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661812 038-1167-90-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village Township Sid & Terrie Kaminski TOWN OF STAR PRAIRIE CST BM Elev: Insp. BM Elev: Description: / . D43 g IBM II �IA�i ^/ �a D4 �-( MMA eho TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ZSYL Dosin Ae ra H,j TANK SETBACK INFORMATION =�Mm - ", __ M='�=01WE mm=lm MMM= = mmmm PUMP/SIPHON INFORMATION Manu cturer Demand G Model Numb TDH Lift Fri Loss System Head TDH Ft Forcemai Length Dia. t. to Well SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. Croix Sanitary Permit No: 661812 State Plan ID No: Parcel Tax No: 038-1167-90-000 Section/Town/Range/Map No: 28.31.18.810 STATION BS HI FS ELEV. Benchmark Alt. BM dg. Sewer SUHt Inlet j SUHt Outlet n Dt Bottom Header/Man. Dist. Pipe Bot. System �e f _ice b� Final Grade i_=? w at Le ,I f2 fi i/ r7 St Cover /aa.39 I-/ ly4j c-1 jas-g << 03,s3 0�11tl �.0 03-0 SE4QRENC)iWidth DIMENSIONS I 3 Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth SETBACK INFORMATION SYSTEM TO Type Of System: 11��5t�6 7J VW e P/L �of BLDG I �13 ( IWELL , �� L-A�4E STREAM �C J LEACHING CHAMBER OR UNIT Manufa e : l ModelNumr G` o ul DISTRIBUTION 5YTrEM Header/M0a ifol Distribution x Hole Size x Hole Spacing Vent to Air Intake L II P (s) I I Length Lee a Spacing SOIL COVER x Pressure Svstems Only xx Mound Or At -Grade Svstems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Location: 1991 104TH ST 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = t ACIV �. Plan revision Required? -❑ Yes No Use other side for additional information. 41��_L( Date SBD-6710 (R.3/97) Inspection #1: g.*o = 100' - 9 �� = 9�. Insepctor's Signature Inspection #2: — S S". E%v'. 10,30 = 49• lB' Cert. No. r n A n 1 n n n A A r n Department of Safety t `" „` ST CROIX D & Professional Services, San i'tnr•iI Ni,rirhrr Ix til Icd In (`,, `iS pS Industry Services Division JUN 1 2024 rare i ICI m ) w 661812 s a 2 'k ` rmit Application State Tr nsrctlontiumher In accordance �,nn Sl'ti :;H; If' I %kis Adm Code_ submission ol'this form w the appropi':: tc usefnurertl11 url'i. Project Address id'diflerent than mailing address) is required prier: A+ Irt+t tt to a .i �,ir nary permit Note Application forms Ibr stat«ouned POW I S sic su'.:r:ioticd to the Department of S:iicll ar'u hole.sslonal Services Persomi, intormation \'oil ptovide ma}' he Used felt sceond,Irs purposes in accordance'Ie nh the h ikacy Law, s 15.04( 1 )i rn 1. titat. 0414 1. Application Information -Please Print All Information Propertp Qwner s Name Farrel # SID AND TERRIE KAMINSKI v im 0381 16790000 Property 0%%ner's Mailing Address [' Property L<reatlllrl 1991 104TH STREET """^ter Govt Lot til.ite hp Code• Phone. Number NEW RICHMOND WI 54017 715-377-6809 SW�'. NW_.___ .. section __2.H_.... 1- 31 N R 18 E or VX 11. Type of Building (check all that apply) Lot 4 ❑ 1 or 2 Family Dwelling - NUMN-F of F3edroorns 18 Subdivision Name RED PINE ESTATES r' ,ck id ❑ PublIc.'Contmercial - Descrihe Use 0 City of ❑ tit,Irr ()versed — Describe 1.1.se - -- VIilageuf 11Numhcr V "I("All ol` STAR PRAIRE Zone X ill. T) pe of POW-1 ti Permit. (Check either ".Nets" or "l2cplacemenl" and ulher .rllplieable on line a. Check one hog on line B. f (Pniplcte line (' if -Au rliCable.j ,� p y � t7ther "kFtxliticatirrn w Exuur.� S• }tem tex ]am) C .4ddninnal F rctrcatment l.lnit explain) 1 ticve �� steer: Re lacement ti -stem ' S _ , P _ ti. E I loll ii- rank 2In-Ground C Ai -Grade 7 Matind C.1 Individu.0 slit [7c,iln El 01hen Type (explain) (conventional) t°• (- Ren �a,:l Iitinre ❑ Revision :1 Change ofPlumber ElTranslrru+Ncse (.honer Ist Previous Permit Number and Date Issued Expiutu'arI i 240753 8/9/1995 IV. DispersaUTreatment Area and Tank Information — Design Flom (gpd) Design Sail Application Ramgp&si I Dispersal Area Required (st) Dispersal Area Proposed (st) Svstem l levauon 450 0.7 643 650 24" below contour Capacity in Total k of Manufacturer , Tank Information Uallons Gallons Units F c P u it _� c ticK-Tanks Sepac or 11,4d,ne. Tank WEEKS 1000 1 WEEKS x Dourly, Chamhel' N . Respiin.ihili9y -Statement- 1, Ow undersigned. assnnte responsibility for ins mnatiou or the PQiY7 S shown on the attached plans. Plumber . N-1, L .Print) Pltimhcr s Signature MPAITIR5 Ntunhrl Rusinen; PhUrle \uinht, PAUL R KOEHLER22541 Q 7152462660 1" r •^Add retie (Si reet, Cirt , State.. Zip Code) 321 WISCONSIN ❑R NEW RICHMOND 54017 y 1. ( (Purity:+Depart ment Ise On Iv Pernut Fee Date lsst.e,: ,long A rent Sign.rturc x'e}pius4d n DIsannoved Owner Glvef 7n rett' Conditions 1 Apl7rtrva R a 3-Valve being installed to utilize existing trenches after a period SYSTEM OWNER: of "rest", as directed by plumber. 1. Septic tank, effluent iaer and dispersal cell 4. System elevation cannot be below 24" below contour, to ensure adequate must be serviced I n-antained as per 36" of separation below system elevation to limiting factor - redoximorphic management plan provided by plumber. features. See soil test. 2. All setback requirements must be maintained 5. Well not shown on site plan. System must meet all required setbacks from as per applicable code 1 ordinances all wells. 4trsch fit carnpictz play. l,,, 161 .4.1i-ur .,nil -i,hmi.r I.:, the Goimt7 —1n on paper nnl Ice+ Ihan S I'2 c 11 inches in eizc 6. Plumber must certify existing septic tank. 41313-6398 (It. 03i22) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) located at: 1/4, 1/4, Section , Town N, Range W, Town of , 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 SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Did flow back occur from absorption system? (if no, skip next line.) Approximate volume or length of time: Tank Capacity: Construction: Prefab Concrete Steel Manufacturer (if known): Age of Tank (if known): Permit number (if known) (Licensed Plumber Signature) (Title) (Date) Yes No gallons Other (Print Name) minutes (License Number) MP/MPRS Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 199I SAN-2024-152 Abr e�z� in�SN 3ar9 ,2" 1,0 a 6�� L` ' _ P. V n p.pt. E 2 well = ?? COPY SA N-2024 152 ® � D. S o p�PR,6 C', s +►eA Q IA'm v 1 � - — ve, 3r DLS S 3� Ne II - SAN-2024-152 CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name Owner's Name: SILT KAMINSKI Owner's Address: 1991 104T1{ STREET NEW RICHMOND WI Legal Description: SW 1 /4 NW 1 /4 SI :C` 28 T 31 R 18 W Township: STAR PRAIRE County ST CRO1X Subdivision Name RFD PINE Es`rATES Lot Number: 18 Parcel ID Number, 038-I 167-90-000 Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Seclion Page 4 Filter Specs Page 5 Maintenance Information Page 6 _ Management Plan Page 7 St. Croix. Cry Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments. Soil Test & House Plans DesignerlPlumber: PAUL, R KOEI--ILER License Number: 225410 Date: 06/ 10/2024 Phone Number (715) 246-2660 Signature �►'' Designed pursuant to the In -Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-1071)5-P (N 01/01), Page 1 199I SAN-2024-152 f� Abr L` P. well = ?? i E 2 6'lw SAN-2024-152 SOIL ABSORPTION SYSTEM DETAIL 1 GRAVELLESS LEACHING UNIT Page of Project Name: C� 1 A )� rx M I n, � i Z No. of Cells f Cell Width t Cell Length t Cell Spacing �_ Per Cel I Total No of sq ft EISA Per Cell (, sq ft Total EISA Maniifarturar MMPI Lavino L.enath EISA Rafina Infiltrator EZ1203H-5ft 5 0' 1 25.0 EZ1203H-10ft 10.' 1 50.0 Gravelless Leaching Unit. Manufacturer: Gravelless Leaching Unit Model: Finished Grade ft Typical Cross Section Observation Pipe with approved cap or vent :___----Soil Backfill Geotextile Fabric fl Infiltrative Surface 12 in - f Limiting Factor 4 in Slotted and Anchored Vend Observation Pipe with. Cap ...r........r.r......ea...r....r................. ....r.... 9....... ■.rr... PlurnberfDesigner Signature: 1 License 212,r2%e Date: -, ,10 L �X Int PmpV7tions inPrecast. (irdll8 p Zabel' ViAgmaur PrActs A Di Aswn of Pony cm Vc. SAN-2024-152 PL-525 Efflt1CIA I ltCV PL-525 Filter The PL-525 Filter is rated for 10,000 GPD (gallons per day) making it one of the largest filters in its class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok PL-122, the Polylok PL-525 has an automatic shut-off ball installed with every filter. When the filter is removed for cleaning, the ball will float up and temporarily shut off the system so the effluent won't leave the tank. Features: • Rated for 10,000 GPD (gallons per day}. • 525 linear feet of 1/16" filtration. • Accepts 4" and 6" SCHD 40 pipe. • Built in gas deflector. • Automatic shut-off ball when filter is removed. • Alarm accessibility, • Accepts PVC extension handle. PL-525 Installation: Ideal for residential and commercial waste flows up to 10,000 gallons per day (GPD). Locate the outlet of the septic tank. 1/16" Filtra 1 LI1 2. Remove the tank cover and pump tank if necessary. Accepts 4" & 6" 3. Glue the filter housing to the 4" or 6" outlet pipe. If SCHD 40 pipe the filter is not centered under the access opening use a Polylok Extend & Lok or piece of pipe to center filter. 4. Insert the PL-525 filter into its housing. 5. Replace and secure the septic tank cover. PL-525 Maintenance: The PL-525 Effluent Filters will operate efficiently for several years under normal conditions before requiring cleaning. it is recommended that the filter be cleaned every time the tank is pumped, or at least every three years. If the installed, filter contains an optional alarm, the owner will be notified by an alarm when the filter needs servicing. Servicing should be done by a certified septic tank pumper or. installer. Locate the outlet of the septic tank. 2. Remove tank cover and pump tank if necessary. 3. Do not use plumbing when filter is removed. 4. Pull PL-525 cartridge out of the housing. 5. Hose off filter over the septic tank. Make sure all solids fail back into septic tank. 6. Insert the filter cartridge bark into the housing making sure the filter is properly aligned and completely inserted. 7. Replace and secure septic tank cover. m switch tionall -Copts I" PVC tension Handle Rated for 10,00(I GPD 525 Linear Ft. of 1/16" Filtration Slots „-. Certifted to NSFIANS1 Standard 46 [1a� he0ector Automatic Sh,M- f BaII RX OuldoorSmartt i!tvir Harm Tetend & Iok04 Pnh']nk, Zabel & lie�t filter. acre^t Lidly installs the SmarthiltcrV switch and aParm inlo evAing tanks Polylok, Inc. 3 Fairfield Blvd. Wallingford, C F 06492 Toll Free: 877.765.956.5 Fax: 203.284.8514 Nv-,mv.polylok.com 6110/24, 140 PM Polyfok Custom Basins SAN-2024-152 P N 4OLY FOX - Inc Search Innovations in Precast, Drainage and Wastewater products CUSTOM BASINS Request a Catalog Request a Quote Perfect for install ing an effluent filter or pump outside the tank, or just as a drainage well. These watertight basins are made out of High Density Polyethylene so they won't breakdown in the harsh septic environment. They come custom made in any 6" height and we guarantee they will be watertight! https:llwww, polylok.comicu star i i -;, , mris-prod-278.htm1 114 6110r24. 3 40 PM Polylok Custom Basins Related Products Goes Well With SAN-2024-152 Details Downloads CAD Part Number 1-di! LUZAU11114V [ leight to miy 6" increment, beginning with a 14" basin Made of high density non -corrosive polyethylene plastic Accepts all 2", 3", 4", SDR 35, SCHD. 40 & corrugated pipe Ideal for retrofitting an effluent filter or pump to an existing onsite system Includes an inlet and outlet grommet Watertight and airtight Ideas for repairs on sites with limited space https:i/www.polylok.com/custom-basins-prod-278.html 214 SAN-2024-152 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 1 of � FILE INFORMATION Dwne. SID AND TERRIE KAMINSKI Permit ,# DESIGN PARAMETERS Number of Bedrooms 3 ❑ NA Number of Public Facility Units ❑ NA Estimated flow leverage) 300 al/day Design flow (peak), !Estimated x 1.5) 4.50 aiiday Soil Application Rate -7 gal+day`ft` Standard Influent/Effluent Quality Monthly average` Fats, Oil & Grease (FOG) f,30 mg/L Biochemical Oxygen Remand (BODs) :=0 mg/L ❑ NA Total Suspended Solids ITSSI 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODs1 :530 mg/L Total Suspended Solids (TSS) C30 mg/L ❑ NA. =ecal Cofrform Iceornetric mean) S104 cfu/100m1 Maximum Effluent Partic,e Size Yi in dia. ❑ NA Other: I t ❑ NA "Values tyoical for domestic wastewater and septic .ank e'fluem. MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS Septic Tank Capacity 1000 Gal C NA 'Septic. Tank Manufacturer WEEKS G NA Effluent Filter Manufacturer poly lack ❑ NA Effluent Filter Model 525 ❑ NA Pump Tank Capacity gal I NA Pump Tank Manufacturer 9 NA Pump Manufacturer lyap' Pump Model g( NA Pretreatment Unit X NA Sand!Gravel Filter ❑ Peat Filter Mechanical Aeration ❑ Wetland ❑ Disinfection ❑ Other: Dispersal cell(s) ❑ NA 91 In -Ground (gravity) 17 In -Ground (pressurized) ❑ At -Grade 13 Mound ❑ Drip -Line ❑ Other: Other- ❑ NA Other-, ❑ NA Other: ❑ NA Service Event Service Frequency Inspect condition of tanklsl At least once every: 3 El monthislyeads ;Maximum 3 years) a NA Pump out contents of tankls) l When combined sludge and scum equals one-third 01`of tank volume ❑ NA inspect dispersal cell(s) At least once every: y ❑ rnonthlsi 3 � years) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: q monthW f gj yearis) ❑ NA. In pump, pump controls &alarm At least once every: ❑ monthislspect El yearW DNA Flush laterals and pressure test At least once every: ❑ monthisl ❑ yearW NA Other: At least once every: C monthisl G year(sl EX 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 tankls) 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 knack up or ponding of effluent on the ground surface. The dispersal cellls) shall be visually inspected to check the effluent levels in the observation pipes and to cheek for any ponding of effiuen' 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 NA 1 3, 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 51 Z 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. SAN-2024T2 Para: cf START UP AND OPERATION Far new construction, prior to use of the POWTS check treatment tank(s) far the presence of painting products cr othe- chemicals that may impede the treatment process and/or damage the dispersa! celllsi. If high concentrations are detected have the contents of the tankls] 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 hign*ater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the celhsl 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 POW`S Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vanities over tanks and dispersal celis. 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 POV%,TS: 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 andror is permanently taken out of se, :,ice the following steps snall be taken to insure that the system is properly and safely abandoned in compliance with chapter Coi-. n. 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected anc '`ri- .iziandoned pipe openings sealed.. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • Aftw pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soi„ oravef 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: © 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 anther soil limitations. Barring advances in POINTS technology a holding tank may be installed as a last resort to replace the failed POWTS. %[ 1 T n µ �e a no ding�ark v bee i a are l ,yt alty 'I'RD41817� �� "J&-oj t�r•15T�rJC710 .. ❑ Mound and at -grade soil absorption systems may be reccmF�iru:r ed in place following removai of the biomat at the infiltrative surface. Reconstructions of such systems must cu npry with the rules in effect at that 'rne. C •CWARNING7 > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND!OR INSUFFICIENT OXYGEN. ❑O NOT TENTER 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 PO"rTS INSTALLER Name COUNTRYSIDE PLUMBING Phone 715 246 2660 POWTS MAINTAINER Name PAUL R KOEHLER Phone 715 246 2660 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name POWERS SEPTIC Phone 715 -410-8820 Name' (f-([ t''; f)L,AjI -2ol; f This document was ❑rafted in compliance with chapter Gong. E v:;tr'Tkdi&Ifi and 83.54111, {Z &;31, Wisccnsir. Administrative Code. SAN-2024-152 STC-I05 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER MAILJNG ADDRI PROPERTY ADD (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION 4�41_ 1/4, �_ I14, Section,_-, T---eL_N-R__Zf W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION .�1�1(S�,� LOT NUMBER_ CERTIFiEDSURVEY MAP , VOLUME , PAGE , LOT NUMBER 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which Nvas in ope.,a[ion :)j r to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requiren;cr.::;ILt Owners of all new systems agree to keep their system properly maintained. 1-lie property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a matey plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating; condition and (2) after insfcction and pumping (if necessary), the septic tank is less than 1/3 full ol' sludge and scum. UWe, the undersigned have read the above requirements and agree to maintain tite private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. ` SIGNED: ^ DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, W1 54016 1 1193 I Thi cati,-)n L'ol-r. ir, tO be COMPlul'('d it; full and SAW0244V the aw r. k: L ::j- t-j,,(j property bc-Ing developod- Any inadequacion will Only r ill dclay!; of tho licn".t i,-Suallce, f:houk! thi-f-; devel .,ant be intendcd for rcsalo by owner/contractor, r, p ec `'ousc) then a ne(-ond lol-it, c�hcu,[Ll bo and t-umpfut.cd wh(m the Property in, BOld ancl cul"InittokI U) thif; Ofric,:, wit ll thc: -113pyopri,itc cic.n�recording. ---- - - - - - - - owncr of proper'--y !,ccaLion of oroperty 1/4 1/4, _cction 3, q AdAress of site 119q 11"t S___. YT--. hc-1 i v i 7, i c n n a m 4, M_ '-)Ll)c,- honics, Oil property? V-1-r!�_; v 4. 0 U:-, 0 W 110 r (') f 1-1 r 0 p c r t Y 4W - L v ;izc of parcel pircel was ovzoatel - ------ Arc -ill corner:; an(l lot -lines isle nt j. f i "It.) I V, 1, u rnf� and 11:Iqo Nljnlhtr J31 with tlle Porlif--ter of INCT.11PE WITIT 'VIII!, THE V-W�*ZAIVFY DFIRD Which inci.mcics -I vniJIMP AIM PAGE I t AUD 111)-; 1, ()F oil i f :Iva i. I ablc_. )11 bo h'] P1,11 1. _'o i�! o :Iv I d -)vocef.,-,. T!- the. d vr d d r p t i () n to :i Ccrt_-ificd survey Mip, Uo Cert.11 i.-c1c] .;Urvcly MC-111-1 br-, roqu i rod PROPrRTY OWNER CER'rIFICATION T cortifY t-h it -111 true to the 0!' 111V (OLIO) ktl()W14'_dYC thlt 1 ('.'!12) 1:1l ire) 1"11(i 0! the 1) r-C I)- r t- Cie sr - i hecl in '--I I 1'!; i t 11 dorm, by v.i 1-tue of I ci I'C 0 1 - J Q d G 5 cp t h L� C t (! 1, o I j)C, I Ll 4,, [)oCUj- (1�jjt NO (w(') presently owil the propo-�Cd :;itc for ,:jjc or. I (we) obt�iincd all casement, to L-Lin the -ibuvc described 1�1:01)ertY, for the System, and tjj_ clul.y recordecl in of fico of t.110 county Rocji�;Vrmr ,,,L Dr.ed- t !)Ocumerlt ITO. 1q, (:.-I r I L 0' Wisco,1sin Department of Industry, Labor and Human Relations Safety and Buildings Division GENERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) Permit Holder's Name: ❑ City ❑ Village p Town of: KAMINSKI, SID X CST BMElev.: Insp. BM Elev.. j� BM Description: 16d . � /�W J, �Q-Y,Y)-r TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic S �CYiC . %GCS Dosi Aeration Ho ldi TANK SETBACK INFORMATION TANK TO P / L WELL BLDG. Air Air I tcntake ROAD Septic/Gd'' r ,�- NA Dosing NA Aeration -_ a olding PUMP / SIPHON INFORMATION Manufacturer odel Number TDH Lift F Ion Sys ossea Forcemain ength Dia. SOIL BSORPTION SYSTEM Demand Dist. To Well ELEVATION DATA County:sT - - S2Q24-152 Sanitary Permit No.: State PlAvqL53 Parcel Tax No.: STATION BS HI FS ELEV. Benchmark 26) Bldg. Sewer 05 r St/ FeInlet St/F�fOutlet �,�yli /D1� 067 Dt Inlet / Dt Bottom Headert S?� yl, /60.76 � Dist. Pipe Bot. System d. za' 99 �'CJ Final Grade BED/TRENCH Width Length �� No. Of Tenches No. Of Pits Inside Dia. id Depth DIMENSIONS/� IMEN I SYSTEM TO P / L BLDG WELL LAKE/STREAM LE anu acturer: SETBACK CHA R Type O / System: C�zr v� l�<:. , ^(�5 �!!� Mo INFORMATION NIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) e' x Hole Size x Hole Spacing ntake Length _� Dia. Length � Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grad st s Only Depth Over Depth Over xx Depth Of xx Seeded / Sodd xx Mulched Bed / Center Bed /�h_Edges Topsoil- - -r'' ❑ Yes ❑ No ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) -,� f ttcLZ L -)(- LOCATION: Star Prairie.28 31.18W, SW, NW, Lot 18, r7'1 Plan revision required? ❑ Yes L6��" o Use other side for additional information. 116 Ete ' SBD-6710(R 05/91) 04th Street r Inspector's Signatu Cert. No INSTRUCTIONS sAN-2024-152 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The -septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, purnp/siphon and holding tanks for this system. Check experimental approval only if tanks receivec experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber isto fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County / Department Use Only. X. County / Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to th,e ca(anty. The plans must include the following. A) plot r:}ian, drawn to scale or with complete dimension!>, location of lic !ding tank(s), septic link(s) or atLer treatrrlent tank,, building sewers; wells; water mains, Y ate sr. f . ice, n - lakes; pump or siphon ti.inks, distri'rution boxes, soil absorption systems; replacement system area,; ar:�l t',,e f the building served; E,j horizo - s' and vertical el,,v,..&on, reference points; CI complete spec `ontro!s; dose volume; ele at;on d lferenees; friction loss; pump perfcrm:.)nce -urve; pump mode' aWKI ,,',rmp mr::nuf,.ct urer, D) cross section of t},e soii absorption system if required by the county, E) soil test data on a 115 form; and F) :al sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practice.. which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. SAN-2024-152 _ �I .9/'' EN Wisco.%sm Department of Industry, Labor and Human Relations Safety and Buildings Division GENERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) Permit Holder's Name: ❑ City ❑ Village [] Town o KAMINSKI, SID �( CST BM Elew insp BM Elev : f BM Description TANK INFORMATION TYPE MANUFACTURER CAPACITY Septi c 5 C["YP C'. . Dosi Aeration Hold TANK SETBACK INFORMATION TANK '0 P / L WELL BLDG. vent to Air pwr ;rttaice Septic NA Dosi ng NA Aeration aiding PUMP / SIPHON INFORMATION Manufacturer k9lodel N,rnber TRH I Lift F ion Demand � Forcema2�iength Dia. Dist. To Well S OLLIkBS0RPTI0N SYSTEM ELEVATION DATA County - - ST. CROIX Sanitary Permit No.: State PIA4Ao . Parcel Tax No : STATION BS HI FS ELEV. Benchmark f r /07. /0 Bldg. Sewer W St / I Inlet St / Outlet Dt inlet i Dt Bottom Header.- Dist. Pipe 9_-3 5Z 1, /�✓ /�' Bot- System M, 9�9 -yd , Final Grade BED / TRENCH width length r No.Of T enches No Of Pits Inside Dia- id Depth DIMEN ! N %� -S IM N ! SYSTEM TO P/ L BLDG WELL LAKE /STREAM LE anu acturer; SETBACK CHA R Type D r System: &., P-. f z c� •-G,'') , , � �� INFORMATION NIT DISTRIBUTION SYSTEM Header 1 Manifold Distribution Pipe(s) �� x -role Size x Hale 5paun 10take Length & Dia Length Dra Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grad st Only Depth Over ri_ Depth Over xx Depth Of xx Seeded 1 Sodd xx Mulched BEd 1 T4enter Bed /Edges r- Topsoil ❑ Yes ❑ No [7 No COMMENTS: (Include code discrepancies, persons present, etc-) k LOCATION: Star Prairie.28 31.18W, SW, NW, Lot 18 Plan revision required? D Yes 6: Use other side for additional information. e,3 P�l SBD-6710(R 05191) Date 04t/h Street f Inspector's Sig natur Wtsc*tsm Department or Industry. SOIL AND SITE EVALUATION REPORT _ I Labor and Human Relations SAN-202XIW -�—of Division of_Safety & Buildings in accord with ILHR 8105, Wis. Adm. Coda COUNTY Attach complete site plan on paper not less than 8 1 /2 x 11 inches in size. Plan must include, but J not limited to vertical and horizontal reference point (BM), direction and %a of slope„ scale or PARCEL ID. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION —PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION GOVT. LOT 1'd 114,5 T N,R 40A PROPERTYOWNER':5 M&LING ADDRESS LOT # I 13LO7 # 1 5UBD. AME 0 CSM # CITY, STATE I ZIP CODE PHONE NUN!9EA ❑CITY WILLAC� JUOWN NEAREST ROAD , (+ New Construction Use jy] Residential i Number of bedrooms ( ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flowgpd Recommended design loading rate <-- bed, gpd/ff2_,,:�_trench. gpcV"2 Absorption area required qjr bed, tt2 �_ trench, ft2 Maximum design loading rate . tied, gpdm2_, -' trench, gpolit2 Recommended infiltration surface elevation(s) /'' g R (as referred to site plan benchmark) Additional design i site considerations Parent material � Flood plain elevation, if applicable _ ft S = Suitable for system CONVENTIONAL MOUND IN-GROM PRESSLRE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable for system ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U D S ❑ U ❑ S ❑ U ❑ S ❑ U Boring # Ground elev. fro. 77 ft• Depth to limiting factor Boring # Ground elev. / ft. Depth to limiting factor SOIL DESCRIPTION REPORT Horizon Depth Dominant Color Mottles Texture Structure Consistence Bcxxtdary Roots GPD/ft Bed Trmnch in. Munsell Ou, Sz. Color Gr. Sz. Sh. { Zi73 S v \ Remarks: GST Name: —Please Print Phone. Address: � i 1 �— � f _ � Signature: Dare CST Number;. ��` 1 ib. -5Z!//V SAN-2024-152 .s M 01- PFIOPERTY©WNER SOIL DESCRIPTION REPORT PARCEL I.D. I Boring 4 .=:::N „ Ground elev. /Gam ft. Depth to limiting factor —`-Z_ SAN-2024-PW�Of_�' a low IBM M��== MM Is �AO M W-- M MI,-2 mm� M Remarks: mom M., OF 1AF marks: MMM M-M MM M e- marks: Remarks:. SBD-83MR 0"2) SAN-202,d�1? pm] � asyy %fit?QZ4s3Ungs Division SANITARY PERMIT APPLICATION Bureau of Building Water System 201 E Washington Ave In accord with ILHR 83 05, Wis. Adm Code P 0 Box 7969 Madison, WI 53707-7969 a Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. "., State Sanitar Permit Number a See reverse side for instructions for completing this application The information you provide may be used by other government agency programs ❑ Check it revision to previous application tPrivacy Law, s 15 04 (1) (m)t State Plan LID Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Prppe wner Na a Property ocatron 1 f4 114, S T N, R Vio , Property owner' Mailin�'i t of Number Block Number C stat Zip Code Phone Number Sub1on Na r CSM Number I T PE F BUILDING: (check one) ❑ State Owned 0 sty Nearest Road Public 1 or 2 Famil DwelIin - No. of bedrooms � ex Town Qr III. BUILDING USE: (It building type is public, check all that apply) Parcel Tax Number(s) y�,/'j 0sy~ �lL��/v 1 ❑ Apartrnent4 Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 El Restaurant/ Bar / Dining 4 ❑ Church 1 School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel / Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box online 8, if applicable) A) 1. �Z New 2 ❑ Replacement 3- ❑ Replacement of 4- ❑ Reconnection of S ❑'Repair of an ------ System -------- Syystem-------------Tank-Only --------------ExrstmgSystem ---------- Existing System B) ❑ A Sanitary Permit was previously issued. Permit plumber Date Issued V. TYPE OF SYSTEM: (Check only one) Non -Pressurized Distribution Pressurized Distribution Experimental Other 1 1 Seepage Bed 21 []Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In -Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 [] System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1 Gallons Per Day 2. Absorp Area 3. Absorp. Area 4- Loading Rate 5. Pert. �ate 6 System Elev- 7- Final Grade Require (sq ft.) Proposed (sq. ft.) (Gals/day/sq ft ) (Min-lipich) Elevation �• Feet % Feet VII. TANK INFORMATION Capacity in gallons g Total Gallons # of Tanks manufacturer's Name Prefab Concrete Site Con- Steel Fiber- glass plastic Exper App New Existingstrutted Tanks Tanks Septic Tank or Holding Tank I ❑ ❑ ❑ ❑ I❑I ❑ ❑1 ❑ ® ❑ ❑ Lift Pump Tank (Siphon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for ins Ilati n % onsite sewage system shown on the attached plans. Plu b "s Na n Plumb 's Si ature. mp MPiMPRSW No. Business Phone Number: L,, /, i,), c L� Iumbe sA dre Stre Cst te, ,Code} r J IX. COU TY 1 DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee i ndudeyGroandwater ate lssue Issuing Ag nt tore [ Scam Approvedsurchargereel pp ❑ Owner Given Initial111f/1�01%1910 Adverse Determination X. CONDITIONS OF APPROVAL J REASONS FOR DISAPPROVAL: SAN-2024-152 AS BUILT SANITARY SYSTEM REPORT-,-:' OWNER ADDRESS ` - a SUBDIVISION / CSM#JrS TOT SECTION _T_ N-R /.4 W, Town of��r u cr ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM r aer14),,, Yew: INDICATE NORTH ARROW �r vide sinformation on reverse of this farm, rovidetb�n�delZvvation e 2 dimensions to center of peptic tank manhole cover. SAN-2024-152 BENCHMARK:�- ALTERNATE SEPTIC TANK PUMP CHAMBER HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well house Other _ Pump: Manufacturer Model#�� Size Float seperatian Gallons/cycle- Alarm Location S©IL ABSORPTION SYSTEM width:—� Length Number of trenches Distance & Direction to nearest prop. line: - Setback from: well House, — Other ELEVATIONS Building Sewer`Z—',-� ST Inlet. ST outlet PC inlet PC bottom Pump Off Header/Manifold a Bottom of systern 9 Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR 3/93:jt ...446330 - LOT -1 CERTIFIED 5��„E. , RED PINE ESTATES 4asas° MAP IN VOLUME 4. - - PAGE ioi4 LOCATED IN THE SWI/4 OF THE NWI/4,. PART OF THE SEI/4 OF THE NWI/4, AND PART OF THE NEI/4 OF. THE SWI/4, _ ALL IN SECTION 28, T31N, R18W, TOWN OF STAR PRAIRIE, ST. CROiX COUNTY, WISCONSIN, O.9.F - NpCNRwAiEP ELEVATION?86181 B.....-! n N-OI-941 UNPLATTIED-------- LANDS LOW WATER ELEVATION IAPPRO%IMATE): 656 '- - - ' / NORTH LINE OF 5112 OF THE NWI14 OF SECTION 28 2626.94' SBB'47'00'W .._Aeo.OD' sso,00' 2eo.00' - 4Op.o� � sod.00' " PP a 14 10 cc 15 53, 1)5 80. FT. I 1 - 24T.a82 S0. FT. 139 El. FT, 2.I4 cc ACRES 13 P 3.38 4CFEE 3.69 A<RES ` 16 J2.OT A ES iA ryy a8. ]65O 2.0] ACRES . - N Sm 126,624 S0. FT. _ Fi - -I ACRES e � W S86•IO'12'W w sO a � W � ♦`\ 96SSt%' /i � I o HI 1'E.55O 12 / IN 23 �' a�. E.23 .sq1 ACRES FT. / O QI W E88.2/•BYW / / I ; �\ 9 8 _-:53.4TSO. FT. 24 A�W II.CRES i r ! m aaR. OI v 1 �. I 1 25 R O0 92,869 SC. FT. 14' \♦� '\\ / ti \ 2.56 -d ES T 2.,a ACRES \ ♦ / 0V - 19 I I e3. aOa 1. ACRES FT. R•$_ 14]10A NES. iT. •ss '� i56.16' E ♦ NSB'47'00'E 1206.16' g NT2,g i6 2 9 6q 7 22 \ / w BO oO ♦♦♦\ \\O�% \116 Si' T'E R5p L1 163.099 so. IT. - s I. h �� UNPLATTED LANDS Div co..'a nnij°O 3.T9 ACPEs 84 �y 572.45'O7"W ♦ 9,23' o c _ I S51'46'56'E Bs N' _ _ s u0i $ I9 >♦ / 74.91' 's64. a 2040561 SRO. FT. sT.S6 Q• IF 0 - ACRE _ _, / �E � /4D/" R _PUBLIC --tee- �{� IN 21 266.113 ACRES 3/ 20 ^ 1 s. ACRES- UNPLATTED LAN05 �9• ��%ys'J%, .. FT. ACRES I/ _ - 9� ➢ Z - T�;are nO objection to this plat W Ith respect to S—.233.15, F:-. / ..13, 236,20 and 236.21 (1) and (Z. WIS. Stats., and ILHR 85 of L[r thAW,,.Ad,IA-C,,de as provided bVSEo.236.12161,VVi9. Slats.- d \ � 33� �- � 540.33' � � \ � /TTR 3g' C,YSi'iOd [M1ls.. Z(1!...daY 0I„40i2k/✓3/1....... 19.W. wur CORNER OF NB 9.4520E F316, 69' ALU mOiNDme CAP IN cONCRETF SO— LINE OF THE SWI/4 OF THE NWIM OF SECTION 2B- Depadmant of Agrl-Itwo, Trade B Consamer Prolettiln UNPLATTED LANDS - ALIEN I`. d 4Y NYHA^EN ALLEN C. NYMAGEN MATCH LINE 61Q9t REGISTERED LAND SURVEYOR, 5-140 (SEE SHEET I) Hum6N �'e r DATED THIS 6+1DAY OF Sa 19 o t `rt•,t�N IVp � � n REVISED TH19 3rtl OAY OF NOVEmeE k, 19 SB, '�'16G$5CL#24°- REVISED THIS 51S OM OF JANUARY, 19 a9. SCALE IN FEET _ s 1 0 200 ioo Tn16 1n6TRDmEnT DPdFTED RY �.;. u. aLl.._4 - - SHEET 2 OF 3 SHEETS �aba f A n ,,;- SAN-2024-152 CApl)( COUNTY NOG 661812 STATE SANITARY PERMI F-1-11- VA- S -17, -1se-•'k-W [04", 311), PREVIOUS OWNER SID £ 17�a(F, �*OAIGM PLUMBER PA-yi. KoCHL9-R- LIC.# 22-S-410 2 :. SEC 1 R AND/OR , BLOCK SUBDIVISION?flue CHAPTER 145.135 (2) WISCONSIN STATUTES (a) The purpose of the sanitary permit is to allow installation of the private sewage system described in the permit. (b) The approval of the sanitary permit is based on regulations in force on the date of approval. (c) The sanitary permit is valid and may be renewed for a specified period. (d) Changed regulations will not impair the validity of a sanitary permit. (e) Renewal of the sanitary permit will be based on regulations in force at the time renewal is sought, and that changed regulations may impede renewal. (f) The sanitary permit is transferable. History: 1977 c. 168; 1979 c. 34,221; 1981 c. 314 Note: If you wish to renew the permit, or transfer ownership of the permit, please contact the county authority. -% AUTHORIZED ISSUING OFFICER — DATE 10//9/2ne� V4-1'v� - TAIS PERMIT EXPIRES 41/17/7,6* UNLESS RENEWED BEFORE THAT DATE SBD-06499 (R11/20)