HomeMy WebLinkAbout040-1174-95-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County. St. Croix
Safety and Building Division
INSPECTION REPORT sanitary Permit No:
430092 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:
Bond, George I Troy Township 040- 1174 -95 -000
CST BM Elev: j n IBM Description: nge /Map No:
1 06 ,1 (J 1 SectioNTown /Ra 24.28.20.676
TANK INFORMATION - T,. A , ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 1000 Benchmark
� • (oho /oy (o � Od. o
Dosing `• ,,_,� Alt. BM � n' ' I
ran y✓
Aeration (,V �� Bldg. Se• �exrr7
Holding t Inlet W
rH Aw � r "� 3 •
Ht Outlet
TANK SETBACK INFORMATION /I •� 2•
TANK TO /L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic ► Dtom a f, - vK aa�t —� S 0 7 g 0
Dosing ►lJ Heade
► P '7.3q X 17 3
Aeration Dist. Pi e
Holding Bo . C1 Z WCI J„04 qr,' y. yy 4 17 3 • )
PUMP /SIPHON INFORMATION Fin d� Z — ►�wi�( & 9S YI
Manufacturer Demand St Cover 9 0�
GPM ( r
Model Number
TDH Lt Friction Loss System e d TDF� Ft
!� (�
Force rr�ain Len Dia. // Dist. o Well
to
SOIL ABSORPTION SYSTEM S�
BED/TRENCH Width Len th No. Of Trench e PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 a n e 5'
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING nufa r:. l
INFORMATION CHAMBER OR 1 6 4
T Of System: / ( J / UNIT Model Number: G
a
�� Stan 1> 10 I
DISTRIBUTION SYSTEM 22 tA�n, 'S �m6P yC�nriG�e�
Header /Manifo ��t q;" 1 istribution [ A r' / — �f ole Si e 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 /0
Depth Over / Depth Over xx Depth of xx Seeded /Sodded xx Mulched "',
Bed/Trench Center Bed/Trench Edges Topsoil Yes l „i,I No L� Yes c No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / 2 �/ Inspection #2:
Location: 272 Cove Rd Hudson, WI 54016 (SW 1/4 NW 1/4 24 T28N R20W) St Croix Cove Lot 19 Parcel No: 24.28.20.676
1.) Alt BM Description =sue ���� t ��' `�QP/l_ /
2.) Bldg sewer length = Ac �dzal 10 / V `
- amount of cover lC ��
Plan revision Required? j Yes j- o
Use other side for additional information.
SBD -6710 (R.3/97) Date Insepcto 's ignature Cart. No.
Safety and Buildings Division County
as 201 W. Washington Ave., P.O. c x 7162
N visconsin Madison, WI 53707 - 7 6 Site Address
Department of Commerce Z-) 2— e Ob 0 N v0•S'O,J
Sanitary Permit Application Sanitary Permit Number �j
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide 3 O / Z
may be used for secondary ses Privacy _ _
❑ Check if Revision
I. Application Information - Please Print All Informatio E M ` L � 7 ;�! w �;) ; State Plan I.D. Number
Property Owner's Name r i Parcel Number
Property Owner's Mailing Address Property Location
2-7 2 0210-e- S � U � �y 'h
if ',f; S T �4 N, R E
City, State Zip Code Phone Number _ Lot u r Block Number
z w �efL0/6 3% 3 y z Subdivision Name G&M- Number
H. Type of Building (check all that apply) ❑City
V 1 or 2 Family Dwelling - Number of Bedrooms 3 ❑village
❑ Public /Commercial - Describe Use
Rhownsh;p Q
❑ State Owned () S Road
(4) ) earest
Co y�e '
III. Type of Permit: (Check only one box on line A (num ering . I er�,�el�wfplete line B if applicable)
]B. 1 ❑ New 2 Replacement System 3 El Replacement of 6 ❑ Addition to For County use
System Tank Only Existing System
El Check if Sanitary Permit Previously Issued Permit Number Date Issued
IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use)
44 P(Non - Pressurized In- Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland
22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line
45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other
V. Dispersal/Treatment Area Information:
Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade
Required Proposed Rate(Gals. /Days /Sq.Ft.) (Min./Inch) S.t'_. Elevation
y�'o ��.� & 53 t�
y � Pb OT
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Tanks Concrete Constructed Glass
New Existing I �j
Tanks Tanks fl
Septic or Holding Tank /�'tj /
Dosing Chamber - 7 5 0 �sO / C S
VII. Responsibility Statement- I, the undersigned, assume responsibility for Installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's Si re P/MPRS Number Business Phone Number
R . 1A L gR; C1.7 ;���� 2 3 -� s 7/5 -7-7 a- 3 5' y Z
Plumber's Address (Street, City, State, Zip Code)
VIII. Counnty /De artment Use Onl
0 Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Ag t Signature (No Stamps)
Surcharge Fee) -
❑ Owner Given Initial Adverse
Determination 2-Z•5 Q ,j
]EK. Conditions of Approval/Reasons for Disapproval n n _ Attach c Putus im we I o P.-5thesVyxdt em onthan 81/2 x it Inches m she iii _
SBD -6398 (R. OS /Ol)
q q'
NON -CON ALL
T SHALL
AREATMENT TANK
gE ABANDON E
ED PRO
PER GOMM. 83.33•
d
4e A)_r
a� di p aK5 S;
d ,A)
01
6 l �S � 3 � 2
G `/o
fo
S'T'. CROIX COUN'T'Y 'ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner (T�/e - J O N O NQ 3 8 tO • �3 y?' 'Z,
City /Stag - , Y(" V S0.J 141 • S'fp 0 0r,
L,egai Description:
Lot Block Subdivision /CSM # 4-v
t /. Y� , Sec. , T N -R W, Town of 0y PIN # byfj //7 Y • 9S• &w o
S EPTIC 'TANK -- DOSE CHAMBER -- HOLDING TANK INT0101ATION
Tank manufacturer = pV sy'/2t , Size 5T/PC tw - / Se tback from: House Well � P/L �
Pump manufacturer Z o E/M Model 9 l
Alarm location O ti — .0 S
(11OLDING WANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line _
Meter location
Alstm location
SO IL ABSORU TION SYSTEM
7' /c &
� � s
Type of system 3 VAe : Width Len th Number of Trenches
g
Setback from: House * 7 Is Well _�"P� /L Vent to fresh air intake ? 2- S
ELEVATIONS A r 5. f • Lo T 60AX -
- p OF 5V RU Ey0)2's / _T P /0 • �
Description of benchmark Elevation ! `
Desc�iptivn of alternate benchmark r'O P Of S1 Elevation
•�? 9
Building Sewer STAIT Inlet 3 r +L ST Outlet q� PC Inlet Z
PC ilgttom g b'� l header /Manifold Top of ST /PC Manhole Cover •
Distribution Lines ( ) O ( )
PU,K tt
Bottom of System ors ,
Dina) Grade ( ) ( ) ( ) � �• �� .
Date of installation / / Permit number 3 State plan number
I
Plumber's signature License number 27 L 6 3 - 13 Date /
Inspector _ /4 s /
Complete plot plan •
THIS POWT SYSTEM SHALL
INCORPORATE PER COMM. Ulbricht & ASS a Co Cons
83.44(2)c A PROPER ZABEL private Sewag
FILTER MODEL # ,Q . Igo D 2812 10th Ave* 54767
/ ' Spring Valley,
3 qq�_
ALL NON - CONFORMING
TREATMENT TANKS SHALL ` ,..{�
BE ABANDONED PROPERLY IV I R1 Ju Cr- v �� `' /� � A ^.)
PER COMM. 83.33. 4Z,5 — ?33 �
/A,' / � wARv 7 �w l�vte�
ASSOCIATES GO.
655 O'Neil hoad • Hudson, WI 54016 neg..veslgne►s o/Engineering Systems
715 -386 -8185 Private Sewage consui►anis
PROJECT INDEX
PLAN — L y^ 63
BATE i t &,%_t
OWNER � J Z ' �4A,) /3a tJv PHONE � --
- -
!� • � ADDRESS 2, 2_ C4gL/ . /�V -- SyO/so
LEGAL DE LOT /y. 57". 4e0 Co 50 /3 , 0
u
pI N o yp • /l7y yS oo� sue, �, S. y T-2- �E'zo w
T MI or 7-�Po
-- Q / COUNTY
LOCAL AUTHoRI'I'Y/ SUPERVISION S� . % X G�l_ 2 z t l
PROJEC DESCRIP'T'ION: , �CP��C�/� -1���
old - r1+Vkr
5 4,,j A; 11-VIIllee
TI
T;?
p,,4
s v� 5
r
ALL NON -CONES MjMG
TREATMENT TANK
E ABANCONEC PROPERLY
THIS POWT SYSTEM SHALL g CO MM . 83.33.
NCORPORATE PER COMM PER
j 83.4 4(2)c A PROPER ZABEL
FILTER MODEL # / f - le6-0 'RO t3 Ur A [ R j C (^
Ulbricht & Associates
Private Sewage Consultants
2812 10th Ave.
Spring Valley, WI 54767
/11 P R
Ll P9-1 INFILTRATOR SIZING WORKSHEET Z3
Pg.2 SYSTEM PLOT PLAN � �L
Pg.3 CROSS SECTION OF SYSTEM, WITH ELEVATIONS.
Pg.4 If n to it of 11
P9.5 OWNER MANAGEMENT PLANS & ZABEL FILTER SPECS
Pg.6 (OPTIONAL) CROSS SECTION AND SPECS FOR DOSING TANK.
PG-7 (OPTIONAL) PUMP PERFORMANCE SPECS.
I
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 /01.
b
y
0 0
0
- - -- - --
HIM Q
In
z N
L A �` - -� --
w
g�
fit o
Oak
0
N
lk
I 3 R �{�iy S 1s - 40 favi2
I
v � qAI Y I RMING
AL L NON -CONI
TREATMENT TANKS OPERLY
BE A8 OMM s3.33.
PERC
� 1
GS �
2
PR
f3 ,0
o�� !�, � ` ;vE w q,,� 1•��aysT
\ P 114s ri c S. r, '
63 5 ,, o
y, q ,' To e-
sy st �
fo
Lt
,,S • ..� _ 3� _ —.� , .. �� 1 � T
ti
q
Y O
3 Tp
1 ff
s4. Qo 9iP.M4 c l. O
wt
IL
OKI
�i�v, 9Cv. So
CRO SS SECTiox) o, 7 s
7e4 7 -0,<'5 oR 5 io Pl rFUS
3 1. Q fir. .tpi�ov cr�lc�r S� T`i'a.r.�
1ff
sc�. '010 yiPf�c= Sy
LA-��L,
. y
OVER: See Reverse Side for Vent/ Observation Pipe Details.
I ' An observation pipe may serve as a combination observation/vent pipe providing it terminates in
the same manner as required for vent pipes. See Figure 6.
Vent cap. Return bend Cep
t r� 12" min..
._ ry 12" min. rinal grade.��
Aggregate Oistributlon lateral
d
System elevation
Figure 6— Vent and combination observation/vent pipes
I ,
t `
Leaching chamber tops are at or below the original grade. Leaching chambers are placed directly
on the bottom of the distribution cell. The locations of leaching chambers are in accordance with
Table 3 of this manual.
• J •
Observation pipes are installed in the distribution cells and are provided with a means of
anchoring to prevent them from being lifted up. Observation pipes extend from the infiltrative
surface for stone aggregate systems or from the inside of leaching chambers to a point at or above
finish grade. The portion of the observation i below the d'
tstnbuti
p pe on i e for stone p p aggregate `
systems is slotted while the ortion above hove the distribution pipe is solid wall. Observatio
P n pipes for
leaching chamber .
g her systems are attached to the chambers in accordance with the chamber
manufacturer's printed instructions, extend from a distance _> 4inches above the infiltrative surface
through the top of the leaching chamber up to or above finish grade and terminate with a
removable watertight Cap. All observation piping has a nominal pipe size of 4 inches. See Figure
5.
Water tight cap i
f — V min. die. Top of
leaching Repair couplings
ch fn. b
Slot���
6" min. 6 "
m
" mill. IntlltratTve surtsa
Water Closet Collar Bar (310" min. dial
Figure 5 - Observation pipes
Vent pipes, if installed, connect to the upper half of the gravity flow distribution laterals and
extend up tout least 12 inches above finish grade. Vent pipes terminate with the vent opening
facing downward by, the means of a vent cap or fittings. Vent caps must allow a free flow of air
between the distribution lateral and the atmosphere. All vent pipes has a nominal pipe size of 4
inches.
1, / 1)
4PPI 04
l/ .�s
•�✓s/��c � io ,v �,¢�' oe --� -gyp .
OW 1,1s Ec r�o v
1 ff
l$
- C
7
A
CRo SS Sic Tiov
2tS /w 6-
w
3 s(v FT, IWA40 e:r if C/ y / L4 t , S r l l ewr)
ff
y �
_---�—
,OVER: See Reverse Side for Vent/ Observation Pipe Details.
PUMP CHAMBER CROSS SECTION ARID SPECIFICATIONS pf}GE `f of to
n
rr S� 46 b E > /D fo wr.�OocJ J7oo� r.P i u
w -VENT CAP I PI P �E
VENT PIPE
p
WEATHER PROOF APPROVED LOCKING
JUNCTION BOX MANHOLE COVER
_ j I 12 "MIU. I w/ 4vAXAJ A /3F/
GRADE
I
L — — x p COIJDUIT ________
f IEU�fr o �
INLET PROVIDE I - - - --
c�l.... —i.- -- - --- - - -- AIRTIGHT SEAL
APPROVED JOINT A I Ny � K I I i I APPROVED JOINTS
1J/ PIPE I AP �UM I ( I I P 4j
CXTENDfNG 3' 0� , I II ALARM EX 3
TENDING '
3 O I I I ONTO SOLID SOIL
ONTO SOLID SOIL B /1 �,
5r,4 ,'¢o pa _ ,, 3 . S I s�<, . -10 Puc
y a I O
3 C I
� ELEV. FT. � P __) 2 ��
` PUM OFF u-SE 3 oe
��/DiP eF
N i0 A1 BLOCK
RISER EXIT PERMITTED GUL4 IF TANK MANUFACTURER HAS SUCH APPROVAL
- SEPTIC E SPEC- IFICATIOUS
DOSE sNousr21iE5
TANKS MANUFACTURER: IJUMBER OF DOSES: PER DA-4
' TANK SIZE: 75D GALLONS DOSE VOLUME
ALARM MAIJUFACTURER:
�vzt .414Am 4 INCLUDING BACKFLOW: / D GALLONS
�t ,
MODEL ►DUMBER: I' Lj CAPACITIES: A= //// C 7 INCHES OR � '� - GALLONS
t SWITCH TYPE:— T B= INCHES OR 3 G ._ GALLONS
PUMP MANUFACTU Z
RER: DWC ,wr G = INCHES OR //� 0 GALLOWS
MODEL NUMBER: 3
�V �•�• D= F 7, INCHES OR w 19- GALLONS
SWITCH TYPE Pi 0yA' CX F /0+7— NOTE: PUMP AND ALARM ARE TO BE
MINIMUM DISCHARGE RATE :25'
GPM INSTALLED ON SEPARATE C IRCUITS
VERTICAL DIFFERENCE b ETWEEN PUMP OFF AND DISTRIBUTION PIPE.. � FEET - rAA.)I- Sr
• MINIMUM NETWORK SUPPL9 PRESSURE . . . . . . . . . . . �_ FEET; �ACt-
-F- i2 G
EET OF FORCE MAIN )( /� - Y F xoFT FRICTION FACTOR.. ''� FEET t O S
`�A�
6) TOTAL D91DAMIC HEAD = FEET
G a rr
INTERNAL. DIMEIJSIOMS OF TANK: LENGTH /2 ;WIDTH 6 7 • iLIQUID DEPTH 11 12- 11
• U tV U D /U.tiE �o� 1.2.5 ` da -2 to, f vG = D • s '4 4 � k P 7 4A)k
THIS POWT SYSTEM SHALL
INCORPORATE PER COMM.
83.44(2)c A PROPER ZABEL
FILTER MODEL # WL67' T O 1 5r - PRO n
1 ,0/5 / r•
if r
-Q SEPTIC TANK, per Comm.83.44 (2) (c) shall be equippe an
ou t attached approved filter devic (Zabel
fllter). Tank shall have an approved a
locking manhole cover for regular (every
12 months or less) inspection & servicing
g Y a
- licensdd service pumper.
ZOELLER EFFLUENT PUMP MODEL,'98
HEAD CAPAC1h1 clu"VE
�- M ODE L - 09-- t �/a 1
.--- M
I 3 'J /a
111 -
e 1 J /16
a _ 1 1/2 -11 1/2 NPt •--�
!, tUL1GNS I---- 90 Jo 1 go '
Ams 0 o 70 so
1 210
FLOW PEp MINUTE
►orue r wA UaafM+tow►IAu•,n,r, � '
f o rt W Ni ANe O•wAri N NA
CAPAt11r 1�
tlNI /e/MIN �
ru/ w // nNtt GA me ,
t 1.62 it a»
10 309 11 231 1
N to ft ore
� ee
leek Valve �� 6/11
CONSULT FACTORY FOR SPECIAL APPLICATIONS'
Elecfrlcel 8 helrlelors, for duplex systems, ere ev:Illable and •
ItiW*d whh on alarm. d Mercury float switches ere avaflable for conlrolling single and
P. M$ch**d ehernelote, ldf duplex syslems, ere ovelleble wilh a • three ouble Phase
ig beck whhoul term hvhch• t, gY mercury 11081 ewdches are avellable lot
varlabie level long cycle conliols.
I
i
611ndaid all mode - Welght 30 lbt • +!, ll,p 1 �•pry ep•rtlsd 2 WICTION Gular
It terl •� •�_ r1. eln le P t eerb 4 row owk h cat•wheh, no e+AsrnrJeonbolt�ulr•d.
Model V h p h F — Amps awhch, fteler b Control 9 •laollon e ek maeury aoy whc a
Mod• double PliOybeek mareury, Ooy
aim tell fMOf11,
M- __ _ ulo 0 6 P Ou leK 3. Mechenkal Allernator to oo12 at 10 001'
°r—!. L _ 1. e.e f 1AOl t ?, for correct model d EleeWcal /tMermla, • E Pak
Oct 0 -t ip —� Am -0 ' = ��21L `. Mercury pma now ewheh t0
tee 135 - ; t or t t I _ duplex (3) or 1 eoU gllern, ~ a cw*ol ActivNa 'Peew
?� t t t a 1 t t . " .H) "1 Pak ", lunedori
eenneetlon a wMed b aim• .
�* a duplex "f 48M to cow
r. ws 1t! here 'J Pall ". for walereefd eeM.,,__... �,�
to 116" aha ere aMbntel Meer f r•► b faf I an CembUv,
U641 11 tl,ebka eon Aun «, rUM11• CAUTIoN
( AM,� ►aeiye If • • M•�nua FW488, ke.tt'"'i 1Uurr•la AN InrtaN•Ilea el eenbelti pd•elren' ileee
ItMtf! "^NN•++• • e•,Ly flro•er and p wM„ Ceneel amt h Ne•n,01 •I AN •Melrteh end whin/ •hejld w dose ►r • w
e In• IM wed r•••nl N Et•ebp C nd �'� sad•• ehtvll ►� IsNewN t elo/-
N••Mt, Atil (ost1At !4 011c) and M (ewNNsw•i N,le1r 644
RESERVE POWEp 'Eb DESIGN
V For unusual condillons
.. , a reserve safel laclor la dngineered into the design of e,iery Zoeller pump.
MAIN rAr.t). 80x 16311
p
Z AW-LIZI l otdevr�'l.,A'r 10736 0311 Mtnulacturers of, , ,
� . #NIP ro: 3 ?6o ot Arne, lant
tetl� R Kr ln.�r6 Qula> rPS .fiver /9„/9"
„� (S ?1JI .• rACjS07► rr13671
OWNER# MAINTAINCE OF SEPTIC SYSTEM
r
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
syste:a. The owner is required by code to submit all 'necessary
maintenance /inspection reports to the controlling authorities.
SPECIFIC CONTACT AGENTS
� Governmental authority/ inspectors:
Licensed installer, responsible for providing an operation/
maintenance "Users manual.
Licensed servkce / inspection agent other than installer:
�iP� - G T � 5 .4� �' T,� -T�i D•v �U,y�i �v G- � .
� Electrician, for um
p P, electric controls, wiring units:
4 - 733
IM_ PORTANT OWNER41AINTENANCE REQUIREMENTS
i• Winter traffic (sledding, shovelring, etc.) across the
area shall not be permitted, or frost can /will
the ce11, freezing up the system. biscontinuos use e In a the into
winter (a vacaction tri
lead to freeze ups, p' resulting in no water use) can also
2• Water conservation needs to be exercised! Or system can be
llydrolically overloaded and destroyed. This sysitem was
designed for a maximum wastewater flaw of
Sa 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 611tage occurs, or a pump ,fails, it may result
I" a temporary overload of effluent being pumped into the
cell, which may adversely impact'the cell (leakdge). It is
recommended that a licensed pumper empty the dosing tank,
I allowing the pump to return to dosing the correct amounts.
Consult your installer immediately for advice.
5• Neglect of the vegetative cover
erosion (the cells insulation &
preventive) can lead to failure. Compaction or heavy
traffic also can destroy t he system. It IS NECESSARY TO
REGULARLY WATER T11E VEGETATION OVER A SYSTEM!! Effluent in
Elie system beneath IS NOT sufficient alone t0 maintain a
grass cover.
G. Periodic inspections by the owner,
necessar.
y or his agents, is
into t!ies and Parts have ebeen incorporated
inspection pipes), cleanout terminals on thefpressurized level
laterals, at each tip - for flushing and cleaning the laterals
out. The filter system in the tanks
ground cover /manhole). only a licensedia q i above
Person should be performing this work which Involves he alth
& severe safety risks. this
of. d
effluent alth
system's treatment cell shall also be regularly p th
Ins ected
� y,
x
iMsconaln Department of Commerce SOIL EVALUATION REPORT 3
rivlsion of Safety and Buildings Page / of
In accordance with Comm 85, Wis. Adm. Code
Mlach cornplete site plan on paper not less than 8 1/2 x 11 Inches in size. Plan must County 7 T eRorJ(,
Include, but not limiled to: vertical and horizonlal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. 0 S/0• //7y • 95 - Qo 0
Please print' all Informaflon. Reviewed by bate
r'ersonal information you provide may be used for secondary proposes (Privacy Law .15.04 (1) (m)). I
Property Owner 1...� 2.3
� -. / ►�- roperty Location
O F 3 V" Lot SA1 1/4I 1/4 S Tai/ N R (
Property - Owner's Mailing Address L 1 # Block # Subd. Name or CSM#
2-72 Co ve - pD • H 2 2002 9 . e;
tat Laves
City Stale Zlp Code Phone�t rpl City Sa$ �� uC� O�
/� ,O�•0� ❑ Village [ Town Nearest Road
FJ ?spa y _WEST
New Construction Use: Ja Residential / Number of bedrooms � Code derived design now rate y�-'o
. GPD
Replacement
❑ Public or commercial - Describe:
Parent material yy T LJ A i Flood plain elevation if applicabto /V
General comments n
and recommendations: - A� si • TE S U/ n vll o ( p E�T%
14 G/ f T f / � /3" XoE2'�
1 A Boring # 11 FA Pit Ground surface elev. — Boring �O�` 3a (( pG • Depth to limiting factor > / 1J in,
Horizon Depth Dominant Color Redox Description texture Structure Consistence Boundary Roots Soil Ap ftl Rale
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
'E1t #1 'Eff #2
o' R 2 /3 Ls / /J1/f /P v 7 c /P 2 z f . - i. Z
3 i0 r2 S S. 4,
,
Boring # Boring
111 - -- 111 Pit Ground surface elev. f�
n• Depth to limiting (actor � in.
Horizon beplh Dominant Color Redox Description Texture Structure Consistence Bounds Roots Soil Application Rate
in. Munsel( Qu. Sz. Cont. Color �' GPM
Sz. Sh, •En #t •Eff!!2
/ D • S /D)/� L .3 — GS /�J•rf '"�� �S 2 f 7 / Z-
2 • S GS
S S o •
Effluent Ni = BOD > 30 < 220 mg/L and TSS >30 _< 150 mg/L • Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) I Signature
R, E/2 T ?.14/.32 / C117-- CST Number
Address 2 Z Ce S Z 5
• Dale Evalualion Conducted Telephone Number
rc ssocia es
30 • (;Lee Z 7�s• 3slc • �lg
Private Sewage Consultants
655 O'Neil Rd.
Irurason, Wis. 54016
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ORIGNAL
D oti � Z 3
Property Owner Parcel ID 0 Page of
Boring 0 Boring 7 G Q
'-� Pit Ground surface elev. 7- fl. Depth to limiting factor ' Y In.
Soil Application Rate
I lorizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fit
In. Munsell Ou. Sz. Cont. Color 'Eff #1 TIM
Gr. Sz. Sh.
°y 10y/zy/ s vfe e- s
/R GS cs
3 3' o % S 2 Sq
Boring # [] Boring
lJ Pit Ground surface elev. It. Depth to limiting factor In,
Sol Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure. Consistence Boundary Roots GPD /fl=
In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. •EIIi/1 'EtfN2
r � Boring >Y L1 Boring
' Pit Ground surface elev. ft. Depth to limiting factor In.
Sol Application Rate
;` Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /n+
In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 6 EN41 #FW2
Effluent 1f1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent 02 = BOD, < 30 mg/L and TSS < 30 mg/L
r
The Department of Commerce is an equal, opportunity service provider and employer. If you need assistance to access services or
need .material in an alternate formal, please contact the department at 608 - 266 -3151 or'ITY 608- 264 -8777.
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ST CROIX COUNTY
SEPTIC 'TANK MA INTENANCE AGREEMENT
AND
OWNERSIIIP CERTIFICATION FORM
Owner /Buyer G d/F' A.)
Mailing Address 7.Z Cd (I R.
Properly Address
(Verification required from Planning Department for new construction)
City /Slate Parcel Identification Number • 117Y- y'O—• 6-r'a
LEGAL DESCRIPTION
Property Location .S�J '/4 ' , �` a
t Y /, Sec. , T N -R W, Town of q'
Subdivision -y o rx < - a v z yU l3 j) " , Lot #
# X11 , Volume , Page # <
Wart - nnfy Deed # 33o0 , Volwne s-s ,Page #
Spec house U yesX no Lot lines identifiable 'q yes O 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 (lie septic lank 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
master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site was(ewaterdisposal 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.
Ilwe, 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
slating tits( 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 ex itatiotr ate.
SIG TURF OF A PLICAN "1' ' ` DATE
d
MR CERTIFICATION
N I (we) certify (hit all statements on this form are true to the best of my (our) knowledge. I (we) 9m (are) the owner(s) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIG TURE OF APPLICANT
x DATE
* ** * Any information that is ►nis- 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 certiCed survey map if reference is made in the warranty deed
ORIGINAL
"
I
(� L/ 7 ?5_ - avj
..
LL , ,
ST. CROIX COUN'T'Y 'ZONING DEPAR'T'MENT
AS BUILT SANITARY REPORT
Owner CTEDI� 3 . 0 �p • d 3 '�, a >..
�ddt ^!sq Z. GOU,R_ 17 . r
City /S(ate f&U V SO..J &j /. S'1/0/c, 3 o 2003 �
Legal Description:
Lot I- flock Subdivision /CSM #
'/� , Sec. , T N -R W, Town of o y PIN # OV6 • //7 1•✓ 9.S' Oa'
S EP'T'IC 'TANK -- DOSE CHAMBER -- HOLDING TANK INE0101ATION
Tank manufacturer r" �fT/2t , Size ST/PC tw - / Se tback from: House Well 7S P/L �
Puma manufacturer _Z o E/ Model
Alarm location O ti � S
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line _
Meter location
Alarm location
SO AIZSOIZ PION SYS'I'ENI jai O,01 FFVS&7e C //S _ s 7 �&A )6 ke.S
u�Ri s
1Type of system: Width 3 Length Number of Trenches
Setback from: House _ Well 1"/L Vent to fresh air intake > 2, S
ELEVATIONS AT S. �'. L-a T 60 V4-
Descri ttion of benchmark TOP or- ` SOUEV O & _ 5 / S � Elevation
r k
Description of alternate be nchmark 7 of ELkl 51 Elevation �
Building Sewer ST /IIT Inlet ST Outlet PC Inlet
PC 13a11lom g'� y Ileader /Manifold Top of ST /PC Manhole Cover •
Distribution Lines O O ( )
Bottom of System ( ) ( ) ( ) ,� of t
Final Gtade ( ) ( ) ( ) b I. O
)A� J-1
Dale of installation / / Permit number 3 State plan number N
Plumber's signature License number 2 Z- 6 3 - 13 Date
Inspector _ �/VJ �t R
Complete plot plan �►
OR
RL
THIS POWT SYSTEM SHALL
INCORPORATE PER COMM. Ulbricht & Associates
83.44(2)c A PROPER ZABEL Private Sewage Consultants
FILTER MODEL # ,Q, . Igo O 2812 10th Ave.
' 1 Spring Valley, WI 54767
� 11 x g
ALL NON - CONFORMING
TREATMENT TANKS SHALL p
BE ABANDONED PROPERLY W I•I21 AJ � C7 'eI61A A.,�
PER COMM. 83.33. �/ � � /, 4Z 5 � �?
pPM P i,✓ r9'I2v ,vke�Z 7 .7310
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DOCUMENT wo. �� mr^rC ���*
VOL ,���JL '� (JL'��� THIS �����������M".°"==
�°��~�
' w�°�x� �
'
Arthur RGK�ST�RS��F�CE
'--����L����������-�������!!'��?'����!���-���'J���I'��?����.......... ST CqO\X CO.,VwIS.
.................. ........ '--'---.......... -- ....... ................. .................. ................... ........ -... 2mcd. forRe�wvd
Bond �s* A.D. 77
� .......... .................................. ---_---...... ........... .......
..................... ....... — .................. ........ ---' ......... - ....................... .... --- '-' 8 me of Deed*
�
..... .... ..... ........... ........ .... ...... ...... ' ------ ............ ............................ ..... , Gra""ee.A.-.
for `al""bleo"sioera'ioo .......... ........... - ...... ................ ................................................
..................... ............ ....... -------- - - "CT"RN`"
the followin described real =*te ................... ............. County.
State "vW/sr"=si".
Tax 4 ............... - ...... _.....
This '^'210.t—. homestead propert
Lot 19, 5t. Croix Cove Subdivision, in Township of Troy" subject to restrictive
and protective covenants and Declaration of Winford all of record.
SFER
FEE
sxopnvo to warranties:
Executed "L 7 �����^��������}�.� ^u^-' _' a" "�-~�r �� ___-.
/
SIGNED AND am^umo IN nvEnsnCmon '— � (ssax)
, W. Renander Jr.
............. ------ ....... .............. ..... - .... '- ......... ...
------ --------- ----- 0��� ---(»cAL)
__--
--------------------- '__.'--- ------- ----- - .............. - ......... (,sAc)
/
.... ...................................................... ... ..... ..... ...... ........ (scAc)
signatures vf .-_-_.__----_--_----_--_.__-_'__'N��- ............ ...........
_----__--__--__-__-____-
WA
Title- Member State Bar of Wisconsin or Other Pam,
Authorized under Sec. 706.06 viz.
STATE OF 'IRSCONNTZt–
to me known to be the persen ... S.. who exe-uted the foregoing instrZ
�d a�ln,
Anderson-Freitag, Inc. N.. 30, �i 73
New Richmond, WI 54nl7
Natnes of Persons signing in any capacity should be typed at prin!ed below their signatures.
WARRANTY DICIRM FORM No. 2 — 1971 Mal.eako. WIS. (.lob "Its)
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