NEW RICHMOND WI 54017 HUDSON WI 54016
CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 08/09/2006 Identification Numbers
Transaction ID No. 1027825
SITE: Site ID No. 687456
Brushy Mound Partners LLP/ Micheal Stevens Please refer to both identification numbers,
338 Soo Line Road L above, in all correspondence with the agency,
Town of Troy
St Croix County
SE1/4, SWIA, S16, T28N, R19W
Subdivision: Glover Station 5th Addition; lot 80
FOR:
Description: Prop. Four Bedroom Mound System; (using 20 - 10' EZ1203H EZFow bundles).
Object Type: POWTS Component Manual Regulated Object ID No.: 973046
Maintenance required; 600 GPD Flow rate; 33 in Soil minimum depth to limiting factor from original grade
System(s): EZflow Mound Component Manual, (N.6/03), Pressure Distribution Component Manual - Version 2.0,
SBD- 10706 -P (N.01 /O1); Biofilter
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in
chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements.
No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s. 145.06,
stats.
The following conditions shall be met during construction or installation and prior to occupancy or use:
• This system is to be constructed and located in accordance with the enclosed approved plans and with the EZ
Flow Mound Component Manual (June 6, 2003).
• This system is to be constructed and located in accordance with the approved plans and with the "Pressure
Distribution Component Manual for Private Onsite Wastewater Treatment Systems Version 2.0" SBD - 10706 -P
(N.01/01).
• The distribution pipe being inserted into the 4" corrugated pipe located in the EZflow product shall have one out
of every five orifices installed at the 6 o'clock position. The remaining four orifices shall be installed at the 12
o'clock position. The lateral(s) shall slope back to the force main to ensure total drainage after every dose.
• The last orifice in each lateral shall be located not less than 6" or greater than F from the end of the cell.
• A sanitary permit must be obtained from the county where this project is located in accordance with the
requirements of Sec. 145.135 and 145.19, Wis. Stats.
• Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with
the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats.
• The area within 15 feet horizontally below the system shall remain undisturbt& Vehicular traffic or soil
compaction in this area is prohibited. �
G ENQFfTMru. _ _ 1
CALVIN W POWERS JR Page 2 8/9/04
• A state approved effluent filter is required. Maintenance information must be given to the owner of the tank
explaining that periodic cleaning of the filter is required. Access to the filter for cleaning must be provided
per Comm 84 product approval conditions.
• Comm 83.22(7) - A cony of the approved plans specifications and this letter shall be on -site dur_in
construction and open to inspection by authorized representatives of the Department which may include local
inspectors.
Owner Responsibilities:
• The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating
to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and
maintenance manual and/or owner's manual for the POWTS described in this approval.
• Comm 83.52(1)(a) - The owner of a POWTS shall be responsible for ensuring that the operation and
maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s.
Comm 83.54(1).
• Comm 83.52(2) - A POWTS that is not maintained in accordance with the approved management plan or as
required under s. Comm 83.54(4) shall be considered a human health hazard. In the event this soil absorption
system or any of its component parts malfunctions so as to create a health hazard, the property owner must
follow the contingency plan as described in the approved plans.
• The owner is responsible for submitting a maintenance verification report acceptable to the county for
maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized
in the POWTS.
In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should
conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review
shall relieve the designer of the responsibility for designing a safe building, structure, or component.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the
installation, operation or maintenance of the POWTS.
Sincerely,
Fee Required $ 175.00
Fee Received $ 175.00
Balance Due $ 0.00
Gerard M. Swim
POWTS Plan Reviewer - Integrated Services
(608)- 789 -7892, Mon. - Fri. 7:30 am to 4:15 pm
jswim @commerce.state.wi.us WiSMART code: 7633
cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544
TITLE SHEET
DATE: I 00 t / PAGE OF_,S_
MOUND SYSTEM
FOR
A BEDROOM RESIDENCE
This plan has been prepared in accordance with the EZFLOW Mound Component
Manual VERSION 2.0 (N. 06 /03)and the Pressure Distribution Manual VERISION 2.0
SBD- 10706 -P. (N. 01/01)
LOCATED IN THE - S � �'� THE -S 1 /4 OF SECTION
R,�W, TOWN OF � �,T�N,
, WISCONSIN.
ST. CROIX COUNT
INDEX C
PAGE 1 OF 7 TITLE SHEET
PAGE 2 OF 7 PLOT PLAN
PAGE 3 OF 7 PLANVIEW CROSS SECTION
PAGE 4 OF 7 DISTRIBUTION PIPE LAYOUT
PAGE 5 OF 7 PUMP CHAMBER CROSS SECTION
PAGE 6 OF 7 SYSTEM MANAGEMENT PLAN
PAGE 7 OF 7 PUMP CURVE
-
VERS UP A R E D FO
( Ct r h d "/M t ' tx .@ `Q if �i2 Ri
PREP y
#2 0537
POWERS EXCAVATING INC.
1969 I85 T " AVE.
NEW RICHMOND, WIS. 54017
PHONE: 715 -246 -5135
FAX: 715 -246 -5135
CELL: 715 -381 -9920
Y GurrE.4E
RECEIVED BUILDINGS
w� vw�uN U� SA FETY BUILDIwGS
AUG 0 2 2004
4 r�;EE 0 C0 e RR Z E1fQNCENCE
SAFETY & BLDGS 01V.
Plot �. i/ a
I N w Y te'S PQ 8 0 4 y V,5 co
`ems R kmcn n 1 5 5 0 7
mCK,-f d, 9 x .
B U)c cam z � �E� �g
I a .=wa I
am - doe 3 it Cam! 9 4 0► � °'�l
J /
/ S /
f 1
r�
0
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a i
.. .: Page,. Of _...
Synthetic Cov ,.ring
,57M C33 Distribution Pipe
Medium Sand
Topsoil e4
3 .1 E n 0
ej R 7
%
Slope
Bad Of !��— 2 %2 Force Main Plowed
Aggregate Layer
D /,a%, 7k VIII-'
Y
E 1,64 9
Cross Section Of A Mound System Using F � I
A Bad For The Absorption Area G — dPk.L-I:l
A !o Ft. H
r
uinea r .oad iY g=ate- � �'� / !�!,,N + ' z m B � Ft.
Desi-gn .iJoading, ; ;at e = JrPu /3q FT K 9 Ft.
L S3,2-Ft.
Ft. ..
Position z /0s5 Ft.
of ----' W A a, c l Ft. r
Force Main
L
r Observation Pipe
�-- -- - - - --- -------- -- - --- -
A k Y4 s °
-- --------- - - - - -- ------------------ - - -.40
Distributio+v Of z -2
2
Pipe Aggregate
Observation Pipe
' 40%cho r se cw m1r
Pion View Of Mound Using A Bed For The Absorption Area
D i*LL butioa Pipe Layout P a ge a:
Place the holes at the bottom of the distribution pipes
at equal apacin$. Remove all burrs from tae pipe and holes.
*teach Ietd ap M* then ram of jMg t= or sS' fimiog 0 a Pam withra s
VWL Twiniu s *& 086 at ** imp* WA a "IM ama iad OF or
dad per. Plea aeerm Dram SW prdie for die vWW, ti iv or d ply.
�CCEsS Bay_.
1t� i
s v C, ouC ,WvG
Lao"
a
s
- - 4
P - 5 -- F =. Hole Diameter /
inch
3 Ft. Lateral Inch(es)
X � I nch*$ Iftnifold ' of inches
Force I% in ` a_ tnclies
I of ho
es/ �� v*--4R.S
Invert Elevation of Laterals__%,� Ft.
SE'P TANK 6 " PUMP CH A� �n��J J�'LLiv.•
4" CI VENT PIPE 12"
M IN. ABOVE GRADE JUNCTION BOX APPROVED VER
25' FROM.DOOR, WINDOW OR WITH CONDUIT MANHOLE ,CO
FRESH AIR INTAKE W/ PADLOCK 9
WARNING LABEL
1 " MIN
1B" IN
i N LET
WATER TIGHT SEALS GAS-
TIGHT t
A SEAL t APPROVED
," JOINTS W/ CI
4 11 i_ + ALM
PIPE 3' ONTO
Cl PIPE B ON
3' ONTO ---- SOLID SOIL
SOLID C RISER EXIT
SOIL PUMP OFF ELEV . FT • '- ` Y OfF PERMITTED ONLY
D IF TANK
MANUFACTURER
HA APPROVAL
3" APPROVED BEDDING UNDER TANK £PAD
CONCRET
SPECIFICATIONS
S ! DOSE
TANK MANUFACTURER: j�;� -- '�(�c� NUMBER 'DOSES PER DAY
TANK SIZES: SEPTIC 5CQ GAL. DOSE VOLUME FLOWBACK: GAL.
DOSE t> GAL.
GAL.
ALARM. MANUFACTURER: S
CAPACITIES: A = aa+ INCHES
MODEL NUMBER: / B 2 INCHES = -3_ 5�� GAL,
SWITCH TYPE:
PUMP MANUFACTURER:
C = '�, 7 INCHES = � �, 3 GAL
t f,+, }�s
MODEL NUMBER: n'1 p = 9 + q INCHES = AL
SWITCH TYPE:
REQUIRED DISCHARGE RATE _ GPM PUMP ALARM WIRING AS PER ILHR 16. 23 WAI
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE • S FEET
FEET
+ MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . . . E n FEET
+ � FEET FORCEMAIN X 3+3 FT /100 FT. FRICTION FACTOR
TATAL DYNAMIC H EAD
FEET
INTERNAL DIMENSIONS OF PUMP TANK: LENGTH i WIDTH __-� DIAMETER
LIQUID DEPTH 4 O ?
J
. pOw TS OWNER'S MANUAL & MANAGE MENT PLAN
sysT>�+l
7 .03 I Owner ca ; Tank
Septic Q Cl lir ldit � o� Permit I n TW* Maw U + •4�j
DOW11111 PAi1Ai1METiEAr *13 gal
Cl NA t7 NA
Number of 8®droovtns
Q NA
Number of Pubf'ic Facility Units
_ Estimated tavaxagal flow 0 ❑ NA
D (per flow = tEstkrwted x 1.51 f } C7 god Application Rate ❑ NA
`
Unit
Standard kdluga tll"kM* tZ�Y ❑ Sandroael FNW Q Peet F ilter
Fats, Oil & Grease (FOG) 530 m9IL ❑ wetland
dte
Biorrrical OXV9W Demand (BODO 5220 am& ❑ NA 13 M Aeration
M g pended pended SoSds (TSSI 5160 rngft.
C! Oisirde�r Q Ottter:
t Y coma)
Month* "Wage rCO nufacturer D NA
persd
gen [�trtand (Boos) 530 rMIL ❑ NA in-Ground (grow" O in-Ground fpressurized)
Sormb 1T5 1 530 �� ,�f Mound
M tW+ is meenl S10' cfuJ10Um1 At Grade r "
❑ Drip- ❑Other.
Mwdmurn Effluent Particle Size Y. in dia. ❑ NA ❑ NA
0 N ONA
Waivas typical for domestic wastewater and argil
c tank affhrent•
ifA iTEN1AMM SCttii:WlLE swvke Ffraquency
Service R~ r is) Oft 3 yaaael ❑ NA
At kupect condition of tarrklai least ° � 3 of tank vdW"
When combined sludge and stem ata+c one -third (Y ❑ NA
p out cmftnts of tw*(s) 0 When the high water abate is scfiveled �
"ft(s) "ft(s) 3 years) ❑ NA
t dispersal ca(s) At bast once every: O ts1
O nrottihtsl ❑ NA
Clean effl filter At least once every. 1s1
Q r»onthtsl DNA
very: ;1
htsPect Pump• pump controls &alarm At least once e O Via} ❑ NA
Flush laterals and prenum test At bast once evWV. 1 Fear
Q monthtsl 0 NA
At least arcs every: 0 imsio Q NA
IMAMfTtENAWCE IMSTRUC110NS orw of lice foNowing licenses or certifications:
i nspec t io ns of tanks and dispersal toeHs snap be made by irvidual ca
�n9 opera
Mastur Plumber Resttriaw sewer, POWTS Inspector: poWTS MaintsiMaintainer. oken h a Servr i tor (Pumper).
any cracks or
Master �' of the tanktsl to identify any n+isalr+g or broken hardwai►e, �� surd
Tank inspections must include s visual inspection bolt up or pondir g of effluent on the gr
leeks, measure the vobxne of combined sludge and scum and a check for sny lion pipes and to check for any
surface.
The dispersal cen(s) shall be vim► k d to dock the effluent levels m s urface may indicate a fad caption and
ponding of effluent on the gr►ur'd surface- The pond-am of affluent on the ground
requires the itrartedh" notification of the local "MU1001Y eurllww"' -third (Y or more of the tank volume, the
When the cornbined accurnula tiOn of sludge and Septa Operator and in any treatment tank squab disposed of in accordance volt* chapter NR 113,
entire contents of the tank shag be removed bail a �Pt
Wisconsin Admir 'stave Coot• unzed components, pretrestmen
AN other services, Ong but not Wined to the serv�9 of effluent fitters, nvaci d p or p mss
by a certified pWTS Maintainer. units, and any servit� at intervals of 512 months, shall be performed of any service event.
A service report af>sll be provided to the local ray authority within 10 days of cwnPk wn GMW (2/02)
P
Page • of _
START UP AND OPERATION .
For new construction, prior to use of the POWTS clerk treatment tankls) for the presence of painting products, polvents or other
dntwricals that may knpede the bestmen process and /or dam"a the soil disposal c alils). If high concentrations are detected
have the contents of the tank(s) removed by a septage servicing operator prier to rise.
System start up shall not occur when sod condidons are hum at the infiltrative surface.
During extended power outages pump tanks may Till above normal highwater Revels. When power )s restored the excess
wastewater will be discharged to the dispersal cd IW in one Istge don and may overload them resulting in the badmip or surface
discharge of effluent. To avoid this sitwdon have the tmr*wb of the pump tank removed by a Septepe Servicing Operator prior
to restoring power to the effluent pump or contact a Phnanbw or POWTS Maintainer to assist in manually operating the pump
conbohs to restore normal is- within the pump tank.
Do not drive or park vehicles over tanks and 11 i srasl cells. Do not drive or park over. or otherwise disturb or compact. the area
withk 15 feet down slope of any mound or at -grade soil absorptbn area.
Reduction or elimination of the following from the wastewater abeam may improve the perfomwioe and prolong the fife of the
POWTS: antibiotics; baby wipes; cigarette butts; condom s. cotton swabs; degreasers; dental floss; dispars; disittisctants; fat;
founddation drain (sump pump) discharge; fruit and vaget" peafnngs; gasoline; grease; herbicides; meat scraps; medications; oil:
painting products: Psadades; sarutary napkins; ternpons; and water softener brine.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following seeps shall be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33. Wisconsin A ydriletretive Code:
• AN piping to tanks and pits shall be disconracted and the abandoned 'pipe openings sealed.
• The c orvbw is of all tanks and pft shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, as tanks and pits shell be excavated and removed or their covers removed and the void space filled with
sod, gravel or another inert solid material.
CONTINGENCY PLAN
if the POWTS fads and cannot be repaired the following measures hays been. or must be taken, to provide a code compliant
raplaceement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement sod absorption
system. The replacement area shot ld be protected from disturbance and compaction and should not be Mffked upon by
required - nil - As from axloiimg and proposed structure, lot rites and waft. Fdliire to prMer! #W replacement area will
rescrlt in the treed for a new soll and sits evaluation to establish a suitable rat area. Replacement systems must
comply with die rules in effect at than time.
❑ A suitable n"Aac irm area is not available due to setback and/or soil limitations. Barring advances in POWTS
technology a holding tact may be installed as a last resort to replace the failed POWTS.
❑ The aide has not been evaluated to identify a suitable rapiecernent sea. Upon failure of the POWTS a soil and site
evaluation waist be performed to locate a suitable repleoement area. if no replacement area is available a holding tank
may be installed as a last rem to replace the faded POWTS.
Mound and at -grade sad absorption systems may be reconstructed in place following removal of the biamat at the
anfiltrative surface. Reconstrucbons of such systems must comply with the rules in effect at that tittle.
< <WARNING> >
SERIC. PUNIP AND OTHER TREATMENT TANKS MAY GONTAM LETHAL BASS AND/OR INSUFflCIENf OXYGEN. 00 NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CNICU NISTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR UNPOSSE LE.
ADDITIONAL CONK UNM
POWTS NISTALLER POWTS MAINTANRaR
Name
Phone- IS 0Lj - S"..�-S phone .
SEPTAGE SERVICMG OPERATOR IPUMPER) LOCAL REWILATORY AUTHORITY
E Natty 1 "W"
(S �c4 � 4 1 6 A
This dowment was drafted W ow staffs of the mom take. Mar*mm arw *ftushara eounnv Zw tg and Sankstion agencies in compWinc a with
chapter Comm 83.2212iIWl1lld) &(f) and 83.54;71, 12) & 13). VAsconsin Administrative Code.
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Wisconsin Department Industry
Labor and Human Relations SOIL AND SITE EVALUATION REPORT P I of
—
Divisipn of Safety 8 Buildings in accord with ILHR 83.05,
°� I ! ` \ COUNTY
Attach complete site plan on paper not less than 8112 x 11 inches in si ze. tn(st in I d ut-
not limited to vertical and horizontal reference point (BK, direction and ° •at slope, sc err r P EL I.D.
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION r:' "" r I�BY DA
3� Zeo
PROPERTY OWNER: PROPER ; ION 11, 111E: S ffifvD
e CZI��S $ f3AA �1Jhl \S S C 1 Z S8�F�4d v l .1 /4:& iJd 1107 � N,R lq E (a W
PROPERTY OWNER':S MAILING ADDRESS. LOT # BLOCK # I $ . Q >N E OR CS #
ZS8 2lU 2S lDE �2LUE �d> --- (5 v �tft'f) S FTt)D . :�] CITY, STATE ZIP CODE PHONE NUMBER ❑C OWN ' NEAREST ROAD
1Z.1U�' �Ll.. -S w1 Sy,oZ•ZhLS) �1ZS - �L6► �Z -o`-f SDO LAVE �-UFYD
p(J New Construction Use [>I Residential / Number of bedrooms [ ) AdditiQn to existing building
[ j Replacement [ j Public or commercial describe
Code derived daily flow 6 613 gpd Recommended design loading rate Y bed, gpd/ft - trench, gpolft
Absorption area required SOD bed, ft S 60 trench, ft Ma:amum design loading rate S bed, gpd$ • b trench, gpd1ft
Recommended infiltration surface elevation(s) 9 3 • o It (as referred to site plan benchmark)
Additional design / site considerations M u vim wl S ` 6 3 , - z m' . M11N , V OF S prb Fc LL'
Parent material I (I kl.� o ut 6 L47 tN1- -N1 L Flood plain elevation, if applicable IV ft
S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE AT-GRADE SYSTEM IN FILL I HOLDING TANK
U = Unsuitable fors stem O ®
S U ®S ❑ U [Is ®U ❑ S RU ❑ S Bu CIS U
SOIL DESCRIPTION REPORT NewULa - Ifs Texture
Boring # Horizon
Depth Dominant Color I Mottles ( Structure Consistence Beuridary Roots G A/t
I
in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. Be Z
Z 9 —Zg lv `� R 316 _ s a 1 Z`�sb k h2 `fl- e� — • S • 6 S�
Ground 3 2$ -SS/ �.s y/6 1 `�s 1� b►� u �w - , S - 6 . S
elev.
9 & 6 ft. L! - 6 1L) `i2 /6
Depth to
limiting
f actor �t
Remarks:
Boring #
o -e �0- P- 31 st i Z-ks 0
E Z $ 2.2. l u `1 IL 3/ — -S 224 sb1 M - C - l- CS _ • S • 6 ,
Ground 3 �-�� �.S`12 31y — 5�..�5 1.esbk m�'fi^ �s - -�( 'S •.
elev. P- SJ8
fL
Depth to
limiting
factor
Remarks:
FT Print Phone:
Arthur L. We erer 715 - 425 -0165 '
egerer Soil Testing & Design Service -P.O. Box 74 River - Fa11s,WI.54022
Sgnature: Date: CST Number. .
ov-la 3 -8D s-q-0 220254
PROPERTY OWNER �`� _ / Serw L T - Z
PARCEL I.D. �� ;`
SOIL DESCRIPTION REPORT Page? of p � /y
Boring # Horizon Depth Dominant Color Mottles Texture Structure GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Consistence Boundary Roots
Bed Trench
S
Z - i -33 loti lz �J6 - Si 1 - Z hz Sbk ynfi- �w .S ,b •b
Ground 3 3$ -S� i D `1 R 3/6 , -s4p_ S csbl� h� `F!. — z 3 .
elev.
Depth to
limiting
factor
3
Remarks:
Boring #
Z 9- 3S. toy tz 3 j
, 3 7
Ground 3s -q , ) S y 2 yl b - 1`Fs 1 �S b>z vn w6-
elev. y� -foy 1 C SJ(, 1 o S9 r, 1 . S ,� • �
It. _
Depth to —
limiting
factor
X 11 \ V Remarks:
Boring #
"I IL l't Sir Z 1 u _33 10 rz 316 - s� l 2
t W-j IZ r! /� -� Sy r�S18 S � 1 ' 16— s bk `
Ground
elev. �b -�6 7 -S `1R YLG — l 1�b� sh — •S .6
Depth to
limiting
factor
Remarks:
3oring #
l sal
around S 1 Cgb12 C S I O S • Z . 3 ub �l
:lev. y 3g 7� �.S712VA - �. Z esblz 1Mu�i- _ •s ,b
CtV.0
)epth to
imiling
actor� �
h
r
Remarks: _
PROPEMYOWNER SOIL DESCRIPTION REPORT
Page 3 of
PARCEL I.D. #
AvG
Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft
in. Munsell Qu. Sz. Cont. Color Texture Consistence Rotary Roots
_` w Gr. Sz. Sh.
Bed rends
—
,} �=y2 si 1 2 sblz r2�F�• ew 1�' •S •
10 `1 R 316
s)) z -�sbk ��-� � - • s ,b
Ground 3 ZZ_v2 - S `Z lL y /(, 1'C S l �°—Sl� 1z �S w • S ,
elev.
Depth to
limiting t
factor
7 p L E
Remarks:
Boring #
a,
Ground i
elev. t
ft.
Depth to i
limiting
factor
t
I
t
Remarks:
Boring #
t
t
Ground I
elev.
It. I
Depth to ,
'smiting
`actor
Remarks:
3oring #
.<....
,round
?lev.
(t.
Depth to
imiting
actor
Remarks:_
PLOT PLAN Pa of y
SCALE I"= So
So
0
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(715 ) 475 -0165 r
CST Signature Date Signed Telephone No. CST #
t
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
9 t-bp Si�> U ®� c S 3 /%/
Mailing Address
Property Address
(Verification required from Planning Department for new construction) P�
City /State "05-0" l Parcel Identification Number
LEGAL DESCRIPTION
Property Location % y,, Svc /,, Sec lb , T N -R ft W, Town of
Subdivision C-q L-0 V o a Lot #
Certified Survey Map # Volume , Page #
Warranty Deed # 9 - 7 0 . Volume 7(4 / G . Page # 3 .
Spec house ❑ yes ono 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 fimetion 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, journeymanpl1lrnber, 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
days of the three year expiration date.
SIGNATUR&EF APPLICANT DATE
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 owner(s) of
the property described ove, by irtue o a warranty deed recorded in Register of Deeds Office.
6 � 25 o-
SIGNATURE UF APPLICANT 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
RIVER VALLEY ABSTRACT Fax:715- 386 -7664 Aug 13 2004 9:00 P.02
` U 2 6 10 P 4 8 7 79 ?9
i t f KATHLEEN a. MALsK
• • Docume „t Number WARRANTY DEED RMISTER OF DEWS
ST. CROIX CO., MI
THIS DEED made between Brushy Mound Partners, LLP, a
RECEIVED FOR RECORD
Wisconsin Limited Liability Partnership ( "Grantor") and Ge�or a D. 0 IS-.4
Bel! and Susan E. Bel{, h usband and wife, as survlvorshlp marital —
property (°Grantee', WARR DEED
WITNESSETFi, that the said Grantor, for valuable consideration EANR #
conveys to Grantee the following described real estate in St. Croix
County, State of Wisconsin: REC F. 1 1 ` 68
TRANS Fn : 375.0@
COPY FBS:
Part of lots 17, 78, 79, and l� of Glover Stsitio n Fifth Additio Recording AreaCC Fes
In the Town of Troy, St Croix County, Wisconsin described as Name and Return %
follows: Lot 80 of certified survey map filed June 3, 2004 in Vol.
8, page 4766, Doc. No. 764773.
k vi
040 - 1265-90 -000
(Parcel Identmcaton Number)
This lq homestead property.
Grantor, Brushy Mound Partners, LLP, at Wisconsin Limited Liability Panership, is an affiliate of Derrick
Homes, LLC, a Wisconsin Limited Liability Corporation. Grantor develops rt land and Derrick Homes, LLC is
a home construction contractor. Grantor agrees to sell this lot to Grantee on the condition that derrick
Homes, LLC will be the builder of the home for Grantee. H Grantee door. "not commence construction with
Derrick Homes, LLG as the contractorlbuilder within two (2) years of the date of sale of this lot to Grantee,
Grantee gives Grantor the irrevocable right to re- purchose the iot for the same price as Grantee paid
Grantor for it when Grantee bought it from Grantor. If Grants¢ desires to sell the lot to another purchaser
before constructing a home upon this lot, Grantee gives Grantor the right of first refusal to re- purchase
the lot for the same price as Grantee paid Grantor for It when Grantee bought it from Grantor.
Dated this 25th day or June, 20Q4.
* Ro Id L errick
illi khaell R, Stevens
AUTHENTICATION
Signatures) ACKNOWLEDGMENT
STATE OF WISCONSIN
authenticated this _ day of _ , 19_, ST. CROIX COUNTY
Personalty came before me this 25th day of June 2004, the
above named Michael R. Stevens and Ronald L. Derrick,
signature as partners of Brushy Mound Partners, LLP, a WISCOnSIn
Limited Liability Partnemlilp to me known to be the persons
type or print neme who exec the foregoing instrument and acknowledge the
TITLE: MEMBER STATE BAR OF WISCONSIN same. • H�"� �„ L
(If not, NAY
authorized by • 706.06, Wis. Stats.) signature ansin
type or print name Heidi L. Lutz
THIS INSTRUMENT WAS DRAF rSD BY Notary Public $t. Croix County, Wisconsin.
Brushy Mound Partners, LLP My Commission Expires: March 29th. 2008.
PO Box 445
New Richmond, WI 54017 'Names of persons signing In any capacity should be typed or
printed below their algnatures.
VV
* •• 1Y R'
DODGE
3 3.2484 go , 16-2 --4- - 7 6 4 7 7 3
ti CLEAR LAKff,
e ••••. VOL 18 PAGE 4766
'-- qN ••.. oQ KATHLEEN H . W ALS9 -
°�ii D U REGISTER OF. DEEDS
�� " ST. CROIX CO. WI
CERTIFIED ' SURVEY MAP 0 61/03/ 004, 03:45PH
Located in part of the Northeast Quarter of the Southwest Quarter and part of CERTIFIED SURVEY NAP
the Southeast Quarter of the Southwest Quarter, all in Section 16, Township 28 REC FEE: 13.00
North, Range 19 West, Town of Troy, St. Croix County, Wisconsin; being Lots COPY FEE: 3.00
77 -80 of the Plat of Glover Station Fifth Addition as recorded in the St. Croix PAGES: 2,
County Register of Deeds Office.
Prepared for and at the request of: BEARINGS ARE REFERENCED TO THE NORTH -SOUTH
Brushy Mound Partners, LLP QUARTER LINE OF SECTION 16, TOWNSHIP 28 N., RANGE
1505 Hwy 65 19 W. WHICH IS ASSUMED TO BEAR N01 49'24 "E.
New Richmond, WI 54017
Drafted by. Howard H. Herrild 111
CURVE TABLE
CURVE RADIUS DELTA ARC CHORD CHORD BEARING TANGENT BEARING
C1 80.00 622 6" 7,13' 82.89 N 7' '39" S71*11'13 0 E N4624'31 "E
C2 883.00 13'54'31" 214.35' 213.82' N39'27'15.5 "E N46"24'31 "E N32M'00 "E
C3 600.00 33 346.83' 342.02' S74'03'34.5 0 E S5T3O'00 "E N8922'51 "E
200 a 2 \ \ GLOVER STA TION NO TH
GRAPHIC SCALE FOURTH ADDITION
SCALE IN FEET: finch = 200 feet a 66 NORTH 114 CORNER
72 \ -- STC 16 -28 -19
APP -
ST. CROIxX MUNIZL j� 65 64
Planning Zoning a� Parks CCmmit e�
1 + �5�� s 7NOU77�
JUN 0 2004 O ct , ry 1'Q \ 11 NOR L /NE - S i .
F
74 A3
If not recorded wl, �s of 7.3
approval date ap ��!" ` '� °� ¢9 �.J:
grr ,a all be - P OQ� r L �j ' ?0•
null eV v ap
\ G ,, 1 �� , r 0 86
I 0
200,732 SQ. FT. co
1
LOT 79 : 4.61 0 -
-` / 158,040 SQ. FT. g 75' : :so'
/ Zi
� o 3.63 ACRES N L OT 84
75 �',�`° do 'z o Q,
S \ 85 \
EASEMENT . g ,
AS SHOWN N
A •, i
ON AT THE PL sS �' 3Z`'9,w estop
OF GLOVER of N'H'S 1• a �
,/STA7701V
O
Ao nav
..... : • �` Go 300.0 CO. ��
LOT T7 : • •. � �-�
76 ;W �S� . : so- so , : LOT 78 W
0 141,873 SQ. FT. 203,685 SQ. FT. :so• `'' I
(0 3.26 ACRES o�: 4.67 ACRES 81 N+ Cyr
N . i
_ 300.001'25 2 """""'450.00''"' N8 9 . 1 8'0 "W
N89'18'09 W 750.00' 357.34' —
UNPLA TTED_ LANDS ° / 82
NO 7E. 77-//S IS A RECONFIGURATION OF LOT LINE LOCA77ON BE7WEEN
LOTS 77 -80. ALL COVENAN73"i, RESTR /C710NS, EASEMENTS ETC, o
a IN C
C)
ON 7HE PLA T OF 'GLOVER STA 77ON RF7H ADD /770N" APPLY
70 L075 HEREON C g
JOB if IM057SU155 LEGEND 2 "
Prepared by. Section Corner. Monument �\
Ow Gimp Inc, of Record 2 C~o p d
• Set 1" x 18" Iron Pipe weighing I
Phone No. (715) 246 -4319 1.13 pounds per linear foot
Fax No. (715) 246 -3830 0 Found 1" Iron Pipe Z
P.O. Box 325 ® Found 1 -1/4" Iron Pipe
New Richmond, WI 54017 co Found 2" Iron Pipe
Sheet 1 of 2
. • ....... Building Setback Line (As Dimensioned)
Vol.18 Page 4766