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HomeMy WebLinkAbout006-1088-50-000,~/isconsin DE~artment of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT (ATTACH TO PERMIT) GENERAL INFORMATION Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. ermit Holder's Name: City Village X Township 3ird, Shaun C Ion, Town of ST BM Elev: Insp. BM Elev: ~ 8M Description: f1D o a~- , ~~. •wAly IAIenollenTlnA1 GI G\/ATICIN fIATA TYPE MANUFACTURER ~ ~5~ J CAPACITY Septic J tJ ~ Z ~- ~~~ Dosing pp ~' ~b~dJ~~n law Aeration Holding TANK SET6ACK INFORMATION TANK TO •• 11 P/L,, `` N a fl-~. ~W1ELL -pae. BLDG. Vent to Air Intake ROAD Septic ~ ~ 3~p / ~5 ~ aw.. ~ O Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist, to well Cnll ARC~IRPTIl1N CVCTFM County: St. Croix Sanitary Permit No: 499115 0 State Plan ID No: Parcel Tax No: 006-1088-50-000 Section/Town/Range/Map No: 33.31.16.586 STATION BS HI FS ELF\/ Benchrr~iark Alt. BM Bldg. Sewer s ~ -1 g~ St/Ht Inlet ~ ' t 96 ~ ca SUHt Outlet Dt Inlet Dt Bottom I Header/Man. Dist. Pipe Bot. System Final Grade St Cover Z , ~ /~Z. Co ~~ BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P G WELL LAKE/STREAM LEACHING CHAMBER O M ufa urer INFORMATION t Of S T T em: ys ype UNI Model Number: r11CTCIQ11TInA1 CVCTCM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Dia S SOIL COV R Pressure Sys s Only xx Moun r At-Grade ste Only `f Depth Over D of xx Seeded/Sodded xx Mulched Bedlrrench Center Bed/Trench Edges Topsoil ~ Yes I ~ No '; Yes i I, No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 1814 County Road O Unknown (SE 1/4 SW 1/4 33 T31N R16W) NA Lot 5 Parcel No: 33.31.16.586 1.) Alt BM Description = ~-~`'~'"~'~ ~ Lo~,~ ~~' 2.) Bldg sewer length = f Z ~ - amount of cover = ] ~~ O _I I i Plan revision Required? ;Yes ~No g Z4 ~ ~ ~3 ~~ s Use other side for additional information. i __ __ Date Cert. No. SBD-6710 (R.3/97) Safety and Buildings Division 201 W. Washington Ave., P.O. Box 7162 County ~~ ~ (° ~ 1 1, Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) ,5~~~~,~ (608) 266-3151 ,C~19 9~~ S Department of Commerce umber lan Stat Sanitary Permit Application onal information you provide d d C i ~ e -~ ~ o e, pers m. s. A In accord with Comm 83.21, W may be used for secondary purposes Privacy Law, s15.04(I)(m) dress (if different than mailin Ad Project dress) ~ 4 / ~ JL U formation -Please Print All Inform n I ti li A / 0 ~~ on n ca I. pp Property Owner's Name ~ ^ ~ r 1 O ZQ 06 N U Pazcel # Lot # Bl?ock # ~ ~ ~J Ot~ Property Owner's Mailing Ad ress n gT. CROIX COU ' J ] Property Locat~ion~ ~ ~ 4vt.(J C , `'`~ '/4, Section /i ~/, City, State t ~ Zip Code hon ~ ~` ~ ~ Q rcle e) ~~ O T~N' R~o~ ~ II. ype of Building (check all that apply) 2 pd S/ M~ ~ ~ ~ Subdivision Name M Number 3 fjZ1 ' Family Dwelling -Number of Bedrooms V v,, ~/ // / ^ Public/Commercial -Describe Use ^Village own ip of ^City \ / ^ State Owned -Describe Use _ / III. Type of Permit: (Check o ly one box on line A. Complete line B if applicable) d0 ~ p$~ -yD-GYA ~" - O - ~'' ^ New System Replacement System ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System List Previous Permit Number and Date Issued B. ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New Before Expiration - Plumber Owner IV. T e of POWTS S stem: Check all that a 1 ^ ^ Non-Pressurized In-Ground ^ Mound > 24 in. of uitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter Constructed Wetland ^ Pressurized In-Ground/~alding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) V. Dis ersal/TreatmentRrea Information: Dis ersal Area Pro osed s System Elevation Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area R wired (sf) P P ( ~ ~ ~~ ~ VI. Tan I>~ Capacity in Total Number Manufacturer Prefab Site Steel Fiber P1aSUC Concrete Constructed Glass Gallons Gallons of Units New Existing Tanks Tanks Septic or Holding Tank Aerobic Treatment Unit Dosing Chamber VII. Responsibility State - T, the undersig ssume responsibility for installation of the POWTS shown on the attached plans. Plum 's Name Print Plumber' ~ afore MP/MPRS Nu ber Business Phone Nu b r Plumber's Address ( trees, City, State, Zip `-~ ' ~/ /~~/ '~ 7 C,/ 1~~ c~ VI Couu /De artment Use Onl Sanitary Permit Fee (includes Groundwater Date Issue Issuing nt Signatu Approved ^ rsapprove Surcharge Fee) / ZG, ob to 'Li- ^ Given Reason or Denial 7 IX. Conditions of ApprovaUReasons for Disapproval SYSTEM AUVNEt~: 1. Septic tank, effluent finer and dispersal cell must all ~~oes ~ rnai as per management plan provided by plumber. 2. AN setback roquinements moat be ~akled ~ psr appflccabble Cod! / ord. complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in siu SBD-6398 (R. 01/03) PLOT PLAN PROJECT Shaun Bird ADDRESS 1008 192nd Av New Richmond Wi 54017 SE I /4 SW Il4S 33 /T 31 N/R 1 6 W TOWN C to COUNTY ST. CROIX SYSTEM ELEVATION none ^ ~ /~ ~~ 3' ~ ~ BEDROOM 3 CONVENTIQNAL AT•GIxADE CONVEN OVAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE LIFT TAVK SIZE DOSE TANK SIZE HOLDING TANK SIZE 3000 gallon LOAD RATE na ABSORPTION AREA na # of chambers none BENCHMARK V.R.P. NE Survey Iron C~ L,of Corner ASSUME ELEVATION I00' Filter Zabel A-100 ^ BOREHOLE ~ WELL *H.R.P, iVE corner of property _ >k B.IVI. cty Rd 0 Huffcutt Holding Tank n D ve a Property Line Pro 3 Bedroom House Driveway is to act as a service road Sale = 1 /4" = 10' Tank is to be properly bedded and provided with lockdown cover with approved warning lobe! Y Drainfield ~ Alley Property Line ~- Prior testing did not indicate the need for anchoring the ~'~ Prior testing indicates that this site has been fi(Ied tank and is no longer suitable for any other system other than a holding tank. The old system has been pumped and buried. The system served the hardware store and is no longer usable. Lots 4 &5 have been surveyed and the (ine between these lots has been disolved as per county code. ~'d d80~90 QO 9Z ~c0 commerce.wi.gov iscansin Department of Commerce August 07, 2006 CUST ID No. 226900 A77N.• POWTS Inspector Safety and Buildings 4003 N KlNNEY COULEE RD LA CROSSE WI 54601-1831 TDD #: (608) 264-8777 www. commerce.wi. g ov/sb/ www.wisconsin.gov Jim Doyle, Governor Mary P. Burke, Secretary SHAUN R BIRD ZONING OFFICE BIRD PLUMBING INC ST CROIX COUNTY SPIA 1008 192 ND AVE 1101 CARMICHAEL RD NEW RICHMOND WI 54017 HUDSON WI 54016 CONDITIONAL APPROVAL - PLAN APPROVAL EXPIRES: 08/07/2008 Identification Numbers.- Transaction ID No. 1307785 SITE: Site ID No. 716411 Shaun Bird Please refer to both identification numbers, County Road O above, in all comes ondence with the a ene .' Town of Cylon, St Croix County SE1/4, SW1/4, S33, T31N, R16W Lot: 4-5, Block: 3 FOR: Description: Three Bedroom Holding Tank System Object Type: POWTS Component Manual Regulated Object ID No.: 1090112 Maintenance required; Replacement system; 300 GPD Flow rate; ' System: Holding Tank Component Manual, SBD-10571-P (8.6/99) 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 use: Reminders • This system is to be constructed and located in accordance with the enclosed approved plans and with the "Holding Tank Component Manual for Private Onsite Wastewater Systems" SBD-10571-P (R.6/99). • A notarized Holding Tank Agreement between the local governmental unit/Municipality and the property owner is required prior to the issuance of a sanitary permit: A Holding Tank. Servicing Contract may also be required if no other service provider for the holding tank has been identified. Condi~ • A service drive or. road is to be provided to the service access opening or pump out port. The minimum ~~~~ measured distance required is 25 feet. The well must be a minimum of 25 feet from an POWTS tank. chs. NR 811 &'812c D RTMEN7 y ON 0 C ~_ • A Sanitary Permit must be obtained from the county where this project is located in accordance with the SEE CORRE 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 SHAiJN R BIRD Page 2 8!7!2006 • Comm 83 22(71 A copy of the approved plans specifications and this letter shall be on-site during construction and open to inspection bYauthorized representatives of the Department which may include local injectors. 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. Comm 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. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for 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 charlie.bratz@wisconsin.gov Fee Required $ 60.00 Fee Received $ 60.00 Balance Due $ 0.00 WSMART;code: 7633 cc: Leroy G Jansky, Wastewater Specialist, (715) 726-2544 .* .ti Cover Page Shaun Bird Bird Plumbing Inc. 1008 192nd Ave New Richmond Wi 54017 715-246-4516 Date: 7/25/06 Owner: Shaun Bird Location: SE1/4 SW1/4 S33 T31 N,R16W Lots 4&5 Cty Rd O Cylon System type: Holding Tank Manuals Used: Holding Tank Component Manual Page# 1. Cover Page 2. Holding Tank Plot Plan 3. Holding Tank Cross Section 4. Maintan Signature License n~ ~~C~/~' s `'~~ ~ 9F~ ~~~~~ ~. . '~~~~r~llyn ~: D OF COMMERCE cY ~ INGS SPONDENC .. ~ti BOLDING TANK CROSS-SECTIQN ~~ Approved Weather Proaf . -~1ent Cape Jurtti on Box ; 4" C.I.--~. - Approved Locking Manhole Cover With Warning Label Attached Vent Pipe 1 Minimum 12" ~ w.`.L Final Grade - ~ ~ 4" Minimum -~ t. -- fApproved Joint ~_-__ 18" Minimum Water Tight-°` - - Seal ~ - ~ Nigh `r~a;~' ., ,~ ~ AT a rm S~~ii ~~ ~r ' ~- ,1 SPECIFICATIONS - ~ ----~ TANK New Exis in Approved Join Manu acturer: w/ C.I. Pipe -Blind~C.I. Tank Size. Ga lons Extending 3" Plug ~r Onto Solid So ALARM Manufacturer: (1~C~ry- S'~~~e~, s7 .~ Model N~;~~+uer: lJ ~..~ ' . twitch Type ~~ rn e ~-~ Nt1MBER OF BEDROOi`1S: ~ GALLONS PER DAY :~~ ~ ~ 3" of 8eddi ng finder Tank Owner's Name • ~ ~~.//~ Legal Discr~ption: e S- f/ S >--3~1t/n/~c.,,,,,~ Townshiplhlunicipality: ~, ~,,,.,/ County :_ 5~~,-7~-~. PLUMBER/DESIGNER Signature: License Number Date: ,- HOLUt.~.a-WANK MANAGEMENT Pi_ANi This Private Onsite Wastewater Treatment System (PQWTS} has been designed, and. is to be installed and maintained according to Comm 83, Wis. Admin. Code, the Holding Tank Component 1Nanual(SBD-10511-P 6/11/1995}, and the s~, ~~ ~ County Sanitary Ordinance. - 1. This POWTS is designed to accommodate an estimated domestic wastewater flow of ~ gpd. 2. The owner of this POWTS is responsible for system operation and main#enance, including all provisions in the attached Holding Tank Servicing Convact and Maintenance Agreements. 3. Each time the wastewater in the second tank reaches a level of 12° below the inlet invert (at which Time the alarm wi(I activate}, the pumper listed in the current Servicing Contract must be caned to empty the tank's contents and dispose of them in accordance with NR 113, Wis. Adm. Code. 4. At each service event, the service provider should visually inspect the condition of the tank, risers•~aad manhole cover(s) and verify tha# the alarm system #unctions and manhole Locking devices are present.. Discrepancies are reported th the ownner in a timely manner for corrective action. Ali corrective actions shall comply with the county sanitary ordinance and Comm 83 and 84 Wis. Adm. Code. 5. Ait service events or inspections of #his POWTS shall be reported to the county within 10 business days. 6. The owner may not remove any of the wastes from the holding tank(s), or cause such wastes to be removed by any person not authorized to do so under Ch_ 281, Wis. Statutes. The discharge of wastes #rom this holdng tank to the grourxf surface, including intentional discharges and discharges caused oy neglect, constitutes a #aiting POWTS and may result in issuance of correction orders or a citation by the county or state. 7. No one should enter a hold"~ng tank for anv. reason without being in full compliance with OSHA standards for entering a confined space. 'ifiiYatrnosphgfQ within these ~~ may contain lethal gases, and rescue of a person from the in#erior of the tank may be difficult or impossible. - acode compliant-replacement holding tank may S. In the event that this POWTS fails and cannot be repaired, be installed in the same lora#ion (a new sanitary permit is required for such a replacement). Connection to municipal.services would also be considered at this time if they are deemed available to the property. 9. it this POWTS is replaced, or its use discontinued, components no longer in use it shall be abandoned in accordance with Comm 83.33 Wis. Adm. Code. ` 10. 1# there is a problem wish, or question about this installation, th following persons should be contacted: 5~~,,~~~ Phone: ~i~s--a 6 -zl~°l a Installer......_ .................... Phane:'~,r-_ o?c b. Service Provider.---.......,; .._ 7r't~;~+•- /~' cry Phone:7t .~- ~ ~~-• `t~6a't~ c. County Zoning or Health Dep#.~~~. C r ca i x ~:- `""'"`'7 11. Project: Transaction: Wumber: ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM c OwnerBuyer ~ l Mailin Address g ~~ g Property Address % `~`'"-` - (Verification required from P 'ng & Zoning Department for ~ nstru ti~ -',~' l ,O ~ L/_ -l City/State Parcel Identification Number 1'QC/ ./~~~' S vt~ LEGAL DESCRIPTION '"~-~ ` Location r/a , ~~/a ,Sec. ~/ J T ~/ N R~, Town of Property ,Lot #~~'~ Subdivision U~ ~'~~~~ a o (/ ,~ Certified Survey Map # ,Volume '' ,Page # Warranty Deed # ~ ~ ~ ~ ~ ~ ,Volume ~ ~! Page # Spec house ~+ no Lot lines identifiable es no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, i£ needed, by a licensed pumper: What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 ~ays ~ the three year expiration date- Uwe certify. that property described abovy on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the ~rranty deed recorded in Register of Deeds Office. OF APPLICANT(S) ~a,~~ DATE *~* Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.*** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (ItEV. 08/OS) U 2752P 070 State Bar of Wisconsin Form 2-2003 WARRANTY DEED Document Number Il Document Name THIS DEED, made between Martp A. Wallin ("Grantor," whether one or more), and Shaun R. Bird ("Grantee," whether one or more). Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property") (if more space is needed, please attach addendum): Lots 4, 5, 6 and 9, Block 3, Original Plat of the Village of Cylon. St. Croix County, Wisconsin. ~8~~~~ KATHLEEN H. WALSH REGISTER OF DEEDS ST. C.RDIX CO.. WI RECEIVED FOR RECORD 02/18/2005 08:00Ai1 WARRANTY DEED :~S~iRT # REC FEE: 11.00 TRANS FEE: 180.00 COPY FEE: CC FEE: PAGES: 1 Recording Area Name and Return Address /~ ,$ /~c:c.c~w ~; rrvG I oU ?~ (Q ~~Cl~ -~•~~ 006-1088-40-000;006-1088-SO-000 006-1088-60-000: 006-1088-90-000 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Exceptions to warranties,,Eaasemen/ts, restrictions and rights-of--way of record, if any. Dated 0 2,~'~/ ~ 7 ~ `~ ~ /~/~ (SEAL) C~/~l~c-===~ (SEAL) * *Marty A. (SEAL) (SEAL) * * AUTHENTICATION Signature(s) Martv A. Wallin authenticated on Z ( V *Kristina land TITLE: MEMBER STA BAR OF WISCONSIN (If not, authorized by Wis. Stat. § 706.06) ACKNOWLEDGMENT STATE OF ) ss. COUNTY ) Personally came before me on , the above-named to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. THIS INSTRUMENT DRAFTED BY: Attorney Kristina Ogland Hudson. WI 54016 Notary Public, State of My Commission (is permanent) (expires: (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED O 2003 STATE BAR OF W ISCONSIN FORM N0.2-2003 * Type name below signatures. INFO-PROTM Legal Forms 800.655-2021 www.infoproforms.com HOLDING TANK SERVICING CONTRACT Y' 4 '~ This contract is made between the Ho/lding Tank Owner(s) N(~ame(s) and Pumpers Na/m~e We acknowledge the installation of a holding nk(s) on the following property: (Pr~vide legal de~scriptions~ --------------------------------------------- 1. The owner agrees to file a copy of this contract with the local governmental unit that has signed the pumping agreement required in Comm 83.52(lxc)1. Wis. Adm. Code and the approved Holding Tank Component Manual. This agreement will also be filed with the St. Croix County Zoning Department. 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the local governmental unit that has signed the pumping agreement and to the County, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volume in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract, the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with local governmental unit and the County named above within ten (10}business days from the date of change to this service contract. Owner(s) Name(s) (Print) Owners Signatu~ss`,~ Subscribed and sworn to me on this date: ~~Cc._ C.t. r`-~ f~ r Pumpers Name (Print) Pumpers Registration Number c~/~.~~ _y_~ ~ Todays Date 1~en.ee ~~r~ Public Signature ~~ ~3 scion €xpirafien ~~-~~ 0 \~~ ~~ ~i./ ..Z ~'``• W i ~ J `~ ~ cr. ~ ti n, '~ A _ ~'\n\i CS ,~~ ~' -~ - _~- ~~ - ~ . ~~ :~ler1 to acre- Zls~~- t - P P U ~ ~O t3rRT t-t 5 T. e r s ''' 6 ` 0 7- 7 ~ _ ~s ~ A 0 4 E3 ~ '- O ~' _ U1 3 (~ eEs 7D ~ ~ ~ !1 - ~ ' n 12 0 7:. J T ~- ' n` ~ST. m ti sTNiR~goJ~l Z ~~ ~ y F ~ 6 c B ~ ~ f . L 2 _ ~ ~, s ~ K _~ t _ 8 .a / 2 ~ ~ ~ Y 9 :r Z ~o ST- a - z ' b 7 ~.. ~ Q _ - .. ttl ~ =~_• = LtXL cc ~ 'f c..-_ ~ T . - _~'~ sue- - .ss ~~~ ter.: _~ Q ~' t rr•.t!~f _ i~l: ` - . S~ul~ ~DO/ar1 eo o..o. rn.J.. w FO U RT H S T. ;; ~ .i K ~_ •~ $ s _ ~ ~- ~ 9 4 Q ~" {- 9 c `_ ~ so ~ 3 ~ ~ 3 1p - ~ z g n 2' .» w z~ ;c n ~ f2 L a _x ~ ®Y: aTHlRO ~ ST. a ~ ~. 7 6 ® 6 7 g ~ . • B .. S ~~ ~ t : g 9 ~ ~ .; ~~ 3 70 . Z ~ Z 2 fl ._ v t 1 -72 .S. S_ .B e. e. b e~ ~~'~ _o ST. ~ • • 2 - Q ' ~ - _ ~ ~' 3 2 .ya ~ ~ Zb~1 ~ ~ N .c~..- +.r~.: -1 L / / _J ' ~ i-d ds~=ao so so qa~ ~' . ~~:, , -Y,' .. t~ ' S/I ~ l ~Str111i ~ z a ti ,~ d R p "/~/ / _.[~L h ' C , ` r n ~ v ~ ~ V ~5 ~e~le bpi ~,~ s,:e1 Y .~ti .vim`' ~- _____ ,_ ..~..a ~ . ~ .. ... •~ i I__L V d /~ G __.. ~_ h .. V i` W ~i iI I~ IV ~n ~~ Ih ~~ ~ s' ryll~ )r ~4 6 li4` S'~ 1 9 h V' h y y ~:I ~' ~' ~ ~ V I~ b S..d. 17/ ~ .TZ', sy. J,D. ~. ' >z '-`' ~~' y s 7 ~ N K I ~. St. Croix County Holding Tank Agreement tats Pian Trans~ajction Number -/ ~ ~ Name - (Ownerl TyQed or printed being duly sworn ,states, under oath, that: 1. He/she is the owner/part owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume 'Z7jL Page 67 ~ Docttment Number ~)St. Croix County Register of Deeds Office: A parcel of land located in the,,'/+ of the/+ of Section ~, T 3 ~ N - R ~ ro W, Town of o St. Croix County, Wisconsin, being duly described follows (include lot no. and subdivision/CSM r detailed legal description): L of s y f - .Y !~`j~,,,~ ~j ~11~~,~~y~~- ~reemen Data: ~_~ ~3~217E~ KATHLEEN H. iiAL~H REGISTEk tIF t)EEItS ST. CRUIX CO. , ttI RECEIVEt7 FttR RECORI) (?f8! 14l10t?IE. t48:5t4Ati HOLUING TANK AGREE?iEti3 REG FEE: 11,00 TRAKG FEE: CC]PY FEE: cc FEE: PAGE: 2 ne and Return Add ~O N i _~ We acknowledge that application is being made for the Installation of (a) holding tank(s) on the above described property or that continued use of the existing premises requires that a holding tank be Installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer,, or any other type of private onsite wastewater treatment system as permitted under Ch. Comm 83, Wis. Adm. Code, or Ch. 145, Wis. Stets. As an Inducement to the county to issue a sanitary permit for the above-described property, we agree to do the following: 1 . Owner agrees to conform to all applicable requirements of Ch. Comm 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the holding tank properly serviced in response to orders (sued by the governmental unit or the Department of Commerce to prevent or abate a human health hazard as described in s. 254.59, Stets., the governmental unit (Town) may enter upon the property and service the tank or cause to have the tank to be serviced and charge the owner by placing the charges on the. tax bill as a special assessment for gurrent services rendered. The charges will be assessed as prescribed by s. 66.0703, Stets. 2. The owner agrees, pursuant fo s. Comm 83.54 (2), and Comm 82.40(3)(e), Wis. Adm. Code, to have a.water meter installed in the structure. The water meter shall be installed by a plumber authorized oy tfie 'ueparunerri oi.',omm&ica io Ii'idK~ such i~u~;iai~aiicr~s, w9u ~ said irstaliatiaz complying with State regu{ationa and manufacturers speeiflcaUons. The. tswner agrees to ~be financially [asporisfble for the purchase, Installation, maintenance, and repair of the water meter, and agrees to allow the govemmentbt unit or the Department of Commerce to enter. the above-described properfy on a regular basis to read and/or inspect the water meter. 3. Owner agrees to pay all charges and costs incurred by the governmental unit or county for inspection, pumping, hauling, or otherwise servicing and maintaining the holding tank In such a manner as to prevent or abate any human health hazard caused by the holding tank. The governmental unit shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges may be placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law. 4. The owner, agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code, to have the holding tank serviced and to file a copy of the contract with the governmental unit. The owner further agrees to file a copy of any changes to the service contract, or a copy of a new service contract, with the governmental unit within ten (10} business days from the date of change to the service contract. 5. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code, who shall submit to the county on a semiannual basis a report detailing the servicing of the holding tank. The governmental unit or county may enter upon the property to Investigate the condition of the holding tank when pumping reports and meter readings may Indicate that the holding tank is not being properly maintained. 8. This agreement will remain in effect only until the county office responsible for the regulation of private onsite wastewater treatment systems certifies that the property is served by either a municpal sewer or a private onsite wastewater treatment system that complies with Ch. Comm 83, W1s. Adm. Code. In addition, this agreement may be cancelled by executing and recoMing said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 7, This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit this agreement to the register of deeds, and the agreement shall be recorded by the register of deeds In a manner which will psrrnit the existence of the agreement to be determined by reference to the property where the holding tank is installed. OwneCCr(s) ,Name(s) -Please Print c~/i ~L ~) r~ Subscribed and sworn to before me on this date: ~" ~'_ L~ ~o Notarized r ignature(s} Cam-- Notary Public ~ new ~~u, ~~~~e ,1~ir~ Governmental Unit Official Name, Title -Please Print My ommission Expires ~ ``~~,,,,,,,,,,~~ ,: , ~ ~' •. Governmental U Offl 1 Signatu Drafted by a ;fit'` Qr ~ r .,, InfomyrStion you provide may be used for seconaary purposes trnvacy r.aw s. ia.ugti itm/~ ~ ~ ..i ~ ~~ ~`i ,~ ~.iC~ "THIS PA~iE IS PART OF THIS LEf3At. DOCUMENT - DO NOT REMOVE" '~ ~?,~•'••.«..•• ~~ This information must be completed by submltter, docume to title. name & return address. and p_(~( (if required). Other lnformatinh' ad~,aA Jha ~' granting clauses, leggal description, etc. maybe placed on this first page of the document or may be pieced on add/tlonal papas of the document. ~te~ Use of tiria cover page adds one page to your document and 52.00 (q~@ recsudlrro~Tee W/aoorraln Statutes, ti8 817. 1/ commerce.wi.gov isconsin 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 August 07, 2006 CUST ID No. 226900 33.3! • /(o • S~~ ATTN.• POWTS Inspector SHAUN R BIRD BIRD PLUMBING INC 1008 192 ND AVE NEW RICHMOND WI 54017 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 08/07/2008 SITE: Shaun Bird County Road O Town of Cylon, St Croix County SE1/4, SW1/4, 533, T31N, R16W Lot: 4-5, Block: 3 FOR: ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 ~ Identification Numbers ~ Transaction ID No. 1307785 Site ID No. 716411 Please refer to both identification numbers, above, in all corres ondence with the a enc . Description: Three Bedroom Holding Tank System Object Type: POWTS Component Manual Regulated Object ID No.: 1090112 Maintenance required; Replacement system; 300 GPD Flow rate; System: Holding Tank Component Manual, SBD-10571-P (R.6/99) 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 use: Reminders • This system is to be constructed and located in accordance with the enclosed approved plans and with the "Holding Tank Component Manual for Private Onsite Wastewater Systems" SBD-10571-P (R.6/99). • A notarized Holding Tank Agreement between the local governmental unit/Municipality and the property owner is required prior to the issuance of a sanitary permit. A Holding Tank Servicing Contract may also be required if no other service provider for the holding tank has been identified. SHAUN R BIRD Page 2 8/7/2006 • A service drive or road is to be provided to the service access opening or pump out port. The minimum measured distance required is 25 feet. • The well must be a minimum of 25 feet from any POWTS tank. chs. NR 811 & 812c • 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(7) A copy of the approved plans, specifications and this letter shall be on-site during construction and open 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. Comm 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. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be 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. SHAUN R BIRD Sincerely, Charles L Bratz POWTS Reviewer II ,Integrated Services (608)789-7893 , 7:45 am - 4:30 pm Monday -Friday charlie.bratz@wisconsin.gov Page 3 8/7/2006 Fee Required $ 60.00 Fee Received $ 60.00 Balance Due $ 0.00 WiSMART code: 7633 cc: Leroy G Jansky, Wastewater Specialist, (715) 726-2544 Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT Page of rn accoraance warn ~.omm a~, vvis. room. ~,oae County--~ , ~~~ I Plan must Attach complete site plan on paper not less than 8 1/2 x 11 inches in size . 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. Reviewed by Date Persona!erHormatwn you provide may be used for sewndary purposes (Privacy Law, s. 15.04 (1) {m)). Property Owne / ~ ~ ~ erty Location 4 ~~T ~ ~ N R E CZ(~Y~/ j .Lot 1/41 S (or W Property Owners Mailing A~ress Lot Block # Subd. or CSM# City State Zip Code Phone Nu r ^ C~ ^ Village o Near st Road ^ New Construction UserResidential / Number of bedrooms Code derived design flow rate ~ GPD placement /Public or co meraa~~r~'~ ________ __ ___________ __ Parent material FI Plain elevation if applicable ,f1/1 ~l ft. Ger>eralcarrYnerns AUG 0 9 2006 and reconurrendations: Q System Type s ~~ ST. CROIX COUNTY Sys em Elevation ~/J 1~ j ~~ # Boring y `~. I pit Ground surface elev. ft. Depth to limiting factor ~_ in. Soil ication Rate Horizon Depth Dominant Cdor Redox besaiptron Texture Structure Consistence Boundary Roots GP D/Ffl= in. Munsell Qu. Sz. Cont. Cdor Gr. Sz. Sh. •Eff#1 •Eff#2 7 - U _ )~ - -- -- ~~~ 2 Ong # Boring q ~, it Ground surface elev. ~_ ff. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 ~ - 5 31 i ---~~ ru- ~ C, ~ - 1 ~ ~ ' ~ D ~~n J i~ r~~ 'Effluent #1 = BOD > 30 < 220 mglL and TSS >30 < 150 mglL 'Effluent #2 = BOD < 30 mg/L and TSS < 30 mglL CST Alarr>Q (Please Pant) Sig CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Con ucted Telephone Number 1008 192nd Ave, New Richmond, WI 54017 --- ,~ 715-246-4516 Property Owner Parcel ID # Page of Boring Boring # pit Ground surtace elev. ft. Depth to limiting factor in. Soil ligtion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 •~ . ~. I -. ,~ ^ 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 DIFf? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring # ~ Boring pit Ground surface elev. ft. Depth to limiting factor in. Soil ication Rate Horizon 'depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GP Dlff in. Munsell Qu. Sz. Cont. Cdor Gr. Sz. Sh. 'Eff#1 'Eff#2 'Effluent #1 = BODS > 30 < 220 mglL and TSS >30 < 150 mglL 'Effluent #2 = BODS < 30 rrxyL 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. seo-eaw crt.6roo~ Soil Test Plot Plan Project Name Shaun Bird Address 1008 192nd Ave New Richmond Wi 54017 CSI #226900 Lot 4&5 Subdivision Village of Cylon Date 8/8/06 SE 1/4 S W 1/4S 33 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 Survey Iron System Elevation TBD *HRpSameasBenchmark Alternate Benchmark Top of Well @ 102.0' * g,M, Cty Rd 0 Dr~vevr~ay Property Line Neighbor's Well Pro 3 Bedroom House Drainfield ~ O B-2 Alley Scale is 1" = 40' unless otherwise noted 1 ~ Scale = 1 /4" = 10' Property Line Prior testing indicates that this site has been filled and is no longer suitable for any other system other than a holding tank. The old system has been pumped and buried. The system served the hardware store and is no longer usable. Lots 4 &5 have been surveyed and the line between these lots has been disolved as per county code.