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HomeMy WebLinkAbout040-1105-70-020 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division Sanitary Permit No: INSPECTION REPORT 538834 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: Briese, Daniel & Beck Troy, Town of 040-1105-70-020 CST BM Elev: Insp. BM Elev: BM gescription: Section/Town/Range/Map No: 1 - i 27.28.19.422A04 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS Septic) Benchmark oo, -0 51 I Alt. BM t~7 Aeration BI rSe er t ZCI c' VLAI r cT St/Ht Inlet Holding St/Ht Outlet All: a ~~vCt r, TANK SETBACK INFORMATION TANK TO P/ WELL BLDG. Vent to Air Intake ROAD Dt Inlet r' f ) Dt Bottom i ) Septic ~ r7 / 1> ; Bader Man -7 Z Aeration h rh Dist. Pie 2 0 Holding Bot. ystem q V7 Final Grade I S ~t -C, rtL 3 q t y PUMP IPHON INFORMATION nufacturer LI V-1 V% ? e and St Cover 'Uv~c z M - 7t c~ 13 Model Number `iV 30 • / _ y , ~j TDH Lit Frict o Syst TD~ Ft Len t b Dia. 7 /r is r to Well Forcemain L_ 11 I SOIL ABSORPTION SYSTEM -3 3 3 BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLD WELL LAKE/STREAM EACHIN Man o . INFORMATION CHAMBER R T e Of System: / r Model Number: R t1 lk 1c 6 7~C ) DISTRIBUTION SYSTEM 0 ibution y/Ipy / x Hole Size x Hole Spac Vent to Air Intak I py, eadew 1nifoldrLpe'pn 11 (s) rl1 0 If, ✓ (fT CJ IcIJ Length . Dim th Dia Spacing %OIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center :v (1 ' Bed/Trench Edges I R1 Topsoil Yes No Fal Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:-LL1,;LL1 I ( Inspection #2: Location: 155 Bjerstedt Court River Falls, WI 54022 (SW 1/4 NW 1/4 27 T28N RI 9W) NA Lot 3 I l~ Parcel No: 27.28.19.422A04 / ~f -7 1.) Alt BM Description = ( ) ! /Q Q~~~~, C~"~/'~ p 2.) Bldg sewer length = ► } H y>✓ ° Gt; y~ ~70 r - amount of cover = > Pla a Wkec es ~ f se other side for additional information. ~_'_l_~ - - - - or's Sig t e Cert. No. Insepct Ste,, SBD-6710 (R3/97) p _ i Otis L . o t 'N 133HS --b rrl 00 0 OtN rril ;o M ~o ada A m 52 V) x --I c~ C7 Z d'~ 3 rn o~~ oc rn rri ° ~o oo~ p / ~°~-rr 00 -I / m < a D W -p M U' D{ C a ~lrc.:s,~ m ° CD ° --j r z n d (D 0 m cn m Z z 70 V""` m ° m p m y~(,SF 25' 0-°0:3- WU) -1 m mo°(D C: n < < rTi 0 (0 0 :5 rCI) -n r ' ° z rrio m * STq o o -1D (D -U (D 01.0 C °n -aF z C' vtN~~ ~T o ° z0 m lT' ` r GZ z z ~otn n oa y a a r O 6' W n° O rn N co, m ° rP W o G Q (D (A (D 0 s+~ CC) 0 ;5 (pn 00 ° -i 0 N sue' x • ~0 m m s ` / O CO n~ O~ 200 r -44 c ~ -nn o >K C R1 - C W o o N z p zzM mo ~p 0 0 > Z >f pc Xf m m ~j, m cn o O ;o CO ~6 0 O (n . o m z(n ocn OC -I \ m cm z~ rri D 0 D $ OT. Z D-1 D m mCr F z D x r 0 N Cn X 1T rn 0 R • O ZO C . z g 0 U (3Z (31 ' She-, ~ l0 3/ c i S00.19'09"W 166.86' 0 Cottmter WI. S ety and Buildings Division County 201 W. Washington Ave 162 r 0) D'IL SCO adison, WI 537 - A Sanitary Permit Number (toy filled in by Co.) Department of m1a ` j g 3 15 3 9 Sa, 1Ca I lon State Transaction Number t ~ , X In accordance with s. Comm. 93. @ettC; ssmon o this form to the appropriate governmen d1A unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Addrafi (if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law s. 15.04(l m Stats. 16 r J ~oY S~{'~ I r 1. Application Information - Please Print All Information Property Owner's Name Parcel # Property Owner's Mailing Address Property Location • 22,6 ~i~ i J Govt. Lot City, State Zip Code Phone Number -b~ y, Section s f t11 J O Z T JO ry ~i (circle one N; R~~Eor&) II. Type of Building (check all that apply) / Lot # I or 2 Family Dwelling - Number of Bedrooms t/ Subdivision Name Block # ❑ Public/Commercial - Describe Use ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village of 7l {Town of TWO III. Type of Permit: (Check only one box on line A. Complete line B if as plicable) A' New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. V 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) 1K Nor-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application RaWgpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elev lion 4-56 1 M. e?- I sa o~~ t VL Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units New Tanks Existing Tanks ~l U v in~ y wC7 C% Septic or Holding Tank V Cng Chamber {lJ 1 W 1 K VIL Responsibility Statement- 1, the undersigned, assume responsibility for Installation of the POWs shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number Cal 1 _;l 4q-V 6SW Plumber's Address (Street, City, State, Zip Code) V IV. County /De artment Use Only Approved ❑ Disapproved Permiitt Fee Date Issued suin=Agentigna e Owner Given Reason for Denial ~ IX. Conditions of Approval/Reasons for Disapp d -/V f'DIrUT 3 - VA `71" r , Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches In size SBD-6398 (R 02/09) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 538834 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: Briese, Daniel & Becky I Troy, Town of 040-1105-70-020 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 27.28.19.422A04 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BIM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet I TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet I Septic Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes N] No 0 Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 155 Bjerstedt Court River Falls, WI 54022 (SW 1/4 NW 1/4 27 T28N R1 9W) NA Lot 3 Parcel No: 27.28.19.422A04 1.) Alt BM Description = 2.) Bldg sewer length = amount of cover = revision Required? 0 Yes ❑ No ther side for additional information. 10 (R.3/97) Date Insepctor's Signature Cert. No. co Safety and Buildings Division 58anitary y ` 01 W. Washington Ave., P.O. Box 7162 7- i s o n s i n Madison, WI 5 3707-7 1 62 Permit Number (to be filled in by Co.) Depa nt of Comme N Sa a Flit pplication State Transaction tuber N In accordance with s. Co m. 83.:BT2, -~6*w - ~ sion of this form to the appropriate governmental unit is required prior to i Vt rs'd ote: Application forms for state-owned POWTS are Project Address (if different than mailing address) submitted to the Depart ommerce. Personal information you pray be used for seconds r~ Q + Q rs rya j C purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. J tvtil I. Application Information - Please Print All I ation Property Owner's Name , Parcel # Reck, 1 ago- 116 5- o- Property rrOwner's Mailing Addre Property Location A Pr~ / Y!~ / l f 1! G4I Govt. Lot J City, State ' . j Zip Code Phone Number ~ y,, YV Lr y., Section I U Cf Fa I l s WIT .S 4b Z Z- T N; R , circlE oon( 0< II. Type of Building (check all that apply) L ~J Subdivision I or 2 Family Dwelling - Number of Bedrooms Name Qlw~.. ❑ Public/Commercial -Describe Use dk ❑ City of CSM Number El Village of El State Owned -Describe Use (sj J n n~ I R Town of 110 t ` U(t?a~p( III. Type of Permit: (C ck onl one box on line Co to line B if applicable) A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) List Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New Owner Before Expiration , O O IV. Type of POWTS System/Component/Device: Check all that a 1 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersal/Trea ent Area Information: Design Flow (gpd)J t) Design Soil Application Rate(dsf) Dispersal Area Required (sf) Dispersal Area Proposed stem El lion ~ - 3 as-~ VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units t j B y New Tanks Existing Tanks o. U rn rn w C7 a Septic or Holding Tank /000 O p 0 1 fp,I Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plu ber's Signature MP/MPRS Number Business Phone Number a~0ss~ psi-49 -as-9 gel --e Plumber's Address (Street, City, State, Zip Code) VII oun epartment Use Only Permit Fee Date I sued Issuin gent Signat re Approved =en $ Reason for nial IX. ConditS";FAWglpNWeasons for Disapproval ~ / V~ 1. Septic tank, effluent filter and V q dispersal cell must all be services /maintained ✓ O I , as per management plan provided by plumber. v L,~ J~~f lw 2. Al( setback regtrirements must be maintained ~wv as idab1le code / ordinances. Attach to complete plans for the system and submit to the County only on paper not less than S t/Z x I I inches in size SBD-6398 (R. 02/09) Valid thru 02/11 DAN 3 E r,( i9'3 ~ PLO i PL A to L aT S i o N ~ 1~N f ~OO~~a~Scp' 1 rlJS 1` t~Y ,V 4wSC~R3S" s da. wtl1 t~! aioc~1 1n~~ ! a I ' ~ _s h rJ h c~5 , ov` V if s ` 1-r4~ rfit` ~ sP ppe 1 f v t E ~~atP. PCO~ -JQ v CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: pOt,~n t~ J Q c $ ° Owner's Name: / Owner's Address: a i >r l o 1vW ~~~1 1.c~'L S¢o2Z Legal Description: L al X S "I 'A W ul YQ S r Q 7 T ,-VR~ 1 Q ild Township: fiY o County: roi JL Subdivision Name: Lot Number. Parcel ID Number: 0 AD 1) DS - 7 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 Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber: a v t el, H e Su License Number: ~c ~54 Date: $ _3 0 - 1 / Phone Number S/ 4go2 Signature c~ Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 DAN ~ OFCKY 139IC3E Poi PLAN PA Q' L'7o40-1105-70-bZ0 L or 3 SCaI~ 40 lot, o 'N W Well o~ X000 ~'A Sip ~ 1 w~Pdy ~.A 52_ p G ch` !"i~t'CV 4~~S~R3S 1 I Ce\\S Ga-'^~~1 toy-2 Flow (kn,~l d ~ ~d PP r L ,,Svc 3 ~rS~~~'t nN v 1 o r^ , VIP 6 N ~ 9 tL, 9~ rL ~ q EL I f .5,3 ~lvl0. all ~ III t a INS 0 0 0 0 11111111111111111111111111110 IN II II I c U U O ^ (V O N r- E co U CO U O G N N E O C h d U co N00 ~d tG ~j U Mium ( * I N Go U _ O d ~y 10PAA1 ' u Co U N C6 ~ u W O U w ¢ N U O m U c co co N Q0 N U cn cn N V to Z N L Co 0 LC) J U W to O N L4 0 a cn ~ p v w w toWL, ¢ C.3 a U' ~ W Y ¢ w L w U) ccn z o.~ Q W M - O) U J LCI) co d U ED u-, y ~J ~NO y~~4i i LJ-L LO d Z Q.' IVu'~na vu,a a. a N J O U) ~C7 a_W ~ J C O J J Y D Q LL LL OJ Z J J \\\\\\\\\\\\\\\\\O\\ I- w O ¢ Q J~ ~ d d M O O O - ~ _0 _0 m -1 N z cn O csOCO 00 ip- m c N = ~~Z cn(-- O 00 ~ cNncn C= :z cn -0 C) m ~m W O m C -0 O 90 ccn ~m r C-) _0 rn r- c ~czi ~c Z ..P X m cn m o m m o z ccn 0O o c Z to v o - a> co cn o0 OD N A T W f~ W C T1 O N a 0 r~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page l of Y FILE INFORMATION SYSTEM SPECIFICATIONS r s Septic Tank Capacity 11 NA Owne j ,S0 gal 'F Q c f fS Permit # Septic Tank Manufacturer c. 11 NA 1 CSc Co. DESIGN PARAMETERS Effluent Filter Manufacturer pa'` Lok ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model JC S ❑ NA Number of Public Facility Units X NA Pump Tank Capacity al Or NA Estimated flow (average) C1 gal/day Pump Tank Manufacturer 0 NA Design flow (peak), (Estimated x 1.5) 4 S gal/day Pump Manufacturer I]Yl NA Soil Application Rate C)gal/da /ft2 Pump Model E~ NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit IN NA Fats, Oil & Grease (FOG) :930 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODS) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) :5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD5) :_30 mg/L J&ln-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) :!530 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) :_10° cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ 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: ❑ month(s) (Maximum 3 years) ❑ NA year(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every' ❑ month(s) (Maximum 3 years) ❑ NA 0 year(s) Clean effluent filter At least once every: I1L month(s) ❑ NA / ❑ year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) I$ NA ❑ year(s) Flush laterals and pressure test At least once every: 0 month(s) ® NA Y' ❑ year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) 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 (Y3) 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 :_12 months, shall be performed by a certified POWTS Maintainer. A"service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) 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 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 POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: I~ 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 tanj( 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 INSTALLER POWTS MAINTAINER Name 00.x` 4' X15 Name Phone S if _ ~~02. , S g Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name j-, Phone Phone 38&_ ' o 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. Oct-15-2010 01:59 PM St. Crcix County Plan/ton ng 715-386-4686 1;1 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address Property Address ASS 31 9- ,r- S7' d Lo %J Vt (Verification t tired rrom Planning Sc Zoning Department for new construction.) City/State .t vg_r l S V-1 Parcel Identification Number 0!~O-J y-- 7U - dZQ S~~OZZ LEGAL DESCRIPTION Property Location S in/ 1/; . N W 1/4 . Sec. , T b' N R~W, Town of 1 Subdivision Plat: , Lot # 3 Certified Survey Map # S((77_ 7-:7 , Volume Z3 , Page # Warranty Deed # _ (before 2007)Volunte _ _ , Page Spec house -yes no Lot lines idendriablo yes no SYSTEM MAINTENANCE AND O)YNER CERT FICATI N Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists ofpumping out the septic lank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the fttnction of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities arc specified in Wonu». 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) ille 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 P3 11111 drsladge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards sot 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. Uwe certify that all statements on this form are true to the best of my/our knowledge. I/we amlare the owner(s) of the property described above, by virtue ora warranty deed recorded in Register of Deeds Office. Number of bedrooms 5 ATURE OF AP LICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department, Include with this application at 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. 48/05) f c p o a OA r J O U L2 0 0 co H Z CAL a' ¢ v C rT-~ C:; O ~■CV J S O U O_ erg„ H W to a lJ 1 C"i wwoor` maw wLUCW5 W O H LU C= L L2 Co SH HNQ [NCO Ua " -~~N 1- C3 W 3 W o :2 F. 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A o LJJ _ i LL- w V) O J w Q Z \ \ .7 wpd Q~ Qw Q U LLJ W FZ ~Z ~0 m F-- m00 tnO VLLJ ) Z UJ o V) m (Y- 02 LLJ E5 w W w r- L- o o w o z > N Z: :2 00 5 t}- j oo ~o m o -OD ~dcSp V Z N N ~ C { - to ~ 3 (40 C) M \ s-~ ma= c ~ N • cs7 Z v ~ N ~s~ O 00 0 v Q o 0 1= o cn U w z ee U W J p o w o € a s~ •o 6 N ° os_ 00 r,V:~ JZ Z (n o z Y 25' § Via' . O ~~=Ncn CC U Jp U V v N W Q Q twi m> w (~J) Q~ N~ m ON J O LwJV z O d LL 4~ W O W> ~ o al w ~ a _ i -o o J W a~ rw ~S2O \ w p W a cr- w Z U p v nQ) 0 Y Q i a U Z J uj 0) Q O> Q0 m°' 0 V) LL- 11 -j 0 or_ uj O J w Q Q R Q U v F- ~ Q~~e /OAP 0/ / Z5 ,O~s\ V) y °40 w W Om Z LLJ r \ ow NO. OF U RV EY MAP pREPARED FOR: CERT 1 F I ED S VALLEY LAND CO. INV. NW 1 14 OF SECTION 27, PARTNERSHIP, LLC- E SW 1/,4 OF CROIX THE COUNTY, WISCONSIN. 523 WESTRIDCE CIRCLE .OCATED IN PART OFF l Y, ST. RIVER FALLS. WI 54022 MEIN, R19w, TOWN :TRO Centr°I TABLE (ALL LENGTHS ARE IN FEET, Tangent Bearings DATA Chord Chord Arc Tangent In Tangent Out DOUGLAS J. ZAHLER & N LAN Radius gearing Length Length 544'15'88"W S86'35'55"W S D SURVEYING, INC. Lot Length Angle S65'2558"rN 223.81 228.98 88635'58"W S69126'08"W 2920 ENLOE STREET S78'01'03'W 237.31 238.20 5696+08"W S20'46'08"W HUDSON, WI 54016 309.91 42-20'00- 795.16 17'09'50" 197.78 203.85 S86.35'58'W loll 240.00 48'40'00" S45'06'08"W 544'15'58"W 884'47 565'25'58"IN 247.64 253.36 S86'35'58'W '13'W Il~ 34291 42.40'0°- 01'48745" 585.41'35.5"W 24.11 24.11 S58'26'00'E 46.07 47.28 60.00 513'17'00"E N28'53'17"E 762.16 S35'51'30"E Oo 45'09'00' 101.28 326.59 558'26100"E 817'89'86"E o~ 70.00 267"19'17" S75'13'38.5"W 86.61 93.38 S58'26'00'E 520'13'02"E S17'59'56"W S66'57'26"W 70.00 76'2556" 58.01 59.81 N34.52'09"W 4 48'57'30" S42'28'41"W 95.51 S66'57'26"W d 3 70.00 N34'52'09"W N28'S3'1TE / Ln 2 70.00 78'10'25" N73S7'21.5"W $3 94 77.89 N06-12'52"W " N02'59'26'W 36.76 N28'53'17"E 1 70.00 63'426N11,20'12.5' E 36.19 S69'26'08"W 60.00 35-06'09' 87436'42"~N 137.52 137.71 569'26'0 ,W 520'46'08"W 1'o 762.1 q~ \ n. 6 10'21'08" .59 175.82 ~o y y. M 207.00 48'40'00' 545'06'08"N1 170 0 LOT ' W - 11 - 1~ r`4 LLJ 000 AREA TABLE I I Oo_O(~. o pC ~ - M o ACRES SQ. FT. syKORA LA{~1E f 586.35'58"w G,~ z 1 .r 2 445 106.488 178.011 / ~e1.289 56.155 J 6 6'Lr' 2 94,653 ii o o OO i 2173 105,612 0 (aC~~ C2_, 5 86'35 58 W s 0)iLO in w or aOo hoop 2425 - 178.01 \ ca~~4 ~i L01 u- ~~i /,~5~ / ~g1 '1~-~$ • 75' , Z N ~'1 Si#$ d~ 01 rj i 'N = z P i R3 EDT'. ' Y.. BJERST48 COURT N / Y5' - w o ~ .56g ,,1*rt, \ \ / OP OF V iRa+ P%)E In qtL ~~s• \ LOT . / H 914.0 NAw lees) OM E"'_913.52' E 916.0 , N00o9 09 OT QLOT 2 ~ -~N \ ti ~o~ f... ~ . LBO- W- . • P t --277. 8E 3 X33.75' .66 IRON • g f 94.04 ToP Oi l 35. 6`4r • N89'21 28E 8 952.24' sw EUv,-913.s~ 88171'24"E 369.39' ""w--'=88) E1 /4 COR• _ SEC. 27 O.L. 2 OF PH©p®~~Q_ (C~o~ICEAS~ ~ 1/4 LINE _-N89'21'287E 5272.28-- W1/4 COR• SEC. 27 Wisconsin Department of Commerce SOIL EVALUATION REP013TPage I of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County ST. CROIX Attach complete site plan on paper not less than 81/2 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. Please print all information, ewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). :Y_2 r Property Owner roperty location VALLEY LAND CO. INV. P RTI ICC~® vt. Lot SW 1/4 NW 1/4 S 27 T 28 N R if E❑(or)W Property Owner's Mailing Address of # Block # Subd. Name or CSM# / 526 Troy R Z007 3 ~-3 7 k3 City State Zip Code Phone Number FICity []Village Town Nearest Roadt# ~S► River Falls, WI 54022 ( ST. IROOUNTY T-rou B,jerstad r E] New Construction UseE] Residential / Number of bedrooms 3 or 4 Code derived design flow rate 450 or 600 D Replacement Q Public or commercial - Describe: _ p@f@nt mat@d@l ®tttwa®h F1-Coading @ tion ff @pplio@bl@ ft: General comments Conventional In-ground trennccherate pm may ' irre/d and recommendations: > 3!v a.. > 4001"'~ &4 S '314 L 1 Boring # 0 Boring F] , Q Pit Ground surface elev. 913.40 ft. Depth to limiting factor 108 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 'Eff#2 1 0-24 10YR2/1 as 2vf-m 2 24-30 10YR4/3 - sil 2fabk mfr as lvf-m 0.6 0.8 3 30-43 10YR4 c2d 10YR3/4&10YR6/1 cl mff as lvf-f 0.0 0.0 4 43-90 7.5YR4/4 4' sl lmsbk mvfr as 0.6 1.0 E5 90-108 10YR4/4 Q k9r fsl Om mvfr as 0.2 0.5 6 108-120 10YR4/4 17f 10YR5/6 fil Ott 1111 0.2 0.5 (24" frost) 2 Boring # Boring 913.61 d TT 120 , F q Pit Ground surface elev. ft. 5 v pth to limiting factor in. Sit Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 I 0-26 10YR2/1 as 2vf-m 2 26-50 10YR3/3 sil 2fabk mfr cs lvf-m 0.6 0.8 3 50-67 7.5YR4/4 sl 2fsbk mvfr aw 0.6 1.0 4 67-120 7.5YR4/3 fsl Om mvfr as 0.2 0.5 5 120-126 7.5YR4/3 f2f7.5YR4/6 vfsl Om mfr 0.2 0.5 (24" frost) ' €ffluent #1 = €99 > 30 4 220 @nd T€S >30 150 mgl~ ' €fllutsrtt #2 = €99 430 and TES 30 rrVL CST Narm (ft Pflnt) CST Nul Ma Jo Hollister Hollister's Soil Testing & Design) JMA A" S& 224832 Address Date Evaluation Conducted Telephone Number W9875 690th Avenue, River Falls, WI 54022 02 - - 07 (715) 426 - 1775 yytaAt a ~a` 6e--. u~ I l Property Owner Valley Land Co. Inv. (Lot 3) Parcel ID # (pending) Page 2 of 3 Boring 3 Boring # [D Pit Ground surface elev. 916.76 ft. Depth to limiting factor 105 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 'Eff#2 cs 2vf-m 1 0-24 7.5YR2.5/1 2 24-36 10YR4/3 sl 2fsbk mvfr cs lvf--m 0.6 1.0 3 36-49 7.5YR4/4 sl 2f-msbk mvfr as lvf-f 0.6 1.0 4 49-105 10YR6/4 fs Osg dl as 0.5 1.0 5 105-115 10YR5/4 flf 10YR5/6 vfs 0 mvfr 0.4 0.6 26" frost) Horizon 4 has some rock frag. 7 ❑ Boring # Boring r a Pit Ground surface elev. Depth to limiting factor in. Soil Application Rate it qb Horizon Depth Dominant Color Redox Description nxtb' Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring Boring # Ground surface elev. ft. Depth to limiting factor in. Pit 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 'Eff#2 * Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mgA- ' 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. S1313-8330Test (R.07/00) Page 3 of 3 MARY JO HOWSTER CST - Uc. / 22y$3L $ P& 2760 / RIVER FALLS. MA 540221& ph. 715-426-1775 - - SYKORA LANE ~ v v\ VALLEY LAND CO. INV. PARTNERSHIP, LLC. Lot #--2- PROPOSED CSM LOT ` SW 1 /4 OF THE NW 1 /4 OF SECTION 27, T28N / '8i R18W, TOWN OF TROY, ST. CROIX COUNTY, LOT' i WISCONSIN. Wf: i~ . SOIL BORING SCALE IN FEET 1' = 40' BENCHMARK Ci'r 40 sritte~o 0 40 M 913.6 91 .76 913,85 T 3 ~~~~P100 913.27 1 F O 91249 91 .40