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HomeMy WebLinkAbout006-1019-70-000Wisconsin Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENEF2AL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). Permit Holder's Narne: City Village X Township Doe, Duane C Ion, Town of CST BM Elev: Insp. BM Elev: BM Description: ~ ~ ~ "' I GS TANK INFORMATION TYPE MANUFACTURER ;~q + CAPACITY Septic ,) 7~. 3 ~~ K F'~~ ~ l0~ c v - s Dosing ,~•~ S- GO ~.. 1~/ tien j~ ~,b~-' ~~ ~~ Holding - TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ ZS 7 /dti /9L + /'L + Dosing / 7ZS / y'~ + igL. + ~9t Aeration Holding PUMPISIPHON INFORMATION Manufacturer ~ Demand GP ~ o M Model Number ~~ ~ e ~ L~ TUH Lift Friction Los System Hea TDH Ft Forcemain Length i Dia. +~ Dist. to Well > ~~ ~ ~ LD Z Cf111 ARC(7Rf~TIf1N CYSTFM ELEVATION DATA County. St. CI"OIX Sanitary Permit No: 506170 0 State Plan ID No: Parcel Tax No: ' 006-1019-70-000 Section/Town/Range/Map No: 09.31.16.124 STATION BS HI FS ELEV. Benchmark 7 a i ~7 ~ o ~ Alt ~~ ~b~- lw.S I~ • Z Bldg. Sewer ~ S ~ 9 ~ ~ SUHt Inlet I z ~ S 9y' S SUHt Outlet ~ Dt Inlet ~ ~ Dt Bottom ~b.7 7 ~ ~ , S Header/Man. Dist. Pipe Bot. system ~~e, Icy, s Final Grade St Cover 3. Z ~03.~- {,. ~ i~o ~ ~•6,~-ors +!' `.~. ~`} ~c3. D BED/TRENCH Width / Length ~ f Tre ches No PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ ~ 5 ~ ~____ - SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: CHAMBER OR INFORMATION Type Of System: 7 ~ / ~ ~+ ~ ~~ ~ ~ UNIT Model Number: `` f11STRIR11TIt7N SYSTEM Header/Manifold l / // / Distribution x Hole Size ~/ x Hole Spacing' `J it to Air Intake ~ ~ Di ' ` ~/ Pipe(s) J T ~, ,t~" acin S h Di L 3 ~~ ~. -+~ ...~.. C~ a_ _ Length g a p engt . C/lll ('_(1\/FR ., o.,.~~...., e.a.e.,,~ n.,n. ~.. MrvinA Or Ct_r;rarie Systems Only U/ it. _ Depth Over -^~ Bed/Trench Center ' . ! Depth Over Bed/Trench Edge xx Depth of Topsoil ~( xx Seeded/Sodd~'ed // 1,r-v No xx Mulched es No s ' es s 7 S~ J COMMENTS: (include code discrepencies, persons present, etc.) Inspection #1: ~ / 1 I / UZ ~ Inspection #2: / / Location: 2271 220th Street Deer Park WI 54007 (SW 1/4 NW 1/4 9 T31N R16W) 40 acres Lot P~ o ~..r ~~ Parcel No: 09.31.16.124 1.) Alt BM Description = ~ ~ 2.) Bldg sewer length = / Q'g ~~ ~-q.... o.~'E"' - amount of cover = + ~~+ ~`~o.~- ~oJS~. ~~ ~ ,~,~ `,p~,b O ~ __ -, ---- Plan revision Required? Yes y5ij No ~ G~ ~ .L b~ ~ ~~ 'r ~ ~~~ Use other side for additional information. J ~ ~_-~____L-_~_~ Date Insepctor's ignature Cert. No. SBD-6710 (R.3/97) Comrrleree.vvi,goV Safety and Buildings Division County 201 W. Washington Ave., Box 7162 .r p L~- /~^ ~ ~ (~ Madison, WI 537 62 Sanitary Petmit tunber (to be filled in by CoJ Depa7rtVtneyrtt of Comore[ roe ~J O ~ b Sanitary Permit Application to Tra/nysa~cCt~ion Number submission of this form [o the appropriate Bove Wis Code 21(2) Adm In accordance with s Comm 83 l J 1 , , . . . . . unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project ddress(ifdifferentthantnailingaddress) submitted to the Department of Commerce. Personal information you provide may be used for secondary u oses in accordance with the Privac Law, s. 15.04 1 (m), Stats. ~~ ~ ~ / ~ ~,~/f r 1. A lication Infor tion -Please Print All Informati ` ''VV YY J Properly Owner's Name VG.th~Q- Parcel # Property Owner's Mailing ddress ~ Property Location ~ ~ Z~ ) f ~7 Z e ~ City, State ' ~~ ( ~ ° Zip Code P e y., !~/ Y Section (circle o ) , ~~ / ~~ ~ ~ . r T (check all that apply) e of Bnildin T Il Lot # 111 g p . 6 k or 2 Family Dwellin - Number of Bedrooms ~ _ Gd K _ ~-°'~-' ~_ Subdivision~ne tl~ 110 ,Q,j uZ ~ ~ ~ )" jy ~1q,: ~ LQ_ Block # ^ Public/Cammercial -Describe Use ~, ~+-~- ^ Ciry of ^ State Owned -Describe Use / CSM Number ^ Village of X c> 7 ~~~' Town of Ill. T ype pf Permit: (Check only one box on line A. Complete line B if applicable) A' ew System ^ Replacement System ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System (explain) B. ^ permit Renewal ^ Permit Revision ^ Change of Plumber ^ Permit Transfer to New List Previotu Permit Number and Date Issued ~ Before Expiration Owner lV. T e of POVVTS S stem/Com onent/Device: Check all that a l D ~ ^ Non-Pressurized In-Ground ^ Pressurized In-Ground ^ At-Grade ^ Mound ? 24 in. ofsuitable so il <~ 24 ia_ o~~i~ble~I ~ ~~~' ~ ^ HoldingTank ^ Other Dispersal Component (explain) ^ Pretreatmen t Device (explain) •.1 V. Dis ersalli'reatment Area Information: De ~ n Flory (gpd) _ Design ~~il~piicatio ate(gpdsfJ Dispersal Area Requir ~ ~ ~fl Dispersal Area Proposed m E~ation Syste l D Vl. Tank Info apacity in Total # o Manufactwer Gallons Gallons Units a ?? ~ [? ~ u h •° New Tanks Exist Taaks Q ce' / o'" i ~ ° 3 °al ~ / - . Septic or H4tding Tank x Dosing Chamber ' ~-~ VII. Responsibility Statetnent- I, t ndersigned, assume responsi f installation ofthe POWTS shown on the attached plans. Plumber's ame (Print) ~ Plumber's Sigttature MP/MPRS Number 2Z6p~ Business Phone Number 7 - ~-~~/ ~ .~. ~,T o Plumber's Address (Street,/CitGy, S1tate~Zi~ode) ~ /~ ~ ~C VIII. otrttt /De artment Use Onl pproved ^ 'sapprove Permit Fee Date I sued Issuin ent Signatwe G~0 oa s~.~ 0 7 ^ ne ven Reason for ial IX. Condi;ti'~~7~I~~~easons for Disapproval ~\ .~i5 ~ ~ ~~~,. 5ec.ov.,~1 ~ne~SE,. o ~ YD ~~'~~ 1. Septic tank, effluent filter and J s'}, ~bi K Cam dispersal cetl must all be services ,/ maintained ~~" °)^° ~~ I' ~ ~' . as per management plan provided by pluml>tr. ~~.~~ ~~~ ~ -? ~ ~ t f 2. Ap setback fequiremente must t;te maintained At[ach to complete plans for the system and submit [o the County only on paper not less tnan a to x t t mcnes m sao SBD-6398 (R. 01/07) Valid thtu 01/09 m PLOT PLAN PROJECT Dwavne Doe ADDRESS 2253 220th St. Deer Park Wi 54007 SW '1/4 NW 1/4S 9 /T 31 N/R 16 W TOWN Cylon COUNTY ST.CROIX SYSTEM ELEVATION 104.0' 1.5' sand lift BEDROOM 3 CONVENTIONAL AT-GRADE CONVENTIONAL LIFT HOLDING TANK MOUND XXX SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 630 HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 456 # of chambers none BENCHMARK Y.R.P. Top of 1/2" pipe ASSUME ELEVATION 100' Filter BEST GF10-8 ^ BOREHOLE O WELL *H.R.P. Same as Benchmark _~ 220th St. 180' Grading is to be done to divert run-off away from 103' 8'4 system ~r•~ 100' 8- 10% Area 15' below system is to remain undisturbed 600' 1320' Property Line Well is to meet all setbacks found in Comm. 83 100' Building ~ B -1 Sewer Pro 3 Bedroom I House B - 2 '----' I ~ Huffcutt Combo Tank 102. S' Tank is to be properly bedded B.M. * and provided with lockdown covers with approved warning AIt.B.M. labels SEE CORRESPONDENCE Scale = 1 /4" = 10' 37 Acre Parcel Y~ PLOT PLAN PROJECT Dwavne Doe ADDRESS 2253 220th St. Deer Park Wi 54007 SW '1/4 NW i/4S 9 /T 31 N/R 16 W TOWN Cylon COUNTY ST.CROIX SYSTEM ELEVATION 104.0' 1.5' sand lift BEDROOM 3 CONVENTIONAL AT-GRADE CONVENTIONAL LIFT HOLDING TANK MOUND XXX SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 630 HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 456 # of chambers none BENCHMARK V.R.P. Top of 1 /2" pipe '_ ASSUME ELEVATION 100' Filter BEST GF10-8 ^ BOREHOLE O WELL *H.R.P. Same as Benchmark _ 220th St. 600' 1320' Property Line 18 0' Well is to meet all setbacks found in Comm. Grading is to be done to g 3 100' Building divert run-off away from 103' B - 4 system ~ B _ 1 Sewer ~ Pro 3 Bedroom House 100' B- 10% Area 15' below system is to remain undisturbed B-2 ~' I I Huffcutt Combo Tank 102.5' Tank is to be properly bedded B.M. * and provided with lockdown covers with approved warning AIt.B~ labels SEE CORRESPONDENCE Scale = 1 /4" = 10' 37 Acre Parce! ~• commerce.wi.gov ~ ^ ~sconsin Department of Commerce Safety and Buildings 4003 N KINNEY COULEE RD LA CROSSE WI 54601-1831 TDD #: (608) 264-8777 www. commerce.wi. gov/sb/ www.wisconsin.gov Jim Doyle, Governor Mary P. Burke, Secretary Apri130, 2007 CUST ID No. 226900 SHAUN R BIRD BIRD PLUMBING INC 1008 192 ND AVE NEW RICHMOND WI ATTN.' POWTS Inspector ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD 54017 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 04/30/2009 SITE: Dwayne Doe 220 Street Town of Cylon St Croix County SW1/4, NW1/4, S9, T31N, R16W Identification Numbers - Transaction ID No. 1392113 Site ID No. 724727 Please refer to both identification numbers, above, in all corres ondence with. the a enc . FOR: Description: Mound /Three Bedroom /Sloping Site Object Type: POWTS Component Manual Regulated Object ID No.: 1128567 Maintenance required; 450 GPD Flow rate; 19 in Soil minimum depth to limiting factor from original grade; System: Mound Component Manual -Version 2.0, SBD-10691-P (N.O1/O1), Pressure Distribution Component Manual -Version 2.0, SBD-10706-P (N.O1/O1); Biofilter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or user Reminders • This system is to be constructed and located in accordance with the enclosed approved plans and with the component manuals listed above. • The bench mark as located is in an area that will be disturbed during the construction of the component. A new bench mark is needed that is located outside of the disturbance area and still accessible for the construction of the system • The minimum distal pressure at the end of the distribution lateral is to meet three feet. This amount of pressure L+o~~j will supply a discharge of 0.72 gallons per minute through the 3/16 inch orifice. ~~~ • Per manual cited above limited activities are allowed in the area 15 feet down slo a of the com onent area. ~pARSM~ p p DE Soil compaction, excavation,. vehicular traffic and other'similar activities that impact the treatment and N OF dispersal are prohibited, SEE COR • .The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption area. chs. NR 811 & 812c SHAUN R BIRD Page 2 4/30/2007 • A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and, 145.19, Wis. Stats. • Inspection of the POWTS installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec.145.20(2)(d), Wis. Stat • Comm 83 22~) A copy of the approved plans specifications and this letter shall be on-site during construction and oQen to inspection by authorized representatives of the Department which may include local inspectors. Owner Responsibilities: • Comm 83.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Gomm 83.54(1). • ~ Comm 83.52(2) A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. • Comm 83.55 The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. Asper state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility fox designing a safe building, structure, or component. Inquiries concerning this correspondence maybe made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, ~~~~ Charles L Bratz POWTS Reviewer II ,Integrated Services (608)789-7893 , 7:45 am - 4:30 pm Monday -Friday charles.bratz@wisconsin.gov Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 WiSMART code: 7633 cc: Leroy G Jansky, POWTS Wastewater Specialist, (715) 726-2544 ,Friday, 7:00 A.M. To 3:30 P.M. RECEIVED Cover Page Shaun Bird Bird Plumbing Inc. 1008 192nd Ave New Richmond Wi 54017 715-246-4516 APR 2 4 2007 SAFETY ~ BUILDINGS 3, Date: 4/ 20/07 Owner:Dwayne Doe Location:SW1/4 NW1/4 S9 T31 N,R16 W XXX 220th St. Cylon System type: Mound System Manuals Used: Mound Component Manual Version 2.0 (01/31) Pressure Distribution Manual Version 2.0 (01 /31) Page# 1. Cover Page 2. Mound Plot Plan 3. Mound Cross Section 4. Pipe Cross Section/Pipe Layout 5. Pump Chamber Cross Section 6. Pump Curve 7-8. Maintance and Co igency plan 9-11. Soil test I Shaun Bird , , ,/'~ Signature r License nu r 226900 ~ion~rlly ~~~~ 'T OF CONfiYI Ff EY ~zESPONDENC . ~,... ~~ Dale i ~ ~ 1~01t-Wa'S7~21 ~~3:t~ F8}3Z~C 4n Obsezvatioa pipe. Perforated ~ ~~estribut'sa~e Pips Beiaw Filter Fabric r ' i- ~S'1!E C-33 ~g~d~ j K ~ .. '~ . /~ 7. Sjape ~ ,f~fawecf . $etf ~t f~ 2 %Z FocCt t~afr~ i?rain Rac3~ ! Frame ~u~R Lctpss d". Grass Seciian Ot A trso~rsd~•S stsm tis~ ~,., .~~ ~~- A $td Far T#~e Absar~jtian Arc,Q &.'~ i • A Ft. ~'~'._ ~ Q ,.~ s ~k ~~ u~s J .. ~- - ! . • 3 QbServd! ian Pipe-~ __._ ~ ~ ~ __ _ ~• --- ----- 1 Fvrct Main _ rr '~ ~ _ E• O D;Sfri~i~Sia~4 fed t}f ~Z "2~z a Ff~ • [}rain ~?azX . -- ~'j.4 t3~istvQ#ion ~'fpt t€~Ca~=~, ~ermorten# Mork~r • ~S~'- ! ~ •~v~- tac.~ - P~ pe ar Rods { ,c~,~.- ~, /'~ j• Pfare Yit~r Qf«~-+to~nd ~3ting ~ Bed ~faT T~~ Absorption Araa ~ . - FAGE,_. gF...__ Rs: ftssata~ ~s~~ Oei~ti C~ toce~ss Qs 8~~s~ EgosiFS $tMCea ICfT tReR.L stiaR '~ C.aieeeltC}'oon r ~~. p // ~~t;tu,,~ -'f "a ~1.¢.~ ~ `I 'i"~ rte/ ~r ~'~~L..~.~s ~ -~ ~'• ~ ~ ~'~.. • L~ s sit: ~ SEE CORRESPONDENCE ~~~ ~~~~er ~~~.~~~~ . ta~era3 -"` :., ~ inch{ss~ . €.icens~ N~e~-: n~ifold '~, Itt~tes k~ate: Farce I~$7R .' ~-- ~3EChE5 ._,_.,.. ~ of he~e5~~~#~ ~. S _ ~ ~ Ir~Yert ~e~r~tias~ Qf Later~ais,~f~~t~.. =:f. .~ 1. :~^.: r.~.n.'.."" 1 ~~s , -. ~, \, ~i ~P€.~~FFCRZ'~t~~5 S~~~~ ~ ~` ~ ~£~T p~P£ }2" 3+t~1~. ~B~~E ~F.~€3E ~ J~i~`~#3f+~ $E)X ~£3L~ t£it ~ C~ ~~~ ~g ~ ~~' ~~~~ y ~ ~~ ~ ~t ~t ~~~ ~ i ~ = , . IN1~ ~ ..: ~ s .. ... - GFsS- s ~iA~g gl~~ . SSA?-S _ T'~~I~: .. g _ ~ ~,1t3 Sff~t ~ . !! T i . ~s~ ~ ~ C ~. ApPR~ - ~ ~-o=r yam/ v~ - SP~I~'ICA'3'Y43d5 ~.:. i ~~ ~~f'AC'3~3R~ = ~,E st £s 3:E3 i'iE ~ ~ ~~~ G----r""- f A-TE.- ~Ri,. '~Ej ~ SAL- Tlt1i1G SIZES ~ ~~ ~~ ~~ ~H,. ~p~}~I'~~= '~.: " -t"'_' _ -~~ - ~r_~- iGa' ~ _ ..~ -I~ ~,1ET~-AC~~C£R s i~ - - - 15.23 'F~ P~K? ~£L ~ ' ~ • . ~` ~l'3~`'~y-- ~ ~ ~ ~ i~TRZ ~iG AS Z ~ ~,~$ 3'1~= r7 as.I~F. g A.T+~.R ~~~J~~. FEE'S -<--_"' i~3't`I fit ~'g~ REQi32RED ~?'ISC~~ ~i3'~ ~ ai ~' .~~ i?IS'SR ~ ~ ~ .. $~,~E£i~ '~~P - FA~~ ' ~ ~ ~ FELT BE'R~'?~+~. DIYF'E~t~'~ gt3~i£ !""~~ ~l~S~' `I'f~K : ~..£?~ yob _ 1~£~f~ . ^{~S 7 77b `J.7't tStsL! ; aa~ty-a-vo e.;>cars,, . may.. ~J.. Sent By: ~ iiP t.aserlet 3'! t3t); ~ ~ ~_ '~ ...~~-`~ ~._~.~.~ 9EH SERIES SUMP/EFFLUENT PUMP ~+~ sasaa 88iiY+~B Sfl~SD tRr~ ' ,rs ~r~i 4N0 P iu ~5o 915 250 as s~ sta Sil ,sr+ ,aoa ~ sa ~ ~ ~ ,ss ss ~aoo ~ sa ss ~ 3z ~~s t3D 1030 T6 6d 55 n 3g X9.8 &5 ta10 JB fid ST+ 1S ~ ze aEr 2a zs ~ v 27 sx+ sst&tKa9a sn :115t:S9a 8.5t stt.6t:a5# 3.it xSS.5ix89e ~d! Ott ~~ Stp tarAMnou~Du~A~Mii-'Llek6i~ a S ~ ~-salro~o mAYacla~as7lrYantranwltldnSrD it;QV- tiYE 0 ~Y'WwK~i~E~s~8lltPelflip.GOtII RAoxc~rr ~i 18 •-•• voIuu_ ~.s ~ Poway Cc¢d ~ Ntechanica+l Shalt Sea( s g _ ... Fasteners ~ ShafE - -- 2~ -- B~~ ----- Goatee! case Tron ~.^1 . _.._. _.. .. Nitrite with carbon astd _ . oera5aic facrs Sria~3ess Sues' . ... _ . S~€nlesx Suet Upper Sleeve and Lawn Matt $eari~sgs ~e G~i~ant P~m~ Cv. pn ~.,~ ,~ • c>f~ r.~ o~c r~t~r p0,~,~f6S.947.251! ~Fszf66.2~6 F.ar~ ~ Fam 99s?.3S-t27A33 FIQY- t.AL{.ON$h1INti'fE ~ur~ ~vns~a~c~ ct~vt_ 5isv smiZ ~ 1MFOR Owr~r Pett~~ ~be~of Bedt ~~~;~~ Un~is ~~~ ~ Reffi ~~ ~yg~,,,~tt SPi~t Segtfa Tarsfc CsP' ~~ Q NA • Tart~C ~+~~~~ fl idtA ~~ f~ Mangy ~,~.5-1 Q IVA ~tiuertt ~ff~~ ~/G~ ~? ' Q NA ~ ~ . Pump-'fad Capa~Y ~ c~ fl NA ~t+FA pomp TBr~tc ursr ~ ~..~`Z7 afld .Pumpi~ ~•`- G G~ ~ ~~ -- ri aY • PuE~'~P ~ £7 ~fA Mot>ttstY 8ve-~9e ~~ Utsit t3 PeBt Fes' Q $8t1dK~t8~ F~ Lj'1At8ffan_d n ~ S'f 5Q rTt It.. Msnufac~r' MoaltsiY asretage" DisQetssi Ce[i{s} Q ~3 in.~round (gravityy ~} S30 m$1L ~ m~ CI 14t-grade n 51Ci'` cfrs!'IQQiri II Dri e . • 4nd~ diameter X v~s~s ~' dOeassBc t~~ ws~swso~r ana a ~ Isere a . ,•~• il~IetsS Q'P~ Aar '"r~sL°'rst°r. ~F pU11V'TS C31tYt~tER'S NIA~+iUQ.L 8c ~iEt/~I'+~AC=~CATK~t~S x Serrice Evaltt ingpeQ coaditon of ffink(s3 Pump otrt contErrts of tarriQs) rnsped d colt(s) Ctesn ~stuertt stts•er ptlisrp, PAP ~~ b atarsrs Flush tat~ts and ~ At least once every Rt least onoe every At least ertce every At least once every At least ~~ every Q mks s) CI monttsss? II ~ t3 rnortths II ye~fsy O t~lA Q ~ fI 3+~{s) D I+IA ~gl~'@iANCE L7'iai~ ~,~ ~~ .~. made by an ir:di~vtduat ca;tr~ricr8 grss Qf the ~ or Tres Msste~ p~~ }Zey-trieted ~ r, POWf's s i1D idea'rd[Y °C Mast+s~ ~~~' must include a ~i inspection ui` the artd spa d>ee~ ~ ~ ~~ up S+ervidrfg Operamc T or~arks ~ ~su~ ~$ rrohrrne of o~rYlbined ~ ohe~c ~ etn~ levels t~r8w~. ld ~y She cfcspersa~ cae~{s~ shat[ tae ~ L's ~ ~ of t on ti~a cr d ~an~ bn ohecic ~' any ~,~ of efSuerrt arl Sae ~ of ttie ~oea1 sue' maiB~Y in the obssr+-aSori ~ $ ~dbon and nxt~~ me •immedrat~s or mare of the tantc ~~• ~ Sulfs~ ~Y s cup ~ sktdge a~ ~rn in arty ian[c eq When a aaaslt~d ~ ~ a Sep#age Servlctng C3}~erab~r alb d'T*Posed °~ In ~'~' ~' Mz c of ~ tank shah be rerr+~ . Admin~tire Code. - ~~ ~ ~ t13. ~ ~~ ~ ~ pr,~surizesi POWYS aamPar~ts P~~$ ~ ~~ Mfg ~~ of~'!2 mortltls or•i~ss sfiaii be #~~ ~ ~cx or ~~orislg at try within 10 ~ ~ camper of ~ . q serviQe repot stratibe ~ ~ the total regtlta~ry atrlhorify STARZ UP ailt0 OPERAT#i3N ~FE ~F ~ Fos new axe. ~e crse cif ~e F'vw~ Ss cti~c.tr~n?~r tank{s}~ fix tea; P ~°C t avatar damage tf~e dt ifs)- ~€ oocloest dremiC~ shat mair ~psde tine P a septage ser•,~fc'rng oper~ Prfoc m use. Qty 1'ta+re ~ ocrnt+er+~ of ti~.e tan3cf53 rprrtov~ by Satrtcs Frrgstaru:Y © months s) fMaxirssusn 3 prs.} A2 toast once every ~ ~ tank vo2usne When c~mt:trtad studge and stain e4u~ aye-~sird ~K3 C3 rs~onths s) (Msximrsra 3 yrs.) At least arm every . / .. ~ :. .% ~~ of . g art uP srsaTT not t~crwtsers'sost"c~r<dsfians are ftn~ers at the ints'lfrative sucEaoe_ w ~S Po+~°i~'~ ~p ~ t~y~ above nossnaS highsrraPer Levels. hrtttse:s l ~ tesmtted Sze tee „~ Abe dtsdmuged mo the ~ cett(s; in one Large dose. ~~ the ae~Ks3 and ~ itz ~ . ts~ ors~srfaoe merge tat t To avoid ~ ~ havt; tree cc~ txf the pcanp~4~k tsa~cfoviaQ by a € cam- ~ ' }~~~+ ~ps~'1t'1S Posher ~ the etiicrerst purrtg orl a P oc POiIVt~ -Sty gi ~~, ~ ~ tai cats 10 t1~tOFL titZt777Sf ieYe15 s~tttits the pnTrnp taniC. • ~? t~ dt11lA ~ Y L1ft~t ~ RRd d:,ss# ~. ~ th0~ dEiYe Ot~ p3t~C fljhP.~j flf i~3eiilit~ ~ orco~p~, ~ ate is is~et down slope c>i` any ntrxicad ~ at-grade sal absor~a~~t i~a. ~ _ . React ot =eitt+ninadcn of gte ~g !S ur:z S'~ snra~srabes steam mayrnij Frr~ #f;ie perfnm~3t>s~ acrd pmfong' ~ elf the PQWI~ ~#~Ys•~~ buti5; condoms; ~i~n svsr tiegt~ers; dl~peTs d~ tel: fioc:ti dia~3~{s+~P p~ ~"aber; fnu~ and vaege4ab~e p~ ~ ~ mat . ~ ~ g prsoduebss; l~ ' rsapkiris; tam s~ sxa~tss' bt~rte. waAr~rolul~a~' Yittsr'rs the Ps~'ltt+'t'S Ease andlar is pexntant~T>ry.raicen Qut of service rise fi~IIaESrfig steps shalt ljg fatten ~ ktsz~se !fiat the sys~ a a~.xaTe[yabactdorted isa txxnp~iarsce wins ch_ s:.orrsrrr 83..3, W~saocssin Atfcsttrsls"Tra53re Codt~ • Rt! ptptng to taisks acsd p€ts shelf ~be dsconrsected and ti'1e abandoned IPA ~ scated_ ';~?.~ cnnl.rts afaTi ranks ttnd p~ shall be rrsmov+xf and profler[y dzsp~sad of bye Sopsia~e9eY1~ Qptxat~ p+~ p~P~, aS tarsks and pits shaII be t:x~cavateQ ants rernosneQ flr ##seTr cx~viers r~aaso~ved~nd ifse ~ spans 4~'{edzs~[t soil; grave)t~rartoSietTnettso~rd rrsateriaL C4MT'ttlfC~E't1iCY PLAN tf fhe POItYTS taifs and tanrtot l"ie t+egairffi 1ht: icsfiawing :treasures have been,i or Ertust be taket:r >D ps'rasride a ~ cortspfrarst ttettt systant: C1 A she t~t'ar+eva teas been evaluated and may tee ui~ized ~ tTze fta~ran of a reptaoerrterst ~ absorpSon systssrr. She ce~r area sisouks tee protected fronts ffrrtsassoe acid tsocttpae~oct arsd shoatid ctot • be wed upon by roquir+ed setbacTcs irons eadsting aril pr'apostsd s~rc~sre, Tot Trees and weSs. Faiitme to probed fT>e taepla~rnent atEa[ ~ in rise need iar a never spit and s~~ewaluataroEt to esFablish a a:earuo r+epTacemecst area. ReptaoemQrst systems must osmpTy vsritir tine rotes irk eti~ed at that fare. D A sortable r~ep# eras "s not avas7abie' Qua io setback ar~Qlor snit ~rssi Barrfttg advances ~ PL3YYT$ a hofdfng tank treat' Tae frtstatied as a last resort to repiaoe tf>e faaeai PO'wTS_ e sTbe teas rust been eraTuabaQ ~ iderrtrfy a suitable r'ePiacerrseat ar~eaa Upon far~s}re of the PC3VYT5 a so$.arsd . . sTle e+raluabipts must be ~ si3 ioca~ a' ssiiable reglaoernertt asset.. Tf tso ~ arse is asra~aDfe a r fsoTd:rsg tank may be isss~ed as a fast r~ascsrr to regiace the fasTed P01NT~ •ii j~3/--~Cm_ d acrd at-grade s~ abs<uP~on systems ma3' be reoonstrucbeQ in pf8oe fnltosarusg rarnasrai c# the biansat at the utf'(!ts add s+utt~0e, Ft of sstch sysbesrss must taornply w~ the ttrtes ~ d€ecX St ~t tires i c<YI~gRisffAtp~ SEPTlC, f=iJTIdF AND EITHER TRPA'l<11dF~i7" TANKS fS+fAY C©NTA,ttY LEii-TAE ~a~SSE51~iVffltQR INSLiFFts~Tti' aXYGE1sE. DO tlTaT t3-tTER A SEPTiC,1?iftiiEP BR QTHER 1'f~E~,TMFNT TANK s'1NDT:R ~4f1tY CtfZCiJMSTAT1fGE5. DEATH 6SAY RESifY.T. ,RESCUE OF A PFRSCAi f=ROifd 'r'Hl~ ~RiO~t t3~ A TAI~tK iVf1s:,Y $E UfFFICtILT OR 1TidP.OSSiBL6 ADDF[tONAL CORMS j POYfti'SINSTALt.ER PD~Ift~'S ff~kFlst"~'Atlsff•R Name Q ~ ~' l Narni? ~` , f.,..,i i i~ Qtzone 7 J ,S"~-- -~~'~.'~ ~o ~ Pta~ne ~ ~ ' ,f-~ --. ~' _ ~r- SEPFAGE S11tCs t?P~iTOR LOCAL R1=Gt! Tsfame '`.'"` - ~~t3' Phone ~ ls' v2 ` h ', 7 ~ 7 b' _ Ptsons j etoa~t+.s:ar~ea ~x~ i~ at`tns tin tstes, Ifdargxrette and w~st~arl t:ountyZ.ws7ng nee rra~ ~ att7s. t`.aesun 33.22~(b3ftXfia{t3 ~ 83-5s(s?.1~ 8~ f31. W~sm2ctn A6rr goara,itec ~e pcrforrssaace atlt+e pOY~i 5. ITCTRY I~€1'~fiQRRY t '~C. C ! d Ss+si'bSot: spdsdes. This tsset~s iras~a Cade. ifaia of titlt: doersrsent ~ trot . ,('f~tW(IADi} Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of ' Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County ~ ~ Attach cemplete site plan on paper not less than 8 1/2 x 11 inches in s' ~lan must indude, but not limited to: vertical and horizontal reference point (BM), 'redion nd Parcel I.D. percent slope, scale or dimensions, north arrow, and loa3tion and istan rest road. Please pri Revi ed by Dat Personal information you provide may be u ed fors . es rivacy La 5.04 (1) 5 3 i) Property Owner Prope oa3tion ~' ~ qPR ~ 3 2007 Govt. Lot cJ 1/4/U!{~l/4 T N R E ( W Property Owner's Ma ing Address Lot # Block # Subd. Name or CSM# 223 o2a0~/~ ~ ST.CROIX000NTY _ ~ 7 ~s~~ City State Zip Cod ~7 /' ^ City Village own Nearest^Roa/dO f / a r-FC Lc~I 54~~~ / (~/s) D f//rOS/77 ,~/ ~~ ~/~G7 ..t'~. ew Construction Use• esidential /Number of bedroomc.~.~ Code derived design flow rate 1 J~ GPD ^Replacement ^ P'ub~lic~orcom~mer/aa/`/Desaibe: ________ __ ~ .__ ___ Parent material _.~ L'rtiCir~Ti.! <.S Flood Plain elevation if applicable ~~// /T J------ ft. General oorrxner>fs and recorrunendations: /_ h J~ ./ System Type y~d /.L ~ r s _.S~ ~G~t ~ ~~System Elevation /(J ~ v Boring # Boring ~ I pit Ground surface elev. ~ ~ it. Depth to limiting factor ~ ~ in. Soil lia3tion Rate Horizon Depth Dominant Cdor Redox Description Texture Structure Consistence Boundary Roots GP D/ff in. Munsell Qu. Sz. Cont. Cdor Gr. Sz. Sh. 'Eff#1 'Eff#2 ~ 7- l ~ ~ 6 ~ 3 -~- iC ~S~ ~ Gc~ it//~ .~ ~~ ~ 3 ~ ~ ~G ~ /` rr~ ~/r~ o~ yd , S' ~ ~ s r- ~-yy~~ hj n~r~' / . O - D ~~ # ~ Boring Z / ~,, pit Ground surface elev. ~ ~ ~ ft. Depth to limiting factor ~ ~ in. Soil ligtion Rate Horizon Depth Dominant Cdor Redox Description Texture Structure Consistence Boundary Roots GP D/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 D-/ ,- 3l-z --~ ~ fir- , ~ , o 2 p ~ r3 -- ~ ~i~ Effluent #1 =BOO > 30 < 220 mglL and TSS >30 < 150 mg/L 'Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Alame (Please print) Signatur CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 54017 ~~ 0 ~~ ~ 715-246-4516 Property Owner _ / Parcel ID # Page of ^ Boring ~'~ ~ Boring # Pit Ground surtace elev ft. Depth to limiting factor _~~ in. Soil lication Rate Horizon Depth Dominant Color Redox Desrxiption Texture Structure Consistence Boundary Roots GP DJff? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 - ~ z ~ 3I~. ~--~ S m C .~- ~ , 2 r2-z b I .b ~ 3 ~ s ~ 1M. -~ ~,J ~ ao-~ ,~ ~ c ~z s s~ ~ ~-- '~ ~ N~ ~, ~~ a ^ BOnng ~ ~J' Boring # Pit Ground surface elev, ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fP in. ll Munse Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'EtT#2 1 ,F~ V ~ z J r J~Z- -- ~ ~ ~ ~ ~L.i Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil icaflon Rate Horizon 'depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GP D/fl= in. Munsell Qu. Sz. Cont. Cdor Gr. Sz. Sh. 'Eff#1 'Eff#2 'Effluent #1 =GODS > 30 < 220 mglL and TSS >30 < 150 mglL 'Effluent #2 = BODS < 30 mg/L and TSS < 30 mgll. 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. 580.8330 (8.6/00) Property Owner _ n Boring # ^ Boring Parcel 10 # ~~~ ~ ~.. Page of ~n 1 l I I~PIt vrounu sunac:e r~ev~ - - n. uepui w urniuny ~auu~ ,~-~ ai. Soil ication 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 ) z ~ 3I ti -- ~ m C' ~- > Z )2~Zn I ,bi3 ~- s 1~ ~ L,J ~ p Boring ~r~3- ~ Boring # Pit Ground surface elev., ft. Depth to limiting factor in. Soil ication Rate Horizon Depth Dominant Color Rector Description Texture Structure Consistence Boundary Roots GP D/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `EN#2 ~~ # ~ Boring pit Ground surface elev. it. Depth to limiting factor in. Soil ication Rate Horizon 7epth Dominant Cdor Redox Description. Texture Stn7ch7re Consistence. Boundary Roots GP D/rP in. Munsell Qu. Sz. Cont. Color Gr. Sz Sh. `Etf#1 `EtT#2 • Effluent #1 =BODE > 30 < 220 mg/L and TSS >30 < 150 mglL `Effluent #2 = BODs < 30 mglL 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. 580.8170 (R-~00) - ~ ~ ' Soil Test Plot Plan Project Name Dwayne Doe Shau ird Address 2253 220th St. Deer Park Wi 54007 #226900 Lot ----- Subdivision -------- Date /10/07 S W 1/4 N W 1/4S 9 T 31 N/R16 W Township Cylon Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of 1 /2" pipe System Elevation 104.0' 1.5' sand *H R pSame as Benchmark Alternate Benchmark Top of ii2" pipe@ 98.5' 220th St. F~~' ,. il. 2573 P 198 STATE BAR OF WISCONSIN FORM 3 - 1998 QUIT CLAIM DEED i Document Number ', This Deed, made between Amanda B DQa._ Grantor. _. __ __ _. and Duane M Doe __ __ -_-- _ _ _ __, Grantee. Grantor quit claims to Grantee the following described real estate in St Cr'Z'Q1X County, Stale of Wisconsin: ~ 6 2 ~ 9 2 KATHLEEN H. MALSH REGISTER OF DEEDS ST. CROIX CO. , IiI RECEIVED FOR RECORD 05/ 17/:>_004 10 s 00AM OUIT CLAI?I DEED EXEMPT # 8 REC FEE: 11.00 TRANS FEE: COPY FEE: CC FEE: PAGES: 1 .~ .. _. .... : l..r;.--. Name and Return Address JASON W WHITLEY ~NOVITZKE GUST SEMPF & WHITLEY 1314 KELLER AVE N #399 AMERY WI 54001 c j _._ ,_~-_ 006-101=7~=~Q0 Parcel Identification Number (PIN) This ~ G homestead property. (is} ~typ~ I iThe Southwest Quarter of the Northwest Quarter (SW} NWT) of Section Nine (9)Ij, jTownship Thirty-one (31) North, of Range Sixteen (16) West. ~! '.RESERVE unto the grantor herein a life estate in the above described 'property for her own life. Together with all appurtenant rights, title and interests. Dated this 14th day of May 2 0 0 4 - (SEAL) ___SC/s_~a~ ~ (SEAL) Amanda S Doe (SEAL) AUTHENTICATION Sl t O ACKNOWLEDGMENT (SEAL) .- gna ure s _____ ___.__ _ ._ _ -- State of Wisconsin, Ss. authentfcated this day of TITLE: MEMBER STATE BAR OF WISCONSIN (If not. authorized by §706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Polk County. Personally came before me this -14th day of Mav ____, 2_QQ 4-, the above named Amanda ~ _poe ~__ -- -. ___ __- to me known to be the person t~d the foregoing instrument and acknowledg t~i .safti¢.• ~, p~ ,~ g Jason w whitie.~ #1027052 __ Sally M Pick E u~' 1' SEMPF & HITLEY Notary Public, State of lti Amery WI 54001 _ My commission tsc~ac (Signatures may be authenticated or acknowledged. Both are not _ eXplreS 11- necessary.) _. __ _ __ _ `Names or persons signing in any capadty must be typed or panted txlow their signature. STATE BAR OF W[SGONSIN QUIT CLAIM DEED FORM No. 3 - 1998 Y ~-_- :`: L'9 L~~ T_ ,. - $tate.~ ~ ration date: ti _ ~ ,~i W,SCO,ISIn Legal frank Co.. Inc. Milwaukee. Wis. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT` AND OWNERSHIP CERTIFICATION FORM OwnerBuyez Mailing Address c~ D.-~~ Ube property Addres~ °~' ~ ~ ~ ~ ~ ~ `~ ~ - Pl & Zonmg Department for new construetton.) City/State (Venficahon required from amm~g Parcel Identification Ntunnber ~~~ ~ r LEGAL DESCRIPTION Q pro Location S~ 1/a ~~~ r/a ,Sec. / , T ~N R~W, Town of Pent L ,c.~ ~ ,Lot # Subdivision '"' ,Volume ~ ,Page #-' Ceriafiied Survey Map # 2 Volume ~ ~ ~ J Page warranty Deed # _ ~~ Spec house yes o Lot lines identifiable ~ no SYSTEM 1VIA.INTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to beadle wastes.Wha~u ut into maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumpe : Y P the system can affect the function of the septic tank as a treatment stage in the waste disposal sys~~wn~ maintenance responsibilities are specified in §Comm. 83.52(1) and in Cha ter 1_ - St. Croix County Sanitary The property owner agrees to submit to St. Croix County Planning & Zoning Department a certificati ln~ rm> ssgned by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that ( ) 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 Degarrmear of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix Gounty 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. Uwe am/are the owner(s) of the described above, by virtue of a warranty deed recorded in Register of Deeds Office. 1 SIGNATURE OF APPLICANT(S) ~~~/~ DATE *** Any information that is misrepresented may result in the sanitary permit being revoked by the Planning 8t Zoning Department.*** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05 Centu ies . rY 60'-0" ~ -- _.:__ ':._.. 101' x12'-0~' 21 3"x11'-8" BEDS 13'- x11'-6" GREAT ~ ROOM 16'-9"x13'-3" BED #2 13'-3"x12'-0" MASTER BEDROOM 18'=0"x12'•0" ~. -I ' - v =w = o 11..If OPTIONAL II IIOOY~ II GAR~~GE 20'-4"x20'-0" ~i ~-4~~ ti~ See Your Local Amwood Builder TODAYI P.O. Box 311 m ~ ~ ®Janesville,lM 53547-0311 "Your Best Inti~sh++~nf" (608) 756-2989 Total Square Feet 1,564 Sq. Ft. Ranch C-'1248 AERIAL OVERLAY MAP THE SW 1/4 OF THE NW 1/4 OF SECTION 9, T31 N, R16W, TOWN OF ST. CYLON, ST. CROIX COUNTY, WISCONSIN. N SCALE IN FEET 1" = 200' 200 0 200 PREPARED FOR: SURVEYOR: x DUANE DOE TY R. DODGE 2253 220TH STREET S & N LAND SURVEYING, INC. DEER PARK, WI 54016 2920 ENLOE STREET SUITE 101 HUDSON, WI 54016