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HomeMy WebLinkAbout026-1135-04-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 538$03 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 Zdroik, Anthony J. Richmond, Town of 026- 1135 -04 -000 CST BM Elev: Insp. BM Elev: BM Des ption: Section /Town /Range /Map No o M ) G sT 24.30.18 934 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION B HI FS ELEV, Septic Benchmark Dosing ' � �� Alt. BM Aeration �� we � Z• /62 / / ; l Bldg. Sewer Holding St /Ht Inlet •' , - -- V TANK SETBACK INFORMATION St/Ht Outlet 5. 57• DZ TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Z / Dt Bottom • r0 �� BIZ A5 / Z •� 93.0 Dosing / I S 489 _ Header /Man. 9 Aeration Dist. Pipe y Holding Bot. System � , � ' ] PUMP /SIPHON INFORMATION Final Grade Manufacturer 6 1 S Demand St Cover GPM 6 't G� �.. .3 /az -3 Model Number o 2? 1! 57P t w ) 4 TDH Lift , Friction L System Head TDH t • 16 Z Forcemain Length I Dia. Z Dist. to well /OZ SOIL ABSORPTION SYSTEM J1 1 - BED /TRENCH Width C Length No. Of nches PIT DIMENSIONS No. Of Pits Inside Dia Liquid Depth DIMENSIONS ! � �`V \ SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer. INFORMATION CHAMBER OR Type S stem: /� T UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spac�g Ven Air Intake Pipes) / L / / 7 Length Dia Length Dia Spacing � tJ SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only a► Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched ] Bed/Trench Center �� Bed/Trench Edges ` Topsoil 1 • 1 . � Yes �t; No s No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: g/ j ! �� Inspection Location: 1443 141stAvenug w N Richmoryd, WI 54017 (SE 1/4 SW 1/4 24 T30N R18Vt'} Evergreen Overlook Lot ' Parcel Np: 24.3 .18.934 1.) Alt BM Description= (/' 4 L �J"�� G� : "'+�Q. a,-) J 2.) Bldg sewer length = P f �..� Ok_ - amount of cover d L� Plan revision Required? ❑ Yes � l � {GJ v ��✓ Use other side for additional information. Date Insep is Sign re Ceti. Nn SBD -6710 (R.3/97) ��r,;E1VED c mmerce .wi.gov Safety and Buildings Division * hiO. Box Madison, WI 53707 -7 rym (to be filled in by Co.) Depa S 0111 memerit of Commet�JNTY sact 201 W. Washington Ave., P. ion Number Application In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary u ses in accordance with the Privacy Law, s. 15.04(1)(m ), Stats- 1. Application Information - Please Print All Information Property Owner's Name Parcel # I P A Property er's Mailing Address Property t ovation i Govt. Lot City, State Zip Code one Number Y., Section .2$ / (circle one},, GNyfm ,S'yB/ � 9 r� T to N; R /S Eora If. pe of Building (c k all that apply) Lot # Subdivision Name or 2 Family Dwelling_ - Number of Bedrooms: / v(/ fivLlY�{ L �' r/L Block # L� . N f%!/ X. /c C1 Public /Commercial - escri Use — ❑ City of CSM Number ❑ Village of ❑State Owned - Describe Use l�''fown of /1?, > III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A ' ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System (explain) B. ❑ List Previous Permit Number and Date Issued Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New Before Expiration Owner 3 f S7 /S^ 2 p0o IV. Type of POWTS S stem /Corn oneat/Device: Ch t appl El Non-Pressurized "round ❑Pressurized In Grou d �At -Grade Mound ? 24 in. of suitable soil El < 24 in of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) 2 V. Dis ersaVrreatment Area Information: Design Flow (gpd) Design Soil Application Rate( Dispersal Area Required (st) ispersal Area Proposed (s ystem Elevation yoo �o 2-„ �- `��v 7s-0 / 6 ,/ VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units New Tanks Existing Tanks 4 0 :t: m w a Septic or 1 toidingiank BGd W eX e r Dosing Cbamber j� -- VII. Responsibility Statement- 1, the undersigned, assume responsibility for installati of *e POWTS shown on the attached plans. Plumber's Name (Print) Plumber' ignature MP /MPRS Number Business Phone Number Plumber's Address (Street, City, Qw Code) ` • _ / CE� 7�` Y� ^ O Vlll oun /De artment Use Onl ID-/Approved El. Disapproved EPermit Fee Date Issued suingAge Si❑ Owner Given Reason for Denial & IX. Conditions of Approval/Reasons for Disapproval yt �• SYSTEM OWNER: 1 Septic tank, effluent filter and dispersal cell must all be serviced / maintained V1��i S - W 2 - 1 as per management plan provided by plumber. 0, I 2. All setback requirements ' ns for the system an sum only Qu paper not less than 8 in x 1 I inches in size as per applicable cts�9b(41fW�41�'��. a t bit to the �� SBD -6398 (R. 01/07) Valid thru 01/09 � I e � t 4 a&f `7+''r a ',�' u l �' / U tJ vl�Girt Lc�t� f 3.3 3 . Page 8 of 8 FN# 1443141st. Ave. 0 20 40 Sanitary Site Plan Graphic scale (Feet) For:Tony Zdroik 1 inch — 40 R Parcel in the SE1 /4 -SW1/4 Sec. 24 T30N -R18W Town of Richmond - St. Croix County 410 ft. LL Existing 1000 Gal. Wieser Concrete Septic Tank Note: Three Bedroom Home Poly -Lok PL -525 Filter to be installed 4 FF Bldg. Sewer Existing 4" Conveyance Piping Existing Dispersal Cells 98.00' BM P #1 Pr Wieser Concrete 750 Gal. #2 Dose Tank 97.30' BM I 1 /2 "F.M. 96.00' 6% BM #2 = Top of field vent pipe . Elev. = 100.70' Proposed 9'x 84' At -Grade Mound Cell w/a System Elevation of 97.30' p/L AL BM = Top of Field Vent Pipe * HRP =Same AL Wetland ASSUMED ELEV. = 100.00' '� P2 Safety and Buildings commerce.Wl.gov 10541N RANCH ROAD HAYWARD WI 54843 Contact Through Relay isconsin www.commerce- wi- gov /sb/ Department of Commerce www.wisconsin.gov Scott Walker, Governor Paul F. Jadin, Secretary July 19, 2011 CUST ID No. 221180 ATTN. POWTS Inspector DAVID B FOGERTY ZONING OFFICE FOGERTY PLUMBING & PERK TESTING INC ST CROIX COUNTY SPIA 2473 ROLLING GREEN RD 1101 CARMICHAEL RD SPOONER WI 54801 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 07/19/2013 Identification Numbers rabove, ransaction ED No. 1962121 SITE: te ID No. 769373 Tony Zdroik Please refer to both identification numbers, 1443 141ST Ave in all correspondence with the agency. Town of Richmond St Croix County SE1 /4, SWl/4, S24, T30N, R18W FOR: Description: At grade, 3 br res Object Type: POWTS Component Manual Regulated Object ID No.: 1324975 Maintenance required; Replacement system; 450 GPD Flow rate; 43 in Soil minimum depth to limiting factor frcjc 1 -i original grade; System(s): At -grade Component Manual, Version 2.0, SBD -10854 (N.03/07), SSWMP ,Pub. 9.6; Effluent Filter The submittal des cribed above has been reviewed for conformance with applicable Wisconsin Administrative Codes 18P and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed OF SAFE 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 SEE. CO 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: Key Item(s) • In the event this soil absorption system malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. In addition, the owner must insure that the operation, maintenance and monitoring duties as described the At Grade Component Manual are complied with. A copy of this information must be given to the owner upon completion of the project. • The float switch shall be a type that does not contain mercury. 2009 Wisconsin Act 44 prohibits the installation of float switches or relays that contain mercury. Please specify an alternative product prior to applying for a sanitary permit ". • The location and elevation of benchmark #2 must be verified prior to construction. • The designer proposes to install an effluent filter to achieve the requirement of wastewater particle size. Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the septic tank outlet filter will be required. The outlet filter shall be installed per product approval stipulations. RESIDENTIAL AT -GRADE DESIGN Pressurized - Sloping Site INDEX AND TITLE SHEET Project Tony Zdroik Replacement Mound Owner Tony Zdroik Address 1443 141 st. Ave. New Richmond WI 54017 651 - 983 -5950 Legal Description SE1 /4 -SW1 /4 Sec. 24 T30N -R18W Township Richmond County St. Croix Subdivision Name Evergreen Overlook Lot No. 4 Parcel ID Number 026- 1135 -04 -000 S, Plan Transaction Number sally Index sheet Page 1 C Calculations Page 2 W At -grade drawings Page 3 Laterals and dose tank Page 4 E Specifications Page 5 UPON Management & contingency plan Page 6 Pump Curve Page 7 Plot Plan Page 8 J Designer Dave Fo License Number MPRS# 221180 Signatur �,, Phone Number (715) - " " -- Date 06/23/11 Designed pursuant to: 1 0 gS7 �IV O3 0'7� ° - �rc.+rlc ylsfj At -grade Component Manual for POWTS SBD 4 -P , n cvfA G/er r * SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST - S/ ` '- Version 3.11 (05/01) RECEIVED Page 1 of 8 JUN 2 9 2011 SAFETY & BUILDINGS PRESSURIZED AT -GRADE DESIGN At -grade Design Worksheet - Sloping Site Flows and Site Data Entry. (r or c) r Residential or commercial? 300.0 Estimated wastewater flow (gpd) 450.0 Design wastewater flow (gpd) 6.00 % Site slope 97.30 Contour elev. below lateral (ft) 43.00 Depth to limiting factor (in) 0.60 In -situ soil application rate (gpd /ft ^2) Distribution Cell Information (1 or 2) 1 Influent wastewater quality 6.00 Linear loading rate gpd /ft 9.00 Effective absorption width (ft) 10.00 Max. effective width permitted (ft) 84.00 Aggregate length (ft) Pressure Distribution Data Entry (c or e) c Center or end lateral connection 2 Number of laterals 0.188 Orifice diameter (in) e.g. 0.188 Not a final calculation 2.00 Estimated orifice spacing (ft) 2 fl3 1.50 Forcemain diameter (in) 5.01 Forcemain flow velocity (ft/sec) 20.00 Forcemain length (ft) y or n Does forcemain drain back? 1 ' 35 /� 92.00 Pump tank elevation (ft) y or n Are laterals at highest point? l NA 3.25 System head (ft) x 1.3 1.8 Forcemain drainback (gal) 4.80 Vertical lift (ft) 37.5 5x Lateral void volume (gal) 1.35 Friction loss (ft) 39.3 Minimum dose volume (gal) 9.40 Total dynamic head (ft) 27.6 System demand (gpm) Lateral Diameter Selection Gallons /Inch Calculator (optional) Pipe diameter Design options Design choice Total Tank Capacity (gal) Designer 1 in Total Working Liquid Depth (in) must select 1.25 in x Gal /in (enter result in cell G46) one lateral 1.5 in X X diameter 2 in x Treatment Tank Information 3 in x 1000 Septic tank capacity (gal) Wieser Concrete Manufacturer Effluent Filter Information Dose Tank Information Pot -Lok Filter manufacturer 750.4 Dose tank capacity (gal) PL-525 Filter model number 20.3 Dose tank volume (gal /in) Wieser Concrete IManufacturer Project: Tony Zdroik Replacement Mound Transaction Number: Page 2 of 8 AT -GRADE PLAN VIEW r AA Observation pipes (2 typical) A 9.00 ft T ID B 84.00 ft — i-- ft W C 11.00 ft D 5.00 ft E 2.00 ft D L 94.00 ft B W 21.00 ft A x B 750.00 ft^2 1 L T <-- Cap Typical obs. pipe. = Total aggregate cell A x B Slotted in the lower l� x s e and anchored area = Plowed L W securely. 6 ° AT -GRADE CROSS SECTION Svnthetic fabric cover 99.09 ft Finished grade Lateral elevation invert elev. 97.80 ft �— Observation pipe at aggregate toe E Surface contour 97.30 ft C q 6 %Slope and system elevation D —� ® = 12 in. topsoil and subsoil plowed layer over aggregate and tapered to toes. y below L x W = 6 in. aggregate below pipe(s), and 2 in. above pipe. Project: Tony Zdroik Replacement Mound Transaction Number: Page 3 of 8 PRESSURE DISTRIBUTION AND DOSE TANK Lateral Diagram - Center Connection P ' I IE X <­,12`1 x12 41 Laterals & force main of PVC Sch 40 lest hole dulled next to end cap (per CONVA Table 84.105) Holes drilled on the e bottom of the lateral, i gv•,fly ipaci d • = Turn -up nWball valve or cleanout plug Lateral Specifications 0.188 Orifice diameter (in) Center Lateral connection point X 2.00 Orifice spacing (ft) 2 Number laterals 21 Orifices /lateral P 41.00 Lateral length (ft) 13.8 Lat. discharge rate (gpm) 1.50 Lateral diameter (in) 1.50 Forcemain diameter (in) 27.6 Sys, discharge rate (gpm) 20.001 Forcemain Length (ft) 9.4 TDH (ft) Typical Pump Chamber Layout Approved manhole cover with Weather -proof warning label and locking device junction box Final grade disconnect -- 0 4 , Tank component is Alternate properly vented - 1 ' �� outlet location 18^ min. Electrical as per NEC 300 and X ^ Approved outlet joint Comm 16.28 WAC Tank full ches Gallons JA Provide 1 /4" A 1.0 426.9 Alarm on weep hole or B 2. 40.6 13 antisiphon C 1.9 39.3 Pump on device. E D 12.0 .6 93.00 ft C "Note" ?double Float Pump Switch _ Totals 36.9 750.' —� Required due to narrow pump Pump off Setting ` D 3" Bedding under tank ~ - 92.00 ft Goulds Pump manufacturer S.J.Electro Alarm manufacturer PO4 Pump model number 101 Alarm model number roject: Tony Zdroik Replacement Mound r sac tion Number: Page 4 of 8 `;ote : Use Alternate Pump settings to allow increased pump run times at least 1 minute. ° inchps or 405.60 gals. = 2 inches or 40.56 gals. C = 3 inches or 60.84 gals. D = 12 inches or 243.36 gals. At- rade System Maintenance and peration Specifications JA3 o wars ".►. a :sl 7 = Service Provider's Name _ _ Phonel. _ -- POWTS Regulator's Name St. Croix County Zoning Office Phone 715 - 386 -4680 System Flow and Load Parameters Design Flow - Peak 450 gpd Maximum Influent Particle Size 1/8 in Estimated Flow - Average 300 gpd Maximum BOD5 220 mg /L Septic Tank Capacity 1000 gal Maximum TSS 150 mg /L Soil Absorption Component Size 750.0 fe Maximum FOG 30 mg /L Type of Wastewater Domestic Maximum Fecal Coliform >10E4 cfu /100 mL Service Frequency Septic and Pump Tank Inspect and /or service once every 3 years Effluent Filter Inspect and clean at least once every 3 years Pump and Controls Test once every 3 years Alarm Should test month) Pressure System Laterals should be flushed and pressure tested every 1.5 years Mound Inspect for ponding and seepage once every 3 ears Other Miscellaneous Construction and Materials Standards 1. Observation pipes are slotted and materials conform to Table Comm 84.30 -1, have a watertight cap, and are secured in as shown in the at -grade component manual. 2. Dispersal cell aggregate conforms to Comm 84.30 (6)(i), Wis. Adm. Code. 3. All gravity and pressure piping materials conform to the requirements in Comm 84, Wis. Adm. Code. 4. Tillage of the basal area is accomplished with a mold board or chisel plow. 5. The at -grade structure and other disturbed areas will be seeded and mulched to prevent soil erosion and help reduce frost penetration. 6. Areas within 15 feet of the downslope toe will be protected from compaction. 7. All other construction details are as per the at -grade component manual SBD- 10570 -P (R. 6/99). Lateral Turn -up Detail Finished ............... ............... Grade 6 -8" Diameter Lawn Threaded Cleanout Sprinkler Valve Box Plug or Ball Valve Distribution Long Sweep 90 or Two 45 Degree Bends Same Diameter as Lateral Project: Tony Zdroik Replacement Mound Transaction Number: Page 5 of 8 Page 7 of 8 ITT GOULDS PUMPS Wastewater PERFORMANCE RATINGS COMPONENTS r Total Head Gallons Per Item (ft. of water) Description Minute No. \ Minute EPOS 1 Impeller - - 5 53 - 2 Base �t - 6 10 46 62 3 Pump Casing 8 5 36 55 4 Mechanical Seal 20 21 46 5 Ball Bearings r 25 0 33 6 6 0 -Rings 9 30 1 1 7 Power Cord 5 8 Oil Filled Motor a 9 Motor Housing/ o Stator Assembly 10 Motor Cover 2 METERS FEET Ior 9r 30 �� GPM ''.. 8r -- 2.5 FT 25 � 7r Q y 6' 20 z 5' > 15 c a 4 r >EPO4 O 3C 10 2 1 0` 00 10 20 30 4GPM 0 2 4 6 8 10 12 mi /h CAPACITY 3 • Page 8 of 8 FN# 1443141st. Ave. Sanitary Site Plan Graphic S**U (Feet) 1 inch 40 tL For:Ton Y Zdroik Parcel in the SE1 /4 -SW1 /4 Sec. 24 T30N -R18W Town of Richmond - St. Croix County 410 ft. • WELL Existing 1000 Gal. Wieser Concrete Septic Tank Note: Three Bedroom Home Poly -Lok PL -525 Filter to be installed 4" Bldg. Sewer Existing 4" Conveyance Piping Existing Dispersal Cells 98.00' P BM #1 Proposed Wieser Concrete 750 Gal. #2 Dose Tank 97.30' BM 1112 " FM 96.00' 6% BM #2 = Top of field vent pipe . Elev. = 100.70' Proposed 9'x 84'At -Grade Mound Cell w/a AL System Elevation of 97.30' p/L BM =Top of Field Vent Pipe * HRP =Same ALL Wetland ASSUMED ELEV. = 100.00' AL p/L Vft minOrp tarconsneras SOIL EVALUATION REPORT pup at l�liondBsAeyard Bddinjp _ inamordniosvmcmuskyAL mkv Coda AB. ChcordpieMsllspen +onpdpsrnotM�sN�en8 VZx11 id�eslasta�.Plonnow InoNrd�, bA9sdWMlw In ad' I poldf ft I l& gald • pned In psoNtslcpe ,saMaardaerniorls,eloe�anaw,o dloasrlonsrr11 1p iplstMe& - //3 S-- D -ODD PAwn pdat alf hvbnmdb& Daft grp �Ow.wr PMpwvtaoe#an . Z OVA td .S a IN f 114 S.., T 3a N R E F;;rwh► MdbV td# j 9b*# j 9ubd.NMwcrCSW 3 eAl A9V er o o f tm, MrJ11,114d Al; I S'YPIZ I Cyr - VRw am -MwW A d r ❑ i�lslroaraw o tlsletfl fiilwMlloallrlNar d6rlr IaNns 3 (;a& 'IN ddesigr►llawtab Ys D oPD (9'�Waom"I t ❑ FIiftarC0lrwrlpPd� Dairohirec Para A, Flosai" N R Oft 0. g73 A E sof# ❑ soft �. / " Q P8 6�opeida�ssaosals�r. -�a Depwb11 0iolor , w k SolApplaift Now DepM Dwkw* R-d-Desalfpton• Team 8tuchss Conolsksms Boisda3y ttools - ln. MIN" QL SL COOL Cdw Br. &L 9h, re 'E#i1 'fit s 3 !h- 3 - p .z m UJ )r ; FP Gu 2 - S' 7-) - 7G L z 13 = - � ❑ Boma L.J eodryt 0'» Alnurldslsismsdw. 9i� o R Dopobsoaftwor la. tlorimn Depw Elasltlnnt l"NFCWmcdpl m irso a ftudm Oandd,6os omdmy R o GPD111< Is. Mmulmd al.eL ON&Color f$SLSil cc 'M 'Ll182 . — L .znr x Gs • G 2 - If - 7 .57.,- GS 2 rr+ T - • E�slNl#fi� >>�e3ffi�ard'[l18�8D <'161i •'i:JwlNStita • < aDrlrp�ad'1��30tsplt. ca f161rrrr (!'1sslls Ring `> CSTNsp W 1yddlsrs S 1/ TalepMMWM rrRer a Lt�l Gam' 715- - �OIADO Property Owner f,pir/7 2.J^0 e'* Parcel ID# O-2 G-//3 3-d y^'z9c 2 Page 2 of 3 3 Boring# 0 (Boling Q Pit Ground surface elev. 97.2- ft. Depth to limiting factor 93 in. l Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ' T/`eG "Eff#1 `Eff#2 / ,O -/2 /D/'r t5/12 S L ..??_r/3/t• IyJFIz /5`w 3 c , G-) A O /-1..-1 .r'Z 7„5--- r. y S Lf XA ..?m SiLe Pi?Fj? S 1-I--. /• o 3 -,? -./ Syr. s(4 — _ _. rn S G•- _ m L , _ , 7 /. V ii3-7Y,�,.> r .3`! ,-.1•5 y r. Y7.g C 2,JS _St 1 F,48K m FA -- • Y • 7 ,s- ,;L/-7eS' ..7,Ty r 3,1A‘ — s!.- l/,PL FTL — _ `_ , 9 .4 • Boring y Boling# ❑ © pit Ground surface elev. 71..0 ft. Depth to limiting factor CT' in. l Soil Application Rate Horizon Depth Dominant Color Redox Desaiption Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qtr.Sz Cont.Color Gr.Sz.Sh. s. "Eff#1 "Eff#2 / 4 /Y /n ,fr 3/-> - , sL ..znrsAX /lrtC/e 5 3 ✓F 6 /.o !y .2Z,5 r 3l L __zrjrs/SA' _ illFR _mow _J ✓F •cr .22-3/ syr y/6 — yyis es� nr i. At$ — . . 7 /• 4 V 3!—, ,.›, .s'y r S- — SL I F iPYSX sf,F2 G s . ` • z/ , 2 $7- 7 ,s yr V4 — nr3 :CS rr "L -- `_ , 7 /•6 Boring ' Boring# El 0 Pit Ground surface elev. ft. Depth to limiting factor in. I Soil Application Rate Horizon Depth Dominant Color Redo(Description- Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu.Sz Cont.Color Gr.Sz Sh. "Eff#1 "EN#2 Effluent#1=BOD3>30<220 mg/L and TSS>30<150 mg/L "Effluent#2=BODs<30 mg/L and TSS<30 mg/L 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. S8D.8330pe.6,00i e Yo nj ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Buyer Lic�l. of K Mailing Address ' 1 V 1 A- ✓c r - _ Property Address (Verification required from Planning & Zoning Department for new construction.) City /State /2,,`L, Parcel Identification Number LEGAL DESCRIPTION Property Location S6" 1 /4 , eJ 1 /4 , Sec. �'-� , T 3() N R W, Town of ex �— Subdivision Plat: 1Z(, O of _ , Lot # 01 1. Certified Survey Map # / , Volume , Page # Warranty Deed # i` j (before 2007)Volume 1 �4 , Page # `J Spec house ❑ yes Vno Lot lines identifiable n yes ❑ no 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 maintenance 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 (1) 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 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 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 3 'A Mail � I IGNA I TOF APPLICANT(S) 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. 09/07) 11/30/06 THU 14:31 FAX 715 386 4686 ST CR% CO ZONING 0002 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK Thi� to certify that I have inspected the septic tank presently serving the ..k., gym,' residence located at: s� _Q 1 /4, Section 12� ; Town 3 o N, Range ' W, Town of / ;oH , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of service / 0 Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: — gallons — minutes Capacity: Z p gd Construction: Prefab Concrete ✓ Steel Other Manufacturer (if known): — (,I,- Age of Tank (if known): Z 7 7 ..- _ / ,r r (Licensed Plumber ignature) (Print Name) (Title) (License Number) MP/MPRS (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) , Plle Z`le -7Qa2836 i� Z N S 9 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 12/18/2002 11:30AK EXEMPT # REC FEE: 13.00 TRANS FEE: 246.00 COPY FEE: CERT COPY FEE: PAGES: 2 WARRANTY DEED Z-Ir o�t � ' INDIVIDUAL TO JOINT TENANTS yy3 y s� v�K� e- A State Deed Tax Due Hereon $ N e iv �Z zc w� j , ,) Sao/ ? Parcel Identification no. 026 - 1071 -40 -000 FOR VALUABLE CONSIDERATION, Anthony J. Zdroik, a single person, Grantor, hereby conveys and warrants to Tracy Ann Johnson and Anthony J. Zdroik, grantees, as joint tenants, real property in St. Croix, County, Wisconsin, described as follows: Lot 4 Evergreen Overlook, St. Croix County, Wisconsin AND 1 /26th Interest in Outlot 1, Evergreen Overlook, St. Croix County, Wisconsin together with all hereditaments and appurtenances belonging thereto, subject to the following exceptions: covenants, easements, restrictions, and right -of -way of record, if any. Dated: An4U., . Zdroi � ©-U.J m lam. V) ] 1 Ln 00 1 L s c i cc 16- 1 � Ln LO '." • *+� Q , • Z (v 2 -- m O 2 O h Ozw >-Q�jW A WN l38 All 1Sd3 Q W •w o y= 0 } � Q N V I 0 311V1dNf1 a Z Z I N Ost 00 . ---- __�__._ . o� w I • 9 to .0605 La I / r1 O g i N 1► to Q o a p LU co cc Z cn =� o I g ss'Zt� SC 9Z q g o N _ I .00N _ o co LAJ dw i n O w I N a O � ��� 4 tai I t --+ � st M � L .00 t - _ +o / O c I c0 �� %7 �iAlp � p M - -- sp � � � I .[ l'£6t 3..tt,� t•00N .✓o0'6ot CO v \ i �cl) N C? tr a 'fl v U W I to Q °° ' '? ,if CA c 2 Cb - 1 F- / p a dl N U ' n 1 '""L£/ �LZ00.LON � w .W ' Q If) a (A OI Vo CA oQ JI �^ 1 \ �cn /~ 1 z ^ N `� 10 �•- . L n u JO N /y H 701 cy) y 0 La \ / . Wes( c r- _ y, _ _ tiR � •_ r� � m -.` -- . - -- - -- � - -- F-'� - -v� -a --- -� - - -- - -, _ : _ . ,�6 9 ms`s Safaty lAd B irgs D-4'1011icn 201 W. ''.oeto Ave., P fl. Bay► 71 l9I WON. N . WT $3707 - 114 Oft Mims mmigary tit eeee� tow 1' In tlst. lY9c. Ada Crde t , glad • Awe LIB. !lumbar cr) s a e Itmubr 2 .30.1 3 .. : fuz O rp 1I;f O -+QOp c - J ed t 3d •a�S �'�`1�1� .�'`�. {ate e� �! aye ^+�� ,�,Y„�e► �i. TAW OF v* em boot as In A ou&bw* ubm (W fwon d we, an a a ape") �3 st b � Ar�tdop sa • Oak if Paso PUVW* I" . its Daa Pb tit to ,K t0a 4tfi� � Imd � 47 � ku3 3�61� � Wstlead 22 G "WAW tA-0pl w E! ©NOW* Tok 4s Q Au Sf Q Deb Lis 0 4613 '!b ttaic Q 6� D as ' e- 47 `' 7` �� Sl��+ b 3Wt(� 8q.3s.} � •1f>ssb� SY �ttraa� F Yip , d.sd 2.7 Tog lu Pam 9. sD ! pillt c: *so= at'hiict d:a1l m commmo E Pt1't. � tae tl�a ev rftws "M OWL i mov ha A4w IL 1 CI l�,art t�as6�t�ar�t- ZZS� � �tlD( Al Nua 6 +"R"c o� �ytn„ tart a�NOrr . �6 ) . a' "' iu�frs 't�� s t s oivWm ctc�arr mmm PRIVATE SEWAGE SYSTEM St. Croix INSPECTION REPORT s P No= 39519'9 GENERAL INFORMATION (ATTACH TO PERMIT) Stye Plan to No Pownel bnfonnalim you provide Mw be used for secondary purposes (Privacy Law, s.1&04 (IXmM. Permit Holder's Name: city Viii X Towmship Parcel Tax No: P.C. Colloya BuIldeM Inc. Richmond Township 028.11354)4 —M CST BM Elev: Imp. BM BM Descriptbrr: A;i�tek ISOZ% T 1 -9 It" TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS Hl Septic .. Bendtnma .'+. Dosing L BM z Aeration Bldg. Sewer 04 ��j 4 Holding Inlet • E TANK SETBACK INFORMATION sum Outlet , TANK TO PAL WELL BLDG. vent to Art trm" ROAD Dt Inlet .. Septic } _ _ Dt Bottom i Dosing Header/Man. Aeration Dist Pipe L Holding Bot Systedr y N• t!�[ L r t4�? PtIMPtSiPHON INFORMATION Final Grade Manufacturer Demand St Cover PM Model Number TDH Sysfem Head JTDW Ft Forma Length Die. SOIL. ABSORPTION SYSTEM C> BEDfMNCH r LengM 8 No. Of Tres PIT o1MEi'ISIONS . Of Pips Inside Dia. Depth DIMENSIONS y i� 6-29 SETBACK SYSTEM TO T, PA. BLDG tWELL LAKEISTREAM 9 ;�F ft r _ INFORMATK)N Type Of SYSISM } j --- t N U'w ` DISTRIBUTION SYSTEM Headedmwh lct u Di IbL -ban x side Sim x sine Spacwrg Io Air Irt" Fgp�sl /na� r ..-�'. Lerch Oil, Length Dia SOIL... COVER x Pressure Systems Only xx bound Or At -Gfede SySterns OnlY i)epm Over 10op1h Over - Depih of xx Seaded6odded hk dw ewTrerrch Canter eedtrr dr Ed Yes Na Yes A m COMMENTS: (include code discrepancies, persons present, etc.) Inspection x"1:_1 inspection s2: Loc stiOn. 1443 141st Avenue Now Rf mxmd, Wt 54017 (SE 3 SW 1f4 24 T30N I218M Evergreen ,� 1 Parcel No: 1SS3�4 1.) Aft BM Desc dption =fit ¢ ar " L � � ! l �rc✓vI t� �S + ` }� �'4" �U r+""_'� 2.) Bldg sewer length tu � RA i t of tower = b� I n srva4:r�.. =pcs r� sl'xjl Apt y, `' Plan revision Required? F€ Yes W No 1 l c�� t •. �y I Use other sfde for additional information. ? 1 I sBD-8714 (R.3P87) pale insepctor's signa" Cart. No. r 1 ice, ST. CROIX COUNTY i WISCONSIN - - - ZONING OFFICE * r ST. CROIX COUNTY GOVERNhIENT CENTER 1 141 Cam ichael Read ... .._ . ----- Hudson, WI 54416 -7710 :.• (715) 386 -4684 FAX (715) 386 -4686 Friday, November ail, 2001 P.C. Collova Builders, Inc. 1443 141st Avenue New Richmond, WI 54017 Regarding septic Inspection for P.C. Coliove Builders, Inc.. [Locatlon of Property in St. Croix County: Municipality: Richmond Township Subdivision or Plat: Evergreen Overlook Certified Survey Map: Lot: 4 Address: 1443 141st Avenue Dear Applicant: A septic inspection of the above reference property was conducted on October 25,2001. This property Is located In the SE 114 SW 114 of Section 24, T30N R18W, Evergreen Overlook (Lot 4), Richmond Township, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a 3 bedroom home. If you have any questions regarding this, please contact our office at 715.M.4680. Sincerely, Kevin Grabau Zoning Staff cc: file NOTE: System was Completely covered at time of inspection. -Not all elevation shots could be verified at inspection time. "Wabc&h Depwiment of Cone ahiis�rt $eNh►a� S OIL AND SITE EVALUATION Pa a, Spraau d mama Sentices in accordance with Comm 83.09, Ws. Adm. Code Attach complete aft plan on paper not Sess, Yvan n 8112 x 11 k tm in size. Plant nit cmultY inciude. but not bdiad to: vestal and horizctai rsferenoe point (SK, direction and S4 _ (—'' percent slope, scale or dimensla . north arrow, and location and distance to nearest road. Parcel I.D. # APPLJCANT INFORMATION - P/easa print all inftmation. by Oats P amonat irimmMon you provide may be used for saoor4sry prxpo®es (P*Wy - L*,h 4.1-5.04 (t) (mj ;. Pmperty oww Pr Location W Govt lot S C 1l4SLtf 414,5 Z' � T 16 .t,R E (oe W Property Owner's Melling Address Block# Subd. Name or CSW las aA+ State ip Code " Ph&* Number � city village S Town Nearest Road (g New Constnwdkt use: [5pesider dW 4"w,af.bedn:pms' Addition to existing b ►g �I RepWcerrent 0 Put& or Code derived defy low JA gpd Recommended design loading rate , bed, gpd* ` trench, gpd/ft AbWrpkn area MMred a0 had, g r O try tranc h, ft2 Maximm lw&V cafe _ bed. -g trevck Wile l3eoorrrrcended ktiNhs4fort surface el�rt(s} ST.1 e ft (as referred to site ply benchmark) AdOWW dedgnMa considera ns b 1'P{ f 4 Low c r �0 Parent material a)4%-Y= Flood plait elevation, d applicable x'91 It S = SUN" IM system Conuenft* Mould In -Giou ld Pressure T AT -Grade System in Fill Hot�ng rank u; uns *Mole for system WS d u Q U id's 11 u S Q u ❑ S W u O S J;3 SOIL DESCRIPTION REPORT Also C&JA- gonng # Horizon DepM Dominant Coinr Mottles Texture struct Consistence Soutclary Roots G ! n. Munso ou. Sz. Cont. Color Gr, Sz. Sh. Sed , Trench. 13 s► 1 rnobk m-�r cs Z � lq--:* lb 1-4 Sit k m-Pr I cs Grourw - 5 54 M 10 vr 4N 5L 2m C5 S (� • ' Slam. 4-Lvo—ft Depth to 3 Remarks: Boring # F3 { Mckh Mkf c J VC of — t 2 . S ° (� •s Gmund elev. Depth to M_jrL Remarks: CST Name (Please Print} Sigrtebue Telaphone No. Address A#W Data CST Number _ 1 ` q 25 i ! ♦ � t � " w� ! • + • � � � �� �: .�. is �� x � �� � ► ���������� :. . f f ����� ������ :�i � ..._ �'it � �I�L��� ��� ®�� r::r �,:. �- ����-� ♦• �® ������ �- �����® �� ���_�® ti �J f `Y Alz /DD. a I I .,:JA4 !� n 6 ' I I �I Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 395199 GENERAL INFORMATION (AT7AcFrTO 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: P.C. Collova Builders, Inc. I Richmond Township 026- 1135 - 04-000 CST BM Elev: Insp. BM Elegy ( BM Description: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI EV. Septic Benchmar Dosing Alt. BM V • 2 -619 Aeration Bldg. Sewer y Holding t Inlet TANK SETBACK INFORMATION St/Ht outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet .�- Septic ! r _ Dt Bottom > 2D Dosing Header /Man. Aeration Dist. Pipe L Holding Bot. Syste ( !1. 4- . q PUMP /SIPHON INFORMATION Final Grade x•35 Manufacturer Demand St Cover PM Model Number — � •� TDH Lift rictio ss System Head TDH Ft Force main Length Dia. SOIL ABSORPTION SYSTEM o BED/TRENCH Width 1 1-ength I No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 ttI 4; s C 2 / SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LL h Manu 2 f � er: INFORM ATION T OR t " a � M �' Type Of System: �— T b r: 'UwJ D DISTRIBUTION SYSTEM Header /Manifold U Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) L Length Dia `� Spacing � SOIL COVER x Pressure Systems Only xx hound Or At -Grade Systems Only Depth Over Depth Over xx Depth of eeded /Sodded xx Mulched Bed/Trench Center 1 13ed/Trench xx S Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: P / 2� / 0 L Inspection #2: Location: 1443 141st Avenue New Richmond, WI 54017 (SE 114 SW 1/4 24 T30N R18W) Evergreen Parcel No: 24.30._ 18.934 1.) Alt BM Description 5 ` s > 41 te~fe- stk- is d «,,�s(q� P� �.�•� �� = t 2.) Bldg sewer length = 3 • J E3i1 l - mount of cover - T-) O d trvci,4 ?nom P =Pes r10 S a e l ot Plan revision Required? �[] Yes ❑ No I) Use other side for additional information. r 6 t SBD -6710 (R.3/97) Date Insepctor's Signature Cart. No. ST. CROIX COUNTY WISCONSIN ZONING OFFICE N M ■ • ■ rn■r ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016 -7710 (715) 386 -4680 FAX (715) 386 -4686 Friday, November 30, 2001 P.C. Collova Builders, Inc. 1443 141st Avenue New Richmond, WI 54017 Regarding septic inspection for P.C. Collova Builders, Inc.. Location of Property in St. Croix County: Municipality: Richmond Township Subdivision or Plat: Evergreen Overlook Certified Survey Map: Lot: 4 Address: 1443 141st Avenue Dear Applicant: A septic inspection of the above reference property was conducted on October 25,2001. This property is located in the SE 114 SW 114 of Section 24, T30N R18W, Evergreen Overlook (Lot 4), Richmond Township, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a 3 bedroom home. If you have any questions regarding this, please contact our office at 715.386.4680. Sincerely, Kevin Grabau Zoning Staff cc: file NOTE: System was completely covered at time of inspection. Not all elevation shots could be verified at inspection time. Safety snd Bui,uirgs D"'siC. 01's 2 0'. A' , W asi�taa Av F.0. BoA 7162 I S 7`GYo� Ma I dison, WI 93707 - 1162 life Address Qa ar tt»�rtt of C mmorc• SaWWY Per App = 'rurnber to mead we m In OW k Rainy via *mw 041. Wu. Ads nacre. awe � � �� d chi& it' hVis /9q i p4rq� O" Ws Nwa s� GAC Aatoal l+tambmr 2.30. 18.93 /d� s 026 — /( ;f 01 o� aao ..... Pr°" y ; Ftopoety Locttion 703 C4 �J 'A TSd R �7 City, 3aa Ccx}e Plea lo bor Block Nuarbat ubdtruti" Nam CSM HUMber err r A, L, oo n. Ty" of &Aft (dim* all ors D w ,3 ..-- .......�. elL'r� - Naffs of tledrooacs ...._.�_.,...._._._ .....,.�....,..._ { QVivape ® publw*=wcial - Daacriba use ! sacra ownad Nu IlL Typo d PKtstttr (Check =IV oru boat on ilea A (Auatbuig aohanta for ir+tarW we). Complato mina B if spbUcable) A ' 2 )U*W 2 © %*name fteram 1 3 Cl belt mat of b C Addition to For Caul" tta Tuk Only tin 3 a n 8. d Qwk if kttm7 P#Mdt Praviou* I" Pa Numb" � Issuad . Ty" Of Fat'Aft (Ctteetc alt 9i tlppiy)Otmba q acboms is for iat mal we) 42 ZMX X 44,* "'?MWdud Ia•Gr*NO x:Q NOW 47' Stnd Filter 15 D Cotlamusd Watland � 1 C ft"RXri%ad btdimw 61 Q Holdltcg ?talc 44 Q Slagle Pan 9l Cl Drip Line 45 C At** 46 C 6M Lim Treatasant Unit 0 © R ecirmiade 30 Q O**r p ulp w Sots Agpiloetion Pac"doo W >Kyatesr fUntion I Finai Grads �ip) Propased � /r�dj R►te(3als.l»t►yeJ5q.8t.) (Mitt,ltnc)lerarton jz, ?d VL Tattle Uft Toad Nttmbsr i moufacuor Pmftb Site Slid p b Piaatic tht! tbcttaaa atTsaks L*w"ma Cotawwwd aim N ow i wor x e9 V& Sit to tZMe StOW, w mae fm Woml6du of POWTS yaws as Lisa atiadtad lasts. i a NAM Mft PTetasbrr a olow Pltoat wobw nNabW Addam ltaet, Coda) t '� Q1 o thttehie3e Fiej (iSC GtaW :�waoer Do Isw Iaeuiag Agent gsrdiuca (INTO Sramps) i C`� tiu+nar Gtvatt btidat Adwe :ce � � i 1 ZS• IY� �>renl�Uxweae for DipD> _.........� rwu.s�4-1o�. �►'�"'�- SBI630$ (fit. 05101h , ?�& /.j - klwe ly `v f � I y � L �. edG /A Ci. ✓1 Ccr S/ e, � ��eYp Y l i ( J l Js Yh 2 ®bla e f s • M.2 ,.hilt/ � U z c� 'Wisbohln Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page I of 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 size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and S4. C r I percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information a iewed by Date Personal information you provide may be used for secondary purposes {Privacy Law s. 15.04 (1) (m)). 'S Property Owner Property Location l Govt. Lot St­ 1 /4SGJ 1/4,S Z Y T 36 ,N,R E (o<0 Property Owner's Mailing Address Lotke Block# Subd. Name or CSM# Rd. 0 A Ever re over 1 City State Zip Code Ph66e Number s Nearest Road / ❑City - 1 Village � Town New Construction Use: EeResidential,i Nximber of bedrooms ` Addition to existing building Replacement ❑ Public or coriin ipia4 - Describe:" Code derived daily flow � gpd Recommended design loading rate � . 5- - bed, gpd /fi l LP trench, gpd/ft Absorption area required 1 20 0 bed, ft / O ClC) trench, ft Maximum d n loading rate -L bed, gpd /ft trench, gpd/ft Recommended infiltration surface elevation(s) -tf' d• ST-) 1 r ft (as referred to site plan benchmark) Additional design/site consideratii M e_ r q�• 7 LOw t e- Q0• Parent material CX )W'W'2 S Flood plain elevation, if applicable S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for systeml Q9 El U LA'S ❑ u s El U ❑ s C&P u ❑ s &R'U SOIL DESCRIPTION REPORT Lo Cdtk Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /� in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ' Trench D - I 12 5; I m��bk m G.s t v • Z: 3 .2 Z I`f-3iP L-i )? f�G n cs Ground c� 41 ` SL Lrn ` r f '' us 5 •� �j r.ev ft. Depth to limiting fact Kin. in. Remarks: Boring # M: i — 5i K rm-�r CS Ground elev. 9 ;x ( ft. Depth to limiting factor '�/ in. Remarks: CST Name (Please Print) Signature Telephone No. 2 (7i - ) 2'f 7 - �Do Address Date CST Number 2- LIJ PAGE J OF NAME 0, 110 QC LOT# Ll LEGAL DESCRIPTIONS 1 /,5U` /,,S zg T Gp,N,R IB' E (orY SCALE: F'= ' BM 1 ELEVATION BM 1 DESCRIPTION Ala . (i n� BM 2 ELEVATION BM 2 DESCRIPTION ✓1 u+ 1"N G SYSTEM ELEVATION �,o d cv-,.5� u l (�CJ•5 a ALTERNATE ELEVATIO ef? Z. 70 Lm---e CONTOUR ELEVATION /f/ .w 4 fir^. • B rCS 3 3t� � i 5 SIGNATURE DATE �� All VSAUJ tiE C T Cq C x l2 N — — = x IRE a - a CD c�a� v cn .•. Lm ! •� � a) r U U ��c T *ir I ti[ tz ti i / n i l 1 C 4 . ISO a b � Y L ' • � � s ul l ��� � � \ .�. ; ♦ � (� � � ' � t 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 q Number of Bedrooms 3 Design Flow - Peak (gpd) O Estimated Flow - Average (gpd) 1 3c r D Septic Tank Capacity (gal) Soil Absorption Component Size (ft 560 z Type of Wastewater D mestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) or" S7 a- Maximum Influent Particle Size (in) V 1/8 D Maximum BOD (mg /L) 220 Maximum TSS (mg /L) 150 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 6 be r removed d outlet filter shall be assessed at least once every 3 years by inspection. The let filt be cleaned as necessary to ensur p roper o e i on. The filter cartridge sho of unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the 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 1/3 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 Management Plan for a Septic Tank and Soil Absorption Component Plantings of deep- rooted trees and shrubs directly over or within ten feet of the component should be avoided since root intrusion into the component may obstruct wastewater flow. 3 sT CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND n OWNERSIiIP CERTIFICATION FORM Owner /Buyer ( I oVA Mailing Address — 70 , 00. Property Address (Verification required from Planning Department for new construction) City /State Parcel Identification Number LEGAL DESCRIPTION Property Location, i F 'V, , nW V,, Sec. 041 T - - RAW, Town of Subdivision �►.Q�(� 1\Qt?� ��n� � Lot it Z /_. Certified Survey Alai) It Volume Page It Warranty Deed # & at 3 3 S `7 Volume /S/ Z. , Page It 2- Z. Spec house O ye - Io Lot lines identifiable Byes El 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 wastewater disposal 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. Uwe, 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 o ee year expiration date. SIGNATURI✓ Or /7V/ 0 APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form arc true to the best of my (our) knowledge. I (we) am (are) the owncc(s) of the pe described above, by virtue of a warranty decd recorded in Register of Deeds Office. U� � SlGNA1 OF APPLICANT DATE ** * * ** Any information that is mis- represented may result in the sanitary pcmiit 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 decd 08!05 TUE 11;33 FAX 713 366 4687 REGISTER OF DEEDS Q001 1. i. Nu 4 IT A U W w W DRID Iowa DoauaonHamer is Tliial)ouud�mndCbv�Nean $crWnJ� k �"lOOp owt I rW � Grantor. and P.C. C®Uova 8u11dsrs (ne. a Mli eacts Carpop + lion 11 J yA 1t - s- .- ...d..,....,_.. . r t00 Groru Oraator, far a voluble eoasidentiou, coovo to Gmn , to;fowic d tacrlbad nud claw IS A4 Croix �a th duo of W €scows to (if mono spice 19 needed, idetwe wash addtxsdamp >tatorsiry Aral 0 V ThoSouthtast Quarts ofth $"wog 4uortrr (SE %of 5W hl of Sr No= LOFU 24 and that lwrt of thv N 'A of Soalan 25, Was, Nordwly of 140th Avaagt � ti� 7t �17C 1 t 5" ALL in Tt>,sasrhlp a0N, Raoga 1I Wwf, &. CM& Calmly , Wiscomin, Ot EXCEPT Port otN K of Section 25 dacrqud as follows: Commcming atN &'A, K amwtr Of aa)d lSasU 2$i %homos North 84 dcgrsaa 06 migWq Won on Nartp UDa of sold &cation 25; 60 fiws thaaaa Sowh a 1 dcgna 23 minutoo Wass 1353 fact; tlwuos Sowb 89 44grus 06misu ms Earl tm 1504. theeco 7�1071�4t1-0a4 2¢lorl -7aooa North l degsoe 23 mlwAoe S 1353 fool w said N p aw; the= North A9 larool idrNlAwlao tl,�atba 01 w) dagrastt 06 min -atus West on said N line 6{7 Got to lbw or aagfnataS. St T4is is cal � s rre0nt7. Croix County. WWCCrtiim oil ib tot) Exaeptlooa to wanaaties P.asemeatt, rosarlodota sadeiglua•af way aPncar>L Ifsur�. 1 8ftm Dan[dt AUTIUNT3CAT1ON I.CUNOWLIDMUNT Sirnatwo(s) Mn" J. Derrift S OF WISCONSIN ) tuthanU94484 s �olmy of _ 20x4 '� ,7 ... ttrlorrpr owns 4sfora me tblt _day of tho abova atarod t tU IMA Oabid --_ TrrL6• MMMER STATE BAR OF WISCONSIN 41rar4, so me knowa to be the persons) who +wt"utod tba tarog„ing rut4a.l:,w b 7US.u6, W sirsu.) lnst�vmam and aataowkdytd Ow aruaa 7711% tNSTttUMSNT WAS o Lwj OY Atsnra Y VrUt tnr�d t1 Notary Public. Stan of Wf mmla My Commiiclon is ptnnuunt. (lf not scale oapin0an date (3msa wls onw bt alANro CAW a trAR"11444. iso14 stn rol napsar),) ) +Naaeservutaas analutayaspt,ityauut ty a lsbwtln slswtKS. ivawraw +srtwn+..rC.n�nr.►..r WARRANTY OCiCO $TA7I;4st0FWW0Wj" IO0.14 NIL 2. 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