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032-1018-80-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No'. 538772 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: Plourde, Douglas R. & Constance I Somerset, Town of 032- 1018 -80 -000 v: Insp. BM Elev: BM Description: 2 Section/ CST BM Ele Town /Range /Map No: a'a 9m / GS'r 07.31.19.94A TANK INFORMATION A ELEVATION DATA TYPE MANUFACTURER r 0 CAPACITY STATION BS HI FS ELEV F Ae ?� c Benchmark ) )_ r b NP Alt. BM ng � � ttion Bldg. Sewer 4. 6-5 3. 5 � Holding St/Ht Inlet St /Ht Outlet 7• I C J /Z• „ T� L•7 TANK SETBACK INFORMATION > TANK TO P/L WELL BLDG. Ven�w Air Igtake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. - 7 r, Aeration Dist. Pipe / r . �. a W Holding Bot. System 1D ". 3 Final Grade /,3 . �QZ PUMP /SIPHON INFORMATION Manufacturer Demand St Cover jr GPM Model Numb 1/ * �• 3 /A TDH Li Friction Loss ISystern Head DH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Tr enche s PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer INFORMATION CHAMBER OR .I. At�i r Type Of System � / 7 � ) /� `! UNIT Model Number: O� ,��e4 DISTRIBUTION SYSTEM �► 5 - Header /Manifol� Distribution x Hole Size x Hole Spacing Vent to Air In ake Pipes) E S L Length \ Dia ` Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over j xx Dept f xx Seeded/ odded xx Mulc d Bed/Trench Center 3 . 9 Bed/Trench Edges Topsoil 4: Yes E [ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 2300 Timber Rd. SOMERSET, WI 54025 (Gov't Lot 3 7 T31 N RI 9W) metes & bounds Lot Parcel No: 07.31.19.94A 1.) Alt BM Description = 2.) Bldg sewer length - amount of cover = .►� �� > / Plan revision Required? 0 Yes X No Use other side for additional information. - — - --- Date Insepctor's gnatur Cert. No. SBD -6710 (R.3/97) commerce.wi.gov a ety and Buildi s Division County UV 201 W. Washington Av , P.O. Box 7162 i sco n s i n �� 53 07 -7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce Sanitary Pe l�j T E State Transactign �ber In accordance with s. Comm. 83.21(2), Wis. Adm. o t is form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Addre s (if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary purp oses in accordance with the Privacy Law, s. 15.04(1 )(m , Stats. 1 O -0 I. Application Information — Please Print All Information Property Owner's Name Parcel # - D o u 6 tk £ 03 7 — 4 a -go ed 6 Property Owner's Mailing Address Property Location , q1 1A o Dry ` Govt. Lot 3 ( / City, State Zip Code Phone Number cr , , ^7 -� /, -7 '7 -� p � / <, �� /,, Section CJ (circle on) arvh£e -iC'� �,l ,Sy �vS" / "7 /�i� r/GQ T31N; R/9 Eor II. Type of Building (check all that apply) — Lot # X or 2 Family Dwell pg — , Nu of Bedrooms ac, jQ C' Subdivision Name P ` ° "u 1 Block # / , " r / J A ❑ Public /Commercial — Describe Use ❑ City of El State Owned — Describe Use CSM Number ❑ Village of Er Town of c�0 �'►' ►�iLS III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ffl - N ew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. Type of POWTS System/Component/Device: (Check all that apply) ❑ Non - Pressurized In- Ground ❑ Pressurized In- Ground ❑ At Grade El Mound > 24 in. of suitable soil. ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑Other Dispersal Component (explain h 17 M40 r D � Cfit Device (explain) V. Dis ersal/TreatmentArea Information: Ctl S 3 Jt Z (o d k -C 5 Design Flow (gpd) Design Soil Application Rate(gpdsf j Dispersal Area Required (sf) ispersal Are Proposed (s System Elevation '/ 900 QZ.0 , � ' 98• f VI. Tank Info Capacity in Total # of Manufac er C Gallons Gallons Units New Tanks Existing Tanks E eptic olding Tank /da0 j a w Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS sh the attached plans. P ber's Name (Print y Plumber's Signature Number Business Phone Number QC 1AC �Cw17 / NS Z L 7Z Plu ber's Address (Street, City, State, Zip Code) Z /5 _ 741 �k �'. t5 Psi VIII. oun /De artment Use Onl pproved ❑ Disapproved Permit Fee Date Issued I ing Age t Signa El Owner Given Reason for Denial $ � f 5 L3 Jd/l IX. Conditions of Approval/Reasons for Disapproval ' SYSTEM OWNER: � �_iv t 1 Septic tank, effluent filter and dispersal cell must all be serviced /maintained — p /,v� as per management plan provided by plumber. V£,GJJ 0 iJ Z • O ��� /U 7 p j ( X10 2. All setback requirements must be maintained A d �� tta com lep to pans for the syste d submit to the County only on paper notes �p 1 &� Or Z c Ad n ( NI 0 ti IL CA �o v o � �a Q r � o , b 7 0 0 e n o ► rte_ 0 0 0 d CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAG'E�J Project Name: (.-, 4 Owner's Name: o a ti Owner's Address: "_ Legal Description: �J E ^ 7 3/ N //L�`� LA-) Township: County: �- Subdivision Name: Lot Number. Parcel ID Number 6 j ��� �$ � _aa °, 0 3 2-/01� —�� C Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross - Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenanc Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer /Plumber: G4 k `Y�w 11 i',k S License Number: 2 Z Z $3 Z Date: S `� -f Phone Number V U 2 y Z 1 Signatur Designed pursuan to he In- Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD- 10705 -P (N.01/01). Page 1 ( A � t ° 3 0 j lie kv IV pt- o d 1 0 � o h w 3 0 Q q vs, yJ z Soil Absorption Svstem Cross Section - � /o Z • - ft 4" Schedule 40 Final Grade PVC Vent Pipe �Q I With Vent Cap ♦_ ft Leaching - ► 98 / Chamber ft ~- System Elevation ft .� ft Soil Absorption System Plan View 9L ft 3 ft ft Leaching Trench 1 Vent Or Observation Pipe � Chambers 4" Dia. Trench 2 Header Leaching Chamber Specifications Manufacturer And Model G , c.K Y s EISA Rating 2 o sq ft per chamber Soil Application Rate S gpd /sq ft gpd Design Flow Soil Application Rate T ZO EISA = Y Chambers 2 rows of Z 3 chambers each. i Page of RECIVED - p REP6R� -- 3 J f • Wisconsin Department of Comme MAY 2 3 201�oi L VALU ATIQN Page o Division of Safety and Buildings t}a �Com 85, Wis. Adm. Code County Attach complete site plan on pap r FF size. Plan must ��' include, but not limited to: vertica rizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all Mformation. R sewed Date > Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ��^ ' ✓ ��) Property Owner ) ` Property Location D 04 /��(�a Govt. Lot£ 1/41/1 1/4 s7 T31 N R /q E (or Property Owner's Mailing Address Lot # Block T bd. Name or CSM# ss1� le u cdc DIC- City State Zip Code Phone Number ❑ City ❑ Village EffTown Nearest Road �d+s..fi[�TC� LVi SyaZS ( ) c5O C� �✓��Y 1 d• 991 -New Construction Use: Residential / Number of bedrooms • Code derived design flow rate S�.S'o GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable ft. General comments r/ and recommendations: U l� �-' S �tt.., -, �ltv • 98� I _ �r �, D • s �- � ��,,.e. Spa F- / 1 Boring # Boring ® Pit Ground surface elev. (e ft. Depth to limiting factor ? 97 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2 j 0 -? / 10 /- -1z 1 s-` 1 7 ,. � c s Z. Z 'moo � 5r : ! z � ..� s ��' • �rr rj Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor > 8L in. [ S:oi:I:,Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr Sz. Sh. *Eff#1 *Eff#2 3 18 30 7. S z'� -7 * Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Nam lease Print) Signature CST Number Ct e* kA r Z 2-7-97z— Address Date Evaluation Conducted Telephone Number ZCoS 1 S��'' 3`�• �uck : S� S- U /I Y7 - �- a ' o� qj N Ap s a c Of 0 v o - a z rr w h .• 1 om 1 PC n Th ° N I 1 1 13 10 I A' ��• 3 j i A w A �' A N CIO d zs » I h ¢9 N I 6'3 I ,�, ��•�� Q 'h a � ° � h h I 1 0 0 .., O a� t'1' I s' eD m G9 r 3 f •� _ 3 b QV N C N N N ,",.•P.,, L' O O �p Q O A i d 'O W gig lu IF m Uh A fwd O T7 �R 1R iY f1 f1A O m CD e o er w n W .n W T.' f3. if F . h Q A •S, 0 0 .1 G d a f rrr 9 W o S.O. r. FD T a ® '" d f e -w, per, O om nyS�T m fD a7C IMP b N O er - [^� O _d _� a F^� n E r--'t rD OD w L m . POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page _L of FILE INFORMATION SYSTEM SPECIFICATIONS Owner D ldu�t� c Septic Tank Capacity / 0416 al ❑ NA Permit # -70 Septic Tank Manufacturer 15- 11S(A- ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer j S ❑ NA Number of Bedrooms 3 ❑ NA Effluent Filter Model �� /p ❑ NA Number of Public Facility Units NA Pump Tank Capacity a l - B'NA Estimated flow (average) 'YJ gal /day Pump Tank Manufacturer EB'14A Design flow (peak), (Estimated x 1.5) ( Z J� gal /day Pump Manufacturer --E3 Soil Application Rate - - 7 gal /da /ft2 Pump Model ENNA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit CI-NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD :5220 mg /L P/N A ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) :5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD :530 mg /L 211n-Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L .a NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia.jq Other: 13 NA Other: ❑ NA Other: ❑ NA * Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: . T o � 1 (s) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 ears) ❑ NA �# � �ear(s) y Clean effluent filter At least once every: onth(s) ❑ NA 3 ❑ year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) .110 ,NA' ❑ year(s) Flush laterals and p ressure test At least once ever ❑ month(s) ye ar(s) 9 p y' ❑ yearls) Other: At least once every: (s) ❑ year(s) ❑ NA Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections 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 cell(s) 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 shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of :512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local reculatory authoritv within 10 days of comDletion of anv service event. Page _o f v 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 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 shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the P TS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacer ent system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALL R POWTS MAINTAINER Name Ccr..r f�iti -� 4e Name L ± f� ,� r % C Phone 7: r Y7L Z V Z / Phone 7L Z t/1 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY -� Name asks Name A Phone I / �- j �� YR Phone J - This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1 ), (2) & (3), Wisconsin Administrative Code. INGROUND SOIL ABSORPTION MANAGEMENT PLAN PURSUANT TO COMM. 83.54, WIS. ADM. CODE General This system shall be operated in accordance with Comm.82 -84 Wis Adm. Code and shall be maintained in accordance with its component manual [In- ground Absorption Component Manual for POWTS Version 2.0 SBD- 10705 -P (n.01 /01) and SSWMP publication 9.6 (01/81) and local or state rules pertaining to system maintenance and maintenance reporting. No one should ever enter a septic tank or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with Comm. 83.33, Wis Adm. Code when the tanks are no longer used as POWTS components. Septic or pump 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 and 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 a tank or component. 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. The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should 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 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 sludge and scum in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of the triennial assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maxium scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such products are used they shall be approved for septic tank use by the Dept. of Commerce. Pump Tank The pump tank shall be inspected at once every 3 years. All switches, alarms and pumps shall be tested to verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary. Soil Absorption System No trees or shrubs should be planted on the absorption area. Plantings may be made away from the cell's perimeter, and the area shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic (other than foot or for vegetative maintenance) on the area is not recommended since soil compaction may hinder aeration of the infiltrative surface within the system and snow compaction in the winter will promote frost penetration. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner, and any levels above 4 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component shall be immediately repaired of replaced with a component of the same or equal performance. If the dispersal area fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or replaced in its' present location by biologically clogged absorption and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. Replacement in a suitable area nearby is also an option at which point a diversion valve will be installed between the old and new systems to allow dispersal cell rotation at a schedule to be determined at the time of cell replacement. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Bu y er D D u �/ ©� '` 4 t' Mailing Address ) Property Address I - 3 G 0 (Verification required from Planning & Zoning Department for new construction.) City /State �Y►�Z �, �Z Parcel Identification Number U 3 Z `Oa! 8 Lp —Ob 0 LEGAL DESCRIPTION , Sec. - 7 , T N R_ Property Location �� ' /4 , N£ '/4 ,Town of �d I.�L.S Subdivision Plat: , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # 3 (before 2007)Volume , Page # Spec house yes no Lot lines identifiable ! =1 yes( i�o SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintepance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that ( I ) the on -site wastewater disposal system is in proper operating condition and /or (2) after inspection and pumping (if necessary), the septic tank is less than L/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 Planning & Zoning Department within 30 days of the three year expiration date. 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. Number of bedrooms SI TURE OF APP ICA ) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application 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. (REV. 08/05) . . PLANNING CB4O1X COUNR & ZONING, Mr. Doug Plourde 566 Plourde Drive Somerset, WI 54025 ' RE: Plan Review for filling & grading in Shoreland Overlay District Parcel I.D. 07.31.19.94A, Town of Somerset Code Adm nistra 715 - 386 -4680 Dear Mr. Plourde: Landlnformation After completing a site visit on May 16th and reviewing the proposed house Planning construction site plan for the above property, I have determined that your project 715 - 386 -4674 will not require a land use permit or special exception permit at this time Your proposed building project area is within 1000 feet, but outside the 300' setback, of Real P10 an unnamed pond's ordinary high water mark (OHWM). Your calculation for land 715 -3$6 677 disturbance area includes --521 feet of driveway (the remainder is not subject to Reding Shoreland zoning), the house and garage footprint, and the Private On -site - 386 -4675 Wastewater Treatment System (POWTS). The topography of your building site was measured in the vicinity of the proposed walkout foundation where slopes are approximately 15 %, but the majority of filling and grading will be on slopes less than 12 %. This project will meet filling and grading requirements that are allowed without a permit pursuant to Section 17.29(2) (c) of the Shoreland Ordinance and Section 17.12(7) General provisions. As part of the sanitary permit application, house plans need to be submitted that document the square footage of the structure and the number of bedrooms used for sizing the POWTS. Please be aware that land disturbance in the Shoreland Overlay zoning district is cumulative, thus a land use permit may be needed for future projects that result in <10,000 square feet of land disturbance within 300' of the pond's OHWM or a special exception would be necessary if filling and grading were to exceed 10,000 square feet. I will attach a copy of this letter to your sanitary permit application materials and, if you prefer, fax a copy to the building inspector for the Town of Somerset. If you have any questions or concerns prior to construction, please feel free to contact our office for assistance. Sincerely, Pamela Quinn Zoning Specialist ST.CROIX COUNTY GOVERNMENT CENTER 1 101 CARMICHAEL ROAD, HUDSON, W1 54016 715386 -4686 FAx PZPCO.SA /NT- CROIX.WI.US WWW.CO.SAINTCROIX.WI.US Page I of I Pam Quinn From: Douglas Plourde [drplourde @gmail.com] Sent: Tuesday, May 17, 2011 10:55 AM To: Pam Quinn Subject: Douglas Plourde Sq footage map Attachments: D. Plourde home measurements. pdf Pam, Here is a layout of where my house will be relative to the pond. We moved it all the way to the North as possible. We are out of the 300 ft setback from the wetland requirement. In the new home location the slope is less than 20 degrees. (6 foot rise over 40 foot run). Also by moving the home North we have shortened the driveway a great deal. We will be disturbing a total of less than 10,000 sq ft. All distance measurements were done using the County web site. We hope to have the new borings done this week. Thanks, Doug Please confirm that you have received this email. 5/17/2011 rt tl O � r r If O log CL CD N W O O 3� cr CD Q O 3 CD cn CD � ` m Parcel #: 032- 1018-80-000 05/23/2011 03:33 PM PAGE 1 OF 1 Alt. Parcel #: 07.31.19.94A 032 - TOWN OF SOMERSET Current OX ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): 0 = Current Owner, C = Current Co -Owner 0 - DELAITTRE, BARBARA M BARBARA M DELAITTRE 2303 TIMBER RD SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description SC 4165 SCH DIST OF OSCEOLA SP 1700 WITC Legal Description: Acres: 20.000 Plat: N/A -NOT AVAILABLE SEC 7 T31 N R1 9W GOV LOT 3 EXC PT TO USA Block/Condo Bldg: IN VOL 558/230 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 07-31N-19W Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 841/75 07/23/1997 805/584 2011 SUMMARY Bill #: Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 04/07/2011 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 20.000 3,500 0 3,500 NO 10 Totals for 2011: General Property 20.000 3,500 0 3,500 Woodland 0.000 0 0 Totals for 2010: General Property 20.000 3,600 0 3,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 rn co 0 r� 2 c� y �o c� • I) I�I I) III Ili) l) II VIII I�I II lIl STATE BAR OF WISCONSIN FORM 1 - 1998 WARRANTY DEED 8 0 2 2 6 7 4 Tx:4016577 Document Number 933457 This Deed, made between - Barbara DeLaittre single Grantor, BETH PABST and Dxglas R. PlcLxde and Ceristame M. Plounie, disband and wife REGISTER OF DEEDS , Grantee. ST. CROIX CO., WI Grantor, for a valuable consideration conveys to Grantee the following 03/14/2011 10:43 AM described real estate in SAINT CROIX County State of EXEMPT*: N/A Wisconsin (the "Property'): REC FEE: 30.00 TRANS FEE: 1575.00 PAGES: 2 Recording Area Name and Return Address Return to: Burnet Title 5151 Edina Industrial Blvd. #500 Edina. NIN 55439 Attn: Post Closing Y T 0 d - 014 do vca 032 - 1018 -20 -00 :0380 -000 032 - 1018 -60 -000 r Parcel Identification Number (PIN) , This is homestead property. See Exhibit A attached hereto (is) (is not) Together with all appurtenant rights, title and interests. Grantor warrants that the title to the Properties good, indefeasible in simple fee and free and clear of encumbrances except Dated this 1st day of March 2011 (SEAL) (SEAL) Barbara DeLaittre (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Minnesota, authenticated this day of Washington County } ss. Personally came before me this j day of March 2011 the above named Barbara M. DeLaittre. single to me known to be the person who executed the foregoing instrument and acknowledge the TITLE: MEMBER STATE BAR OF WISCONSIN same. (If not, authorized by §706.06, Wis. Stats) THIS INSTRUMENT WAS DRAFTED BY Not Pub c, tate o �; �� Burnet Title -Scott Tranby 5151 Edina Industrial Blvd, #500 My commission is permanent. (If not, state expiration date: Edina, MN 55439 11 -01360 ) (Signatures may be authenticated or acknowledged. Both are not necessary.) KELLY LYNN HECKSEL �wi" NcTAnY Pueuc - t:uNNESCTA * My Comm. Ec P11— Jan.31. 2012 Names of arsons signing in an ca acit must be ed or rinted below their si STATE BAR OF WISCONSIN Wisconsin Legal Blank Co, Inc. VY o _#ANTY DEED FORM No. 1 — 1998 Milwaukee, Wis. K^ EXHIBIT "A" Legal Description File No. 11 -01360 The East one -half (E 1 /2) of Northeast one - quarter (NE %) and all of Government Lots Two (2)and Three (3) and that part of Government Lot Four (4) that lies Southeasterly and Southerly of the following described line. Commencing at a point on the North line of Government Lot Four (4), Section 7, Township 31, Range 19, said point being on a bearing of 89 degrees 30 minutes West 1412.5 feet Westerly from the Northeast corner of said Section 7; thence South 24 degrees 57 minutes west for 42.1 feet: thence South 82 degrees 05 minutes 30 seconds west for 231.9 feet; thence South 62 degrees 08 minutes 30 seconds West for 376.2 feet; thence South 34 degrees 31 minutes West for 327.6 feet; thence South 0 degrees 59 minutes West for 87.5 feet; thence South 44 degrees 04 minutes West for 305.4 feet; thence South 29 degrees 04 minutes 30 seconds West for 357.4 feet; thence South 25 degrees 23 minutes 30 seconds West for 132.53 feet; thence Westerly on a bearing of North 89 degrees 30 minutes West and parallel with said North line of Government Lot Four (4) to the West boundary of said Government Lot Four (4), all in Section 7, Township 31, Range 19, Somerset Township, excepting therefrom all of the property conveyed by that certain Warranty Deed dated July 28, 1977, from Carl L. Weschcke and Sandra K. Weschcke, husband and wife, Grantors, to the United States of America, recorded July 28, 1977 as Document No. 341914* in Book 558 of St. Croix County, Wisconsin, Records, Page 230, and further excepting therefrom all of the property conveyed by that certain Warranty Deed dated December 12, 1977, from Carl L. Weschcke and Sandra K. Weschcke, husband and wife, Grantors, to United States of America, recorded December 13, 1977 as Document No..345365 ** in Book 566 of St. Croix County, Wisconsin, Records, Page 131, and further excepting therefrom all of the property conveyed by that certain Warranty Deed dated June 25, 1980, from Carl L. Weschcke and Sandra K. Weschcke, his wife, to Charles D. DeLaittre and Barbara M. DeLaittre, recorded October 2, 1980, as Document No. 366774 * ** in Vol. 618, page 384, in the office of the St. Croix County Register, together with all easements of ingress and egress as shown in Volume 558 Page 230, Document No. 341914 of record serving the property herein conveyed and owned by Grantors. And except the NE' /. of the NE' /. of Section 7, Township 31 North, Range 19 West. * Exception further described as Book 558, page 230 Document No. 341914. A tract of land situate in Government Lots 2, 3 and 4, Section 7, Township 31 North, Range 19 West, 4th Principal Meridian, St. Croix County, Wisconsin, described as follows: Beginning at a point North 89 degrees 30 minutes West, 1412.5 feet, South 24 degrees 57 minutes West, 42.1 feet, South 82 degrees 05 minutes 30 seconds West, 231.9 feet, South 62 degrees 08 minutes 30 seconds West, 376.2 feet, South 34 degrees 31 minutes West, 327.6 feet, South 0 degrees 59 minutes West, 87.5 feet, South 44 degrees 04 minutes West, 305.4 feet, South 29 degrees 04 minutes 30 seconds West, 357.4 feet and South 25 degrees 23 minutes 30 seconds West, 132.53 feet of the northeast corner of said Section 7; thence South 0 degrees 30 minutes West, 63.28 feet, South 89 degrees 30 minutes East, 309.42 feet, South 0 degrees 30 minutes West, 1320 feet and South 36 degrees 52 minutes 12 seconds East, 1650 feet to the southeast corner of said Government Lot 2; thence, along the south line of said Government Lot 2, westerly 1600 feet, more or less, to the left bank of St. Croix River; thence, along said left bank, Northerly 2700 feet, more or less, to a point North 89 degrees 30 minutes west of the point of beginning; thence South 89 degrees 30 minutes East, 500 feet, more or less, to the point of beginning. 2 of 2 commerceml.gov Safety and Buildings Division County ■ 201 Washington Ave., P.O. Box 7162 �t , i W. s co n s i n ,�adln" 53707 -7162 Sanitary Permit Number (to be filled in by Co.) - Department of commerce j 1 . Sanitary Pernff State Transaction Number In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of is fo tal �� / r unit is required prior to obtaining a sanitary permit Note: Applic on forms t o 1 WTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information u provide may be used for secon ary Rurp oses in accordan ce with the Privacy Law, s. 15.04(1 )(m), Slats. 0 �� !7 J I. Application Information — Please Print All Information Mit Property Owner's Name Parcel # out ST. CROIX COUN'!'Y PLANNING a ®' Z — /0 /,? a —Q o a Property Owner's Mailing Address Property Location Govt. Lot 44040 City, State Zip Code Phone Number , S� �, ' / <, Section �— I JOr» �;2 f , (/v ' r /D L � s> - y 7Z �� (circle one) II. Type of Building (check all that apply) 0 �- O - k- Lot # T N; R 9 E or W 0 4 or 2 Family Dwelling — Number of Bedrooms / `. / /„ t• %� Subd Sion B Name vU(/ KJ �J 11 Public /Commercial — Describe Use lock# t City of El State Owned — Describe Use l CSM Number r ❑b Village of T I� Town of k 6 vr�+ 0 '/- -T L `f III. Type of Permit: (Check only one box on line A. Complete lid if applicable) A. ly New System ❑ Replacement System ❑ Treatment/Holding ank Replacement O y ❑ Other Modification to Exist' System (explain) B • ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ it Tr sfer to New L' revious Pe ate Issued Before Expiration Owner IV. Type of POWTS System/Component/Device: (Check all that a I ) A N-n- Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > in. o table soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretre ent Device (explain) V. Dispersal/Treatment Area Information: 2 — C e: // S' , X ca Y ' � Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Requir (sf) Dispersal A Proposed (sf) System Elevation VI. Tank Info Capacity in Total of Manufacturer New Gallons Gallons 4-its C 0 Tanks Existing Tanks Ld. O a+ U y .O R • CC cs y Septic r Holding Tank J Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibil' for installation of the POW TS sho the attached plans. u ber's Name (Print) y Plumber's Signature MP PRS umber Business Phone Number WI -Lyz/ Plumber's Address (Street, City, State, Zip Code) VIII. Coun /De artment Use Onl ❑ Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature ❑ Owner Given Reason for Denial IX. Conditions of Approval/Reasons for Disapproval /o- Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x 11 incites in size z Soil Absorption Svstem Cross Section 9 7 _ q - ft 4" Schedule 40 Final Grade PVC Vent Pie Q With Vent Cap �. 9 q ft v Leaching 93 4/ — 91 • $ Chamber ft � System Elevation ,3 ft a ft Soil Absorption System Plan View ft _5 ft { `� ft Vent Or Observation Pi Leaching Trench 1 p e � Chambers 4° Dia. Trench 2 Header Leaching Chamber Specifications Manufacturer And Model r. -k 13 EISA Rating Z 0 sq ft per chamber Soil Application Rate ' 7 gpd /sq ft gpd Design Flow - -7 Soil Application Rate z v EISA = 3 Chambers 2 rows of /7 chambers each. r Page of RECEIVED Pfd Wisconsin Depa entot imaSOIL EV ALUATION REPORT Page of Division of Safety nd Building ST. CWOV COUN nce with Comm 85, Wis. Adm. Code PLANNING & ZONING 4W County Attach complet no ess an 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. I.D. l i Please print all information. Revie d by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner i� Property Location p J1o(A I �1 ` O u A, c� � Govt. Lot _'Y� 1/4,U f 1/4 7 T N R E (or& Property Owner's Mailing Addre� Lot # 113lock # I Subd. Name or CSM# City State Zip Code Phone Number oq ❑ City ❑ Village 05Town Nea rest Road * f �' �)Ff: �. (�J l) 7Z y /Lv / jd — 4 -New Construction Use: Residential / Number of bedrooms Code derived design flow rate `/J V GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable ft• General comments and recommendations: F_ / ❑Boring Z_ Boring # Pit Ground surface elev. D r ft. epth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDAf in. Munsell Qu. Sz. Cont. Color Gr Sh. *Eff#1 *Eff#2 r� Boring # ❑ Boring ® pit Ground surface elev. 9, ft. Depth to limiting factor in. Soil A "Cation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 fD � ZD ��� — S. Z�s6 -m ✓7� s /f S q9 7.57 3 /y — ,S* o,s f — .7 1 • (� 5 * Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST N (Please Print) Signature CST Number Address 61 Date Evaluation Conducted Telephone Number (Qj 5 /v`d� � X- Imo;f3S3 J Y —// y7Z —LY�� . Z. Ll a r; � a t � F� -7P N�l CA G f U w � z � c z l� r :S 0 0 \ \r e \ yv o n L� 'b I °� 'Al M o — v v b y W _. - 0 Ll -4 F .