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Home My WebLink About012-1019-20-050Wisconsin Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL Ilv'FORM~TION (ATTACH TO PERMIT) Personal information you prout~a may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). Permit Holder's Name: City Village X Township Haworth, Rick Erin Prairie Townshi CST BM EI~: Insp~ MOEIgv: ~ BM Descriptio~^ ~ / ~ /~' TANK INFORMATION TYPE MANUFACTURER CAPACJ.T~ ( ll~,, Septic 6s ~ y~ ) Z/ S% Dosing ~~ ~ ~ Aeration ~ Holding TANK SETBACK INFORMATION TANK TO P~ ~ BLDS,. Ve~ Air Intake ROAD Septic , 5 ~ ~~ VV r 5 / 0~'l Dosing p `(,~~ ~~,v S Aeration --- Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model N ber TDH Lift tion Loss System Head TDH Ft Forcemai Length Dia. SOIL ABSORPTION SYSTEM // ELEVATION DATA county: St. Croix Sanitary Permit No: 430099 0 State Plan ID No: Parcel Tax No: 012-1019-20-050 Section/Town/RangelMap No: 07.30.17.94610 STATION BS Ht FS ELEV. Benchmark ~~~/ I Z 10~. Z / ~^ .Q J C Alt. BM / , 1 • S.~ ~ ~~, Bldg. Sewer ~ `~ / ~ St/Ht Inlet tin, , 7 .~Jl/ ~~ 8 ~ ~ Z. / ,~ SUHt Outlet p ~a . 0 Dt Inlet ~_ ~- Dt Bottorxt J ~~ Header/Man. ~ ~ g Dist. Pipe '~o ~ R~rn Y 2'1 Bo . Syste ~ ,~ J• Final Grade ~ q,3 ~~, 1 St Cover 62~t_ `~ 4.1~ BED/TRENCH Width ~ Length ~ No. Of Trenches PIT DIMENSIO No. Of Pits Inside Dia. Liquid Depth DIMENSIONS `J( 41'_ SETBACK SYSTEM TO P/L B DG WELL LAKE/STREAM LEACHING Manuf er. INFORMATION CHAMBER O s Ty Of System: , ~ ~~f ~~/ ~~ I / UNIT Model Number: ~ DISTRIBUTION SYSTEM Header/Manifold d Length Dia Distribution Pipe(s) `~ /~ ~~ '~' Length~~ Dia J'~pacing~ x Hole Size ----~"~- x Hole Spacing _' SOIL COVER x Pressure Systems Onlv xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ~ Yes ~ No ~='~ Yes ' ~j No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: `(~ /d-~ /Q ~ Inspection #2: / /_ Location: 1555 Cty Rd GG New Richmond, WI 54017 (NW 1/4 NE 1/4 7 T30N R17W) NA Lot Parcel No: 07.30.17.94810 1.) Alt BM Description = ST~CdV~IZ ~.1Ls ~/~~" 2.) Bldg sewer length =~(~'yIG, - amount of cover = ~ . , 'J `~ Plan reviswn Re uired . I Yes ~ ~ ~ I~ ~ '~ Use other side for additional information. No ~- i ~ ~ ~~.,.~ /, Cv ZLP ~d 3 Date Insepctor's Si ature Cert. No. SBD-6710 (R.3/97) O l~- B~o.C~tl/ Vent to Air Intake ~ o2rn~ G~rn 6.Gv~'vY+, S~ Safety and Buildings Division 201 W. Washington Ave., P.O. Box 7162 County ~J ~ ~~( ~D~,x ~ Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) ,~~01~~~~ (608) 266-3151 ~3QQ Department of Commerce State Plan I.D. Number Sanitary Permit Application personal information you provide Code Adm Wis 83 21 i h C d I , . . omm . , w t n accor may be used for secondary purposes Privacy Law, s15.04(1)(m) Project Address (if different than mailing address) I. Application Information -Please Print All Information P"'°°~--~--..,-.-a,,n„„ vy W.~ (s~,~~\ Property Owner's Na me "' "" E Parcel # Lot # Block # <• Property Owner's M ~ g Address ~ i ~~,;, r ~ Property Location ~~~~,~ ,Section City, State ~ Zip Code otti;- ~ c~ _~_ ~ / ~ ~~ ,/~~ ~!/ G/ ~ ~~circ one T N; E r l h ` at app y) II. Type of Building (check all t Subdivision Name CSM Number 2 Fancily Dwelling -Number of Bedrooms _ ~- U se _ ^ Public/Commercial -Describe \ r- ~ ~ - 1C b a ~ _'Village~ownship of r ^City • / ^ State Owned -Describe Use ~2 J 3 _ III. Type of Permit: (Check only one box on line A. Complete line B if applicable) '~' ^ New System e lacement System ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System B. - ^ Permit Renewal ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: (Check all that apply) ~}• ~ ~ n -Pressurized In-Ground ^ Mound > 24 in. of suitab a soil ^ Mound < 24 in. of suitable s oil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding 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/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdst) Dispersal Area Required (sf} Dispers Area Proposed (sY) System Elevation , - l ° ~ ~J ~ ~ ..~ ~ f ~ . VI. Tank Info Capacity in Total Number Manufacturer Prefab Site S•. Fiber Plastic Concrete Constructed Glass Gallons Gallons of Urtits New L-xisting ~ Tanks Tanks Sep[ic or Holding Tank Y /\ Aerobic Treatment Unit ~ I Dosing Chamber i ~ VII. Responsibility Statement- I, the undersigned a responsibility for installation of the POWTS shown an the attached plans. _ Plum/be'r's Na me (Print) Plumber's re MP/MPRdS Number ~s~~ ~ ~ Business Phone Num1b/er ~/ ~~ ~ ~ ~ C ~ ~i ~ / c.J " G Plumber's Addre ss (Street, City, State, Code) ~~~ VIII. County/De artment Use Onl Approved ^ Disapproved Sanitary Permit Fee (includes Groundwater F h S ' Date Issued ss ~ g Agent Signatu (No Stamps) ee) arge urc 225 / 23 ^ Owner Given Reason for Denial IX. Conditions of Approval/Reasons for Disap//p~'roval Ir ~/' ~ ~ ~ ~ ~ ~ '~yAt~ ~ n ` L t '~[1 ~~ ,t ~_ ~ ~ ~ r'1 ~~ ( ~t ~~/~ ` /~ ~n t1,, ~ ~ ~~//I I OWAVT'L__ ~/l/J~//-/NQ',,-/~` ~1w1.(v}.(,`'JIX(!L"~Jl`/) ~/~y}~ 1\I ~ , _. ,..~~ a.... Qc !~ Y 11 ;nrhes in size _l n /! 1 1 ~~/ !~ ~~-S'I~ ; = t Q lJ ~(J ~ pl_ . ptanS (to the untY Y) i~,,..,.. ,...Y.. l/Y~ l Vts ! w`.'~V ~ (eJL PROJECT Ricky Haworth A ESS 1555 Ctv Rd GG New Richmond Wi 54017 NW 1 / 4 'NE 1 /4 S 7 /T 30 N/R W TOWN Erin Prairie COUNTY ST. CROIX 6/17/03 BEDROOM 3 MPRS Shaun Bird 226900 DATE CONVENTIONAL XXX IN-GROUND PR RE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000/260 LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambers 22 ,BENCHMARK V.R.P. Top of Garage Slab = ~~~= ASSUME ELEVATION 100° Filter Zabel A-100 ^ BOREHOLE O WELL *H.R.P. Same as Benchmark ~^ SYSTEM ELEVATION 86.5/87.5 6' Below Grade 10', ' Nell _ Alt. BM= Base of Walkout Door @ 100.0' Existing 3 5, ~~ Bedroom M House B.M, Plans Designed Using Conventional Pow Manual Versi .0 60' ~~~ S~ .~ ~ 5~ "~ mac,` T ~~ ~. ~ vl 0' ~ 5 Vents B_1 11% / Slope Aprrox Drain field ' Faili g Syste ~ ~ 3' X 69' Cells with >3' Spacing B-3 ~, 10' 15' ~ Ven B-2 a >6„ Standard Biodiffuser Vents ~ of Cover ing Chamber ~ ~ / b ~ ~U ' R~~~ 6' Long 11 " 3 4" Grade at System Eleva ' n 235' Property Line _ 150' PLOT AN PROJECT Rickv Haworth A Ess 1555 Ctv Rd GG New Richmond Wi 54017 NW i / 4 NE i /4 S 7 /T 30 N/R W TOWN Erin Prairie COUNTY ST. CROIX 6/17/03 3 MPRS Shaun Bird 226900 DATE BEDROOM CONVENTIONAL )00C IN-GROUND PR RE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TAN K SIZE 1000/260 LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambers 22 ,BENCHMARK V.R.P. Top of Garage Slab = ~~~= ASSUME ELEVATION 100' Filter Zabel A-100 ^ BOREHOLE O WELL *H.R.P. Same as Benchmark SYSTEM ELEVATION 86.5/87.5 6' Below Grade ell 10' 3 Existing 3 Bedroom House Plans Designed Using Conventional Powts Manual Version 2.0 BM=Base of Walkout Door @ 100.0' Alt. B.M. B.M, 60' 35' T ST n' Aprrox 12' X 42' Drainfield \ Failing System 5' Vents B_1 11% --Slope 2-3' X 69' Cells with >3' Spacing B-3' 10' 15 >6" of Cover Vent ~~' ~ B-2 Standard Biodiffuser Vents Leaching Chamber with 31.1 ft2 of Area 90' 111 " 6' Long 235' Property Line at System U 150' Property Owner _ ^ Boring # ^ Boring Parcel ID # Page of 9~.s- ~. Pit c~rouna surrace eieyc ft. Depth to IimiUng factor ~n• Soil lication 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 -- ~--" ~ .7~J /~ ,~ . S~ 4 2D Boring # ^ Boring ^ pit Ground surface elev. ft. Depth to limiting fades in. Soil lication Rate Horizon Depth Dominant Cdw Redox Description Texture Structure Consistence Boundary Roats GP D/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Ong # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Destxiption. Texture Structure Consistence Boundary Roots GP DIff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2 'Effluent #1 = BODE > 30 < 220 mg/L and TSS >30 < 150 mglL 'Effluent #2 = BODS < 30 mglL 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. SBD-6330 (8.6/00) Soil Test Plot Plan Project' Name Ricky Haworth Shaun Bi Address 1555 Cty Rd GG New Richmond Wi 54017 CSTM 226900 Lot ---° Subdivision ------- Date 6/17 3 N W T /4 NE 1 /4S 7 T 30 N/R17 W Township Erin Prairie Boring 0 Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of Garage Foundation System Elevation 86.5/87.5 *HRpSame as Benchmark ell 10' Base of Walkout Door ~a 100.0' Existing 3 Bedroom House Alt. BM 25' Alt. 60 Scale is 1" = 40' unless otherwise noted 35' B-1 Aprrox 12' X 42' Drainfield \ Failing System 45~ \ ,~6~ ~ -3 ,~`~ '+ `~1 10 15 B-2 J 95 ~ q5' ~~ 235' Propertv Line 150' Maintenance and Contingency Plan for a Septic System Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in order to extend the maintenance interval of the filter. 3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of the cells. 4.Owner agrees to limit greases, garbage, and water conditioner discharge into the system. 5. The owner agrees to save this plan. 6. Do not plant trees nor park nor drive over system. 7. Watershed is to be diverted away from system. 8. Discharge into system is not exceed those required as per Comm. 83 Contingency Plan 1. If system fails, determine cause of failure, use alternate area and install new system or install system at a lower elevation. 2. Replace any other failing components as needed. Plumber: Shaun Bird 715-246-4516 St. Croix County Zoning 715-386-4680 Pumper Tom Mondor 715-246-5148 Shaun Bird #226900 . W V V • ST. CR~STX CUUNT'Y ZONING OFFICE CERTIrzCATION STATEMSNT FQ12. C1T:LIZATION 4F AN EXIa^TINv 9EF'`1;IC TANK This is tc c®rtify that I have inspected the septic tank pres~Qntly serving tk-e ~-,`r~~~~~~aJ residence located at : /f/~, /1/~ ~~ Sec . ,,,,2_, T,,,~3~ N, ~~W, Town of ~ 1r+- ~~~~..~e St . Croix County, wiscons~,n. 'Upon insp®ctian, z certify that I have found tho tank end baffles to be in goad coxidit~,an, and it appears to be functioning properly. mast time ®erviced (~ 3 nid flew back occur from absorption system? Yes_~ Wn~ {if liO, skip next tin®. ~P1?roximate valurne ar length of time: gallons ~„~ miri'~tee Capacity:. Coristxvatiaa: Pro s Cnnc to .~„~ Steel ,~, Other Maautactuxer (if known}: Age of Tan if known}: tore yNama, Please Fx nt Title ( icense ~TUmbetS ~' ' ~~ DetQ) Form to be csm~pletad by licensed p;.umber (a. 1?(5.06, wa.scon$in stntuttsf or licer~se9 di~eposer (NR 113 Wiscan~in Administrative Code} Flunlber (applying fc~r sanitary permit) Certification: In aocepting the above ata4ement regarding exiting certify that the tank, to the best of my know rGQLlireT:tbl7ta of ILHR fi 3 , 'n is _ A.dm . Codc { exGep ~ outlet baffle?. N~lli1@~f-~i'~ti~ ~ ~ f2 Signatur MFfMPR ? eptiC tarifc condition, 1 s, will conform to title inspection opening soar OwnerBuyer Mailing Addr~ Property Address City/State 5T CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM (Verification required from Planning Department for new construction) ~/ J Parcel Identification Numbera~~ ~""~,~//' ~~ t7~~ LEGAL DESCRIPThON,~ ~/ Property Locatior~__~g~i+,/~'~/4, Sec. ~ T~~~ W, Town ~,~ ~ Subdivision i __ .Lot # i Certified Survey Map # ,Volume ,Page # Warranty Deed # ~35~~29 .Volume ~ s~~ ,Page # 3a Spec house ^ ye"~~'ap Lot lines identifiablyyes ^ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification fomr, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 f the three r expiration date. ~_! SiGN~. OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I {we) am (are) the owner(s) of the pro erty described above, by virtue of a warranty deed recorded in Register of Deeds Office. t~~ SIGNA OF APPLICANT DATE ******. Any information that is mis-representedmay result in the sanitary permit being revoked by the Zoning Department. ****** ** Include with this application: a stamped warranty deed from the Register of Deeds office. a copy of the certified survey map if reference is made in the warranty deed V~i..15G9PAh~ 3C~9 STATE BAR OF WISCONSIN FORM 3 - 1998 Ardyce Haworth, quit-claims to Ricky A. Haworth and Judy R. Haworth, husband and wife, as survivorship marital property, the following described real estate in St. Croix County, State of Wisconsin: A parcel of land located in part of the Northwest Quarter of the Northeast Quarter of Section 7, Township 30 North, Range 17 West, Town of Erin Prairie, St. Croix County, Wisconsin described as follows Commencing at the North Quarter Corner of said Section 7; thence, on an assumed bearing along the north/south Quarter line of said Section 7, South 00 degrees 30 minutes 54 seconds East a distance of 285.30 feet to the point of beginning of the parcel to be described, this being the southwest corner of that property described in a Warranty Deed recorded in Volume 518, page 441 in the Register of Deeds Office in said County; thence, along the south line of last said property, North 86 degrees 51 minutes 07 seconds East a distance of 356.14 feet; thence South l l degrees 09 minutes 18 seconds West a distance of 133.45 feet; thence North 83 degrees 40 minutes 18 seconds West a distance of 331.13 feet to last said north/south Quarter line; thence, along last said Quarter line, North 00 degrees 30 minutes 54 seconds West a distance of 74.87 feet to the point of beginning. AND A parcel of land located in part of the Northwest Quarter of the Northeast Quarter of Section 7, Township 30 North, Range 17 West, Town of Erin Prairie, St. Croix County, Wisconsin described as follows: Commencing at the North Quarter Corner of said Section 7; thence, on an assumed bearing along fire north line of the Northeast Quarter of said Section 7, North 86 degrees 51 minutes 07 seconds East a distance of 413.44 feet to the point of beginning of the parcel to be described, this being the northeast corner of that property described in a Warranty Deed recorded in Volume 518, page 441 in the Register of Deeds Office in said County; thence, along the east line of last said property, South 00 degrees 30 minutes 54 seconds East a distance of 285.30 feet; thence North 54 degrees l9 minutes 55 seconds East a distance of 25.16 feet to the southwest corner of that Lol shown on a Certified Survey Map recorded in Volume I, page 69 in said Register of Deeds Office; (hence, along the west line of last said Lot and the extension thereof, North 04 degrees 5l minutes 29 seconds West a distance of 271.60 feet to the point of beginning. The parcel shown on this document is being added to the parcel shown on [he document, recorded In Vo1.518, Page 441, Document No.325006, St. Croix County Register of Deed's Office to create one parcel, and this transaction is tbcreby exempt from Chapter IS of the SL Crofx County Land Use Regulations pursuant to Section 18.05(A)(3). Dated this ,~~ day of , 2000. 'TAr yce Ha rill AUTHENTICATION Signature(s) ArdVCe Haw01'th authentic to t~ 20t1d of December 200 ,~ 'wl • Hendrik W. Van Dyk TITLE: MEMBER STATF, BAR OF WISCONSIN ([f not, authorized by ~ 706.06, Wis. StatsJ THIS INSTRUMENT WAS DRAFTED BY Hendrik W. Van Dyk VAN DYK, O'BOYLE & SILER, S.C. Post Office Box 118 New Richmond, WI 54017 (Signatures may be authenticated or acknowledge. Doth are not necessary.) 635?29 YATHi.EEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED Fit RECORD i2-22-2044 9:30 AM DUIT CLAIM DEED EXEMPT X 8 CERi COpY FEE: COPY FEE: TRANSFER FEE: kECBRDING FEE: 10.00 PAGE5: 1 Nome and Relum Address Hendrik W. Van Dyk VAN DYK, O'60YLE & SILER, S.C. Post Office Box I I S Ncw Richmond, Wt 54017 012-1019-40-000 Parecl Identification Number (PIN) This is not homestead property. ACKNOWLEDGMENT STATE OF WISCONSIN ) )ss. County ) Personally came before me this _ day of , 2000 the above named to me known to be the person(s) who executed the foregoing instrument and acknowledge the same. Notary Public ,State of Wisconsin My Commission is permanent. (If not, state expiration date: °0_ ) •Names of persons signing in any capacity should be typed or printed below their signatures QUIT CLAIM DEED STATE BAN Ot' W ISCONSIN FORM No. 7 - 1998 INFORMATION PROFESSIONALS COMPANY FOND DU LAC, W I 800.655.2021