HomeMy WebLinkAbout040-1308-00-161
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
561029 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Fredrich, Troy & Ellen Troy, Town of 040-1308-00-161
CST BM Elev: Insp. BM Elev: BM Description: r ection/Town/Range/Map No:
ism C'a 19.28.19.1980
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER tom- CAPACITY STATION BS HI FS ELEV.
Septic / Benchmark O ' gg# O
ZO
sestrrg ` Alt. BM r► ~.~J•-:..r•. p . $9:51 3, (4 890.0
Aeration Bldg. SeweraP I, g~$ GS~•$
Holding St/Ht Inlet A ( gv~ t(` 7
l
TANK SETBACK INFORMATION St/Ht Outlet T.
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
W46 -6 sh " **-N
Septic 5 Dt Bottom
y~ I S ~ iao' ~
Dosing Header/Man. Q 8g3
Aeration Dist. Pipe 9 • d D DD
4 ~~3 •'i
Holding Bot. System m. O 412
!d . $ IrZ•. 447
a~q ~ L f
PUMP/SIPHON INFORMATION Final Grade •
Manufacturer GPDemand StCover
~l~ Z, -1 111• C16. -2 7
Model ber
TDH Lift Friction Loss System TDH Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width / Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia`_ Liquid Depth
DIMENSIONS 7~ ~t
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer
INFORMATION Type Of System: CHAMBER OR Model Number: y~~e tea
ot1); ,,J-;o~..lZ NCI- o~: Ply
Go
DISTRIBUTION SYSTEM ,Zta- ZiZ = ~'odrs-~.
Header/Manifold j/ Distribution x Hole ize x Hole Spacing Vent Air Int ke
tu1 Pipe(s) ~ 1
Length 11 Dia T Length Dia_ - Spacing~_ ~ 5
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Dep of IxSeeded/ odded xx M ched
BedlTrench Center Bed/Trench Edges ` Topsoil es No Yes ] No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: / /
Location: 212 Muirfield Trail Hudson, WI 54016 (SW 1/4 SW 1/4 19 T28N R19W) Troy Village 6th Addition Lot 161 Parcel No: 19.28.19.1980
1.) Alt BM Description= ` r (I.-&, G;~ a
2.) Bldg sewer length = Z It
- amount of cover =
5 j
Plan revision Required? Fm~ Yes j No
Use other side for additional information. ` - Cert. No.
Date Insepctor's gnature
SBD-6710 (R.3/97)
PLOT PLAN
PROJECT Trov Fredrich ADDRESS 317 Meadow Ridae Ct Hudson Wi 54016
SW 1/4 SW 1/4S 19 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 3/6/13 BEDROOM 4
CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 891 # of chambers 44
BENCHMARK V.R.P. Top of survey iron ASSUME ELEVATION 1001 Filter BEAR Filter
❑ BOREHOLE O WELL * H. R. P. Same as Benchmark
All piping shall be SDR 30/34, within 10' SYSTEM ELEVATION 889.5/889.4' 4' below qrade
of tank, piping shall be Schedule 40.
25 B.M.*
ALJ- 134' Property Line
Well is to meet all , 30'
setbacks required by
~o NR nVents
-3' X 90 c"-eIls with >3' sp cing
Vent I'
/b
ick4 Standard
aching Chamber rQS+~
Of with 20.0 ft2 of Area
12 5
. ft^2/pair of end caps 80' Grade at System Elevation 1~ ,l6
34"
B16 A
c e is 1 4 o'
L9
otherwise B161B 10'
not d 60'
S
I~
20'
Pro 4
Bedroom
House
325' property line 0
Muirfield Trail
commerce. Wi.9a w
Safety and Buildings Division fday
, WI Ave.., 7.-7Box 7162 ~r
~ ?-01 W.M dis n
'>R ~ laeparttnleat o W1 537(Y7. 716'1 lx[y u [ N Sait ~ ~ ernlit AppYieatidtr 'Pransaction Number an ac ordanue with s. Comm. 83.~T' W, Adm
Codis submission of-tt,is form to the appropriate tr i+
ovemm/ V
unit is required prior to obtaining a sunny ptr4tit. Note: Application forms for state-owned POWT S ct Address (if diitirt nt thin mailing ddress)-
submitted to the Departawnt of C~nnte-d. Persona! infbnnation you provide may be used for secon
I. purposes in accordance with the,lhN Cy Law, s. 15.G4(l)(m , Stats, Application Information Plesse .Print All IHformatioll /0 , w) , l
Property Owner's Name r`- - - -
;y~ J- Pnrcel _
- _L ire rj 6"T 13ag-- 6D- /Co
-Property Owner's Mailing Addre67 Property Location - -
Govt. Lot
%a, Section J
( ity, state aly~~_ ode Phone Number - - l )
D( a ule one -
Ill. Type of Building (check all that apLot 4 - 7 --_L_. . N; It
or 2 Family Dwelling - Number of Bede Subdivision Name w T
~ t
E t Public/Commercial - Describe Use s^ -of'.
- laity
- - -
~..j State Owned Describe Use CSM Number U Village of
['own of, 2.. s _Ce,V.. t J Z Z ZZ tC~a e (
111. Type of Permit: (Check onl one !box on litre A_ Complete Dine 8 if applicable) - -
A_ ew system U Replaeetnt'alt System ❑ Treatment/Holdiag Tank Replacement Only U Other Modification to Existing System (explain)
R. D Permit Renewal U Pcmtit ite,. isiorl U Change of Plumber F1 Permit 'T'ransfer to New 1.isl Previous Permit Nranber arhd Axle tssate(t - -
Before Expiration Owner
IV. T e of PO'WTS S stem/Com uncut/Device: (Cheep all that applvl-_-_-__--__
un-Pressurized !n-Ground U Pressor ized In-Ground ❑ Al-Grade 0 Mound 24 in. of suitable soil Ll Mound < 24 in. of suitable soil
❑ Bolding Ttutk U Other Dispersal Component (explain) - - F1 Pretreabneat Device (explain) - - -
- - - y -
V. Dispersal/Treat ut Area Information: /11
Design Soil APP" licadon Rat -
Design Flow (gpd) pdsf) Utspersal Area Required (sf Disperssal Area Propose System E!e io
Vi. '!rank info Ca,,acity in Total ii of Manufacturer b
C iallons _ Gallons Units c
New Tanks - - Existing Tanks Rq Y 43 V A a
Septic ur Holding Tank - ~W hM~~~+ - - -
D llaurbnr - J~ - - - -
V.11. Responsibility Statement- 1, the undersigned, assn aponsibility for installation of the POW'Y'S shown on the attached plans-- Plumber's a (Prim) Plumber' ature
MP/MPRS Number Business Phone Number
r n
Plumber's Address (Street, City, State, Zip
Vla ount /De rtment Use Only -kin
pproved tsapproved iEFee I?atc Issne I issuing rit Signature
n Reason enial 7S' oe 7 /3
- -
l3f. Coad" easons ibr Disapproval
1~~effluent finer and 3) A)0 ~ ~ t:
dispersal cell must all be servIces / majohiiad
as per management plan provided by plurnbec,
2. All setback requirements must be msintik W
as per applicable code / ordhinarites
Attack to co®pletu darts for the systow and sebwit to the County only on paper, not less than 8 In 141 Inches in size
SBD-6398 (R- 02/09)
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi 54017
715-246-4516
Date: 3/6/13
Owner: Troy Frederich
Location: SW1A SW1A S19 T29 N,R19W Lot 161 Troy Village Troy
System type: In-ground absorbtion system(conventional)
Manuals Used: In-ground absorbtion system (version 2.0)
Page#
1. Cover Page
2. Plot Plan
3. Chamber Cross Section
4-6. Maintanance and Contingency Plan
7. Filter Specifications heet
Signature
License nu er #226900
PLOT PLAN
PROJECT Trov Fredrich ADDRESS 317 Meadow Ridae Ct Hudson Wi 54016
SW 1/4 SW 1/4S 19 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 3/6/13 BEDROOM 4
CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 891 # of chambers 44
BENCHMARK V.R.P. Top of survey iron ASSUME ELEVATION 1009 Filter BEAR Filter
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
All piping shall be SDR 30/34, within 10' SYSTEM ELEVATION 889.5/889.4' 4' below qrade
of tank, piping shall be Schedule 40.
25 B.M.*
134' Property Line
Well is to meet all 30'
setbacks required by
WDNR Vents
B16 'C
2-3' X 90' cells with >3' spacing
Lent
'
>6„ Quick4 Standard
eaching Cha
mber
of Cover ith 20.0 ft2 of Area .6ft^2/pair of end caps 80' r
4 Long
3491 Grade at System Elevation
B16 A
Scale is 1" = 40' 0'
unless otherwise B161B 10'
noted 60'
S
20'
Pro 4
Bedroom
House
325' property line
Muirfield Trail
Cross Section of Infiltrator Quick 4 Leaching Chamber
Typical cross section for 2 of 2 cells
Quick 4 Standard Leaching Chamber
with 20.0 ft2 of Area per Chamber ,
5.6ft^2 pair of end plates To be >1 above grade
Finish grade elevation
Typical Installation 893.0'
Vent Al Grade Vent
3' 4" 3'
X30134 Septic Tank
5' Long 179 5' S' Long 1
3699 Grade at System Elevation Grade at System Elevation
Spacing 5'
2-3' X 90' Cells
Same on other end Observation tubeNent
At end of cell
A
B
22 chambers per cell
System elevations:
A-889.5'
B 889.4'
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner
Permit # Septic Tank Capacity al ❑ NA
Septic Tank Manufacturer ❑ NA
3ESIGN PARAMETERS Effluent Filter Manufacturer
!Number of Bedrooms ❑ NA
❑ NA LEffluent F~ter Model NA
Number of Public Facility Units
yd NA Tank Capacity NA
Estimated flow (average) al
aUda fank Manufacturer NA
Design flow (peak), (Estimated x 1.5)
-y- ~ gal/day Pump Manufacturer ❑ NA
Soil Application Rate
allda /ftz Pump Model ❑ A
Standard Influent/Effluent Quality Monthly average" Pretreatment Unit
I
Fats, Oil & Grease (FOG) 530 mm DNA
Biochemical Oxygen Demand (BODs) 522o/L ❑ Sand/Gravel Fitter ❑ Peat Filter
9 ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (SS) 5150 m L
❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s)
Biochemical Oxygen Demand (BODs) 530 m L ❑ NA
n-Ground (gravity) ❑ in-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L NA 11 At-Grade
Fecal Coliform (geometric mean) 6104 cfu/100m L1 Mound
rX-
O Drip-Line 11 Other:
iMaximum Effluent Particle Size Y8 in dia. ❑ NA Other:
Other: NA
NA Other:
NA
"Values typical for domestic wastewater and septic tank effluent. Other:
❑ A
INIAIN'TENANCE SCHEDULE
Service Event
Service Frequency
linspect condition of tank(s) At least once every: ❑ month s)
ears (Maximum 3 years) ❑ NA
(Pump out contents of tank(s) When combined sludge and scum ' equals one-third
(X~) of tank volume ❑ NA
(Inspect dispersal cell(s) Monceevery: very: _ 'ear{s)s) (Maximum 3
Clean effluent filter ery: ❑ ear(s)s) ❑ NA
Inspect pump, pump controls & alarm ery; month (s) ❑ NA
1=lush laterals and pressure test ery: IJ ear(sjs) ❑ NA
{ether:
ery; ❑ month(s)
ether; ❑ year(s) ❑ NA
O NA
MAINTENANCE INSTRUCTIONS
In spections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master
(Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must
:include a visual inspection of the tank(s) to identify any missing or broken hardware, Identify any cracks or leaks, measure the volume of
oombined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be
visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface.
The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local
Iegulatory authority.
When the combined accumulation of sludge and scum in any tank equals one-third or more of the tank volume, the entire contents of
[he tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin
Administrative Code.
INN other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units,
land any servicing at intervals of s12 months, shall be performed by a certified POWTS Maintainer.
i4 service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
Page of
START UP AND OPERATION roducts or other chemicals thrlt
For new construction, prior to use of nd/or PoWTS damagehthe dispersal treatment ~ (s(). s) if for high the presence of concentrations are painting p detected have the contents
of tho
cell
may impede the treatment process orator prior to use.
tank(s) removed by a septage servicing op p
System start up shall not occur when soil conditions are frozen at the infiltrative surface. ble
ower outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater Power will
restoring discharge of ef#luenlt.
the or su During p In one large dose, overloading the cell(s) and may result in the b rotor prior rface
discharged the dispersal cell(s) um controls to restore normal levels removed of avoid this s situation have lthe contents of the umberr or POWTS Ma tanklner to
assist Inymanualy operati ig the p
effluent pump or contact s a
within the pump tank.
Du not drive or park vehicles over tanks and dispersal coils. Do not drive or park over, or otherwise disturb or compact, the area within
1 1i feet down slope of any mound or at-grade sod absorption area. disinfectants; fat; found ation on drakn
of the following from the wastewater stream may degreasers; dental floss diapers; disinfectants; prolong the life of the POtl ss; Reduction or elimination medications;
oil; 9 i
antibiotics; baby wipes; cigarette butts; s °gasolineb grease; herbicides; meat scraps; paintin
(.sump pump) water; fruit and vegetable
pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT is permanently taken out of service the following stops shall be taken to insure that the system is propejly
When the POWTS faits and/or
and safely abandoned in compliance writh chapter Comm 83.33, Wisconsin Administrative
sealed.
• Ail piping to tanks and pits shall be disconnected and the abandoned pipe op Septage Servicing operator-
• The contents of all tanks and pits shall be removed and properly disposed of by a
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filed with s{pll,
gravel or another inert solid material.
lis
CONTINGENCY PLAN measures have been, or must be taken, to provide a code comp hn
if the POWTS falls and cannot be repaired the following
replacement system: A suitable by requU~ed soil abso replacement area has been evaluated and may be autilized for the nd compaction and sof a replacement infringed
psrpt nnthe teed
The replacement area should be protected from disturbance with the a nEj the
replacem setbacks from existing and proposed strums sh aisuitablea placelms. Fa ent area.t Replaccem nt systeemsomustcomply ruleft in
for a now soil and site evaluation to es
effect at that time.
E3 A suitable replacement area is not available due to setba aandd/orO~Smitations. Barring advances in AOWTS techno ogll a
holding tank may be Installed as a last resort to rapists t
t been evaluated to identify a suitable replacement a~ eUpon failuavail b e aOholdfng tank may beeinstaifed~as
0 The site has no
must be performed to locate a suitable replacement area. I no repl
e.moval of the biomat at the infiltrai ve
a last resort to replace the failed POWTS.
[3 Mound and at-grade soil absorption systems may be reconst~ rules in ellace following
surface. Reconstructions of such systems must comply with th in at that
«WARic, PUMP OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT
ENTER OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE O~ A
SEPTIC, PUMP AND
A SEPTIC, PUMP OR
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. -
ADDITIONAL COMMENTS
pO'-'TS MAINTAINER
POWYS INSTALLER Name. ~ '
Name
l Phone J
Phone r ' ¢7
SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY
SEPTAGE Name ~f ✓
Name ez - Phone
Phone 7J ✓ J
was dratted in compliance with chapter SP5 383.22(2)(b)(1)(d)&(f) and 383.54(1), (2) & (3), Wisronsu► Administrative Code.
This document
ILTED . L
RTRIDGE INSTRUCTIONS
Iraestallatirn
s,ri5p Y Dry it the giggler case, 'into the and of the outlet pipe to ensure it is
centered under the access opening, if nutv then either insert 11,18 pipe into the
tank through the outlet or solvent weld (yflue) additional pipe onto the nutlet
pipe.
.5 MP 2 While the rase is edit dry Fitted on the outlet pipe, measure the length
of 114-inch pipe needed to bractj the filter to the tank and wall if utilizing the
vpNonal supplemental Side support. If side support method. Is not utilized,
proceed to stop '(our.
s• V.•i' ~i For' installations utgrzjog the optioned supplemental side support:
solvent weld the '%-inch tripe onto the finer case. If side support Method is not
utilized, proceed to step four.
-Solvent weld the Biter case Onto the nutlet
cartridge into the case, preesin) down until the filteriocks into the bottoms of
the rasa.
..tJd
';txr
If a VAS switch is utilias d. insert into the filter and cock b ttirnin r$ ;
clockwise 9ti°. Y J
Maintenance
1. The effluent filter should he cleaned every time the septic tank is
serviced.
2. Open the outlet access opening to inspect the tank and War. ~ I
3. Pump the septic tank colr lutist
p Y, making yore to re
layer on the bot move the sludge
tom at the &lnk and not Just the scum and effluent.
4. once the effluent level has heart lowered below the invert of the • c•
i~outlet pipe, firmly pug up on the titter handle to dislodge the ~
cartridge from the case.
a;
5. Slide the cartrdge up and of it of the case for cleaning.
~
G, it a Vtts swgatle connected to an alarm is present, the swrtth
should be removed by turning counterclockwise 9Q
and deaetetd
with water only.
7. While holding the cartridge cn its side (large flat surf ice facing T ,,y
down) over the access ope 4iii, rin6t tiff the cartridge with water y
only, making sure all septa S!,: material
Is rinsed
back
into the, :.l • ,
t tank_
s. if vRs switch is utilized, replace by loserting into fitter and
turning clockwise 9t]
.h
9, msca the filter cartridge back into the cage, pressing dawn tintil
the filter locks into the bottom of the case.
10.ReplaCe and secure the acce5's Opening or, the tank.
~rr:••.: K;, r.:..,, lc-Yq;aq ~S:d+trt' rlrq,. ,,t,t,:.frFt'wl_`:VAS?ft.t v..
wwwbeamaWte.com 877-MMLPI ,T`ERS (653-4583)
12
. 1111111111111111111111111111111
81 21652
State Bar of Wisconsin Form 1-2003 Tx:4097682 -
WARRANTY DEED 971055
BETH PABST
Document Number Document Name REGISTER OF DEEDS
ST. CROIX CO., WI
01/09/2013 3:30 PM
THIS DEED, made between Troy Development Corporation EXEMPT*: N/A
REC FEE: 30.00
("Grantor," whether one or more), TRANS FEE: 119.70
and Troy M Fredrich and Ellen C Frcdrich - PAGES: 1
("Grantee," whether one or more).
Grantor, for a valuable consideration, conveys to Grantee the following described real Recording Area
estate, together with the rents, profits, fixtures and other appurtenant interests, in
St Croix County, State of Wisconsin ("Property") (if more space is Name and Return Address
needed, please attach addendum): River Valley Abstract & Title
1200 Hosrford St. Suite 201
Lot 161, Plat of Troy Village Sixth Addition in the Town of Troy, St. Hudson WI 54016
Croix County, Wisconsin. File: 2810393
040-1308-00-161
Parcel Identification Number (PIN)
This IS NOT homestead property.
(is) (is not)
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except:
Easements, restrictions and rights-of-way of record, if any.
Dated January , 2013
Troy Deve me Corp do
(SEAL) (SEAL)
* Courtnie Kirvela , Vice esident
(SEAL) (SEAL)
* *
AUTHENTICA`IONE L, DeACKNOWLEDGMENT
4 -11
Signature(s) - STATE OF WISCONSIN )
) ss.
authenticated on - r: ST CROIX COUNTY )
e~ Personally came before me on January 7, 2013
oration clay, Vice President of
TITLE: MEMBER STATE BAR`t`'*Q"III fill fS1yaR9I~ Tro bDevelopment Corrtnie
(If not, to me known to be the person(s o /c ed the foregoing
authorized by Wis. Stat. § 706.06) instrument and knowledge
THIS INSTRUMENT DRAFTED BY:
* Lorrie . DeMars
Doug Berg Notary Public;'Sta o
1200 Hosford St, Suite 201 Hudson WI 54016 My,Commisgion (i ermanent) (expires: March 20, 2016 )
not necessary.)
(Signatures may be authenticated or acknowledge . Both are
NO•rE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORA SHOULD BE CLEARLY IDENTIFIED.
WARRANTY DEED ® 2003 STATE BAR OF WISCONSIN FORM NO. 1-2003
*'5y& game below signatures.
$9620" 14 E 10 114
i ~
160 ~ ~ i~ a 1 1
161 1101 162
IMO ACK
4 3*5" Sfa F 43,586 &F
~ a
134..Q i ~
1,3.05#
IL
UIRFIELD TRA
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer .1.0
Mailing Address
Property Address ?r
(Verification required from Planning & Zoning Department for new construction.)
City/State
Parcel Identification Number
LEGAL DESCRIPTION
Property Location Sec. L~ T z N R W, Town of
Subdivision 7' (J ~ 11~
C/ - - Lot #
Certified Survey Map # Volume ~
Page # _
Warranty Deed # Volume
. Page #
Spec house ye no Lot lines identifiabl
yes 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, if needed, by a li tensed 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 ver.fyinb 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 days of the three year expiration date.
I/we certify that all statements on is form are true to the best of my/our knowledge. I/we am/are the owner(s) of the
property described above, by virtue of a rranty deed recorded in Register of Deeds Office.
Number of bedrooms
SIGN OF APPLICANT(S) 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.
(REV. 08/05)
SOIL EVALUATION REPORT Page _ of
Wisconsin Department of Commerce i
Division of Safety and Buildings In accordance with Comm 85, Wis. Adm. Code County
ST. C 1 `
less than 8 112 x 11 Inch
Attach complete site plan on paper not
a I 11
include, but not Omlled lo: venical and horizontal reference porn (BM). ,
Percent slope, scale or dimensions, north arrow. and location a dlSta Date
2dD3 '
Please print all Information. e ewe
~1~ TiS~•a)c~t~ I
Penooar lnlortnauon you ProvWe may be used for secondary purposes rivecy !
Property Loca
Property Owner ST. ROIX CO Y
CONTt NEt.1 tla Y~ 11d S 1~1 T 2-t N R 19 W
~f~'P• Z DE El_OP b
M EM .Name « CSM# .
Property Owner's Mailing Address 1161 TROD( Q1 LI~GG Ai7D~ .
1~0 ~ ~p 6T. E SultE 100 ;
Phone Number. (C33 City (3 Village ;R Town Nearest Road
City State p Code '
5549 c7(►3 > 1-?5t.8 oy
00 1
-
New Construction User Residential / Number of bedrooms Code derived design Mow rate (0 GPD
,
❑ Repiacament Public or corttrnerclal - Oescrlbe: ~J~---
scw I A I r ~CVIAI_ _ Flood Flain elevation if applicaoie 1
Parent material _Z!
General comments i
CON\)SAT1104AL MA),L; UA)1D _MWQCtR-
and recommendations:
0. 1 Lop~u►rJ 6 RASE
~y
Z rt. Depth to limiting factor 7 12-14 in. Sor ication Rats i
[:.]A Spring # Boring
pit Ground surface slay. GPOR4
Texture Structure Consistence Boundary Roots
Horizon Depth Dominant Color Redox Description Gr. Sz. Sh. Etf#1 .Etta
in, Munsell Ou. Sz. Cont. Color Z.
_ 19 bK 6-5 34f- 0,7
1 -10 24 Z d1 C5 2uf-M .1 I,L
2 -I~ IOV rr 5 dt c~ - 0.1 LZ 1
MS r
00-1 d 0 1 3 L10 ~ '
0 l ZD - Z a" f
Z lzA zo 2 S
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o - 940
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pit Soil ' leatlon Rate r
®Spring # n Depth to limiting (actor n
Boring Ground surface elev. z6 q
xture Structure Consistence Boundary Roots
'Ett#2 j
Horizon Depth Dominant Col Redox D . Pllon GPD/~
Sz. Sh. '01#11
in, MunseU Qu. Sz. o t. Color Gr. s I
o-s o aZIZ d 1
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z/z L -M d Z~~-m 0 5 0. r
sl ~ - d as ,
3 3 1, wait 2f
d c s 2- 0.7
3 z
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1416 -too 10 v$ - i I I s 05 ad
s s. I I ofd 6e- i
Efluent #2 = BOD S 30 rnglL and TSS 30 mg1L
Effluent p1 = BOD > 30 220 mpll and TSS >30 < 150 rnyL CST Nlttrtber
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CST Name (Please Print) Signature
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Address L L STE Date Evaluation Conducted TelephonNumber ;
L4 ,Z, b -1'17.6
W9a75 1~4o'~AVe, RIUE FADS WY 54022 0 -0 (-"1t5
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(LDT 1W) Page Z- of
property Owner ~'n►YtlfilcJ~TAt- DE~EME,1n Pa I10#a~ -
❑ Boring
Boring #q3. Depth to limiting factor > In. Soil ication Rate
C Pit Ground surface elev. _
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPO/ff
Gr. SL Sh. -Eff#1 'Eff#2
n. Munseli Qu. Sz. Cont. Color
-4 ~21a - s Z- s h -m t7. J .Z
s Q,b :zqf " 0.1 I• Z
Z - 0 \k -
3 0-1`6 10%.A1t 2 ti d Lvf-rn 0
g d.S CS ."7 1 Z
'F t8-'LS 1 ~ 3 ~
zs 51ti
i '
Ew ES Wag"
i
a Boring # Boring . factor _ in.
❑ Pit Ground surface elev. It Depth to limiting Soil ~eplication Rate i
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPO/ff
'Eff#1 'EN#2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
i
❑ Boring
a Boring # _ in.
- Depth to limiting factor_ in. A lication Rate
❑ Pit Ground surface elev. N
Roots GPOIff
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary E1 'EB#2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. i
A'r
! 1
t
i
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Effluent #1 = BOD > 30 1220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOO, < 30 mg/L and TSS < 30 mg/L
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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. r
SBU-9310(1.6100)
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ELEV. 890.70 ELEV. 891.02
134.05'
8161C
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The site. %v rs graded after soil evaluations were ~
B 61A completed (see page ith final grade cle\ ations).
1 S\SICm ClCAaMOIIS should not be affected. but
EV. 894, depth below grade will need to be determined f
based on the amount of cut or till. BM
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4Vlsoonsin Department of Commerce SOIL EVALUATION REPORT Paco
Olvision of Safety and Buildings
in accordance with Comm 85. No. Adm. Code j
-coual 5T. C t
Attach Complete site plan on paper not less than 8 112 x 11 Inch in sl l 'V E P LD
include, but not Ilrntted lo: vertical and horizontal reference palm SMI. r ~~~tp1 ( \ I
percent slope. scale or dimensions, north avow. and tocatlan an distance to nearest road. C p sN o fN G 1 pate r
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Please print all Information. OCT 2 9 200 Rs wed b 5 /7 0
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Personal mronnsuonyou provide may Doused for secondary purposes ( Navy "W. 15.04 0)(-)).
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Property Owner T L~ N R I C1 W
CotJTI Na✓/JZ~kt_ t78 El.l7PM EM L7t~ 114 S I Lot # Blo if Name or CSht#
PropeMOwner's MadingAddress ctc C OY UVL~GE '
11a,00 A 6T. E sutTE 100 A00 Town Neatest Road
city State p code Phan umber'
f
t_A1n16 55449 (7~3) 7- lEw ~
GPD
~f Code derived daetpn now rate Q
Now construction User RetsldenUel! Number or bedrooms
❑ Repiacamenl t~ Pubifo or commercial - Describe:
Parent material ?~St UA_-j't A r -EVIA Food Plaln elevation d applicabia
General comments j
,
andrecommendations: COMje_h MONAL -r`►'_~ Ko D T~~~~S
0.1 LOAOW& 7ATIL
FAI C] Boring goo
Boring # in.
Pit Ground surlace elev. r n. pepih to limiting (actor SW ication Rate
Horizon Depth Dornlnant Color Radox Oescription Texture Structure Consistence Boundary Roots •E GPDmrEfttr2
in. MunseB Ou. Sz. Cont. Color Gr. Sz. Sh. i
0-b L _ L 0.5 0,
1 tO~cK~I _ -
Z fo-LY 40-2l t - L - L d 5h f - 5 a
3 - ~ Y 313 S►1 Z -m a.bl dh 't -fA • 5 0' ~ ~ '
S o t
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S 39 -to 1 vICS y 0 ~b 0 `IrK-b I 11 f- rr abK 5 Z-
tv -V- 1040(, - s
0 ( CIS o. f • Z
5Z-(~3 aYfr<3h, - S is I as - 0.1
I. Z
Boring #
7,A (COAT.) ~ Fj Boeing Pit Ground surlxbe elev. 111( h. Depth to Ilmltin() favor in. 'n• ~l - l"(1041 Rate
l GPO/
Horizon Depth Dominant Col Redox Description Texture Structure Consistence Boundary Roots •BR#1 •Etfd2
in. Munsell Ou. Sz. Cont. Color Gr. SL Sh.
e I
j r MI`S
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• Effluent #1 , BOD > 30 220 mg1L and TSS >30 1 150 mg1L Effluent #2 ■ BOO 130 mglL and TSS 130 mgk
CST Name (Please Print) Signature CST Number
ARI JO HOWL STE Nt,r„~r
Nl
Address pa vela. on Conducted Telephone liapho"a
W9%75 64C~'AVE:, IvE FALLS WI 5y02Z OS-LR-03 L~iS N11~-x'17$
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