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HomeMy WebLinkAbout040-1303-00-004 Wisconsin Department of Comrp&ce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Divisioj% . 4 INSPECTION REPORT Sanitary Permit No: 463221 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan 10 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: Wayne Homes I Troy Township 040 - 1303 -00 -004 CST BM Elev: f Insp. BM Elev: BM Description* Section/Town /Range /Map No: �. C / 0 ►U = � 22.28.19.1739 TANK INFORMATION E EVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark � (.J G--L 5 6 rt 12 f a5.( 1 J Dosing Alt. BM Aeration %' Bldg. Sewer • 1 `� oZ . 1 4 ' Holding St/Ht Inlet I St/Ht Outlet TANK SETBACK INFORMATION 6. 90 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic ! )S / 2� �__� - Dt Bottom Dosing Header /Man. Aeration Dist - f 3 Tpe Holdin Bot. System PUMP /SIPHON inal Grade ON INFORMATION cd.(' J Manufacturer Demand St Cover % - _-- -_____ GPM Model Nul,b7 I 9.9 TDH Lift Friction Loss System Head TD Ft I� v� Forc ain Length I Dist. to Well I SO&#B15ORPTION SYSTEM , C/TRE N Width / Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIM NS 3 0 Pte. 3) SETBACK SYSTEM TO I P/L BLDG WELL LAKE /STREAM LEACHING Manufacture INFORMATION CHAMBER OR Type Of System: > �S Model Numbe(f: 1 ylo�af.A� NIT DISTRIBUTION STE Header! anifold Distribution x Hole Size x Hole Spacing Vent to Air Intake � Pi (s) Length is Lang Dia Spacing SOIL tOVEA x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over — F — Depth of xx Seeded /Sodded r Mulched Bed /Trench Center Bed/Trench Edges Topsoil [� Yes 7N7o , � CO METS: ( d�`c,'od di cre encies, persons present, etc.) Inspection #1: � Inspection #2: - - t -- 1 - Lo tion: 648 Tribute Parkway River alts, WI 54022 (SE 1/4 SE 1/4 22 T28N R19W) Wain 9.1739 1.) Alt BM Description = 5 V�ww4�eM2 -CJtk �op5 2.) Bldg sewer length= if. 30 9 7 . 33 ' amount of cover = /Z� "� ) to .qr_ I l- 90 91 — — — — — Plan revision Required? Yes No Use other side for additional information. SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No. r Safety and Buildings Division County 57- C' /Qd� 201 W. Washington Ave., P.O. Box 7162 f '� AM W N isconsin Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 51 �(03 Z2 Sanitary Permit Applicati state Plan I.D. Number N/ In accord with Comm 83.21, Wis. Adm. Code, PM may be used for secondary purposes Privac Law, - flu) `_ ' 4- Project Address (if different than mailing address) I. Application Information - Please Print All I�ormati 0 4 (, 42 Property Owner's Na me Parcel # t Block y WAN cow S 1,34/0 Property Owner's M ailing Address _ Property Location 2 `q 2.2 5 Sr ` 6�t S '40 %, s � 'i,Section 2 Z City, State ION. Co de Phone Number / "' V J 5 / 77 ' S ' SS Z � le U. Type of Building (check all that apply) y � S „wt T N; ubdivision Name � GS#4- NnnbeF 4 • 1 or 2 Family Dwelling - Number of Bedrooms o � � ❑ Public/Commercial - Describe Use cz••• t L !»C.. _ t 113 ❑ State Owned - Describe Use ❑City _ ❑Village *ownship of TRM III. Type of Permit: (Check only one box on line A. Complete line B if applicable) - 1 3o 2 , — m - p p 0 f \, A. IXNew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only El 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. Tyw of POWTS §y-stem: (Check all that apply) CKNon Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter L.eac ' Chamber ❑ rip ine ❑ Gravel -less Pi ❑ Otbe (explain V. Dispersal/Treatment Area Information: S Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) ispersal Area Ppposed (so rys tem Elefatiod e VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel -Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank Aerobic Treatment Unit C O W Ca 1 Dosing Chamber iC VII. Respo nsibility Statement- I, the undersigned, assume respo nsibility for installation of the POWTS shown on the attached plans. Plumber's Na me (Print) Plumber's i gnamre PRS Number Business Phone Number R - &1 hRZt. � � BRV _2 , 61, 3 1 715 • 77.). • 3 11Y Plumber's Addre as (Street, City, State, Zip Code) -z,V 12- /o n— 51 % v6— U // GU /. 5 y7Ce VlJ9. CountynDepartment U5e O nly Approved ❑ D' pproved Sanitary Permit Fef Groundwater Date Issued ls gent Signature tamps) Surcharge Fee) ❑ Gi eason Denial IX. Conditions of ApprovaMeasons 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 pleas (to the County only) for the system on papa not has than 81/2 x 11 iwkm in size SBD -6398 (R. 01/03) Part of 040-1086-60-000- M of 040 - 1085 -50 -000: part of 040-1086-10-000: and part of 040- 1086 - 80-000 Parcel Identification Number (PIN) This is not homestead property. kJ,(fL Ltd s 33 RM � Aar (�M ,NA- P -------- - -_ - -- w �3 �lld ty0 Iu� SYST SHALL, r1 M. "E , ,-CIS POWT COMM. W 4d PER R ZABEL CORPORATE E P IN A PRO / Z.s D - l7� 1,3.44(2)r, �_ �ba � J FILTER MODEL # S TPC r! �o T" o� 133 J ?/fir co Z-0 7 1 5p ULBRICMT & ASSOCIATES CO. 2812 1 Oth Ave. - Spring Valley, WI 54767 Reg P D880x" of &Vneedng System 715- 772 -3442 PROJECT INDEX PLAN ID # DATE N O U . 2-Z- D f/ OWNER �W/ YNE /���5 �D'N -C. PHONE 7G 3 ' $5 4 ' .SS / 91 ADDRESS 2 2.Z.5 5 T• �5 /� Z j �"exl'r*,o M K1 . SS ,3 X4 LEGAL DESCRIPTION 4- 07 y W41N TAt, f e . ,411 of 6' Fy Y- 4, . Z z T2- Rte, TOWN OF 7 A'--OK COUNTY CSTM LOCAL AUTHORITY/ SUPERVISION T C /CD %x C�� .e LOCAL t''J PROJECT DESCRIPTION: Ne!� e&0,5 7`/eUC A . y` ai2 o HIS POWT SYSTEM SHALL ,tit & Associates INCORPORATE PER COMM. t=: ivate Sewag Consultants 83.44(2)c A PROPER ZABEL 2512 1 0th A e. FILTER MODEL # 4 S .rino Valley, WI 54767 t�o13C"RT S Pg.l INFILTRATOR SIZING WORKSHEET P9.2 SYSTEM PLOT PLAN Pg.3 CROSS SECTION OF SYSTEM, WITH ELEVATIONS. Pg . 4 " to 11 it 11 " P9.5 OWNER MANAGEMENT PLANS & ZABEL FILTER SPECS P9.6 (OPTIONAL) CROSS SECTION AND SPECS FOR DOSING TANK. PG.7 (OPTIONAL) PUMP PERFORMANCE SPECS. 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(N01 /01.� a _ 3 Vq 43- m Ra, Iv kA G A a L „ vim 1 e e WA v SHAL PO E SYS CO gEL r� � tS PER INGOR p, PROPER ZA D /Z $3.44( s f/�C ` T . F4LTER MODEL # A -1 60 15 A? T y GD � li /t1=e o� P�?opa54� ©T 3 133 u9�11 �D � 0�5T* r9 Pf ' +0 l D ` 11/N. ! 2 ., Irr Ir K .5a<, 4 � D,� C1 t Z L� ��L iE'A��J� TiC'�Y� �r� � s��7�•� Y 6 C,f4 SS 5 T/ox) O� T/�L` � i K 1q-1 e".-Mof C, /t� r/ Aj - � T IWIA/. 12- Iff tir� r N o K 3G', 1 OVER: See Reverse Side for Vent/ Observation Pipe Details. OWNER's'MAINTAINCE OF'SEPTIC SYSTEM -. POWTS (landowner) is reponsible for proper operation and maintenance of this system. Regular periodic inspections and servicing is necessary for the safe healthy operation.of.this system. The owner is required by code to submit all necessary maintenance /inspection reports to the controlling,authorities.. SPECIFIC CONTACT AGENTS * -Governmental authority/ inspectors: 3 g� 7(0 * Licensed installer, responsible for providing an operation/ maintenance. "Users" manual: 7a • 3 yy 3"401P'G4 7 * Licensed servwce / inspection agent other than installer: TiPt. '12113 0 *, for pump, electric controls, wiring units: IMPORTANT OWNER MAINTENANCE REQUIREMENTS 1. Winter traffic (sledding, shoveking, etc.) across the area shall not be permitted, or frost can /will penetrate into the cell, freezing.up the system. Discontinuos use in the winter.(a vacaction trip, resulting no water use) can also lead to freeze ups.` 2. Water conservation needs to be exercised! Or system can be hydrolicAlly overloaded and destroyed. This sys�em was designed for a maximum wastewater flow of & 6D - gals. daily. 3• POWTS are not designed to accomodate wastes from . a garbage disposal unit, or any other unnatural sources of waste. Any introduction of such waste materials will overload and destroy this system. 4. If a power outage occurs, or a pump fails, it may result in a temporary overload of effluent being pumped into the cell, which may adversely impact the cell (leakage). It is recommended that a licensed pumper empty the dosing tank, allowing the pump to return to dosing the correct amounts. Consult your installer immediately for advice. 5. Neglect of the vegetative cover (the cells insulation & erosion preventive) can lead to failure. Compaction or heavy traffic also can destroy t he system. It IS NECESSARY TO REGULARLY WATER THE VEGETATION OVER A SYS'T'EM!! Effluent in the system beneath IS NOT sufficient -alone tO maintain a L % ovwr . 6. Periodic inspections by the owner, or his agents, is necessary. Inspection pipes and ports have been incorporated into the system: on the mound basal area (effluent level inspection pipes), c.leanout terminals on the pressurized laterals, at each tip - for flushing and cleaning th out: The filter syst g e laterals efi in the tanks (via a locked above ground cover /manhole person should be )' Only a licensed properly quali6ied performing this work which involves health & severe safety risks. Evidence of effluent ponding in the system's treatment cell shall also be regularly inspected, Wisconsin Department of commerce SOIL EVALUATION REPORT Page of 3 Division of Safety and Buildings in accordance with Comm 85. Wis. Adm. Code County ST GA 1L 'V Attach complete site plan on paper not less than 8112 x 11 inches in size. Plan must 407– �� H include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions. north arrow, and location and distance to nearest road. )De,. j9 /, 6 b Please print all Information. doar� 15.04 R b D a bM ym provide +ray be used 11W seCWWWy Low. . c ( / Pro To D �3 ERS Te7f� 7 % i91� 17i govt Lot !r1 p yia 5 1/4 S T ZB N R / / E (or) W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# O t 5 C A tti IA- Ave IVALWO r E rtl City .HIV WR State Zip Code Phone Number 0 city ❑ Village (jd Town Nearest Road bP POE .H T5 M,k) L SSOWe 1 ( &5t 198 OY SD 6 -jouER _ o g& New Construction Use. M Residential i Number of bedrooms Lode derived design flow rate r OZ� GPD ❑ Replacement ❑ Public or commercial - Describe: tA Parent material 10 & - .15 O U S Olff2U Flood Plain elevation if applicable _ ^�/ �l tl General conrrients and revotlutieridafions: • �'�%�- r�sr�v S T ��� / �� �-ti %U y �Pov,�Q 1�•O.Cc�.T: s . P Boft �N I # ® pit Ground surface elev. " D ft. Depth to limiting favor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Text" Structure Consistence Boundary Roots GPDff . in. Mu nselt ou. Sz. Cart. Color Gr. Sz Sh. •Eff#1 I 'Eff#2 s /oy�3 L lsK s w at • . Co y l3 S l L T .5 hK 3 - 7• s YR SL 2,W shk G, a S 9 2. e«kg # ❑ Bourg /00.0 J0 . " fact � :,. . \• ® Pit Ground surface elev. ft. Depth l Soil icatiori Rate ` } Horizon Depth Dominant Color Red Description Texture Stricture Consistence Boundary Roots GPDW in. Munsell (]u. Sz Cont. Color Gr. Sz Sh. *Eff#i *011#2 (� /0 2 3/ Z- Z f N Z • l S �o �- �z- h v A C5 • z- • 3 N 3 15.2f �, a — • �' 75 1YlKe Z'S (. Z • Effluent #1 = BOD > 30 1220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L 'Number csT Name (Please Print) LB I? i G j T _ Signature / 042 Cs 3 � 5 Addrm Ulbricht &Associates Date E�i conducted Telephone Number' Private S P • Y p 7! S • 77A • 3 yy Z 2812 1 Oth Ave. Spring Valley, WI 64767 p;,)S - FO R ,q-p,P K . 2 yo 4 &e 5 0Y0 • 108 S • s ©. o 0 I0 k6 . /0 - OW t dyer • ���� � zo • o� o Yo • /0 *l - 70 • 000 0 00 • oar I l GUq� � � h�i // �tf�M • ' Tov�? r3 -1& P,5 TE ©T � Z 3 roperty f3vvner Parcel 10 # Page Of F31 ff t Groundsurfaceetev. /O /• 3 O tt_ Depth W WnIO g factor LM 5oit Rate "ortzon Depth Dot Cotor Redox Descrip#m Texture Shuct" Corw,istemle Boundary Roots G r _ in Munwit Qu. 5z. Cont. cow Gr. Sz. Sh. I i *Ef fei *F-M Y D /d 3 L 2 S hK dsA w f. • S z • 20 ,j o 71 .S 7 S o — S or *4.o F] Boring # C] SC-i -g [� pit Ground surface etev. ft. Depth to 8rniting factor in. Sol Application Rate � Horizon Depth Dorrninant CoW Redo Description Texture Structure Consistence Boundary hoots GPM iM Munseti Qu. Ste. CO* Color Gr. Sz Sh. `M °E"2 El Fit Ground surface etev. ft. /Depth to *n" factor in. Sol A lit�lort Rate Horizon Depth Darrfnarrt Redox -Description. exture Structure Consistence Boundwy Roots GPM in. Munsefl Qu. Sz. Cont. Color Gl. Sz. Sh. 'EIN1 'Eff#2 t 3 El BOnng Boring # Fit Ground ce eiev. ft. Depth to g facia' In. Sol Appkafion Rate Hortzon Depth Dominant Redox Description. Texture Sbvchure Gonststeix Boundary Roaft P In. Munsel Qu. Sz Cant, Color Gr. Sz. Sh. `E # 'E tf#2 ' Effluent #1 = B s > 30:S 22o m_q& and TSS >3o < I SO mg1t. ° Effluert #2 = BW,, < 30 ffV& and TSS <_ 30 VIWL The Department of Commerce is art equal opportunity service provider and employer. If you need assistance to access services of need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608-264-8 seuaaao n<smor l a ' dw PLOT PLAN WA LNUT HILLS FARM. LOT # � Pg. 3 of 3 d = Contour elevation lines. • = Backhoe Soil pits. Q = Benchmarks set, maRKED WITH FLAGGED lathes. 1/2 steel conduit pipes. � Af N SCALE: 1" _ 3 d N F Flo 3� e �1; tt" n /bot u /\' u 101, o � of /o /,o 3 mat � y o 2 74968 t f +. y ?1 P 3 STATE BAR OF WISCONSIN FORM 2 — 2000 KATHLEEN H. WALSH WARRANTY DEED REGISTER OF DEEDS ST. CROIX Co.. WI Document Number RECEIVED FOR RECORD This Deed, made between BrightKEYS Development Corporation, a Minnesota Corporation Grantor, and Centex Homes, a Nevada general 12/19/2003 10:30Alt partnership d/b /a Wayne Homes by Centex, Grantee. WARRANTY DEED EXEMPT # Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more TRANS FEE : 11.00 TRA FEE: 209.70 space is needed, please attach addendum): COPY FEE: CC FEE: Lot 4, Plat of Walnut Hill Farm in the Town of Troy, St. Croix County, PAGES: 1 Wisconsin. Exceptions to warranties: Easements, restrictions and right -of -way of Recording Area record, if any. Name and Return Address Wayne Homes 3650 Annanpolis Lane Suite 107 Plymouth, MN 55447 Part of 040 - 1086 -60 -000: part of 040- 1085 -50 -000, part of 040-1086-10-000. and part of 049- 1086 -80 -000 Parcel Identification Number (PIN) This is not homestead property. Dated this day of December, 2003. BrightKEYS Development Corporation * * ACKNOWLEDGMENT AUTHENTICATION STATE OF WISCONSIN ) ) ss. Signature(s) authenticated this day O *//- County ) of , - Roge r D. Bevers Notary Public ersonally came before me this day of 144 J 0 -9 the above named BrightKEYS * State of Isconsin Development Corporation, a Minnesota Corporation to me known TITLE: MEMBER STATE BAR OF WISCONSIN to be the person who executed the foregoing instrument and (If not, authorized by § acknow ged same. 706.06, Wis. Stats.) IP THIS INSTRUMENT WAS DRAFTED BY BrightKEYS Development Corporation, Donna M. Cavwood, Notary Public, State of Wisconsin 1809 Northwestern Avenue. Stillwater, MN 55082 MILCOmmission is permanent. (If not, state expiration date: ( Signatures may be authenticated or acknowledged. Both are not necessa *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 ! nta OF THE HOMEOWNERS ASSOCIATION, BUFFER SPACE, OR OPEN ACRE 15Z 47.01 ' o' \ " 478.80 37.14 N 85'46 37 E 38 83 \ 188•g � 9' \ 203.9 I z o ' �?\ 48438 S.F. I \ ,�� 6 11 Ac. 1 \ I 3 0 96 48115 S F 4 I M LO 46900 \ S. F. \� \B = �,. .. N 1 F `�' I 5 � .08 Ac. 1.10 Ac. I 1 48782 S. I I \ LBO - 964 LBO = 965' 1.12 Ac.� LBO = 965 0 . N v, Z 1 TO �- M Rp , , 6 cp 39 J \ -' 45670 S.F� =J2. 2 � 05 Ac. ' \ 15 1 \� 52821 S.F. a. 49159 S.F. 1.21 Ac. � � �\ � � 1 ` 'I _ �' 14 ° 1.13 Ac. N 87'56 \'57" W 219.22 �\ Nk o ` \ •g6 \ I (6 _ \ , N 46794 S.F. co �\ \ 0 F 51673 \ S.F. V 1.07 Ac. \ 1:19 "Ac. ' 143.76' 246.38' N 8218 S2 \ ti�s� . �`�� •� - '2546" W 672.35' _ — — 195.35 03 -- - - -- 2 5- \- -- 3- V` SHED \ \ •93� H0 SE ` 4,g ST CROIX COUNTY U/AWE:- S - . , SEPTIC TANK MAINTENANCE AGREEMENT AM / o wAv�i S 65 • 3 � ��� OWNERSHIP CERTIFICATION FORM Owner/Duyer Be i 6'ti / eA ys �®N Mailing Address �g 9 N W. Property Address V � g 1 r ► .� �-}-� �a r v� o� (Verification required from Planning Department for new co action)__ City /State Parcel Identification Number Part of 040- 1096.60 -000: M of 040- 1085 - 50-000_ part of 040-1086-10-000, and Wait of 040- 1096 - 804000 LEGAL DESC RIP� t'�'t�xa�c" 0 Properly Location 1 G V4, Y4, Sec. ?�. T � $ N R ' � W, Town of r Subdivision X W tl y l (� S rR/ , o U `f��` . Lot # Certified Survey Map # . Volume . Page # ay' 7 Warranty Deed # Volume , Page # s �� 7 Ce Speo house ❑ yes X no Lot lines identifiable yes ❑ no SYSTEM MAINTENANCE Improper use and maintenanceof 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 fimcdon 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 mastor plumber, journeyman plumber, restricted plumber 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 forth, herein, as set by the Department of Commerce and the Department pf Natural Resources, State of Wis^nnsin. 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. 1 SIGNATURE OF DATE yU' 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 rty describeA above, b virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLIC& d DATE * * * * ** Any information that is mis- represented mayit in the sanitary permit being revoked y 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 N #1v 2 S 4 VjG 31'1�2