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HomeMy WebLinkAbout042-1057-20-500 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 561094 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: Dalton, Steven M. Warren, Town of 042-1057-20-500 CST BM Elev: Insp. BM Elev: BM Description: Sectionrrown/Range/Map No: / 65 20.29.18.319A50 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER •IAO CAPACITY STATION BS HI FS ELEV. Septic L Tip- / i Benchmark ~1~-4.j F'& Z. /000 r $J 66 • /lam Alt. BM OO4 Al' l leedk 6pia -rap ar- 1.5 `T?• 35 Aeration Bldg. Sewer Holding St/Ht Inlet 91 7 17/1 0 G J TANK SETBACK INFORMATION St/Ht Outlet 16.6 90• $S TANK TO N P/L WELL BLDG. Vent toir Intake ROAD Dt Inlet a ! V"_ Septic W i A)Pr ,Q Dt Bottom Dosing O Header/Man. 112 .te Z Aeration Dist. Pipe /Z. Q~ Z Holding BotySystem v47. Z PUMP/SIPHON INFORMATION Final Grade D 9I' $ Manufacturer Demand St Cover, GPM Model Number TDH Lift Friction Loss System Head FOH Ft Force Len th Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width 7- 1 Length / No. Of Trenches II PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 Z jeLA-e,1~ A~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING manufacturer- INFORMATION Type Of System: CHA uBER OR 3d c 7 Model Nber:J DISTRIBUTION SYSTEM M& r 7 })-I: 3 05 Header/Manifol~ Distribution x Hole Size x Hole Spacing Vent Air Intake Pipe(s) V Length ~L Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center / Bed(rrench Edge Topsoil ~1 Yes 7M No Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 819 106th Street Roberts, WI 54023 (SW 1/4 SE 1/4 20 T29N R18W) N Lot 5 / Parcel No: 20.29.18.319A50 re. . t+ A 1.) Alt BM Description = , 2.) Bldg sewer length = 3~ - amount of cover = r ~Z 'I d r`- Plan revision Required? ❑ Yes j No Use other side for additional information. p ~(J J Date Insepctors Si ure Cert. No. SBD-6710 (R.3/97) 1 ~s 1 p1SR~>7t~j,T CoArity I L.~ Safety and Buildings Division ~ A- o { 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) F Madison, WI 53707-7162 Y "S4 " 3 S6/bC7 nitary~rmit Application State Transaction Number In accordance with SPS 383.212 , ~o1X& ode, submission of this form to the appropriate governmental unit Alo- is is required prior to obtaining a itary'pemlit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information yo id ay be used for secondary / /6 purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. I. Application Information - Please Print All Information 1 Property Owner's Name Parcel# o ► 7 J 5-f£C, £ D6)/Jnp 0V2--10,T -7 2- - 60 Property Owner's Mailing Address ? Property Location J 13/l _a L £ DI, Govt. Lot ( gm ~O City, State Zip Code Phone Number ~ ,/4 U S Section Z t C71" ~I/ i S/pL.3~ ' q circle one) /21 II. Type of Building (check all that apply) T N; R E or W or 2 Family Dwelling - Number of Bedrooms S Subdivision Name ❑ Public/Commercial - Describe Use ❑ City of O t~Ci ~J ❑ Village of ❑ State Owned - Describe Use y r CSSM Number z Q :to- Ce u,, c✓ 17 f- ( C~ L w."errs . '!i ~T QQO Town of LA__,? Q A. A_f A,) III. Type of Permit: (Check my one box on line A. Complete line B if applicable) A. k~bkw System El 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 Previous Permit Number and Date Issued Before Expiration Owner 1 IV. ""T a of POWTS System/Component/Device: Check all that app ) $m Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil El Holding Tank ❑ Other Dispersal Component (explain) t Device (explain) pffl" V. Dis ersal/Treat ent Area Information: 3 Y / s -fd G. ; CK S(s -Design Flow (gpd) Design Soil Application te(gpdsf) Dispersal Area Required M Area Propose (sf) System Elevation H so - 7 t;, Ll 3 L.8 f 8 7, S VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units ° o New Tanks Existing Tanks / c & Y a t7 a ~Ey3 f ~16 P` v En rn V. Septic r Holding Tank 'Y_ /D d tl / cS r~ w Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POW TS sho the attached plans. ber's Name (Print) 1 Plumber's Signature MP PR umber Business Phone Number Rc~~~ ~w ~i tiS LL2- Plumber's Address (Street, City, State, Zip Code) V11k County/Department Use Only Approved d Permit Fee Date I sued Issui Agent Signat even Reason enial $ #75 IX. Co ditio s of App/rloval//Beasons for Disapproval Or SY EM NEW: * ~d a- o r h y6~^- da,' P..A.3 1. Septic tank, effluent MW grid e/ dispersal cell must all be services l 1118104111116d S ~o✓~- /~Q r, 0, 7 rw~t - as per management plan provided by plumber. °2._ AU se4ack f}quiferrienfs mod ba;mekttafaEd 7 N , v f c5 jpe,_-not as per applkxble code >t ord arioea: Attach to complete plans for the system and submit to the County only on less than 8 1n x 11 inches in size SBD-6398 (R. 11/11) ti a S d d ~D h ~D a a 4ZA 1 CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Sf t v £ Owner's Name: 140 N Owner's Address: 930 /t-av t f ~D rti S c ~.Jl, ~ f ~ U Z _ Z o T Z `3 / c,~J Legal Description: /v/ if- S Township: ~Q .X-ti I" A) County: a r Subdivision Name: Lot Number. Parcel ID Number. C~ L? f-7 Zo -00 0 Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 SL Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber. a LL Ir )1-w K, i-S License Number. Z Z Z 877- Date: G-2--13 Phone Number '7/ ~r-y9/-j-36:g Signature Designed pursuant th In-Ground Soil Absorption Component Manual for POWTS Version 20 SBD-10705-P (N.01101). Page 1 w 1 0 -1 6 O n l d 7 v~ l i -41 ~ e V 1 r h' l a t x 4 n Soil Absorption System Cross Section l /,v ft 4" Schedule 40 Final Grade PVC Vent Pipe With Vent Cap 8~ ' $ ft Leaching Chamber 87. 8 ft System Elevation 3 ft 5, ft Soil Absorption System Plan View (1S ft 3 ft Leaching Trench 1 ft Vent Or Observation Pipe Chambers 111111111111111111 1111111111111111111111 111 4" Dia. I Trench 2 Header Leaching Chamber Specifications Manufacturer And Model OkA, c h (/S EISA Rating 2-0-0 sq ft per chamber Soil Application Rate -7 gpd/sq ft SU gpd Design Flow ; • 7 Soil Application Rate LO.O EISA = 3 Chambers 2 rows of 17 chambers each. Page of F F IMF ~ - E fl u € r c j Lj E v 3 C Q v Z C w ID 5 U= {J I I ac 3° ~ C m c ~ - O r E~ V U Y v - V r - C d= y 0 h t" ? d L' y` a v y m ~ O 3 e s o V E U t>1 v o tom.{ ~ ° y f1 = c y P a ` r w > Y~ C ~ z v a c -t' r v -Z c _L v U y~~ B V1 L C fn fG M. U _ e« I T-i p ~ O-~ y~ V o - a=v ;15 - -0 '7 L-r - d r e V m O _ O 'c. - EE~ a D O ' d^ y C/ 61 y u Y L O ~ p x 0 r~ ~ ~ oo~uN L ( 75 IJa~= L UID `j WINE I& SO m v d - rV :u_ r L G ? L AIML ~ ~ a c O V L V N I V; ri d G! d C ~ ■ R 7. E o r o ( rg rr, L Je till r ~o L 44, c L -z! it - L • v [ ^ d N o ® G o d r-i CU L VJ YJ d U Vl u V vii C H i.+ 11~ 1~ IIi ■s H POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner / 'V Septic Tank Capacity /0,10 gal ❑ NA Permit # Septic Tank Manufacturer f j14 w ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units Z?9A Pump Tank Capacity gal -0' II~A Estimated flow (average) S~ gal/day Pump Tank Manufacturer .0-NA Design flow (peak), (Estimated x 1.5) (0 7,T gal/day Pump Manufacturer -ACA Soil Application Rate - -7 gal/day/ft2 Pump Model 0-11A Standard Influent/Effluent Quality Monthly average* Pretreatment Unit Fats, Oil & Grease (FOG) :530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODr,) <_220 mg/L ,2-NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) <_150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) D NA Biochemical Oxygen Demand (BODd 530 mg/L Win-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) :530 mg/L _0'NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 510° cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y. in dia. 121GA Other: ❑ NA Other: D NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA s'year(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA 0'year(s) Clean effluent filter At least once every: / ❑ month(s) D NA -B-year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) 4T A ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s) .0MA ❑ year(s) Other: ❑ month(s) At least once every: DNA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any 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 regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of <12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant rep I cement system- A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < < WARNING > > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name x 'AS J f ; e- Name Phone ,x'388 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Q 3- 7 Name 51, e't.o>X a Lc All~ Phone. Phone y 164 (PAGE 516 6.4 6 67.4 STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH Document Number I ST. WARRANTY DEED REGISTER OF DEEDS WI This Deed, made between Archie Denucci and Ella Denucci, as RECEIVED FOR RECORD Trustees of the Archie Denucci and Ella Denucci Revocable Trust dated 05-29-2001 11:00 AM September 14, 2000 WARRANTY DEER EXEMPT N i , T COPY V FEE: Grantor, and Steven M. Dalton, a single person CERT CORY FEE: TRANSFER FEE: RCORDING FEE: 12.00 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area Name and Return Address SEE ATTACHED First Federal Savings Bank LaCrosse 201 So. Second Street Hudson, WI 54016 This deed is given in fulfillment of that certain Land Contract between the parties hereto dated December 12, 2000, recorded December 18, 2000 in 042-L057-20-000 Vol. 1568, page 213 as Doc. No. b35444 Parcel Identification Number (PIN) This is not homestead property. ly:d (is not) Exceptions to warranties: Easements, restrictions and rights of way of record, if any. Dated this day of May 2001 slow * Archie Denucci * Ella Denucci a AUTHENTICATION ACKNOWLEDGMENT STATE OF WISCONSIN } Signature(s) ) ss. S-F C a , y County } authenticated this day of Personally came before me this...... A y day of May 2p0 named Archie Denucci and Ella Denucc. ~'a 2• hie y Denucci and Ella Denucci Revgttbl@ u*date gplRSnher 14, 2000 = _ " • TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the persons o e@c t theegoing r (If not, instrument and acknowledged fatq.e2 ` 4L authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Attorney David J. Estreen Notary Pu ic, State of Wisconsin 304 Locust Street, Hudson, 1 016 My Commission is permanent. =anent.(Iff no ot not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) ~ - Information Piofeaal I* Canpany. Fond du Lac, wl 'Names of persons signing in any capacity must be typed or printed below their signature. eoo-esszoz~ STATE BAR OF WISCONSIN WARRANTY DEED FORM No. 2 - 1999 vvi- 1647PAGE 517 PROPERTY DESCRIPTION A parcel of land located in part of the SW'/4 of the SEl/4 of Section 20, T29N, R18W, Town of Warren, St. Croix County, Wisconsin, described as follows: Commencing at the SE corner of said Section 20; thence S89°10'58"W 1302.28 feet along the south line of the SE`/4 of said Section 20; thence NO0°08'34"W 371.09 feet along the east line of the SW1/4 of the SE'/4 of said Section 20 to the point of beginning; thence NO0°08'34"W 280.52 feet along said east line; thence S89°51'26"W 358.70 feet; thence S22°19'20"E 108.35 feet to the point of curvature of a 433.00 foot radius curve, concave westerly, whose central angle measures 24°22'00", whose chord bears S 10°08'20"E and measures 182.76 feet; thence southerly along the arc of said curve 184.15 feet; thence N89°53'54"E 286.08 feet to the point of beginning. Above described parcel contains 2.00 acres, 87,120 sq. ft. ROAD EASEMENT An easement on a parcel of land located in part of the SW'/4 of the SE'/4 of Section 20, and part of the NW'/4 of the NE'/4 of Section 29, both in T29N, RI 8W, Town of Warren, St. Croix County, Wisconsin, described as follows: Commencing at the SE comer of said Section 20; thence S89°10'58"W 1602.70 feet along the south line of the SE'/4 of said Section 20 to the point of beginning; thence S02120'40"W 35.21 feet; thence S87°55'37"W 66.17 feet along centerline of 80' Avenue; thence N02102'40"E 415.07 feet to the point of curvature of a 367.00 foot radius curve, concave westerly, whose central angle measures 24122'00", whose chord bears N10°08'20"W and measures 154.90 feet; thence northerly along the are of said curve 156.08 feet; thence N22°19'20"W 135.25 feet; thence N89°51'26"E 71.27 feet; thence S22°19'20"E 108.35 feet to the point of curvature of a 433.00 foot radius curve, concave westerly, whose central angle measures 24°22'00", whose chord bears S 10°08'20"E and measures 182.76 feet; thence southerly along the arc of said curve 184.15 feet; thence S02°02'40"W 375.11 feet to the point of beginning. IIIIIIII~IIL'bIIIIIIIIIIIIII11111111111111 887468 BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 01/28/2009 08:OOAM CERTIFIED SURVEY MAP CERTIFIED SURVEY MAP VOL REC4FEE:PA1~5.005ti03 LOCATED IN THE SW Y4 OF THE SE Y4 AND THE NW Y4 OF THE SE Y4 COPY FEE: 2.00 OF SECTION 20, T29N, R18W, TOWN OF WARREN, ST. CROIX COUNTY, WISCONSIN, SS9°04'58*W LEGEND Wy CORNER OF SEC. 20. S89°0458W 3915.39_ ( ALUMINUM CAP FOUND) 1 i$ 1304,79c - INDICATES SECTION CORNER ( AS NOTED) BEARINGS REFERENCED TO THE EAST - • - INDICATES V IRON PIPE FOUND WESTY4 SECTION LINE OF SECTION 20. - INDICATES V X 18' (OUTSIDE DIAMETER) ASSUMED TO BEAR S89°04"58'W. `ll w °w IRON RE-BAR WEIGHING 1.502 LBS / LIN. Ff. SET 0: 2 ■ - INDICATES Y4" REBAR FOUND UNIPILAWED + o g g U - INDICATES PROPOSED DRIVEWAY LOCATION LANDS 1 v In - N89°04'58"E 562.28' - W OWNER / SUBDIVIDER STEVE DALTON - 816 106th STREET To Be Dedicated tO the PJbk -o ROBERTS, WI 54023 12' Utility Easement - -A pprmdmattlSbOth- ngof N89°04'58"E 496.25' ~ ®i i the NWY ofthe SE Y. w co I _ _LO_T8 87,1202S.00QUAREACRESFEET I I ~ / L Approximate North line of ~ ; ~ I , as61r the SWY, of the SE Y. o ~ I N89°tM'S6'E m ~ I - ~ C S i m 1 1VM THE DRAINAGE FACILITY z i LOT 7 LU ~ . SHOWN ON LOT 5 WILL BE I I MAINTAINED BY THE OWNERS OF , THE LOTS SHOWN HEREON AND ; PROPOSED 87,120 SQUARE FEET IN ACCORDANCE WITH THE PROVISIONS SET FORTH ON THE DRNE ( 2.00 ACRES ) HOME OWNER'S ASSOCIATION AGREEMENT AS RECORDED IN I I _ DOCUMENT NO. i Mg-W58'E 496.06' I I b N07E THE NET PROJECT AREA OF I'l11 12' Utility Easement LOT 6 LOT 5. EXCLUDING THE 50' SETBACK ; t o0 FROM RIGHT-OF-WAY. THE DRAINAGE , o EASEMENT AND A IS SIDE YARD 87,120 SQUARE FEET SETBACK = 33,038 SQUARE FEET ' _~sE° (2.00 ACRES) (M76 LOWEST BUILDING \ OPENING = 993.35' Q N ELEVATION =1000.71' ELEVATION X95 x \S N86°1 W42-E 449.41' +86.48' S- 2 N_VJ R HCiUD LOT5 : t \'II M 87,120 SQUARE FEET I a • - ( 2.00 ACRES) i a ° LOWEST BUILDING I ° x OPENING = 99335 I S67°40'40"W ` l Nes'iz24_s°e°g-~ 66.00' \ _ oI.>ww I 30 V 82°4224.W 361.51' x I \ \ L®Tg Cakc ELEVA ON -A7.14' \`N \ \ I VOL. 17, PC. 444 \ `7D \ \ L®F'2 C SLAL XI Vol- 17, Pa. 44" i------- _ _ - - - \ \ Scale in feet 1"=120' I C-S.M AV \ x l 4S son L®T3Cam I- - V01- 17 PG. 4 " \ 1 0 120 240 1 SHEET 1 OF 3 DRAFTED BY: S.E.I. REVISED 0609-W ~lXl 1 of 3 Vol 24 Page, 5603 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer D., 17 0 - Mailing Address 930 15A_u Property Address 6 (Verification required from Planning & Zoning Department for new construction.) City/State PIA)r- 5467- Parcel Identification Number /P$] - Z a - b*Q LEGAL DESCRIPTION Property Location '/4 , Sec. T 2-`'l N R ~S W, Town of LcJ ~A- Subdivision Plat: , Lot # .-1--. Certified Survey Map # s-.-6-74406 , Volume , Page # Warranty Deed # ~p4 Ca(,o74 (before 2007)Volume , Page # Spec house' yes/no Lot lines identifiable/ yes l 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 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 ( I ) 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. 1/we, 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 this form e true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty ed recorded in Register of Deeds Office. Number of bedrooms / 4 /t3 SIGNATURE O 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) 1 i r wiwwWnDepartnwtofDomrnorca SOIL EVALUATION REPORT Pago_ ~ of Division of Safety and Buildings _ in aocord,j fj)h Comm 85, Wit:. Aden Code coun"Y ~~OO 15-f, CIst- c:k Attach complete Wto plan on paper ticiLl~than a 112 x 11 Inches in sire- Plan must Include, but not limited to, v4rkal a dzontal refs emopolnt(8M), dira nkr, Parcel Z(~ -Q d 6 paroant alopo, eoalo ordmcndonw, north arrow, nss~tLL hand dl Please P1,10 rmatiarL Ravi by Date Personal Information you provide may he used for oooa (Privacy law, a. 16.03 (1) (m)). Property0wner • " property Locatla7 5a 140 /d C.M. Lot L"', -~Z 3966' 914 ~ 6 T Z ~ N R & E (or) W Prop" owners Mailing Address Lot Ill Block 9 f3ubd. Nan -Wv ay-) state zip code Phdrle Number 0 City © Village 09 Town Nearest Rcs4, -K o &,c ~v; ,5- yd L 3 ( 7!S) 7Y9 l v ,x 4 F /06 , ow Oonelruouan Uoo ke#;Wdentlet 1 Number of bodroorrro OV Cods, dorivad design flow rests 00 C;Pn 0 Replacement [3 Public or commercial - Dewride: Pamt material f=lood Plain elevation it apple-abla _ 11- General comments and rao:iwandationw. Y- a Boring r❑t Boring q tc~ Pit Ground surfateelev. it Depth to limiting factor > (~p ! in. Soil Application Rate morizon Depth DuribtrmdCulur RwdcxDaauipbon Texture atruoturo Coneletence Boundary Roots GPOIN in. Mu IWI 4u, Sz. Cont. Geier Gr. Sz. Sh. 4MI `Eff#2 Y.- - %Sr, ~ 0 .31 °7 9 !6 ti ~`i II ❑ Goring 'r Borir~ ® Pit Ground surface elev. ft. Depth to urrnang taotar Cp d in. Soil Application Rate [H6r&12m Depth Dominant Color Redox Descrtplion Texture Structure Gonslatonce Boundary Roolw GPDff in. Mullwe l Qu. 3z. Oank Color &h. `EffJf1 'H1flk9 0 -7 ~0~ 7 I~t1,tr Y/1, c c w - i A erU4 " Effluent 09 = Bdf?> 30 * 220 mglL and 198 A0t 154 r1101- Etiluent , d2 BOO e < - 34 aril-138,< 30 rrtttlt- - CST (I:11Wsa Print) Signature CST Number A r c rdl y , l.S 7, Z z 8-7 1- a I Data EvNf lk 7 6 6, 1 rlatlon Conductad Telephone Number ddre 3 - i ~t'7L - L L 3 k 3 171 oy- b.:T• F,h'~,? Intl? ~I~'.'TA v Property Owner Parcel ID t# Page Z of( `L opring # ❑ Boring qz . 3 ~~~f y 19 pit Ground surface elev. ft Depth to limitlng racior in. Soil Application Role ~ Horizon Depth Dominant Color Redox Deaoriptlon Texture Structure Conslstanoe Boundary Roote GPD/W in. Muneell Qu. Sz. ConL Color Ur. ;iz, tin. "Efate •ttiAr2 as -7 a,5 2- - J -13 S Z- -7 7- L,0 s o - z 1. Boring f# ❑ Voring u ❑ pit Ground surrace glwv ft. neplh to 1hyd!na factor in. sod Application Kate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM In. Munsell Qu. Sc. Cont. Color Gr. SY. Sn. *EIV1 'EfN#2 Boring # 13ainp ❑ pit Crowed surface elev, ft Depth to Umltlng factor in. Soil A lication Rate Horizon Depth Dominant Color Redox Descriptlon Textwe St lure Consistence Boundary Roots GPDIff in. Munsell Qu_ Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 "002 Effluent #1 = BODO, } 30 < 220 rn91L and TSS >30 r 150 mWL * Eflkient #2 = BODO < 30 mglL and TSS a 30 mgll. The Department of Commcrte is an equal opporhmity service provider Tntt cinpluyer. Iryou need assistance to access scrvices ar need matcrial in an alternate format, please contact the depattment at 608-256-3151 or TTY 608-254-8777. sou-xr~ap~(nrao) Z0/Z0 39Vcl XVA 911Ihll:Z A-10d 9OZ698t,914 6b:91 800Z/8Z/10 JO vl u ~ a N w a ~ W N 1 `C y s I NIZ T ~ / 9o I -JS 1 U n e 3 t 41 \ c+ A Q O Q r. ~ ww A