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HomeMy WebLinkAbout040-1303-00-002 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 453220 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: Bright Keys Developers Troy Township 040-1303-00-002 CST BM Elev: Insp. BM Elev: BM Des ription: Section/Town/Range/Map No: 6 O-Z) c( U K al;A 22.28.19.1737 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Z Be -7.7 0 L( COD- b Dosing 1 Alt. BM L w G 1/0(0 5 D7 Aeration Bldg. -war s- 9 t 2 Holding S t Inlet TANK SETBACK INFORMATION St/Ht Outlet • p, TANK TO P/LL WELL BLDG. Vent to Air Intake ROAD Dt Inlet ~7 Septic , 36 y r Dt Bottom Dosing Header/Man. Aeration Dis I q. 5V Z cl" 61 Holding Bot. System I 10-3 Lpb PUMP/SIPHON INFORMATION Final Grad e,/►~ J _S S 7- 0 p a Manufacturer nd St Cover / /1(( ! ~ Q GPM `C Model Number w TDH Lift Friction stem Head T FH Ft Forcemain ength Dia. D ell SOIL ABSORPTION SYSTEM 2 Z Z 3 4 7j BED/TRENCH Width ~ Length~ No. Of Trenches PIT DIMENSIONS No. Of Pits Inside use. Liquid Depth DIMENSIONS '3 Q q-G 2 SETBACK SYSTEM TO o000 1 P/L BLDG WELL LAKE/STREAM LEACHING Ma ur INFORMATION T Of System: CHAMBER /I a My,i I / UN Number: DISTRIBUTION SYSTEM ~y~J J I w ~I p~~ a,n ba Header/Manifold ID istribution ) Hole Size x Hole Spacing V nt to Air Inta P, Pipe(s)/ ~t Z ~ x :n?~7 Length Dia Length Die b Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over 1 tom,/ Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center 3.7 t1 Bed/Trench Edges Topsoil Yes i No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:a - Inspection #2: / Location: 644 Tribute Parkway Unnkknoow~np (NE 1/4 SW 1/4 22 T28N R19W) Walnut Hill Farm Lot 2 Parcel No: 22.28.19.1737 1.) Alt BM Description = Tb ! 0 J T w n • l,U WO+I264 ~ Q + 9 V (3 Z 2.) Bldg sewer length -amount of cover Plan revision Required? Yes Vo 4- Use other side for additional information. ___L - SBD-6710 (R.3197) Date Insepctor's Sign ure Cert. No. Safety and Builgings Division County s J G ~O f. W 201 W. Washington Ave., P.O. Box 7082 T ~OnS,n Madison, WI 53707 - 7082 Sanitary Permit Number (to be filled in by Co.) (608) 261 6546 -3 2 Department of Commerce ` • State Plan LD. Number AJ/~ Sanitary Permit Application ADD in accord with Comm 83.21, Wis. Adm. Code, personal information you pro may be used for secondary purposes Privacy Law, sl5.04(1 xm) Project Address (if different than mailing address) I. Application Information Pleasure -Won 13 U y~S O YO -/303 . 00 60'Z-J.1 3 Property Owner's Name qp .1 VCMWIC 1 M E Parcel # # Block # 1306rA T- ee 00, utl 2004 w (9 A) P- P, Property Owner's Mailing Pro Location l 8a ~ ~ ~ • ZONING OFFICE City, State 'i/t, Section 2 b> Lip . Phone Number S-fi%l~vA-r M~v5505 Pho t y3 o q(cucleone) 7 (61 T N; R ` >i~br W IL Type of Building (check all that apply) oa P¢(5 vw~ W-1 or 2 Family Dwelling - Number of Bedrooms SubdivisionName CSM Number 11 Gvi4'GNU r - ',C/Lj%//S ~ n~ PublWCommeacial - Describe Use T ❑ State Owned - Describe Use ❑City_❑viliage Arownship of T 0 IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) A' New System ❑ Rephtcement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing Systan. 8. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New last Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: Check all that apply) $,Non -Pressurized In-Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 at. of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel-less Pipe ❑ Other (explain) ► f V. Dis ensinreatment Area Information: , Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevati 66-0 • -7 8S7 87/ VI. Tank Info Capacity in Total Numher Manufacture fab Site Steel Fiber Plastic Gallons Gallons of Units Constructed Glass New Existing a~ Tanks Tanks Septic or Holding Tack Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- 4 the undersigned, assume responsibility for installation of the POINTS shown on the attached plants. Plumber's Nairn (Print) Plum ' Signature !G[P/MPRS Number Business Phone Number . 2tL6 i C1A7`" z>-&3 ? S 17/5 .77x' 3 q Plumber's Address (Street, City, State, Zip Code) 2 d' / Z O & U J/ lv/ S y7lP 7 VIII. Coun artment Use On 'Approved ❑ Disapproved Sanitary Permit F (includes Groundwater Date Issued g Agent Signature NO Stamps) Surcharge Fee, 2~ ' w ❑ Owner Given Reeser for Denial IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNW 1 Septic tank, 9 bent filter and dispersal cell must all be servic9d i rrlaintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code/ordinances. Attach complete plans (to the Coanty only) for the system on paper net less than 81/2 x l t inch" is slue SBD-6398 (R. 08/02) i PLOT PLAN WALNUT HILLS FARM. LOT # Z` Pg. 3 of 3 Q = Contour elevation lines. s = Backhoe Soil pits. p = Benchmarks set, maRKED WITH FLAGGED J~ lathes. 1/2' steel conduit pipes. / Sv~U~yoR's f N'A) LDS ~ A Gp SRN pjV SCALE : 1 " = 3 I` ~ G~iv,~- / 9y NO, 40 7- I$ t3~ ~ ~ao.S° 3Z - /S r O Al" 3M~ ~ sys-rE"' 0.D+ -Z ID ia3. ~o STS sy ,.4s'" peee rL° Leq D~ b Z Y Z) 4g sa o~P o5~ P~ THIS pOWT SYSTEM CSOMMHALL INCORPORATE PER 83.44(2)c A PROPER ZABEL FILTER MODEL # A ' p 'Oy 1 ~f.~.~. I ULBRICHT & ASSOCIATES CO. 2812 10th Ave. • Spring Valley, Wl 54767 Reg- ves~nersofEn i ng 715-772-3442 P Sewage Consonants PROJECT INDEX PLAN ID # _ DATE OWNER 13A'01'&l / I&Y5 i _Q (J~ PHONE ~'s~ y,30• /yda ADDRESS LEGAL DESCRIPTION LD )4- - 4j.41-wV r ///`/s PIA' oYo• /3o3. oo •00Z 3 SPz. 2i • TZft,u, R y w TOWN OF 771cO COUNTY C-D I• x- CSTM ,2• ZlO/4AF 22-Ge3-7 S LOCAL AUTHORITY/ SUPERVISION - 51- 4,01•X c~'`~ 20 l a 6- PROJECT DESCRIPTION: i11 Gt> Gp,U S •rn !J c Tio ,J A VA /1- 104. X144, 11 ~/P/1•~~ ~ 2~Q /~,~-P Zvi Gv~¢-,,5~~ ~ .tJ'P }V >cl64 t) of ova d S . ` Age* 501'T-'f31& /~ie 'N y Le o vv q ? d. W . t UlbdCht & Associates Private Sewage Consultants 2812 10th Ave. Spring Valley, WI 54767 ILO b Pg.l INFILTRATOR SIZING WORKSHEET P9•2 SYSTEM PLOT PLAN P9.3 CROSS SECTION OF SYSTEM, WITH ELEVATIONS. P9.4 if it It If P9.5 OWNER MANAGEMENT F1 " P ANAGEMENT PLANS & ZABEL FILTER SPECS 9 P The attached plans and specifications are based on "In-Ground Absorption Component Manual For Private Onsite Wastewater Treatment Systems." (Version 2.0) SBD-1075-P(NOl/Ol. I Co. co m to it a c awn= 9 ~a m \ m -n 'Ala Z b o i Wisconsin Department of Commerce SOIL EVALUATION REPORT Page / of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must x Sr. GAOIA H include, but not tinited to., vertical and horizontal reference point (BM), direction and Parcel t.D. /-Or polAjf percent slope. scale or dimensions. north arrow, and location and distance to nearest road. p it101A 6- b Please print all Information. e /Date 1~r Persond Wo mation you provide aW be used for secondary purposes (Privacy Law. s 15.04 (1) (m)). PropertyOwner TooO Property Location Oi1n 5 lk~1/4 S ~L T Z-B N R tr (or) W TOPD Z3ERSTLf-r- % AlI"gfA) yM GovtLot 141 J Properly Owner's Mailing Address Lot # Block # Subd. Name or CSW o l CA It t: LL ~V.2 Z cvAan~~ r wi I ftt ~e~t ~ City ZIV W R State Lp Code Phone Number ❑ City ❑ village LA Town Nearest Road 6-AWE . Hn MA1 5SO7(* { 651) ZYdk• Iof~ -rRoy SO. CftouER Fk~ 0 New Construction Use: 0 Residential / Number of bedrooms code derived design flow rate O ~ 4'a GPD '~h ❑ Replacement ❑ Public or commercial - Describe:: - ; , r-- tA Parent material to E'S S D V.~t: S~,vO i/ d Rood Plain elevation if applicable N/ ~l ft. F. General comments and recommendations: i fit- dig A W %GY~t°Otlvl7 ~D. Gt9.1 . $ 'A F Boring # ❑ Boring d o • ~Q I ® Pit Ground surface elev. ft. Depth to limiting facto in. Sol Appkabon Rate Morison Depth Dornir►ard Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Murtsep Qu. Sz Cott Color Gr. Sz Sh. 'Etf#1 'E1#2 l ~•l 0!A 313 L zAvi J Lt W .S N z io S/L z S c / s 3 2•SR S/L Ifsh v aS .Z . 3 t 1/ 37 --Y-fe 7• S s nQ . S D, 54 11 0 2 Boring # ❑ Boring / dd • 6o ® Pit Ground surface elev. ft Depth to knifing factor in. SOS Application Rate Horizon Depth Dominant Color Redgx Description Texture Structure Consistence Boundary Roots GPDW ~l In. Mansell QU. Sz. Cont. Colo Gr. $z. Sh. `Eff#1 'Ef f#2 (~Y 1 0 •~o %Y2 ! G- If shk w z • s N -.d3 4 Z /6-15 / W 314 L -sh& d C F- • 2-- N /o S S D Etiluent #1 = BOD > ..V < ZM mg& and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg& and TSS 130 mg/L rVarrre 0-glase Pmt) R • -4 LB R i G kT- Signature / 4d a2 CST 7 5 Address Ulbricht & Assgciates Data Evaluabon ~ 7t. f. ~e 73 yy Z- Private s 3 2812 1 Oth Ave. Spring Valley, WI 54767 If- Y-9 aj~- PiX,5 OR PR© X . 2- yo PACs aro oya • /o8s • so • t t'~ Z.. 0t-.-TD oyo. /a~~ • ♦o oz~ " 3 oyo • zd a~-o 0 0•/0 70 - 00z' • oar 0 yD - i©8t9 000 ?'ODD? S l e e S Ta~D7- Properfyowner parcel lD # Lb 7`" # page Z or 3 3 t Gtottrad surface efe,r 103 5yfl_ Depth to wnwV factor ~ in Soil W Rafe HorFzorr cdw Depth Donausant Redox Oescripfiaa Texture Struatma Consistence Soundary Roots GPM Munselt Qu. Sz. Cont. Color Gr. Sz. Sh. •tc 91 *E##2 o Ir 1603 L If3 ~ d, 41 3-fL- • Y z5 -7•S fs . s .5 5L !-F s s s e i L---j ❑ Pit Gmund surface elev. ft. Depth to Smiting factor in. Sotl X; prt !fie Horizon Depth €)orrarra €tedox Desaiption Texttxe Structure Consistence Boundary Roaft- GPDIfF i4funsetl tau. Sz. Cont. Color G1% Sz. Sta. `Eff#1 '092 Bortrrg # ❑ , ❑ pit Ground surface elev. R, to tiror&V factor kt Sod qpkabon Rate Horizon Depth Dorratraa<at Color Redox Desa"on_ 7exttae Structure Consistence Boundary Ronis GPM_ In. Munsell Qu. St Cori. Color of. Sz Sh. 'Efl#1 'Elf#2 b a S.ring t F-1 So"ng ❑ pit Ground surface elev. ft. Depth to WrMV factor In. Sort Rate Hamm Depth Doff*v nt C'dw Redox p*m. Textti a Stractaue Consistence soundwy Roars t3Poff in. Munsell Qu. Sz Cqk Color Gr. Sz. Sh. -Efp#1 'Eff#2 • 4 Effluent #1 = SM,> 30: 220 and M >30:S 750 PVJL ° Effluent #2 = SODS S 30 mg/L and TSS < 30 nWL The Department of Commerce is an t opportunity service provider and employer. Ifyou need assistance to access services or need material in an alternate armat, please contact the department at 608-266-3151 or TTY 608-264-8777. SOD-8370 ZR6+tl0) PLOT PLAN WALNUT HILLS FARM. LOT # 2.- Pg. 3 of 3 d = Contour elevation lines. 0 = Backhoe Soil pits. p = Benchmarks set, maRKED WITH FLAGGED lathes. 1/2" steel conduit pipes. 5v~e~~ydR'st0l' f0vN q-1" N. 04" SCALE: 1" = 3o FI NO . Go T 1,1 vV,e / 9y -0. 'o 40 J 17o 2- /o/,o /o3: (Po 3 1,o I ST CROIX COUNTY BU yaxo (~~Gv SEPTIC TANK MAINTENANCE AGREEMENT d lv vew S 65 I. 430 ! OWNERSHIP CERTIFICATION FORM p~Re~ M Owner/Buyer ae 16-4 71 ys A e . TotjOk C+1jV001,2 , oGV.v Mailing Address /go N, W. /`l V~ ST J~~G[I et T /1i) - s s0 Z. Property Addressz / n./I?UT-e c - (Verification required from Planning Department for new construction) 0/0 - I30• oo • o-a Z City/State Parcel Identification Number /IJ~P ~ Z2Z9 ~ g t?3 LEGAL DESCRIPTION a -rpoy Property Location 1/4, V4, Sec. N-R _r W, Town of Subdivision V 7_ . Lot # Z Certified Survey Map # , Volume . Page # n Deed # -7 4 9 7 Q Volume z q I . Page # JC T f Warra ty Spec house ❑ yes A no Lot lines identifiable 0 yes ❑ no SYSTEM MAIN'T'ENANCE 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, journeymanplumber, restrictedplumber or a licensed pumper 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 fprth, 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 a three year expirati date. SIGNATURE OF APPLI 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 pro 7rty described above, b virtue of a warranty deed recorded in Register of Deeds Office. W /e SIGNATURE OF APPLIC 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 748766 STATE BAR OF WISCO IN F 2j 2000 KATHLEEN H. WALSH U 171 REGISTER OF DEEDS ST. CROIX CO.. WI Document Number RECEIVED FOR RECORD This Deed, made between Glove Company, a iscons Limited Liability Company Grantor, anBrightKEYS Development Corporation, 12/10/2003 12:30Pt1 Grantee. WARRANTY DEED E%EMFT It Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more REC FEE: 11.00 TRANS FEE: 2241.90 space is needed, please attach addendum): COPY FEE: CC FEE: =~through:1:6;I))ts 52 through 56 and Outlots 2, 3 and 5, Plat of Walnut Hill PAGES: 1 Farm in t e own of Troy, St. Croix County, Wisconsin. Exceptions to warranties: Easements, restrictions and right-of-way of Recording Area record, if any. Name and Return Address B 'g YS 18 Northwestem Ave. Iater, MN 55082 D Part of 040-1086-60-000; part of 040-1085-50-000; Part of040-1086-10-000; and part of 040-1086-80-000 Parcel Identification Number (PIN) This is not homestead property. Dated this 9th day of December, 2003. Glover Company, L - * - ACKNOWLEDGMENT AUTHENTICATION STATE OF WISCONSIN ) ) ss. Signature(s) authenticated this day ST. Agl )l County ) of , Personally came before me this G Ti/ day of 2jKL4vA i% 20 3 the above named Glover Land Company, * LLC, a Wisconsin Limited Liability Company to me known to be TITLE: MEMBER STATE BAR OF WISCONSIN the person who executed the foregoing instrument a wledged (If not, authorized by § the same. ALLEN J. O 706.06, Wis. Stats.) Notary Public State of Wisconsin THIS INSTRUMENT WAS DRAFTED BY l BrightKEYS Development Corporation. Donna M. Caywood. Notary Public, State of Wisconsin 1809 Northwestern Avenue. Stillwater. MN 55082 My 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 signature. WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 2 - 2000 r- V) E-1 0 ~ ~ 0 C LO 1~ . 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