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014-1016-40-001
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No (ATTACH TO PERMIT) 644715 GENERAL INFORMATION Stae Plan ID No Personal information you provide may be used for secondary purposes IPnvacy Law. s 15 04 i 111nU1 Permit DaviHolder's Name Megan Burlingame City Village Township WN OF FOREST Parcel Tax No dand 014-1016-40-001 CST BM Elev Insp SM Elev SM Description SectionrTown/RangeiMap No O7.31.15.1O7A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic Dosing Aeration Holding PHRAP/RIP4ION INFORMATION Manufacturer Demand GPM Model Number TDH Llfl Friction Loss System Head TDH Ft Forcemain Length Dia Dist to well Bottom Pipe System Cover BS BEDiTRENCH Width Length No Cf Trenches PIT DIMENSIONS No Ot Pits Inside Da Uquid Depth DIMENSIONS SETBACK SYSTEM TO I P/L JBLDG JVVELL LAKE/STREAM LEACHING Manufacturer. INFORMATION CHAMBER OR Type Of System Model Number UNIT HeaderfMandold Distribution x Hole Size le Spacing Vent to Air Intake 1 Pipels)D r 5m Depth over Depth Over xx Depth or xx Seeded Sodded xx Mulched BediTrench Center Bed7Trench Edges Topsoil Yes No Yes INI COMMENTS: (Include code discrepencies, persons present. etc) Inspection #1 Location: 2614 220TH AVE 1) Alt BM Description = 2) Bldg sewer length = - amount of cover = Plan revision Required? Yes No Use other side for additional information. Date Insepctor's Signature SOD-6710 (R 3197) Inspection 02 Corr No �;—� C'APJ -Joss — 179 S` I. 2. Industry Services Division Coonq 4822 Madison Yards Way Sanitary Permit Number (to be filled in by Co.) 1 �O t2 Madison, WI 53705 N 1 P.O. Box 7162 Madison, 370 716 L� 6� 1 �15— St 'N J1L=ZZC3LLLX mix 4F it Application State Transaction Number In accordant mutt (2), Wis. Adm. Code, submission of this form to nit � z.e) ( (� ( — PygjgcSA, dress (if different than mailing address) is required prior to obtaining a sanitary permit. Note: Application forms for stele -owned PO S ere submitted to the Department of Safety and Professional Services. Personal information you provide may be used for secondary IJJI 10 `j purposes in accordance with the Privac Law, s. 15.04(1)(m). Stals. OAIC- 1. A Station Information= Please Print Allinformation any Owner's Name M Parcel p v.Y'l ON- I -'i - Propperty Owner's Mailing Address ( Property Location 1110 ,,, st / \ Govt. Lot /7 5 W '/•, Section r T N R E oOO City, State 5fi N Zip{Code 5 J i Phone Number 1 - b�/.. 7I. Type: of Building check all that apply) Lot s Subdivision Name � y "N or 2 Family Dwelling- Number //pp��tt��Bedrooms e S (V-V a 5Q. ��.� Block N1 Dublic/Commercial - Describe U r0 LILreDow - :]City of State Owned - Describe Use illage of CSM Number 2 N E x own of �rnrDY.l 111. Type ot.POWTS Permit: (Check Itthherr "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C If ADD Iicable. ,. ,.. A. ew System Y I I� P Y []Replacement System LLL❑]ln-Ground ther Modification to Existing System (explain) ❑0 8 Y ( P ) Additional Pretreatment Unit (explain) ❑ ( P ) B' �Fiolding Tank DI -Grade Mound IN Individual Site Design Other Type (explain) (conventional) C. ❑ Renewal Before []Revision Ochange of Plumber Orransfer to New Owner isl Previous Permit Number and Date Issued Expiration rr IV. Dis ersallTreatment Area and Tank Information: Wit)t-lass s Design Flow (gpd) Design Soil Application Rale(gpd/s0 Dispersal Requiral (s0 Dispersal A roposed (s0 ion _ System Elevation/ GO 1913.0 ' Capacity in Total N of Manufacturer Tank Information�l-}ysMQt{ Gallons Gallons Units lam' B S New Tanks Eaisring Tanks Septic or Holding Tank Wo EI JW Dosing Chamber ` 1 , V.' Respon$ibBify Statement- I, the undersigned, assume r slbillty for Installation of the POWTS shown on the attached plans. Plumber's Name (P ' t Plumber's lure MP/MPRS Number Business Phone Number ^,' �AuuM t 2 Nlo-NSI lumber's Address (Street, City, State, Zip Code) ff, -' (11n sH VI. Count /De artment Use Only Approved ❑ Pasplituved Permit Fee D22aie Issued Issuing Agent Signature ❑ caner iven It for Denial � ZZ Conditions pro U I \ MI5 a.xQ_ U., � TEM OWNER: I !• QaA- eptic tank, effluent filter and n ispersal cell must be serked / malntained �� Nrf; $ 4t w, AkW-XtCVAttCe s per management plan provided by plumber. II setback requirements must be maintained C�"r a per applicable code/ordinances.— bt,` Attach to comp It it plant for the system and submit to the County only on paper not leas than S t a I I Inches In e Q t4ea.� :'ti V�+�-2- CuV, (s) ') SBD-6398 (R. 03/21) ` f` � soklaj1 r C /) rvtwr ti ae�. ,li System PLOT PLAN PROJECT Dave Burlinaame ADDRESS 1190 Main St. St. Paul Park Mn 55071 SW 114 SW IMS 7 /T 31 N/R 15 W TOWN Forest COUNTY ST.CROIX SYSTEM ELEVATION 99.5' 1.5' sand 10t CONVENTIONAL AT -GRADE 5/25/22 DATE CONVENTIONAL LIFT BEDROOM 4 HOLDING TANK MOUND XXX SEPTIC TANK SIZE 1200 gallons LIFT TANK SIZE DOSE TANK SIZE 800 HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 600 # of Chambersnone IL BENCHMARK V.R.P. Top of 3/4" pipe ASSUME ELEVATION 100' ❑ BOREHOLE O WELL •H.R.P. same as benchmark m 8% Slope Area 15' below system to B - 3 remain undisturbed Weiser Combo Tank B-1 �\\� 96.5' 97.5' � 8.5'98.0' B.M. Grading is to be done to divert run-off away from system Pro 4 Bedroom House Filter Lifetime 1320' Property Line ell is to meet all WDNR setbacks Scale = 1 /4" = 10' 0' 40' 80' I y GOV I 220th Ave off. 0 T DIVISION Of INDUSTRY SERVICES 10541 N RANCH RD NAYWMW WI M"3-HA4 Coflyd Than* Rd" vr".Wft=r h.PV awn+ - Try Ivan • Owrrrr Own Orin - seardary June 6, 2022 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 2024-6-6 Plan Review: PWTS-062201111-C Shaun Bird 1432 120`h St New Richmond, WI SITE: Burlingame 220fh Ave Forest Township St Croix County SW Y4 SW'/+S7 T31N R15W FOR: Conditionally APPROVED DEPT. OF SAFETY AND PROFESSIONAL SERVICES DIVISION OF INDUSTRY SERVICES Description: 4 bedroom 600 GPD —18" to limiting factor- Effluent Filter - Maintenance required. A&Oi" R4..I9y SEE CORRESPONDENCE Mound Component Manual — Ver. 2.1(May 2022-27) Pressure Distribution Component Manual — Ver. 2.1 (May 2022-27) The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: Reminders • The site shall be properly prepared prior to plowing. Any grasses longer than 6" shall be cut short and removed. To avoid matting, any leaves or loose organic matter shall be raked up and removed. Cut trees and shrubs flush to the ground and leave stumps. Avoid operating equipment on the Mound site. If necessary, use only tracked equipment, during dry conditions, with minimal passes, to avoid compaction. • Components and soil removed from an existing drain field shall be properly disposed of so that there is no risk to public or environmental health. • A sanitary permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.19, Wis. Stats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. • A state approved effluent filter is required. Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. • A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department which may include local inspectors. Owner Responsibilities • The current owner, and each subsequent owner, shall receive a copy of this letter. Owners shall also receive a copy of the appropriate operation and maintenance manual(s) and be responsible for ensuring that POWTS is operated and maintained in accordance with this chapter and the approved management plan under s. SPS 383.54(1). In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Joshua Rowley POWTS Plan Reviewer, Division of Industry Services (715)813-9111 Joshua. rowlev@wisconsin.sov Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 5/24/22 Owner: Dave Burlingame Location: SW1/4 SW1/4 S7 T 31 N,R15W 220th Ave Forest Manuals Used: Mound Component Manual Version 2.0 (N.01/01, R. 10/12) Pressure Distribution Manual Version 2.0 (N.01/01 R. 10/12) Page# Conditionally 1. Cover Page APPROVED 2. Mound Plot Plan DEPT. OF SAFETY AND PROFESSIONAL 3. Mound Cross Section 4. Pipe Cross Section/Pipe Layout 5. Pump Chamber Cross Section 6. Pump Curve 7. Filter Specifications and cross section 8-9. Maintance and contingency plan Attachments: soil test / /l Shaun Bird Signature_ License number 226900 Page 1 of 9 SERVICES DIVISION OF INDUSTRY SERVICES SEE CORRESPONDENCE System PLOT PLAN PROJECT Dave Budinoame ADDRESS 1190 Main St. St. Paul Park Mn 55071 SW 1/4 SW I/4S 7 /T 31 N/R 15 W TOWN Forest COUNTY ST.CROIX SYSTEM ELEVATION 99.5' 1.5' sand lift DATE 5/25/22 BEDROOM 4 CONVENTIONAL AT -GRADE CONVENTIONAL LIFT HOLDING TANK MOUND XXX SEPTIC TANK SIZE 1200 gallons LIFT TANK SIZE DOSE TANK SIZE 800 HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 600 # of Chambersnone BENCHMARK V.R.P. Top of 314" pipe ASSUME ELEVATION toe' Filter Lifetime ❑ BOREHOLE O WELL •H.R.P. same as benchmark B- 8% Slope 1320' Property Line Area 15' below system to B - 3 remain undisturbed Weiser Combo Tank Pro 4 Bedroom House B -1 \\\ 96.5' 97.5' � 8.5'98.0' B.M. Well is to meet all WDNR setbacks Grading is to be done to divert run-off away from system Scale = 1 /4" = 10' 01 40' 80' I 220th Ave a 0 -C Mound System Cross Section and Plan View - r-r--,------.----------------------- - - - - -- — = Topsoil =ASTM C-33 Cap Material sand fill Ft Contour = Clean aggregate '/. to 2'/. in. dia. Slope Direction Dimension Feet A B D E F ,g G H , [7 1 L , W JK q�� z 2 Slope O = 4 in. sch. 40 pvc observation pipe GENERAL INSTALLATION: The mound area is staked out along the design contour. Existing vegetation is mowed and raked off the site. The mound basal area (L x W) is plowed with a moldboard or chisel plow. Plowing may not proceed if the soil is wet enough at the plow depth to form a''/, inch soil wire when a sample is rolled between the palms of the hands. ASTM C-33 quality sand is placed immediately after plowing. Sand is placed with a tracked machine keeping 12 or more inches of sand under the tracks or is placed overhead by a backhoe. Special care must be used when placing sand of less than one foot thickness to minimize compaction of the plowed surface. After the topsoil cap is placed, the entire mound is seeded and mulched to promote vegetative growth, limit erosion and protect from freezing. The observation pipes are slotted in the lower 6 inches and secured in place with rebar or a closet flange. 101071gj Page 3of-- Manifold I Force Main Lateral Diameter X M (Manifold Length) Force Main Diameter Force Main Length 03/05 Igj Pressure Lateral Layout Two Laterals — End Manifold -o Threaded Cleanout Lateral Turn -up --Po Plug M t_ X 1 L Long Sweep 90 Bend ✓!ter-OfC/i In. Z.527 Ft. Pressure System Construction Laterals are constructed of Schedule 40 PVC pipe. Orifices are drilled perpendicular to the pipe with a sharp drill bit and face down. Lateral tum-ups terminate with a threaded cleanout plug and are enclosed in a 6-8 inch diameter lawn sprinkler valve box accessible from finished grade. • • • • • Grade • • • • • • 6-8 Inch Lawn Sprinkler Valve Box Page of- Septic -Dose 'Wank Cross Section ; Tank tvlanufacturer 4/ .7 Tank Model Number 20- Total Tank Capacity Max. Bury Depth Filter Manufacturer , Fitter Model Number Minimum Pump Fa—rfm—mw Ra phred yy GFMr @ Ft TDii Outlet Manhole ivlin. 4" Above Grade With Looking Dowe. mist; Manhole < 6" Below Grpdo Sealed Watertight *% w — — -/ � Finished Grade Outlet Filter `i wet Bate Switch 3 and ao Tank Volume a -ZZ-,2GNI Dimemion, hicbm Volume Cull. () A: (alarm) B ' 2 o9j. j dwo C S Ono D Total L GENERAL INSTALLATION: The mptWdwc tank i manufaaturWa Product approval apeoifioidoas. Maximum del be exceeded without Prior 4pproval. Ma#" covers exposed installed. Piping at the Inlet and outlet to of approved materia laid on stable soil to prevent sealing or nagging. The force ma excavation aid the sleeve is sealod watertight. Electrical servic 02105 i 1 I Page S Pump Performance Specifications Pump Manufeclzw C-- Purnp Model Number Alam Manufaotatrer Vt Alarm Model Number ✓ Switch Type ; Total Dynamic Heed if -me Elevation Head 3 O Dishal Pretleuro , S Neework Lone 1 Ftsee Main Loos Total Manhole Min. 4" Above Grade Securely Mounted With Looking Device Weather-proof Junatioo Batt Vat Mtn, 12" Disconnect Above Grade Means With Vent Cop A Weep B :{ Hole Elevation C Ft '? °ttom 70.33 ' Bo D k Eleev�ation Ft 70' ii: ii i ::':� 'i `': � ::'1 i ill :: i':: i `•.'::'�':•l Lj bedded and bwk filled in acoordeaw with the h of bury as speoitiod by the menufacdhrer stay not i Yee have an effective locking device (padlock) carweew to tie tank with Watertight fittings, and is aleoved with 4" Sch. 40 PVC to bridge the tank epmpties wit NBC 300 and Comm 16.28. 04/18/2012 16:43 llbbMtdbtf rKtrc.Rrtcu rurr «. ^� �- Zoeacr Pump Company Page 1 of 1 1 a is PUMP I flR"C.E.CURVE MODELS 16114161-16314163-lWA165' ev. FWWMR-JAlNM Models 161/4161, 163/4163, 165/4165 __nn- . At.nr.n... a POWTS OWNER'S MANUAL & MANAGEMENT PLAN page �Of__ FILEINFORMATION Owner Permit DESIGN PARAMETERS Number of Bedrooms q . ❑ NA Number of Commercial Units Estimated flow (average) 416 (j gaVday Design flow (peak), (Estimated x 1.5) 66 aYd Soit Application Rate �i 0 gaVdayW Influent/Effluent Quality Monthly average• Fats, Oil (L Grease (FOG) 530 mgA. Biochemical Oxygen Demand (BODJ 420 mg/L Total Suspended Solids (TSS) 5150 Pretreated Effluent Quality NA Monthly average" Biochemical Oxygen Demand (BODa) S30 mg/L Total Suspended Solids (TSS) s30 mg/L Fecal Coliform (geometric mean) 51 W cfu/100ml Maximum Effluent Particle Size K Inch diameter UAINTFNANrF SCHFntll F cocnrs:rceTnNS Septic Tank Capacity N O NA Septic Tank Manufacturer ❑ NA Effluent Filter Manufacturer " ❑ NA Effluent Filter Model ❑ NA Pump Tank Capacity ff tTD al ❑ NA Pump Tank Manufacturer ❑ NA .Pump Manufacturer 7 P ❑ NA Pump Model y - ❑ OPA Pretreatment Unit NA O Sand/Gravel Filter ❑ Peat Filter ❑ Mechanical Aeration ❑ Wetland ❑ Disinfection ❑ Other. Manufacturer Dispersal Calks) ❑ In -ground (gravity) ❑ round (pressurized) ❑ At -grade ound O Drip -line ❑ Other. Values "iosl for dornestic (noncmrsnerdO wastewater and septic tank eekuw L •• Values typ" lot pretreated wastewater. Service Event Service Frequency Inspect condition of tank(s) At least once every month arks) (Maximum 3 yrs.) Pump out contents of tank(s) When combined sludge and scum equals one (K) of tank volume Inspect dispersal cell(s) At least once every ❑ months year(s) (Maximum i yrs.) Bean effluent fiker At least once every O mon r(s) Inspect pump, pump controls & alarm At least once every ❑ months r(s) O NA Flush laterals and pressure test At least once every ? ❑ month s) O Ot1er. At least once every ❑ months ❑ year(s) NA Otfef At least once every ❑ months O year(s) NA MAINTENANCE INSTRUCTIONS Inspec0ons of tanks and dispersal cells shall be made by an Individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer, Septage Servicing Operator. Tank inspections must Include a visual Inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cells) shall be visually inspected to check the effluent levels In the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the Immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum In any tank equals one-third (Y) or more of the tank volume, the entire contents of the tank shad be removed by a Septage Servicing Operator and disposed of in accordance with ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, m"nical or pressurized POWTS components, pretrealfinenl components, and any other maintenance or monitoring at Wervals of 12 months or less shall be performed by a certified POWTS Maintainer. A servigd report shall be provided to the local regulatory authority within 10 days of completion of any service event. START UP AND OPERATION 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 calks). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. 1� �-f- 9 Page _____ of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals theft may Impede the treatment process and/or damage the dispersal cell(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 shell not occur when soli conditions are frozen at the Infiltrative surface. During power outages pump tanks may fill above n"al hlghwater levels. When power Is restored the excess wastewater will by discharged to the dispersal cell(s) In one large riots, overloading the cell(s) and may result In the backup or surface discharge of effluent. To avoid this sflueflon hove the contents of the pump lank removed by a Septage Servicing Operator prior to restoring power to ttre effluent pump or contact a Plumber or POWTS Malntalner 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 sail absorption aree. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWT$: antibiotics: baby wipes; cigarette butts; condoms; cohon swabs; degreasers; dental 1103s; diapers; disinfectants; fat; foundation dra►n (sump pump) water; fruit end vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products: pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS falls and/or Is permanently taken out of service the following steps shall be taken to Insure that the system Is prope(iy and safety abandoned In compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shelf 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. • Ater pumping, all tanks and pits shall be excavated and removed or (heir covers removed and the void space fined with soil, gravel or another Inert solid material. CONTINGENCY PLAN If the POWTS falls 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 mquitled setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will rasuk In the n ed for a new soil and aria evaluation to establish a sutable replacement area. Replacement systems must comply with the rulell In effect at that time. O A suitable replacement area Is not available due to setback and/or soil limitations. Barring advances In POWTS technology a Iding tank may be Installed as a lest 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 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 reconetrucled in place following removal of the blomat at the Infiltrative ce. Reconstructions of such systems must comply with the rubs In effect of that time. «WARNING» SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. 00 1401 ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE O� / PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name ' Phone POWTS MAINTAINER Em aeone 1 /f — 8EPTAGIR 8ERVICING OPERATQRJIPUMPERLOCAL REGULATORY AUTHORITY Name Name ls ye 4�— Phone I q/r— c Phone 7/J jrJ�6 f7� This domunent was dratted In compliance with chapter SPS 3e3.22(2)(bX1)(d)&M and 3e3.e4(t), (2) & (3), Wknon•in Adminildroll Code. 7 1-)�-c � Wuoonsin DspsmwH of Cwnmercw SOIL EVALUATION REPORT Pape _ ol,,,_ D~- of Sataty and B;llidinps in woordar" Mh Comm 85, MS. Adm. Code S cajMeekoo-rolats sko plan on paper nol Ins than I W x t i in iw In ers. Plan must include, W not Meek P"M slaps, s weor dYnenslons, north arrow, l wdm distance tc nearest road. Pawl I.DO !�/��� /� PAuso prtinf all InformsLlon. R"Mwad by (� Dal' ►.rsensl arbnrrxon rsr preries era a weri for ..mesrr PxoosM (�ti'en' w:. s_ +c.a t,t lerll Pmpany l.oCatlon lI'/� yu�, Cbvl Lodj� �,% 1N,&A S T � N R E ( W PMPw►Y Ow Ws MallroAddress I Lot Y 1 Block Y 1 Stbd Norm or fSW Lot �/ .+ / • �.:---------- MART MA 0 U .� FWAIMMG,.MMFYAEV�M M W0WINIR711e 17MMUM' ZIUVA �► rr�s�rr vA W _v VAINIM W% - Eae,.M at ■ 9W. > ao K T2U rrKn and rss 2,3a ,So nw- UM M s? - aw.1 JU myl afro lbJ 1 a, mad CST Name (Please Print) ature CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evsk axon Conduosed Tekptx" Number 1432 120th St, New Richmond, WI 5401 S�p? —G 2 715-246-4516 Parcel ID I Pale d n - MM3Mr&M®rMr�r,�i © rr;M e��� ZWMM I Etl twg #1 - BODE > 30 1220 ffVL and TSS >30 11 S0 mg& ' EMuent 02 • BOO, 130 mplL and TSS 130 nVL 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 7TY 608-264-6777. aawusta.uer Soil Test Plot Plan Project Name Dave Burlingame Shaun Address 1190 Main St. St. Paul Park Mn 55071 Lot ----- Subdivision SW 1/4SW 1/4S 7 T 31 N/R15 W ❑ Boring Q Well PL Property Line RM or VRP Assume Elevation 1001 C64 #226900 Date 5/24/22 Township Forest County ST. CROIX Top of 3/4" pipe System Elevation 99•5' +HRPSameasBenchmark 16.5' 1—\98.5' B.M.' Pro 4 Bedroom House Scale = 1/4" = 10' 01 40' 80' 1 1 I 1320' Property Line 220th Ave Parcel #: 014-1016-40-001 Valid as of 06/28/2022 01:44 PM Alt. Parcel #: 07.31.15.107A Owner and Mailing Address: DAVID BURLINGAME MEGAN BURLINGAME 1190 MAIN ST SAINT PAUL PARK MN 55071 Districts: Dist# Description 1127 SCH DIST OF CLEAR LAKE _ 0038 CLEAR LAKE FIRE DIST 1700 NORTHWOOD TECH 8020 UPPER WILLOW REHAB DIST Abbreviated Acres: 0.000 Description: SEC 7 T31N R15W PT SW SW FRL EXC PRCL 21 T 011-1 AS IN 377/36 (HWY 63) EXC CSM 28- 6416 LOT 1 TOWN OF FOREST ST. CROIX COUNTY, WISCONSIN Co-Owner(s): BURLINGAME, MEGAN Physical Property Address(es): * 2614 220TH AVE Parcel History: Date Doc # Vol/Page Type 10104/2021 ' 1 4 / I WD 10/29/2020 11/15/2017 11115218 / WD 11057363 128/6416 LCSM 10/04/201711055089 1/ WD more... Plat Tract (S-T-R 401A 160Y4 GL) Block/Condo Bldg * N/A -NOT AVAILABLE 07-31N-15W SW SW 2022 Valuations: Values Last Changed on 04/06/2021 Class and Description Acres Land Improvement Total G5_UNDEVELOPED 1 27.9811 0.001 26,100.00 Totals for 2022 General Property 1 51.981 30,400.001 0.001 30,400.00 Woodland 0.0001 0.00 Totals for 2021 General Propert 51.9811 30,400.001 0.001 30,400.00 Woodland 1 0.0001 0.001 0.001 0.00 2022 Taxes Taxes have not yet been calculated Key * - Primary ST CRO NTY SANITARY SYSTEM File r.cr«listii Officee Use Only �0 OWNERSHIP/ADDRESS FORM Creoted2�z011 Community Development Department will utilize this information to provide the property owner with information regarding operation and maintenance of your new or replacement sanitary system! This information will be provided as part of our ongoing efforts to protect public health, your well, groundwater, surface water, property values, and county resources. Once approved, this completed form and educational information will be sent to you by email. OWNER/BUYER INFORMATION Owner/Buyer I ltWee, UVM 11yV\ J.J'rl(/ Mailing Address I 19 C llllo1lt1 tI City/State/Zip Phone Numbe Email Address Parcel Identification Number ci I �~ �Q- "► d ` (found on the property tax bill) 0 NEW SYSTEM: LEGAL DESCRIPTION Property Location i 1/4 , 1/4 , Sec. D T 3A � N RW, Town of �OrttA Subdivision Plat: Lot # . Certified Survey Map # ------ Volume . Page # Warranty Deed # if I-4 03 N (before 2006)Volume , Page # Number of bedrooms LA Spec house D yes)kno Lot lines identifiable 1�yes O no New Property Address Initials) OFFWE USE ONLY aie 14 ZZo AIE. (verificn of new address required from Community Dekopment Department for new construction.) t°ati 3a u. (Dat This form must be submitted with all Private Onsite Water Treatment System (POWTS) applications. New System: Include with this form a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. Community Development Department - Land Use Division 715-386-4680 St. Croix County Government Center 715-245-4250 Fax cdd0sccwi.aov 1101 Carmichael Road, Hudson, WI 54016 www.sccwi.aov O U C � Couch v Rec R 20' 34' Foos Pong 0 W N o 7 u o — -----iwsi� i LANAI 22-7x 16-5 Bedroom 1 11.5' x 12' (138) Utility / Storage 10' x 10' Bass / Shelter 11.5' x 12' Bedroom 2 11' x 16' (176) --------------�, PORCH 147xB-O Bedroom 3 13' x 13' (169) W 1 11' x 16' - - - - _ lAi PORCH 6 WIDE :zr-o:a=OC =] (] U O U C 0 0 Couch U Rec R 20' 34' Foos Pong 0 ■e" LANAI 22-7x 16-5 Bedroom 1� 11.5' x 12' (138) Bedroorn�2 11' x 16' (176) --------- --_ .�, i PORCH 147x8-O Bedroom 13' x 13' (169) 0 0 \Q L 11 0 ! 1 1 Utility / 0 Storage c�1 10'x10' ,. Gu droom 7M Bass - ----- Shelter PORCH8' WIDE 11.5'x 12'_ ---- ---- Home Theater 14.5' x 24' av LANAI 22.7x 16-5 wo x � 0 shelf 11 5mk Van Truck V DINING 11-0X16-0 ' KITCH >> •11117'Or 3-6x 1 9.7 r p 0� ANT ` FOYE 7x16 6x6-4 r— uprommus I i --------------- �l PORCH 14-7x8-0 ; MBA `& 10.5x 1 1-4 ' WIC 10-4x6-0 -----------r FAMILY 19-Ox 190 MSTR STE 16-0x 14-0 STUDY PORCH 1 1-4x 12-0 ; ; B' WIDE ; ; tCOrMMLJnIr'( 'C�0fIEU 1__A _�1 -) GST-ZoZ2-018 n: MAY 31 'd ?--�-V b�► _""- - VAKorwr Depsrvneof Cor- m2j17��eL EV UATION REPORT Pape Cr D,N� o` Satety anc Bultdin_gs R.dT Cooe eveioDmen Aaract% compete she pan or papa' na, less than E , x - in--nes ir. sae Plan -nest 1-dude, W no. tint tec tc vet a and )mzmta re+erenx "it `SV dfrecbo anc Parom percent srope� scale or dimensions, norT'. arror an.- location erw' distance tc nea-es: road. i / ! - 127 Please print all information. Reviewed ry JJ Daub Psrsoryvntormstwr vo. O'ov ma. tx usec fa We n�n pvrW... i -PmDe,h ` 1 Proper'Locahor AAJ� Gout. Ltx5e- 4% a ,k4}a 57 T / N R j E re Property Owner's MaiY. Address L y OT, Bloc R I Sbd. Narns or CSKO State LC eooe Pone Num.'Ar, 1 7 cjty ❑ �rllage f`own Nearest Road Hier ;onstructir, sr es Dent a ; NumSer o' Ded oo ns Code derived oesign bon rate GPD L- Replacement ----- Parent rnstena' l Y _ Fio{q�d Piam eie ation V appi"bie ��1. Gerreral Cm1mDr" I and r000rrrnandations: star- Type �%� `Ysterr. Elevation L 1 L_J p Ci Pitt Ground surface ew /� ft Depth W tinting factor ` Sai Ano{icatian Rate gorov 0 I ' 1 a Pit Ground surface ekv. V - 5 R. Depth Ic Wrv&V factor � tt! iw Ar".t ., Pd. Mw �i � IONM �issue�,,//,_-I E1lkWd f1 • Boo, > 30 < Z!U MWL and I ,J >Ju 1 IOU cnwu• we - ov.+, _ .y. v �.. _ •. •s- CST Name (Please Print) ature CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation conducted Telephone Number 1432 120th St, New Richmond, WI 5401 3 —G z 715-246-4516 Property Owner _ UBoring # ❑g� Bing r� Pit Parcel ID # Ground surface Depth to limiting factor j�E in. Page Zot 3 ®® ■. .. ■ _,.... ...:ram SMZEMM ®1� "Jf Boti g # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor n. ■ ' Effluent #1 = BODE > 30 < 220 mg/L and TSS >30 < 150 ffv& • Effluent #2 = BOD 130 mot and TSS < 30 ng1L 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 TTY 608-264-8777. seouw ra.6=1 ' Effluent #1 = BODE > 30 < 220 mg/L and TSS >30 < 150 ffv& • Effluent #2 = BOD 130 mot and TSS < 30 ng1L 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 TTY 608-264-8777. seouw ra.6=1 Property Owner _ Boring # � Boring Pit Parcel ID # Ground surface elev.�& I �4. Depth to limiting factor 2 ,,5- in. Page Zof Sail Anrgknt. Ra.e FIAMMUM ©Mr"narsFA FA I�r����m�� 0 Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Appligtion Rate Horizon Depth in. Dominant Color Munsell Redox Description Du. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDM 'Eff#1 •Eff#2 1:1❑❑ Boring Boring # Ground surface elev. ft. Depth to limiting factor in. Pit Srvl Ar"irsrinn P t. ®® R. .. : s _... Cola ®®®®®nt. � Effluent #1 = BOD, > 30 < 220 mg(L and TSS >30 < 150 mglL ' Effluent #2 = BOD, < 30 mpt and TSS 5 30 mp4 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 TTY 608-264-8777. seanra (R.wol Soil Test Plot Plan Project Name Dave Burlingame Shaun Address 1190 Main St. G St. Paul Park Mn 55071 Lot ----- Subdivision S W 1/4 S W 1/4S 7 T 31 N/R15 W Boring Q Well PL Property Line BM or VRP Assume Elevation 100 ft. CKGI #226900 Date 5/24/22 Township Forest County ST. CROIX Top of 3/4" pipe System Elevation 99•5' *HRPSame as Benchmark )6.5' ' L. 698.5' Z71 .5 B.M.* Pro 4 Bedroom House Scale = 1 /4" = 10, 0, 40' 80' 1 1 1320' Property Line 220th Ave i• Systeln PLOT PLAN PROJECT Dave Burllnaame ADDRESS 1190 Main St. St. Paul Park Mn 55071 SW 1/4 SW 1/4S 7 /T 31 N/R 15 W TOWN Forest COUNTY ST.CROIX SYSTEM ELEVATION 99.5' 1.5' sand lift DATE 5/25/22 BEDROOM 4 CONVENTIONAL AT -GRADE CONVENTIONAL. LIFT HOLDING TANK MOUND )= SEPTIC TANK SIZE 1200 gallons LIFT TANK SIZE DOSE TANK SIZE 800 HOLDING TANK SIZE LOAD RATE 1 .0 ABSORPTION AREA 600 U of Chembersnone Ilk BENCHMARK V.R.P. Top of 3/4' pipe ASSUME ELEVATION 100' Filter Lifetime ❑ BOREHOLE (Z) WELL •H.R.P. same as benchmark a 8°% Slope Area 15' below system to B - 3 remain undisturbed Weiser Combo Tank B -1 \\\ 9 97.5' 8.5.9B.0' B.M. Grading is to be done to divert run-off away from system Pro 4 Bedroom House Scale = 1 /4" = 1( D1 40' 180' 220th Ave al) T 14 1320' Property Line Well is to meet all WDNR setbacks OF FLA I iiry I'1r.IL. MAIL NLWY IINAN,:_ SPonr6 ENTER7AINW`NT LIFE FRONTIER HELP CENTER DOM(MMEn eA•Mon Ydn Ma W, congws- IHtk)x Unlead Starred Drabs Swll Nchlve Spy MIA) Less Views Photos Docuntertta Subscnpllaw Slloppol(j rieca.plq InwW Folders New I older Hide Hide Find messages, documents, photos or people v (- Back « 4k y Y Archive lilt Move m Delete 0 Spam ••• X Shawn Honx> 21 R@CEIVED JUN 2 8 2022 MV COUNTY CDD (I OP&A""Ao ) couNN No. 644715 I STAT SANIT 1 �2(# Iq 2 L RE 10 PLU TO` SEC AND/OR LOT BLOCK mms' i q666 SUBDIVISION PERMIT NO. a CHAPTER 145.135 (2) WISCONSIN STATUTES (a) The purpose of the sanitary permit is to allow Installation of the private sewage system described in the permit (b) The approval or the sanitary permit is based on regulations in force on the date of approval. (c) The sanitary permit is valid and may be renewed for a specified period. (d) Changed regulations will not impair the validity of it sanitary permit (e) Renewal of the sanitary permit will be based on regulations in force at the time renewal is sought, and that changed regulations may impede renewal. (I) The sanitary permit is transferable. History: 1977 c. 168; 1979 c 34,221; 1981 c. 314 Note: if you wish to renew the permit, or transfer ownership of the permit, please contact the county authority. ZED ISSUING OFFICER —DATE ' 1 It K I64ow PERMIT EXPIRES ZED ISSUING RENEWED BEFORE THAT DATE POST IN PLAIN VIEW VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION SBD-06499 (RI1/20)