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HomeMy WebLinkAbout040-1188-90-001 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Crol Safety and Building Division INSPECTION REPORT Sanitary Permit No: 1q 4881' GENERAL INFORMATION (ATTACH TO PERMIT) st�s�uD�N06 �11 Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. Permit Holder's Name: city Village X Township Parcel Tax No: Kolpin, Shane & Nicole I Troy, Town of 040 -11f CST BM Elev: Insp. BM Elev: BM Description: Sectionfrown /Range /Map No: ! zl:> (; n t G,$ T 36.28.19.814 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Z Benchmark Z IOa. Z JfIZ) Alt. B cb 3.58 . bz B d I Aeration 9. ewer Holding St /Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION (s- 93 '!A S TANK TO P7[: _ BLDG. Vent o Air IntaKe ROAD D Inl et i e� / / Z,7 Z-7 B ottom osing ea er an. 9a Ct7 Aerat D Pipe Y 9 (o H olding. o . ys em �x 9 r ina ra a PUMP /SIPHON INFORMATION 5. ZP anu ac urer G P ^an over (,Z- m odel um i Friction LOSS ys em ea F orce main ] 0131 : to vvell SOIL ABSORPTION SYS I'EM ! gin Of I IGTILMUS 115 1115ine u a. [quitl Depill i ENSIONS DIM U V CHAMBER OR 6z, INFORMATION UNIT Z7' 4b5' k AJA /o 111031111010 P-1 * 1 1 1 11 JA I fole SIM /d Pipe(s) Ength / O Dia Length Dia Spacing SOIL (;UVtK x Pressure Systems Only xx Mound Or At -Grade Systems Only E).PLI I � - r 8MCI.&SOdded Bed/Trench Center 1 Bed/Trench Edges Topsoil ` "* Yes No � ; Yes ' . ! No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / " ` Inspection #2: /� / Location: 75 W Woodridge Drive River Falls, WI 54022 (SW 1/4 NW 1/4 36 T28N R19 Oak Ridge Acres Lot 61 Parcel No: 3 .28.19.814 1. �� P Alt BM Description = ', CoJe.., I��J 1 h �✓� U -Joe-' 2.) Bldg sewer length = ; amount of cover - - -- Plan revision Required? C Use other side for additional information. t -4 Yes �No S (', _Date 1 - -J _ __- .. -- ---- tnsepcto ignatu SBD -6710 (R.3/97) I y and Building Division County off: Washi Ave., O. Box 7162 ��' iseonsi Mt I 5707 - 162 Sanitary Permit Number (to be fine Department of Comme t (608 $$ /3 Sanitary Perm Ap mat' State Plan I.D. N�u)m /bee rr In accord with Comm 83.2 1, Wis. Adm. C per nal i tion u pr e fV may be used for secondary purposes ivacy W. s (1 Project Address (if different than mailing ads _ss) I. Application Information - Please Print All Information Property Owner's Na me j parcel N ✓ t Block X Sham �- � (c of K ©t h Property Owner's M ailing Address Property Location `76 W WaL -art q t Y Yu SCE City, State Zip Code Phone Number 'A, 'k, ISLO Section � �VfY Ft�tWs W1 "T Z Z q (circle ) $ T II. Type of Building (check all that apply) /� T 2 O N; R 1 V E oi( W ) ,* t �2JipJS 5 54*+, Subdivision Name CSM Number XI or 2 Family Dwelling - Number of Bedrooms ,_. � �' /� , l� ' � ❑ Public/Commercial - Describe Use Y . L d e Acrc,,--) ❑ State Owned - Describe Use .84 C 5 ( �` - 0City_0Village'KTTownship of—TI-o(„j Ni III. Type of Permit: (Check only one box on line A. Complete line B if applicable) -j A, ❑ New System 'KRe lacement System y p y ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner t r) O`1 p 1 -30 19 e. IV. T of POWTS System: (Check all that apply) t — t X Non - 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- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) o, 6f EZ V. Dispersal/Treatment Area Information: I F L,) Design Flow (gpd) Design Soil Application Rate( gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (s f) System Elevation (0, 00 ✓ tS ✓ G OO .l lao0 ✓ �jp, p VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New , Existing Tanks Tanks dew 6)(1S Septic or Holding Tank IS�o 1000 /7 a t _ / e) SCY YY CPkS Aerobic Treatment Unit W p 6514 t� Dosing Chamber / VII. Responsibility Statement- I, the unde signed, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Na me (Print) P s ' gnatur MP /MPRS Number Business Phone Number �tUL es sf eir �- as�' Plumber's Addre ss (Street, City, State, ip Code) 0J T_ S(4 �z VII J. County/Department Use Onlyi Sanitary Permit Fee (includes Groundwater Date Issu Issu' Agent 'gna a (N tamps) Approved . ❑ pr�Ra,,n Surcharge Fee) �} �/ �/ ial R 7 U l` I tv - IX. Conditions of Approval /Reasons for Disapproval SYSTEM OWNER: i . 8" t: tank, e(nwt mor and eMaparsal qd must all b t mWntaitted as par namayentenI plan WwAded by plumber. 2. All setback Mpftnerds must be tnsinWned H as per appkablet clock / oftwim. r Attach complete plans (to the County only) for the system on paper not less thm 8112 x 11 inches in size SBD -6398 (R. 01/03) p pprp" 93vwo m3T#YP ��f wit( J A BM Ey 1000 -ri Se raK New �e ver t U�clvr E i N �r�r Fte lad 1g .0 3' f- Flow 2t�a f Flaw it �d 0 -5v I:e" ! e ! V BM S TaK� A1 ecN ?�¢ U� Eve E , ' 1J rte ��� t� �� x ' f Nom, IV L7ra F'� 2 lD e� C .2 flaw � Ba >A 8 14 rte V . /00. o U�G Wisconsin Department of Commerce S TI N REPORT Page l Division of Safety and Buildings in accords witAdm. e � County Attach complete site plan on paper not less than 81 x 11 inl� must include, but not limited to: vertical and horizontal refe nce pon and Parcel LDpercent slope, scale or dimensions, north arrow, and I n ��est ro d. - / — 9a - QG Please print alt inform Revievu d by zly Personal information you provide may be used for secondary p 15.04 (1) (m)). 1 6( o Pr operty Owner Property Location �� � Q I I f ki Govt. Lot 5 1A) - 1/4)V / WI/4 J ( T,�, g N R� Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 7 lie. trt�raac� r r r.c , to 1 ~- 6a k i d -r A ccs City State Zip Code Phoft Number ❑ City ❑Village X Town Nearest Road ❑ New Construction Use: �9 Residential / Number of bedrooms Code derived design flow rate GPD (0 Replacement ❑. Public or commercial - Describer Parent material Flood Plain elevation if applicable ft General comments and recommendations: ❑ Boring # Boring IT Pit Ground surface elev. 7 5 ft. Depth to limiting factor lVbAlf in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fF in. Munsell Qu. Sz. Cont. Color Gr, Sz. Sh. "Eff#1 `Eff#2 Q- !U YX 2 N bh t Sil J - rn � k m fr C S few . fo -S o 3 - ya lbY Y c / M bk t C w N - .3 4 ! 5'3 -S7 10 YR 5 5 S 77 - 16 10 Y — Q& C �l F -1 Boring # F] E] ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD1ff in. Munsell Qu..Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 - Eff#2 Effluent #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg/L " Effluerl #2 = BflD <30 mg/L and TSS < 30 mg/L CST Napes (Please Print) Signatu / CST Number Address Datfy Evaluation Conducted Telephone Number POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pag% 7DESIGN RMATION SYSTEM SPECIFICATIONS r ! � Septic Tank Capacity 1 Q Septic Manufacturer . NA ananuacturer �t�e� (1t B ARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model 0 ❑ NA Number of Public Facility Units NA Pump Tank Capacity — al J? NA Estimated flow (average) ! Cj Jrd g al/day Pump Tank Manufacturer O NA Design flow (peak), (Estimated x 1.5) 6 al /day Pump Manufacturer ❑ NA Soil Application Rate d gal/day/ft' Pump Model ❑ NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average ;4n-Ground persal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD _ <30 mg /L (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) :510 cfu /100ml ❑ Drip -Line ❑ Othe Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA * Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once eve ❑ month(s) (Maximum 3 ears) ❑ NA �': earls) y Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA year(s) Clean effluent filter At least once every: month(s) ❑ NA year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) W f NA ❑ year(s) lush laterals and pressure test At least once every: ❑ month(s) 0 0 N A ❑ year(s) ther: At least once every: ❑ month(s) ❑ NA ❑ year(s) er: ❑ NA TENANCE INSTRUCTIONS ections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: ter Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank ctions must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, ure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. ispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding ent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the ate notification of the local regulatory authority. he combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, n Administrative Code. ervices, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. sport shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) Page of T UP AND OPERATION PF or new construction, prior to use of the POWTS check treatment tanks) for the presence of painting products or other chemicals a t may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tanks) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems mus comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POW technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil an( evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holdin may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biorn infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGE' O ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. F PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS ins .Ma , ,) So lea T he POWTS INSTALLER POWTS MAINTAINER of Name L, C . �s• s rw K Name u C �it1 INN Phone Phone II I- q{ ) G - r co r8 W ASoo , r SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGUL AUTHORI q # Name QCWC L t_xn`l k/V( Name � . 0 C �' 4 nrt s a m Phone '715 _ D5- OZ S Phone q service This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisr START UP AND OPERATION Page of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cel)(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND .OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name L C . Via- / s ` - �✓ Name — Prcu'L c eywr' Phone '71 6- LIZ -SS4 Phone �(J_ `�as_SS�F� SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY E e Dal,Yfat Lknn k/V! Name e "��� _ atJ oZ S Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)0)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. 82.45 1 KATHLEEN H. WALSH STATE BAR OF WISCONSIN FORM 2 - 2000 REGISTER OF DEEDS Document Number WARRANTY DEED ST . CROIX CO., VI RECEIVED FOR RECORD This Deed, made between Thomas J. Jenkins, a single person 09/10/2006 10:45A)l Grantor, and Shane R.D. Kilpin and Nicole Kilpin. husband and wife as WARRANTY DEED survivorship marital property Grantee. EXEMPT # Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin (if REC FEE: 11.00 more space is needed, please attach addendum): TRANS FEE: 697.20 COPY FEE: Lot Sixty -One (61), Oak Ridge Acres in the Town of Troy, St. Croix CC FEE: County, Wisconsin. PAGES: 1 Recording Area Name and Return Address S &CBANK 100 Mill St PO Box 10 t Lake, WI 54810 040-1188- 40-001 Parcel Identification Number (PIN) This is homestead property. (is) (is not) Exceptions to warranties: easements, restrictions, and rights of way of record, if any. Dated this day of April• 2006 '�� 0__ * * Thomas J. Je AUTHENTICATION ACKNOWLEDGMENT Sienature(s) STATE OF WISCONSIN ) C4- r County. ) authenticated this - 3 day of .3 day of Personally came before me this April , 2006 the above named Thomas J. Jenking�` EL "4 TITLE: MEMBER STATE BAR OF WISCONSIN (if not, to me known ti be tfioer (s) who exeatted the foregoing authorized by 5706.06. Wis. Stats.) instrum i>:a owl ed tsal THIS INSTRUMENT WAS DRAFTED BY '_%� 2 Joseph D. Boles - Attorney at Law * +^ c:'. 4 ' 4L - � ..�`� River Falls, WI 54022 Notary Public. State (!t'ir ,, rtctr ,�````� My Commission is etmane t. (If not, state nation date: (Signatures may be audmdcated or acknowledged. Both are not necessary.) L 7 Z p G ) • Names of persons signing in any capacity must be typed or printed below their signature. INFO -PRO (800)655 -2021 www.infoprofocros.com STATE BAR OF WISCONSIN WARRANTY DEED FORM No. 2 - 2000 1 off APR. 5.2006;; E 7:33PM S ESTATE 715 425 1iVfs+ ' 715 9 eele TW15 985 9959 P.3 , '3 ST, CROIX COU1VW SEMC TANK MAMMUNCE AtaW49NT A N 3 OWNMU P CELT CAT10Y FORM eri�uyor mai ling Ac MS$ NaP". Ad ress Ne�catian ragtlited t}am Plaaul a ?o Departyoent i�r now ctattstruatian,) City /$tom Paxtoal IdeKti i '(m Nmnbas ON t TDwh 1 Tro Propaty Coc404 .. 1 Seek er T pj„ ' _W, Town of lAug LUIS �,ub @it►is�tt, � Lot #,jLL Cerdfied Survey Map # Voiutna Prage # ■■. —��.. Warranty Deed VC u= # sp ham Y" no lwoc ltna idettti�i�lo yes no . O Ianproger use sod mahrteU1=o of your aepda system *cold re It in its Pm=zro All= to htmdle wWag. Proper roaiatenaobo t onsists 01 Putn0 1 19 ont ibe sepdo tank every nitres yeeaa r scam, if moiled, by it hairmed pumper. What you put into the system sort Affect the Alnsties of the scpd* tnuk as a txeatnu nt /� otn6 in the waste dispass) system Owner ran itttktmar►oe resppnsik►laa dON xpfied in ¢Cotter, 6l,2 (7) and ra t.,h�ter l2 - Crain C*anry Sanitary Ordi>tiar>ce. ''dire pragerW comer agroee to subrnix to St: Crobt Cnrq Pla 8t Zoning l�epa�tn�aa a aerti#iaotlan si by file dwopx and by a a+aatee pbtnher,,f ottrneymsa pltmtbar, t*strlawd pIu er or 401 Um 1 tlt o Boomed pamper verifying that (1) the an-ole aastpwt 1 ptl of'sy disposal r is itt proper opet atiag cattditi0rt and/or (2) Ifta hispeadon and putmping (if amessary), tips sepdc muk Is Vacs, the undezeigoa$ have rend dm above rey remeAto aide to mainiein the pdVW sewage dispasat systatn with the standOds let forth. hewn. as set by tea Departmaat of ConmMIeea a nd the DepottrrM of NsuwAl Rmutm, State of Wiseomiu. escion stIldog drat your +epdc swim hex bean taaiMisw must completed and repr>•npd m the tic Cram Crnrnty Plsntnistg 8t Zantr<,9 Depnmtent within $0 dolor of the f me gear expimdon date. V" J' Mitt ail OUIRI roertra an d* -ffift ate no to the boo of NW /our lmowledge, Dwe am/ate the avmar(e) of the Oroporly deva ibed above, by 'vtmla of a Wamrity dead recorded in Rq isur of ooeds Offlee. NAmber of bedrooms f TLU DATE "any aatbrn�ndort tfsot is tni reaenCad my esult i y a the OW" PdA being cNVaked the Pta tartiog A zotdttg Depacrbm t lwl wid1 this applioatiar* a recorded warmly deals frain tare Aafflaur DIDeeds Office and a cagy of the certified survey map if refem, nee in made in the wzn=w dead, (I3$!e'Y'a Qfl/l14) I ' Parcel #: 040 - 1188 -90 -001 04/14/2006 01:51 PM PAGE 1 OF 1 Alt. Parcel M 36.28.19.814 040 - TOWN OF TROY Current ❑X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner O - JENKINS THOMAS J THOMAS J JENKINS 75 W WOODRIDGE DR RIVER FALLS WI 54022 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 75 W WOODRIDGE DR SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 0.000 Plat: 2237 -OAK RIDGE ACRES 9 p : LOT 61 SEC 36 T28N R19W LOT 61 OAK RIDGE ACRES Block/Condo Bldg: Tract(s): (Sec- Twn -Rng 401/4 1601/4) 36- 28N -19W Notes: Parcel History: Date Doc # Vol /Page Type 03/02/2004 755630 2519/454 TI 07/23/1997 933/83 07/23/1997 916/310 2006 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/21/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.000 35,000 174,100 209,100 NO Totals for 2006: General Property 0.000 35,000 174,100 209,100 Woodland 0.000 0 0 Totals for 2005: General Property 0.000 35,000 174,100 209,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 201 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Wisconsin Department of Industr PRIVATE SEWAGE SYSTEM c ounty: Labor and Human Div Relations Safety nd Buildings Division INSPECTION REPORT Oak Rid e St. Croix qty si (ATTACH TO PERMIT) Lot 61 Sanitary Permit No -: GENERAL INFORMATION SW4 ,NW Sec. 36,T28- R19,Woodridge Di. 140207 Permit Holder's Name: ❑ City ❑ Village 0 Town of: State Plan ID No.: Quality Blders. /Don Kruger Troy CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: �..:". 0 4), a �/L�� v5&j 040-11 ` . d A) � ..� L7 T E.,L TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic k" Benchmark x,56 Do, Dosing Aeration Bldg. Sewer /0 /. Uc/ Holding St/ Ht Inlet ,09 /00, 79 TANK SETBACK INFORMATION St/ Ht Outlet ,35 /00,5/ TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic I it , I (p/ a l S l,z NA Dt Bottom Dosing NA Header /Man. �,�,� �jct,0'f, Aeration NA Dist. Pipe Holding Bot. System 7, `� C/ PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand SV/ Model Number GPM TD H Lift Friction M ead stem TDH Ft L oss Forcemain Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BED / TRENCH Width Length No. Of Trenches PIT N Of Pits Inside Dia. Liquid Depth DIMENSIONS /g / � � � DIM N 1 N SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O /7 J/ �( OR UNIT mod Number: System DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing 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 ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) � 7 97 �7 Plan revision required? ❑ Yes ❑ No �yy Use other side for additional information. SBD -6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 1 } ©� �Iou5;e S y �c7Pri OeV, 92? 7' 3 ed I 13 � I � 0 E SANITAR Y PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY St. Croix STATE SANITARY PERMIT # - Attach complete plans (to the county copy only) for the system, on paper not less than ❑ ec ision to 7 Q 8% x 11 inches in size. if a revious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER Ll i. i � j1d S PROPERTY LOCATION RiCit ftr4 - FE K, Soy % NW Y4, S 36 T28 , N, R 19 fk(or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # Ret2� --------------- - CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER River Falls, WI 1 54022 Oakrid e Acres II. TYPE OF BUILDING (Check one) CITY NEAREST ROAD El State Owned ❑ VILLAGE Woodridge Drive ❑ Public 91 or 2 Fam. Dwelling # of bedroom PA EL Ax NUMBE ( ) 111. BUILDING USE: (If building type is public, check all that apply) 040 - 1188 -90 -001 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility /Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales /Repairs 11 ❑ Restaurant/Bar /Dining 4 ❑ Church /School 8 ❑ Mobile Home Park 12 ❑ Service Station /Car Wash 5 ❑ Hotel /Motel 9 ❑ Office /Factory 13 ❑ Other: Specify IV. TYffPPEII OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ILJ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit ## — Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other . 11 Seepage Bed 21 ❑ Mound - 30 El SpecifyType 41 El HoldingTank 12 M Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /day /sq. ft.) (Min. /inch) ELEVATION U 430 < ` � 7 Feet 00, Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION . !in ling Gallons Tanks Manufacturer's Name C oncrete Con- Steel glass Plastic App Tan Tanks structed Septic Tank (3 'e , ftP.uX1PZQftW81VIIV_I1%_% , 1� El I LJ El I Fj VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plu Signature: (N tamps) MP /MPRSW No.: Business Phone Number: Paul C.J. Steiner C 6780 1 1( 719 )425-9544 Plumber's Address (Street, City, State, Zip Code): 65 East Woodridge Drive; River Falls, WI 54022 IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue issuing Agent Signature (No Stamps) A Surcharge Fee) Approved El Given Initial /j /s 6-1 Adve e Determination `� U X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS - 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608 -266 -3815. To be complete and accurate this sanitary permit.application include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. Ili. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete litre B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1 -7. VII. Tank information. Fill in the capacity of every new and /or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model ,and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil Wit data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD -6398 (R.11/88) S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor,(spec house), then a second form should be retained and completed when the property s sold a ' Y and submitted to this office with the appropriate deed recording. g ----------------- - - - - -- ----------------------------------- -- - - - - -- Owner of ro ert P P Y Location of property1/4 vo 1/4, Section, TLN -R W Township V Mailing address ls Address of site ` ZL Subdivision name 0 /4C )ZI.04 AJeAZAs Lot n o. _ 1 f other homes on property? yes - No Previous owner of property c �4,41,� '> Total size of parcel J ,Fj 0 V &a]7 Date parcel was created Are all corners and lot lines identifiable? _Yes No Is this property being developed for (spec house) ?,4Yes No Volume �� and Page Numberc as recorded. with the Register of Deeds. ------------------------------------•------------------------------------ INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY.DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available; ;would be helpful so as to avoid delays of the reviewing process. If the deed description references to a certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we).certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded the office of the County Register of Deeds as Document No. , and that I (we) presently own the proposed site for the ewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of County Register of deeds as Document N o. . Signature of Plicant Co-applicant 1 Date of Signature Date of Signature DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2 -1982 THIS SPACE RESERVED FOR RECORDING DATA ' WARRANTY DEED 4'7 -3919 VOL 916P '31 galling Hills Development, T_nc ,,.... a Wisconsin REGISTER'S OFFICE ST. CROIX Co. cor orate on — Ree for Record I rd conveys and warrants to Eugene 0 . Don D . Kruger , at S E P 2 5 199' Larson, M and Lawrence M. Johnson, Jr., doing business__ C�Y'C as Quality Built Homes Register of Dew RETURN TO the following described real estate In St. Cro iX County, State of Wisconsin: Tax Parcel No: Lot Sixty -One (61), Oak Ridge Acres, to the Town of Troy. This is not homestead property. (is) (is not) Exception to Warranties: easements, restrictions, and igh of -way o g4j:I1 i. a Dated this �8 da K0 ING ILLS C. (SEAL) A - By: Richard N Fox, Preside (SEAL) — (SEAL) • - By: Frances J.- Fox, Secreta AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN SS. Pieei:A rot. nty. authenticated this day of 19 Personally came bitfc- me this_dgy. Aug.L sue 19 ,'theabbvenWrieloC) Richard N_ Fox 11d p ;; 0 Frances J Fox - _ TITLE: MEMBER STATE BAR OF WISCONSIN (If not to me known to be the person S who ekl btttd the authorized by § 706.06, Wis. Slats.) f reg i g instrument and ack owiedge t es- 0 THIS INSTRUMENT WAS DRAFTED BY C. L. Gaylord, Attorney River Falls, WI 54022 Notary Public —County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: 7 19 — .L. ) Names of persons signing in any capacity should be typed or printed below their signatures. S82 NTF 0021 WARRANTY DEED STATE BAR OF WISCONSIN Nelco Tax Fcim:l, P.O. Box 10208, Green Bay, WI 54307 -0208 Form No 2 — 1982 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix Count OWNER /BUYER Q3 41t ( S _�Q ADDRESS: C-)'C f6 /_ FIRE NO: F? LOCATION: SLJ 1/4,1/4, SEC. 36, T 2_�/ N -R // W, TOWN OF: To y ST. CROIX COUNTY SUBDIVISION: � ri��1c LOT NO. w/ 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 you septic tank pumper. What P P P Y put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system: St. Croix County residents may be eligible to receive a grant to help with the cost of the replacement of a failing system, which was in operation prior to July 1, 1978. St Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to the St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating 'condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification from will be sent approximately 30 days prior to three year expiration. I /WE, the undersigned have read the above requirements and agree to maintain the private sewage disposal system-in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification form must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: !' DATE: L f St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 r - 1EP,ARTMENT OF RE PORT ON SOIL BORINGS AN D SAFETY & BUILDINGS VDUSTRY, ,.ABOR'AND PERCOLATION TESTS 115 DIVISION 1 BOX 7969 IUMAN RELATIONS. l J P.O. MADISON, WI 53707 ` (ILHR 83.09(1) & Chapter 145) - OCATION: SECTION: TOWNS HIP /MbN+6+P,�kt+T -Y: LOT NO.: BILK. NO.: SUBDIVISION NAME: SW N'w 1/4 3 6 �ToFN�R (`1:E' TR OY G I OAK RIDGE / - \C kGS 'OUNTY: OWNER'S BtYf-ER'S NAME: MAILING ADDRESS: ST, C. R O 1X RICILIARD ICOA R S R /VL,R •/ W/, $4O z Z )SE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DES RIPTIONS: PER LA ION TESTS; Residence 3 RNew ❑Re lace �" - - ,A p IA S= Site suita for system U= Site unsuitable for system :ONVENTIONAL: MOUND: IN- GROUND PRESSURE: SYSTEM -IN -FILL HOLD ®S ING TANK: RECOMMENDED SYSTEM: (optional) ❑U ES ❑U ®S ❑U EIS ®U OS ®U CONVE NTION AL- SED 1 f Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the nder s. ILHR 83.09(5)(b), indicate: L fA = S 2 Floodplain, indicate Floodplain elevation: NA. PROFILE DESCRIPTIONS PIL.L.(3T IL - T 1- 0 -,\tc, R, q I 3ORING TOTAL ELEVATION D PTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH !UMBER DEPTH I N , OBSERVED EST. I G H E TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 3- / g3„ 99. 8/ Al0NC 0 - 2 0 "a/ vfsl; 20 -39 ♦ '8n fssi l; 3 9 - 73' 3 -0 'T7 /00,02 /ti/0/VC $7" 0 / "e/ V. z /) /9 3 "l3rt 1; Med /S J _ X0-57 "13'It , hFC/5 • S1 '7 "13n lned /5W Med s I band " _0 "8 /vfsI� /6, -46 43/1 fIS; 46 --57",6,n r•+1ed 3 $3 /00,3'7 NOME > � _T 1 - T3 !3n C - V c s / 6Q,1 ds fs !; /� -SS" L-3h f IS -67s -67s S4 " B- 4- � 4-� /0 /, Q6 /U Q/VE > v S4 Qn n-�a cr s cv Dk6'yt •,� / 6ar, B S $ /00, 8 �V oil /GC 47 `Bn f /s� 47 -G 2 `lj,1 ,»ed 85 N 7 62 - ES'" [3�, c/s c� r�1ed s / hanvlS ctnd r 3- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL- INCHES RATE MINUTES CUMBER INCHES AFTERSWELLING INTERVAL -MIN. PERT D1 PERI D2 Pr=R100 a PERINCH P . /V. A. P. 5 7", 0/ cCOUnl 7 s OiL. s'vk Iii Y I.vaIIC A 7• t Z P- 5Y 5 TE E� C_ Vr 7 0 /V P- .OT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- ntal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent land slope. YSTEM ELEVATION 97-97 1 i � i 1 - 1 , _. I \4 -� 4�t i �- `� a.wS I 1 � sly , A .T.N. M•1 .. K _ � i F J V• r- � 1 N _....._p !.. _ \ SG g y y on the undersigned, hereby certify that the soil tests reported this form were mare by me in accord with the procedures and methods specified in the Wisconsin iministrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. aME (print): TESTS WERE COMPLETED ON: ]DRESS: CERTIFICATION NUMBER: PHONE NUMBER ('optional): RT. / Q / Z -111q . t v �� G+✓'l, ;3 'D �'7iS)2 "73-362/ / G C CST l NATURE: / t iginal and one copy to Local Authority, Property Owner and Soil Tester. R. 10/83) — OVER —