HomeMy WebLinkAbout042-1004-50-400
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
552330 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:
Matacz nski, Randel & Wanda Warren, Town of 042-1004-50-400
CST BM Elev: Insp BM Elev: J BM Description: Yl n Section/Town/Range/Map No:
03.29.18.37A40
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
4
Septic /00C) Benchmar ( 6
Dosing M ~O y Alt. BM S 6,~O 16
s'tr~f 1^ / g
Aeration Bldg. Sewer
Holding / St/Ht Inlet A
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL jBLDG. Vent to Air Intake ROAD Dt Inlet
Septic ' t Dt Bottom (~T g 13
Dosing HeaclerNap-
G l►
loe
Aeration Dist. Pie S e Y' LT 4 Q -7~ 7
Holding Bot. System lit `5'eiWnY f '
Final Grade
PUMP/SIPHON INFORMATION Co J ~S.s ~g.
Manufacturer Demand SL:5-ver -cF
GPM
Model Number q (7 2~ 3
1 js l(~ r✓
TDH Lif~ 1~ Friction Loss Syste d TDH Ft
Forcemain Len th Dist to Well
5 S
-2- g ~s / s - r✓v~a *111121
SOIL ABSORPTION SYSTEM /rj u~y~yh.Gy~
BED/TRENCH Width) Length No. Of Trenches PIT DIME NS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS --L SD
SETBACK SYSTEM TO P/L I~F BLDG WEL LAKE/STREAM LEACHING Man slur . .
INFORMATION CHAMBER OR v ~Y S~tE
Typ f
System: ,vo► UNIT Model Number:
'L 5
C 1/l
DISTRIBUTION SYSTEM '"~5 Su SAryV, !
Bader aniI fold f Distribution ry h x Hole Size x Hole Spacing Vent to Air Intake (iMl
Pipe(s)
Length Dia ti Length Dia ~ Spacing `mo'd QY+S
SOIL COVER D x Pressure Systems Only xx Mound Or At-Grade Systems Only k S ~O Pn'S
Depth Over r Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center ~J BedlTrench Edges Topsoil / Fo-1 Yes rv~ No Q Yes [E No A-A COMMENTS: (Include code discrepencies, persons present, etc.) Inspection
#1: ~ Inspection #2: / /
Location: 1227 Cty Rd E New Richmond, WI 54017 (NW 1/4 NW 1/4 3 T29N R1 8W) NA Lot 4 ITS Parcel No: 03.29.18.37Ar40
1.) Alt BM Description = srb~n of h t I° k-as-1- a t ~ 5ys~ yw u, vecY
2.) Bldg sewer length = ~J 0' d, , 0
-amount of cover~1
Plan revision Required? 0 Yes o q E/71 Use other side for additional information. e9 (17 fG
Date Insepctors Sign lure Cert. No.
SBD-6710 (R.3/97)
CountyJ
,
)y Safety and Building vi n ~
p 'fir 201 Washington Av 7162 Sanitary Permit Number (to be filled in by Co.)
SP 1 I re'~ Madison, WI 537 -7
S 3v
an* it Application State Transaction, Number
in accordance with SPS 383.2 (20t~ ode, submission of this form to the appropriate governmental unit ~
is required prior to obtaining a permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different han mailing address)
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary / / u-1 A lC
purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. c . yV a
1. Application Information - Please Print All Information %O ~ `
Property Owner's Name Parcel #
i~la G~v2- (004-(- 0 - 000
Property Owner's Mailing Address Property Location
1_~ g5 ;7, Dirl 044 Igo `~S13
City, State Zip Code Phone Number ~W y4 /4, Section_
~ (circle one),,,
o ( J 7 T N; R ~ Eorv
II. Type of Building (check all that apply) Lot #
sZ 41 Subdivision Name
Al or 2 Family Dwelling -Number of Bedrooms V
L:7v Block #
❑ Public/Commercial - Describe Use ❑ City of
CS Number ❑ Village of
❑ State Owned - Describe Use
IL4 r a KTownof
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
PB. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
List Previous Permit Number and Date Issued
❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New G I
Before Expiration Owner 3 g 30 / a000
IV. Type of POWTS S stem/Com onent/Device: Check all that apply) Non-Pressurized In-Ground ❑ Pressurized In-Ground At-Grade ❑ IvloPnd > 24 in. of suitable] ❑ 1 ~OUnd
<24 in. ofJ) suitable syilC~~CI .
❑ Holding Tank ❑ Other Dispersal Component (explain) C7G4✓ J)~C~i'rett~atm nt De ice{2xp
V. Dispersal/Treatment Area Information:
Design Flow (gpd) Design Soil Application Rate(gpdsf). Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation r L
ys~ t,- r r~~
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units U 2
New Tanks Existing Tanks
FU O-i
r'e gt~ Septic or Holding Tank 0
Dosing Chamber V
VII. esponsibility Statement- I, the undersigned, sume responsibili for installation the POWTS shown on the attached plans.
Plu ber's Name (Print) Plu is Si at r MP/MPRS Number Business Phone Number
t-)L5 ra 50 ~S 5 31- Q94M
Plumber's Address (Street, City, tat e, Zip Code) I ' y 0 S a S~
W b 4 ~ y
VII our /De artment Use Only
Permit Fee Dat Issued Issuing Agent ignat e
Approved ❑ Disapproved $ i i~Ct✓
❑ Owner Given Reason for Denial / h Z zL 11K
IX. Conditions of Approval/Reasons for Disapproval 2 , ) ie
SYSTEM OWNER: Gyi-I~r~h/G fiU).(/`~'h
1 Septic tank, effluent filter ands, dispersal cell must all be serviced / maintained kid ,
as, ppr mA13.qqerni-nt pl;;n p %dripri hy plitmi- L =M4~ 64- _F and bmit to the County only on paper not less than 8 /2x 1 inches in size
2. All setback requir&1t9M%cPf1telY4WA1M&1h196
/Ul
as per applicable c de/ordinances.
f C ? ~✓Yt G7 f~J° Sf' 3 S/ 2 r 5
SBD-6398 (R. 11/11)YIR:I Get ~(t[
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own, RAfj ~ e l ~/1112"~C~y 0151d`
g $3 3
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a e(~t cF^ K) uj AU W ` ll 5.3 1$ CJ
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Soil Absorption System Cross Section
-
14 4" Schedule 40 Final Grade
PVC Vent Pipe n .7 ft
With Vent Cap
Leaching
Chamber - e
System Elevation
ft -
Soil Absorption System Plan View
ft
-76-ft
{
Leaching Trench 1
Vent Or Observation Pipe ~ Chambers
4° Dia.
Trench 2 Header
~~v1Lrv~,(-~ ~5 ~
Leaching Chamber Specifications
Manufacturer And Model J--N LT-rv~-tr5 r ~14i c < '1
EISA Rating c~&_ sq ft per chamber. Soil Application Rate gpd/sq ft
gpd Design Flow _ Soil Application Rate ll_6 EISA Chambers
rows of chambers each.
Page of
ra ~C''
Chamber SAS
SYSTEM ELEVATION AND SIZING CALCULATIONS
Below Grade Soil Absorption Systems
Randel Mataczynski Owner's Name 4!18/2012 Review Date
0Y or N Highly Pretreated Effluent
3 ft Suitable Soil Below System ,
12 in Chamber/Unit Height2
8 ft Maximum Bury Depth 3
Infiltrator SiMiMd
450 gpd Estimated Daily Peak Flow
0.40 gpd/fe In-situ Wastewater Infiltration Rate 1125.00 fe Chamber/Unit Area
QaD EISA ft2 / Unit
jf # of Chambers/Units
96.00 It Proposed SAS Elevation 6b Bottom Area fe / Unit
Soil Surface Acceptable Finished Grade EL 4 (ft)
Boring Grade Limitation SAS Elevation (ft) System Minimum Maximum
Number Elevation (ft) Depth (in) Lowest Highest Elevation? 98.00 105.00
1 99.00 74 95.83 98.00 Yes
2 98.60 75 95.35 97.60 Yes
3 98.50 66 96.00 97.50 Yes
4 98.10 78 94.60 97.10 Yes
5 98.10 66 95.60 97.10 Yes
1. Depth of suitable soil required below the infiltrative surface for treatment.
2. Total height of chamber in inches.
3. Maximum bury depth as per manufacturer's recommendations.
4. Based on chosen system elevation, and chamber height. Top of chamber is
equivalent to top of aggregate. The addition of fill for cover or the reduction of
finished grade may be required to meet minimum or maximum code standards.
Version 4.0 (04/03)
y h, 1
A OBE
y `
Ouick4 Plus Standard ,harnbet to and End Viev,_,,
48"
(EFFECTIVE LENGTH)
0 12"
fd
_ W
I~ 3e
uick4 Plus All-in-Oise. 12 Eri 'ront, Side and Enid Viewr
11.2"
13° t514-
' INVi ERT 5.3" INVERT
8T-IM
QLJi k4 Plus All-in-One Periscope
OUKM PUIB
ALL-I,NN-OUE /
12.7" INVERT auacaaw -0i s12
NDIC
NDCAP I~
E
Quick4 Plus Standard Chamber Specifications
Size (W x L x H) 34" x 53" x 12" (86 cm x 135 cm x 31 cm) Invert Height 0.6", 5.3", 8.0", 12.7"
Effective Length 48" (122 cm) (1.5 cm, 8.4 cm, 18.5 cm, 22.6 cm)
INFILTRATOR SYSTEMS, INC. STANDARD LIMITED WARRANTY
(a) The structural integuty of each chamber, end plate, wedge and other accessory manufactured by Infiltrator ( jnl1S')r weer -staiIuo and
operated in a leachfield of an onsite septic system in accordance with infiltrator's irstructions. ~s warranted to the original purchaser ('Holder)
against defective materials and workmanship for one year from the date that the septic permit is issued for the septic system containing r-e Units
prWded, however, that;' a septic permit is not required by applicable law, the warranty period will begin upon the - late that '.nstallation cf the
septic system commences. To exercise its warranty rights, Holder must notify Infiltrator in writing at its Corporate Headquarters in Old Saybrook, -
Connecticut within fifteen (15) days of the alleged feet Infiltrator will supply replacement Units for Unts determned by Infiltrator to b c covered
by this L mated Warra. ~ty. Infiltrator s fiat" Fly fec-ifically excludes Lh cost -i nmoval and/or installation cl the Jnits_
(b)THE LIMITED WARRANT) " AND REMEDIES IN SUBPARAGRAP in) ARE EXCLUSIVE. THERE ARE NO OTHER WARRANTIES Wf RESPECT
TO THE UNITS INCi 2-ING NO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICUI_AP URPOSE
(c) This Limited Warranty shall be void r any par of trio chamber system s manufactured by anyone other than Infiltrator. The Lm,led Warrant' INFILTRATOR"
does not extend o incidental, consequential, special or in^.rest damages. Infiltrator shall no: he liable for penalties or liqu, dal n damages, -
including loss of production and profits, tabor and materials. overhead costs, or other losses or expenses incurred by the Holder ar any :bird party. 5' t i S i tP C: .
Specifically excluded from L.mired Warranty coverage are damage tc the Units c, c to ordinary wear and tear. alteration, accldent, misuse, abuse
or neglect of the Units; the Units being suclected to vehicle Val(c or ot'. er conditions :Mich are not perrroccl by the installation in lru ti --ts, failure
te. n;aintain the mintrnum ground covers set forth in the installation instructions the placement df irrtprocer material ant" the system curtaining 6 Business Park Road ~ P.O.
Box 768
the Units failure of the .:nits or the septic system duet al siting or improper sizing excessive mater usage, improper gr, a e disposal,
or improper operation or any other iavoW not caused by I filtrator_ This Lmitecr Warranty shall be voic the Holder fails tc comply wr h all of the Old Saybrook, CT 06475
terms set forth in this I_innto Warranty. f wtnor, In no event shall Infiltrator be responsible. for any loss or damage to the Holder the .nts. r-~r any 860.577.7000 - FAQ(
860,577.7001
third party resulting from installation or shipment, or from any product liability claims of Holder or any third party. -or this Limited Warranty to
apply, the Units must be installed in accordance with all site conofions required by state and kcal codes, all other applicable laws: and Infiltrator s
installation instructions. 800.221.4436
(d; No representative of infiltrator has the authority to charge or extend Otis Limited Warranty- No warranty applies to any party other than the www.infiltratorsystems.com
original Holder.
The above represents the Standard Limited Warranty offered by IhfiltraiOr. A limited number of states and counties have different warranty
requirements. Any purchaser of arms should contact Infiltrator _ Corporate Headquarters in Old Saybrook Connecticut, prior io such eurchase,
to obtain a copy of the applicable warranty_ and should carefully read that warranty prior to the our: -ase of Units
x
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eNn'.~ in+I•e.h..~ 'U.S its. 4,759.66' S,0 1.5.156.488, 5,336.01 5,401.1'.6: 5,401.459: 5,511,903; 5,716,163: 5588 778, 5.839.844
Cana an Patonts: 1,329,955 .004.564 Other patents pending.
Infiltrator, Equalizer, Quick4 and Owck4 Plus are registered trademarks of infiltrate, Systems In Infiltrator is a registe ed traCemafk in lance 1 lit ater Systems Inc_
is a registered bademark in Mexico. Contour Swivel Connectrdn is a frariemark of Infiltrator Systems Inc. y 2009 Infiltrat ,r ,vstem., Inc 'rintcc r U.S.A. PLUSG'r 10100-9
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ti
r~ ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
" M r N s M r' r~irr ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680 FAX (715) 386-4686
Page of
COUNTY ON-SITE VERIFICATION FORM
Inspector: Date: p / 6
Parcel ID Nu ber 6412. -)yi 5 #06
z rty€ mer ii roperiy omtion
T , Govt. Lot /VA)1kt Aiit f4 s 3 T 2.41 N R f E (or)
Property CSvmer'sMailing Address Lot Block* Subd. Name orGSk
Izz-2 C'6 - Vo H 1191 3 S3 5
GAY State Ap o e Ptme Number ❑ CkY Village awn /Natest Road
i lnJa -
❑ NewConstruoiion Use: ❑ Residential I Number of bedrooms _ Code derived design flow _ GPD
❑Replacement ❑ Public or commercial - Describe:
Parent material _ - ,W,_ ..,,Y. - Flood Plain elevation if ~plicable . _ _ _ ~ ~fi.
General comments Gzi; 6^: (I
and recommendations:
F _t] Boring # wing _
❑ Pit Ground surface elan. ft. Depth to limiting factor in.
3cil ADPlication Rate
Horizon Depth Dominant Color Redox Description Torture structure Consistence Boundary Rods GP[3y1F
in. Munsell !Du. Sz. Cont. Colcx Gr. Sz. 5h. T01 'Eff#2
D-JZ. /b ~L - 4-7 MS &,A- G
Z- 1 ~ J /a Y~ ~ ~ m G
/A Ji5 L Sri o
Conditions: _Pe,~C#LP_V%&e'J_
c u4, • ~ G` L .
Soil Survey description:
Notes:
FEE:
V{ isocsnsio Department of Commerce PRIVATE SEWAGE SYSTEM County-
Sitfety and Buildings Division INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitant Urmit No.:
Personal Information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. 383812
Permit Holder's Name: ❑ City ❑ Village Z) T,Rwrno State Plan ID No.:
Matac ski Randel & Wanda Warren Township
CST BM E ev.-, Insp. BM Elev.: BM Description: Parcel Tax Nn
U 042-1004-50-000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic C p4e G UO Benchmark 3, d 3. S
Dosing Alt. BM ~1
Bldg. Sewer _74Z 9I• P3
Hol S Ht Inlet Z
TANK SETBACK INFORMATION
TANKTO P/L WELL BLDG. Ventto ROAD
Air Intake -9k Wet
Septic _7 j ' 3a / Zq NA Dt Bottom Q 14 Z
Dosing 7S~p r "f Z q ( NA Header / Man.
NA Dist. Pipe G2
Ing Bot. System M 1`• r ` 3
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand St cover
Model Number GPM
TDH Lift q, Friction Z System TDH & F
Forcemain Length,' Dia. Z, " Dist. To well
SOIL ABS RPT{ON SYSTEM d s ea
BED THE Width / Len th / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSTO 1-- N 2 7 DIMEN 1 N
er:
L Mannuctur
SETBACK SYSTEM TO P / L BDG WELL LAKE STREAM
INFORMATION Type O I um er:
System: L too DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipes} i ~x Hole Size X Hole Spacing Vent To Air Intake
Length-_L Dia. Length Dia. Spacing r
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of FxXxx e ded /Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
Inspection #1: /D I Inspection #2: 1 1
Location: 1227 County Road 0 ~ oberts WI 54023 MM:,,J NW 1/4 3 T29N R18W) - 03291837A40 -Lot 4
1.) Alt BM Description I vp a ,,,i 4 k~,`ot~i ~ ' s tv ek"rS 4,j ✓2~w~~q
2.) Bldg sewer length = - 3/' 30 ~Z tuc'~r ~r'rccfJ. ~C~; s~ Ney,4P,-l
-amount of cover = > S'
3~ ~~k~t de v cva s Hof cer ~ a o plot[ P(ow~
X41, e
Plan revlslonhe ~°d. Ye J No%i
Use other side for additiona information.
SBD-6710 (R."7) Date Inspector's Signature Cert. No.
' (2rz} Sanitary Permit Application Safety & Buildings Division
in accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave.
See reverse side for instructions for completing this application PO Box 7302
VISCOnSin Personal information you provide may be used for secondary purposes Madison, WI 53707-7302
Department of Commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not
state owned.)
Attach complete plans (to the count co only) for the system less than 8-1/2 x I 1 inches in size.
County _ State Sant ermit Number ❑ Check if rxi i t vi u€ app i \on State Plan 1. D. Number
756
1. Application Information - Please Print all Information Location:
Property Owner Name Property Location
L
or)
RAfl)8e-41 ?l4 114, S T N, R JJE
Property Owner's Mailing Address 116 i_~ of Number Block Number
Sa 0 Pj y
City, State Zip Code otfNum ~+C C1~,cxC 1`" Subdivision Name or CSM Nom er~
11. Type of Building: (check one) ❑ city
pw~,~,~~,,'•~~"~`` ❑ Village
I or 2 Family Dwelling - No. of Bedrooms: - acalr.t T ."`c.
Town of
❑ Public/Commercial (describe use):_ P~~~1n U
❑ State-Owned
Nearest Ro d
3 7 3 r X g 3~ S t ~ s ~ Parcel Tax Num er(s) U~2 106 Lf - {U U
NB) e of Permit: (Check onl one box on line A. Check box on line B if a licable) "A- I . New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. b.
❑ Addition to
System S stem Tank Only Existing S stem
Permit Number Date Issued
1 ❑ A Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply) I
,KNon-pressurized In-ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line I
❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
V. Dispersal/Treatment Area Information: E
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area AAAO-&~- ation 5. Percolation Rate 6. System Elevation 7. Final Grade j
Required Proposed a/sq. ftMin. /inch) / t Elevation
~1 Sv `1Ci~1d2 ~ Q CD U [O U
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass.
New Existing crete structed
Tanks Tanks V-W-
60mba uw l ctW DO Lt Pry C c45 711' ❑ ❑ ❑ ❑ `
❑ ❑ ❑ ❑ ❑
Vlll. Responsibility Statement
1, the undersigned, assume responsibility for installation of the POWTS shown on th ached Tans
Plumber's Name (print) Plu er's Si atu a (no stamps): MP RS / Business Phone Number
aS(aso 5 1a-339
Plumber's Address (Street, City, State, Zip Code)
(5- -2 9G ~Z Z 2-
l.~ la 410 LA) <L-i St
41H L-(4 So* t 4-
IX. County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps)
Approved ❑ Owner Given Initial Adverse Suriiarge Fee) f It
Determination P o2S-• OD 1Z-E)Lf- 28 t ~
X. Conditions of Approval /Reasons for D'sa~gj,proval: WIU~ss ~a Sour ~+Mnee p
locwtu~s vwxSti< vveo~ (s.~.2~ S~ w~ua (aa r+-Q~D~ ~S;1r J,
I -X- 2 a -wW.4- 6K& . t00.0 mow.. Lao. IS
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i Ttiwn o4 f~t1W(~R►=nl
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pip~cs c 916 SIG w 194Ke, AvY
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Wisconsin.Department of Commerce SOIL AND SITE EVALUATION
Division 6f Safety and Buildings Page of J
Bureau of Integrated Services in accordance with Comm, 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in si?ts. Tian must County
include, but not limited to: vertical and horizontal reference point (BM); dIredtion and, ' 1 4 /'Y 41C
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.: Parcel I;D. #
APPLICANT INFORMATION - Please print all infornatiion. Reviewed by Date
Personal information you provide may be used for secondary purposes (PrivacyVaw, s. I S.F (1) (m));,
Property Owner Prop'drty Ii Dsation
UU Govt. Lot 1144V 1/4,F T 7 9 N,R E (or(W
Property Owners Mailing Address # Blodl# Subd. Name or CSM#
/31S WCA
Clfy State Zip Code Phone Number Near st Ro
❑ City ❑ Village ® Town
14 vct SU✓t W ( SY0 (o (7/57 ) S~ CoZ.~' 1),-e- ~
a New Construction Use: ® Residential / Number of bedroon t_j_/ Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flower gpd Recommended design loading rate bed, gpd/ft2 • & trench, gpd/ft2
Absorption area required Z,?0d bed, ft2 QUd trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2
Recommended infiltration surface elevation(s)~j4w- Guwrr` 9n, /U ft (as referred to site plan benchmark) Fir Additional design/site considerations & -7 Parent material UZJ
4- G Jo-S Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system ® S ❑ U ® S ❑ U ®S ❑ U J ] S ❑ U ❑ S ji2 U ❑ S 0 U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
i o-fz /O r 3 Z Sii Zma m cs 5 (o s
~ c S 5' .lp s
2 z- / `f3 LAS 2m b rn
Ground 3 13-7-1 5 5 I S M4 b J t( L S ,i S (Q 5~
elev.
fr-mot. "4 /p r yl PiF y Vf c.s 4 S
Depth to
limiting
factor
30 (P
in.
Remarks:
Boring #
1 o-lz /v r3/Z 5;1 2a-,abk "Y- tJC s ; .
2 2 JS 2m5bk mi
3 53 /Q r`i/40 - ff ~S IBS m✓~r cs _ 5
Ground y ~s-9o /U r^ y~`f (F -1 r `I I lp V~'~ LAS MJ GS - `4
elev.
~ Depth to
limiting
factor
Remarks:
CST Name (Please Print) ture Telephone No.
Cis Z 117
T cr
Address Date CST Number
7,11 3 s ~So l CVO z - ercj 25-5367
~ s
SOIL DESCRIPTION REPORT
PROPERTY OWNER Page gl of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Structure 2
g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed Trench
3 0,/Z / r3/z Sid ey-icy)K r\n-Cr L-
Z lZ- l r `f~3 J S 2 rn4-; --5 S • C,
Ground 3 3/0 /C~ r `t S 1 S my r- c S S
elev. _
ft• y 1,0-1 lC) r`l~~l t~IF-T r`th vJP S mJ-1~r
Depth to
limiting Z p
= in.
Remarks:
Boring #
I o -1 Z. /v r 3I2. Si I 2 mc~bk ry4r LS 'jg • S
`j 2_ 12- 3S / r / 3 J 5 2 rn5bk -p-l C-
37-7Y 3 ! r `I S IS m d=~r G 5
Ground L{ 78-99 10 r 4 Fir- Z. j r q (o v jpS 0 rr4-pr cS
elev.
,
ft.
Depth to
limiting
Tin.
r' Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Boring # -l2 /D r3/Z s, I 2 mabk rn r LS I j
- 5
j Z- 12 - !O q /3 Z msbK ~ S
3 t0 r~l ~ ~ 5 ~ ~ mv~r ~ 5 1 •J
Ground l0 -7 our-'AN (-1f 1•S ~ ISO V S 05 rY1V } ( GJ 4 S
elev.
1446L-ft-
Depth to
limiting
f ct9r
(3 V in, Remarks:
G
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. 2
Remarks:
q
SBD-8330 (R.9/98) ~i*
PAGE OF
NAME SfOO'F LOT# LEGAL DESCRIPTION ,U&J'1, 6W1,,S t5 T29,N,R jf~ E (or)(0
LLkLj
.//SCALE: I"= ~QBM I ELEVATION 100 •
BM I DESCRIPTION 4o p oR l "coAja~ J- (a +K t4l f: ky-N l//
B(~`~2 ELEVATION ty O • V
BM 2 DESCRIPTION -top ofm
SYSTEM ELEVATION up ~ 4cs %&c-kn q(y . S O
Iower +y-tr%c 96•{0
ALTERNATE ELEVATION qu.-1 y~
CONTOUR ELEVATION / y 14-
-zoo,
03 ter
I dD o
SIGNATURE DATE Gam'
I
i
Page Of
SEPTIC TANK & PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
4" CI VENT PIPE 12" MIN. ABOVE GRADE WEATHERPROOF
? 25' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED
FRESH AIR INTAKE- VWITH CONDUIT MANHOLE COVER
W/ PADLOCK 6
FINISHED GRADE WARNING LABEL
4" CI RISER 4" MIN.
y
, 8 IN. 6" MAX ~
INLET
WATER TIGHT SEALS GAS- ,
TIGHT, , APPROVED
A SEAL
JOINTS WITH
ALM APPROVED PIPE
;APPROVED i B ON 3' ONTO
SOLID SOIL
10 C
'L OFF - RISER EX -
Su 1 P'JMP OFF ELEV . _FT. 1~ i
IIII D PERMITTED ON:
IF TANK
MANUFACTURER
HAS APPROVAL
J', AF71ROVED BEDDT11- UNDER TANK
CONCRETE PAD
SPECIFICATIONS
Ore ~ t"T N"JN.BER DOSES PER DAY:
C'1 SEPTIC GAL. D0 VOLUME TNC LINS J,~~ i
GAL F LOw BAC K: lam- GA
rAPACLTIE`~ . A - Ll INCHES = G.~._
M i~l A ; A C 7,R E.F:. ~~a-~
1.1,_, EEL h !MBEP.. W_i~l B = 2 INCHES GAL
I' C = INCHES
U -2Cj~_S~
t• 0 D E L NUMBER INCHES = U v
Sw' " ~'CH TYPE
rU1
r r GPM PUMP & ALARM WIRING AS PER ILHR 16.23
c.1~(;iLIREiJ ulSCHAR~E RAT...
F E ET
CAL T?IFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION FIFE 2 , 5 FEET
+ IT NIMUM NETWORK SUPPLY PRESSURE FEET
FEET FORCEMAIN X Q,7 F'~/ 100 FT . FRIC'T'ION FACTOR ,
1 _~Q---- TOTAL DYNAMIC Ht.AU FEE'r
4r
-
FL'M TANk: i.~~NC TH WIDTH e DIP,METER
I" ERN.~,L LIM~NSIONS OF r
1,IQv I:D ~1: TIi
?C NSE N"i BER o~~.~0 DATE: 11 a~`.
IGT+Eli:
Cross-section of a leaching chamber
dispersal component
cover material
Observation Pipe S& K 1-16
o ~
System Elevation So
Infiltrative Surface
I/V ` ~Q a v? I 5-C) l 1 °1- oo
Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In-Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWTS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In-Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
10567-P (R.6/99).
Table 1: System Design Specifications
Sanitary Permit Number $
Number of Bedrooms
Design Flow - Peak (gpd) t d
Estimated Flow - Average (gpd)
Septic Tank Capacity (gal) p
Soil Absorption Component Size (ft2)
Type of Wastewater Domestic c,; tQiow~
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component _
Design Flow - Peak (gpd) I n
Maximum Influent Particle Size (in) 1/8
Maximum BODS (mg/L) 220
Maximum TSS (mg/L) 150
777::]
Table 3: Maintenance Schedule
Septic Tank Inspect and/or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the septic t k and outlet filter shall be assessed at least
once every 3 years by inspection. The utlet filte hall be cleaned as necessary to ensure
pro er o The filter cartridge shou not be removed unless provisions are made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
4
Management Plan for a Septic Tank and Soil Absorption Component
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 113 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, defective, or subject to failure must
be replaced. Exposed access openings greater than 8-inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
i
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer i~~il UJr~/EQ~ +T4-c-
Mailing AddressU bil`f Ql (D - - -
Property Address a..~ C `l+ f-~ -
(Verification required from Planning Department for new construction) l>
City/State Parcel Identification Number
LEGAL DESCRIPTION
Property Location A/.~ 1 W, Town of U/,4ACC.C/
Sec. ~ T_2:1 NR.~,
Subdivision . Lot
Certified Survey Map # ( '2,2- 696f , Volume 1 Y ---,.Page # 32-39'
Page #
Warranty Deed # r) 4, L - l OU q - ,~-0 - U0y, Volume /56- S6 1.
Spec house ❑ yes Gil no Lot lines identifiable Q yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the 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 wastewaterdisposal system is in proper operating condition and/or (2) after
inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date.
12-1
I l
4tz
SIGNATURE OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
(Z/~/!mod
SIGNA'T'URE 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
~ sn Ly.,r
STATE BAR OF WISCONSIN FORM 2- 1998 634330
WARRANTY K DEED REGISTER OF DEEDS
YOr.1c762 tGE5D1 5T. CROIX CO., WI
Document Number
RECEIVED FOR RECORD
This Deed, made between - 11-28-2000 9;00 AM
RTcHARD D STO11g' and .TANFT P C~~ch2nd_-
and wife, YARRANTY DEED
Grantor. EXEMPT R
CERT COPY FEE:
and _ 7ND9L--b--- COPY FEE:
r„ ^i-- TRANSFER FEE: 140.70
MA CZYNSKI't cri€a, RECORDING FEE: 10.90
PAGES: 1
Grantee.
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate in ___St--_CrV X _ County, State of Wisconsin:
Located in part of the NW 1/4 and part of the
NE 1/4 of Section 3, T29N, R18W, Town of Name aNReturn Address
Warren, St, Croix County, Wisconsin;
more fully described as:
Lot 4 of CSM filed in the Office of the
Register of Deeds of St. Croix County on
April 28,2000 in Volume 14, page 3839 as
Document No. 6220165.
~5D-~80
Parcel Identificaton Number (PI042-1004-70-600
This homestead property.
is (is nol)
Exceptions to warranties. easements, restrictions, rights-of-way and covenants
of record.
Dated this 27th day of NnvemhPr ?f)O0
i
Pill
(SEAL) (SEAL)
w _Rr i chard 0 Sto t. 7anet P Rtnnt
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature (s)
State of Wisconsin.
ss.
St. Croix County.
authenticated this day of Personally came before me this 27th day of
_ Noyember_ , 2000 the above named
_ Richard O Stout and ill net P.
Stout
TITLE: MEMBER STATE BAR OF WISCONSIN - to
(It not, me known to be the person t yttpLG~cuted the foregoing
authorized by 5706,06, Wis. Scats.) instrument a ackgowl teSUCtSOINIiSIN
r, r~J
.$A
PHIS INSTRUMENT WAS DRAFTED BY KERNON
-
Janet P. Stout ,
135+3 AWatuke& Tr_ ~ - -
Hudson, WI 54016 Notary P blic, State of s onsin
My co mission 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 signewm
STATE BAR OF WISCONSIN Witconsln Legal Blank Co.. Inc.
WARRANTY DEED FORM No. 2 - 1999 neawaukoa. W4
vCb ti°`~ 62•~4~8
rsi FTED BY ED FLANUM JOB NO. 00-01 DATE 1-30-00 m z
4 m
-30
O
00
Z 3)
ARE REFERENCED TO THE w m I Z
Z
m m
NORTH LINE OF THE NW1/4 OF SECTION cn m
3, ASSUMED TO BEAR N88-24-51'E w A 0 Z 0
UNPLATfED LANDS OWNED BY PLATTER m Z>
W~
N01 °06'26" W 468.62'
346.93' 88.69 3.00 .7 -X4 of
435.62' m
EAST LINE OF THE
NW1 /4 OF THE NWI A
pp W- $N 0V° ~ N e ~ r I 2 OT M
00O 9
WEST LINE OF THE ' ' ° Q' w O f~ Qr Z -i
NEi/40FTHENWI/4 0 mcNa pn mpn 1°o D ° ° 10 -n m v
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435.62' q r Fn cm
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00
104.77' 33. m N
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rn 435.62' ` OD w O
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mm p r umi~° W mim I j
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~ ? ❑ S01 00626T 468.62' 45' 33'
y T- T Q (N00°01154"W)
v> ; m~
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cm (A 03OZo 0" :1
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alww w°mZ ° p
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Ito o w 70 rn
m
I
Vol. 14 Page 3839
iSURVEYOR'S CERTIFICATE
I, Douglas J. Zahler, Registered Wisconsin Land Surveyor, hereby certify, that by the direction of Richard Stout, I have
surveyed, divided and mapped a part of the NW1/4 of the NW1/4 and a part of the NE1/4 of the NW1/4 of Section 3,
T29N, R18W, Town of Warren, St. Croix County, Wisconsin; described as follows:
Commencing at the NW corner of said Section 3; thence N88°24'51 "E, along the north line of the NW1/4 of said Section 3,
1231.68 feet to the point of beginning; thence continuing N88°24'51 "E, along said north line, 800.04 feet to the west line
of Lot 2 of Certified Survey Map recorded in Volume 8, Page 2208 at the St. Croix County Register of Deeds Office; thence
S01 006'26"E, along said west line, 468.62 feet; thence S8W24'51 "W 800.04 feet; thence N01 006'26"W 468.62 feet to the
point of beginning. Parcel contains 8.606 Acres (374,892 Sq. Ft.).
Subject to all easements, restrictions and covenants of record.
I also certify this Certified Survey Map is a correct representation to scale of the exterior surveyed and described; that I
have fully complied with the provisions of Chapter 236.34 of the Wisconsin Statutes and the Land Subdivision Ordinance
of the County of St. Croix and the Town of Warren in surveying and mapping same.
Douglas J. Zahler, OF w,sCO
S & N Land Surveying ! y
212 Walnut Street y DOUG l-~►S J.
Hudson, WI 54016 ZAHLER
&2145
HUDSON,
W
t~
Each parcel shown on this map is subject to State, County and Township laws, rules and regulations (i.e., wetlands,
minimum lot size, access to parcel, etc.). Before purchasing or developing any parcel contact the St. Croix County Zoning
Office and the Town of Warren for advice.
I~ cn ~o ~
ao m o -1 m ~
-i --I;9; 1 N R1 1"'~
,F tei o m m
. Vol. 14 Page 3839 XO=N
ry~ o ~ °ey~
ti CIEn X) 0
/ ION
05/02/01 WED 09:59 FAX n608 267 059FAX 2 COVER & BLDGS ~9001
Y M AND BUILDINGS DIVISION
Departmellrc of Coilnmeroe ER SHEET 201 W WashenQton Ave
PO Box7082
Date S t: Madison. WI 53701
Pages Sent (excluding this cover): 1
TO. FROM: Safety & Buildings Division
P.O.Box 7082
Madison, WI 53707
FAX FAX 608-267-0592
PHONE: PHONE: 608-261-8500
Special Instructions:
If there were any problems with the transmission or not all pages were received. please contact sender immediately. at senders telephone number
above.
SBD-8170 (R.02197)
or
05/02/01 WED 10:00 FAX 608 267 0592 SAFETY & BLDGS fih002
Customer Service Center
Safety and Buildings Division
201 W Washington Ave, 4th floor
PO Box 7082
Madison WI 53707-7082
Phone: (608) 261-8500
TDD: (608) 264-8777
Fax: (608) 267-0592
KEVIN J MATACZYNSKI
W8646 W BAKER AVE
LADYSMITH WI 54848
This is your Certification, License, or Registration Card.
Id:231250
KEVIN J MATACZYNSKI
Certification, License,'ot itc~a~stEit'I' 'Name Expires
Master Plumber-ResWcAed SeNicti t,ine* 03131/03
a
Wisconsin Department of Commerce
Signature:
Cut around the card to remove it. Sign the card.
The card should be signed by the applicant. If desired, you may apply a protective plastic laminate (available at some
stores) to the card. Present the card to whomever requests proof of issuance.
This card should indicate other Department of Commerce certifications, licenses, or registrations currently held. Destroy
all previous cards that have a certification, license, or registration category which also appears on this card. Please
review categories specified on the card. If errors or discrepancies are found, please contact the Customer Service Center
(CSC), 608-261-8500. Be prepared to give die CSC representative the Id number printed on the card. The CSC should
also be notified of changes in addresses as they occur. Notification to the CSC of address changes is the responsibility
of the certification, license, or registration holder.
A renewal notice will be sent to the last address on file with the CSC at least 30 days before the expiration date of each
certification, license, or registration indicated on the card. Renewals are contingent upon compliance with the require-
ments specified in Comm. 5, Wisconsin Administrative Code.
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 format, please contact the department at 608-266-3151 or TDD 608-264-8777.
SBD-10183 (8.10/98)
I