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HomeMy WebLinkAbout030-2126-80-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 569552 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: Romzek, Mark& Laura I St. Joseph, Town of 030-2126-80-000 CST BM Elexy: Insp.BM Elev: BM Description: Sectionrrown/Range/Map No: j Cl G�, L� /U�'' C` k- -, -'LCI [-) «7 / 25.30.20.1032 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STA,T,I NI 1 q BS HI FS E LE Vr Septic Benchmark(J p � � /07 Dosi n�� Alt.BM --r-7_3,46. qj 1 Aeration Bld .Sewer / 1 GI B �! " 61%z /''_ �' D ,I `17, 3`f Holding G�t St)Ht Inlet / S�/Ht TANK SETBACK INFORMATION Outlet �6 Z TANK TO - `�L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic >!�3 7, >ZOd `� / Dt Bottom Dosing Header an Aeration Dist.Piped Holding Bot.1 J V M o./ Final Grade / 0).INFORMATION / SSO `D/� ?& Manufacturer VVV GPMand St Cover Model Number ) D .s / ` TDH Lift Friction s stem Head TDH Ft Forcemain Length Dia. Dist. ellq SOIL ABSORPTION SYSTEM �y]/ t 6h. Wi t, U v t-f(.441 BEDITRENCH Width 1 Length 1 No.Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 SETBACK SYSTEM TO P/L fJ JBLDG WELL LAK REAM LEACHING, Ma rer�:L INFORMATION CHA R OR l Ty Of System: , / UNIT 1r6 , 0 \ �� �� Model Number. 0 DI IBUTION SYSTEM tV,/Jz 1 ­71 Bader anifov Distribution t t1 x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length S p acin g / 7D O Dia � SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Dep ve / L Depth Over xx Depth of xx Seeded/Sodded xx Mulched Be t rench Center 7 Bed/Trench Edges Topsoil / Ej Yes No 0 Yes 7LjN], 7 COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / ? � //q t'inspection#2:�/�/� /� Location: 13 1 Birc Park Ridge Hooulton,WI 54082(E 1/2 SW 1/4 25 T30N R20W) Birch Park Lot 28 P Q Parcel No: 2�5.�30.20.1032 ` (� 1.)Alt BM Description= F h tYJ„�r�c'(Cf° h�7 f )h G- > i�(t.r.j I C L vQhU.�,e d 74•tIl�1 2.)Bldg sewer length I -amount of cover n,f'L�_ ' Plan revision Required? Yes No Use other side for additional information. 6 (R.3/97) Date InsepctorqSinatture Cert.No. � I I ' I � � rp �yjj��(j`7 ,1 I C'VAI$)t� Ay �LGQ V v��ts i s C>to-) �.o ca�u c r as 3 I ch. 1 � � I L commerce.wi.gov Safety and Buildings Division County■ W. Washington Ave.,P.O.Box 7162 S" 'S c0 n S'n Madison,WI 53707-7162 Sanitary Permit Num filled in by Co.) Department of Comm e �� Sanita rmit Application S*,teTr action u in accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental tiJ(/ RO/ unit is required prior to obtaining a sanitary permit. Note: Application fortes for state-owned POWTS are Project Addi's ((f an mailing address) ur oses in accordance with submitted to the Department of Commerce. Personal information you provide may be used for secondary £L® � the Privac Law,s. 15.04 1 m ,Stats. / I. A l""On Information—Please Print All Information Property Owner's Name Parcel# Property Owner's Mailing Address 27 -I /YJoiri Property Location / �iI it�a � D Z City,State Zip Code Phone Number Goat.Lot S �!v A. _ u1 Pw '/., Section 2_ (circle on [I.Type of Building(check all that apply) Lo T _N; R .ZD E o WP 1 or 2 Family Dwelling–Number of Bedrooms 2e Subdivision Name 6k lock# ��r ❑Public/Commercial–Describe Use JSe— J C,,v\� ❑ City of ❑State O ed—Describe Use ( r Q / CSM Number , Village of 3 ���• �1.� (�✓ U f.0�� �TOWnOf ST �fOst.ra� t v O O III.Type of Permit: (Check only one box n line A. Complete line B if applicable) A. New System Y ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) B• ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber List Previous Permit Number and Date Issued Before Expiration g ❑Permit Transfer to New Owner �" lG LJ IV. a of POWTS System/Component/Device: Check all that apply) {•� Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) V.Dis ersaVTreat ent Area Information: Design Flow(gpd) Design Soil AP,plication Rate( sf) Dispersal Area Required(sf) Dispersal Area Propos ( System El eva on ISpe 43400 Z11,D0 9 VI.Tank Info Capacity in Total #of Nlanufacturer J r Gallons Gallons Units c New Tanks Existing Tanks iz a C7 v Septic or Holding Tank Dosing Chamber IA/ • 6.r VII.Responsibility Statement-I,the undersigned,assume sume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber' Sign a MP/MPRS Number TBusiness Phone Number Plumber's Address(Street City,State,Zip Code) , . c' VIII.Count /De artment Use Onl Approved ❑D' Per�miit Fee_oo Date sued Issuing t Signatur iven Reason for Denial $ 7 7✓ '� IX.Condt �JIAAg3 easons for Disapproval Y Depot;tank,effluent filter and ,dispersal cell must all be servtces/maintalrA • as per Management plan provided by plumber. 2d ckQuitetants most be malntainad ss per app k tacde 1 ordirWIM. Attach to complete plans for the system and submit to the County only on paper not less than s in x I I inches in size SBD-6398(R.02/09)Valid them 02/11 CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: �C► �+`►�,�J / �!!Lm Z t�/ Owner's Name: fie�/�--�t,��h ,�O �,,•a •�oM ;Z�C I� Owner's Address: .2 7 y,2 /�'f�rh ir�o ��a� �i�/� �/ Cr ��,f 4j,' Legal Description: s 4f y 15 2.S" :36 /U/Q 2D UJ Township: County: Subdivision Name: ,���►c� ArK Lot Number. 28 Parcel ID Number: 03 0 Page 9 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 St. Croix Cty Septic Tank Maintenance Form Page 8 _ Warranty Deed Page 9 CSM or Plat Attachments: Soil Test&House Plans Designer/Plumber: '�ul / ,0M/e,* License Number. /� ?2.s' e Date: �„p / .?yj/�j/ Phone Number Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P(N.01 101). Page 1 _- ry I I I ° � f I G II 1 i fQ �1 f YD �- i �� s 0- U IC --- �l6e e Fovd� Ab J �� �t I(tTLheS c• � �'� ��^tS I I©®'o I 3, �, �tl 1 - = - ►o6 ':k o p cc�i r \ � 3 fJ ) Qrnz IA � rl3 � � S SOIL ABSORPTION SYSTEM DETAIL/GRAVELLESS LEACHING UNIT Page�of� Project Name: No. of Cells 8 Per Cell r -ft Cell Width .73( Total No of,ez )02a,f ft Cell Length �40 sq ft EISA Per Cell _ft Cell Spacing 20v sq ft Total EISA Manufacturer Model Laying Length EISA Rating Infiltrator EZ1203H-5ft 5.0' 25.0 EZ1203H-loft 10.0' 50.0 Gravelless Leaching Unit Manufacturer: Zof/ Gravelless Leaching Unit Model: LIZ F� Typical Cross Section Finished Grade ft Observation Pipe with approved cap or vent ■ �✓ Soil Backfill JZ i • Geotextile Fabric ............. . . 12 in Infiltrative Surface 0 I ---- �It Limiting Factor in Slotted and Anchored Vent[ _ ______ _- Observation Pipe with Cap Plumber/Designer Signature: License#: Date: pmr EZ_1203H ♦ 'f yr s�' _°•ter r-^�• •�': oOrrgt♦ .:`c,,E'.r_�,s.?;r•�., L"".`... Y .C..r rrr�iii� rrerrr 'v`i.: VVVVWrr 24,4 „- <. t: 2 144 �rrr } °__ , ... 4. 25" a '. . ..* v .`• - 1 -'t- W cry. - r`�irif ��irrtvo�r�k��rri� a�►r�� rt-ter ►ar !! rat* - t` r v vri►�r i�l�iir�� t 24" Boers Vo a CadflComt i-waj�,, at 37.4x sett APM O.D.Of r Pik=4.623; b= Sidewat[(z-smawa . Zs��= 344 Void"hoM Per remr ti:t 3.44 Q.D.of�.rF2.3int3tes TwitlSaillAtcrfaaAraat - _ S.l# void.otutr id 3_44• ti.1SaR s t3nf�� `3.44`( Dpi:ofvrtsi*9s=1Z Projected Trem-*At+m .57s s 9a1 R' SdLwM1 IJC4*=`12 in.!2 =2M Sq.FL 'OW rotmne t Sotlon bctw=m 36 fL 3.w$q.ft qR ��tZiwffc t2w/6�� fl�slfe� 6.1tStN P+'ojT-newe[tAs� � � . rotttttte at swede b6m-ems Ftf2.aFvoid vOi bet1MOC7t 14213 12�a.[Q6 as COOS 4.763 oubie per 6 1.763 Xc 7.48 t t A e-4ot . Trench Seem . EZ120.3H , . ow � O-k Gr4DU 65 Pa* Rd. 0 and. TR AaWo - a�ee - � •FZ�it-,rs4- ice: t i t 4t z7-4rt l -inc INSTALLATION INSTRUCTIONS A i°o.00Mokk,:. PL-525/PL-625 FILTER PL-525/PL-625 FEATURES & BENEFITS IL Features & Benefits: •Rated for 10,000 GPD .PL-525 = 525 Linear Feet of 1/18" Filtration PL-625 = 625 Linear Feet of 1/32" Filtration PL.-525 PL-625 *Accepts 4" and 6" SCHD. 40 pipe The PL-525/625 Effluent Filter should operate efficiently •Built in Gas Deflector for several years under normal conditions. before *Automatic Shut-Off Ball when Filter is Removed requiring cleaning. It is recommended that the filter be cleaned every time the tank is pumped or at least every *Alarm Accessibility three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the •Accepts PVC Extension Handle filter needs servicing. Servicing should be done by a certified septic tank pumper or installer. RECOMMENDED PRODUCTS Polylok PVC Fitter Extension Handle N J F�M1 S<y Risers&Riser Covers Extend& Lok- Riser Safety Screens Fitter Alairrn Panel and Polytok risers bring your Polylok Extend&'LokTM Polylok safety screens SmartFilterT""Control septic tank cover to grade. is a simple, easy to use prevent tragic accidents Switch This allows locating and solution that can extend from happening by children. Polylok lifter alarm panels servicing your filter easier the inlet or outlet pipe and and pets falling,into open and switchs provid a visual and time saving by elimi- make filter and/or baffle septic tank entrances. and audible notification of nating digging to find tank installation a snap. impending.filter and tank entrance. Fits.3"and 4".pipe_ servicing. For a full list of Polylok products please visit our web site at: www.potylok.com 0001d1N`�� 95-v8-9Z2-008 OIOZ 'Ndf a3SA3N Z\ :anOd-LSOd 31va OIoz AavnNYP 31v0 05LK IM 'NOON N30IVH Ol AMH sn gurM 1dnNdW OIld3S n3a 3138�11�� 13J31M w �anod-3ad ,o-,t=.b l 3lvOS 3W5 �A8 NMVao aW-009/OOOld1M N w J Z � Z N J O V O Ld ^ t7gJ1 0 W Q O 30 F� (n Q w Loa o a O 7 v3 0 0 �o'er ^� LL. cai o �-m Z �z a o Z m chi I--I � w v I— w t, oQ Q_ i � �' v �� OZ LL, o °° o Q d p mN WJ{�.WW 00 Z Z d O U m m z > U O e s tW,,<Q ¢OO N OD�p WW ppptii fn 0 LL e 0 O M O N 4 m tal 4J N^ O Z> < U a 'Ne� Y n o Q a �U d 2 0 .. ' F- IN tnor co oQ pFt75 � a M� ..$F_ J� BaW � Q (n =3 W UN 00 �fn N 00WW' 03p y W m fn O a.p��>ZOZ�0�pO �Va OHO U O YjZ �� �X w0 z3m0M3:9 m�3 �d�c� �.. c o Z9< oo me F- O Z Z J-C z m Q 8� a � 81.- J Q N I Q H H Q w .6£ a � O � d a K Sv0 .� I wg2 do � i v 3 � °� 1 5 Q _j Q ° I oL ss N..... OL-Q __... _...._ __.. .. _. ...... ....._. ._...... _..... _.._ _.� .._.._.__._.... Wm o I < \ I Sv0 b N 1 „lb do Ix F� U s < M � J Q "Z� w 0036 tis Sv wss x FILE INFORMATION PoWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of -2, ---- Owner SYSTEM SPECIFICATIONS t Septic Tank Capacity Permit # p ty �d0OZ gal ❑ NC Septic Tank Manufacturer �L j, p Np DESIGN PARAMETERS Effluent Fllter Manufacturer Ida/ Lo ❑ NA Number of Bedrooms Q NA Effluent Filter Model a3 ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity N q Estimated flow(average) gal 'q ` 0 gal/day Pump Tank Manufacturer NA Design flow (peak), (Estimated x 1.5) — al/da Pump Manufacturer �NA Soil Application Rate y al/day/ft2 Pump Model N,N Standard Influent/Effluent Quality Monthly average' Pretreatment Unit Fats, Oil & Grease (FOG) 530 mg/L N,"► ❑ Sand/Gravel Filter ❑Peat Fester Biochemical Oxygen Demand (BODS) s220 mg*& ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS► 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BOD,) S30 mg/l g Dispersal Call(s) d NA 09 In-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) �0 mg/L q NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) S10'ofu/IoomI Q Drip-Line O Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: Othu: ❑ NA ❑ NA Other: ❑Nek *Values typical for domestic wastewater and septic tank effluent. Other: Q Nil MAINTENANCE SCHEDULE Service Event Service Frequency inspect condition of tank(s). At least once every: 0 month(s) (Maximum 3 years) ❑Nit year s) Pump out contents of tanks). When combined sludge and scum equals one-third (Y) of tank volume ❑ NA Inspect dispersal cells) At least once every: El Wt in years) Clean effluent filter ex At least once every: ❑ month(s) let yearW El NA Inspect pump, pump controls& alarm At least once every. ©month(s) Q year(sl PI/' Flush laterals and pressure test At least once every: ❑month(sl Cliher: ❑ year(al C4 W. At least once every: ❑ month(s) �NJ, Other: ❑year(s) MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certification&: 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 surfac8. 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 tine immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y) 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 11:3, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Ma ntainercomponCnis,pretreatmerrt A service report shall be provided to the 10081 regulatory authority within 10 days of completion of any service event. Page 1 of 2 START UP AND OPERATION For new construction, prior to use of the POWYS check treatment tankls) for the presence of painting products or other ehemic that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the canter 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 I discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restori! power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls 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 are 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 th POWTS: antibiotics; baby wipes, cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; Lt. foundation drain (sump pump) water, fruit.and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; ni 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 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. a After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with so', gravel or another inert Solid material. CONTING CY PLAN If the P WTS fails and cannot be repaired the following measures have been, or.must be taken, to provide a code compliant replace ent system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorptkn system. The replacement area should be protected from disturbance and compaction and should not be infringed upon ny required setbacks from eXisting and proposed structure, lot fines and wells_ Failure to protect the replacement area %ill 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. El A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be Instalied as a last resort to replace the failed POWTS. alua ' e a >�Di-l[81TI� �-/�/�✓ �N.a T K �o e p ❑ Mound and at-grade sole 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 NCT 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 MApVTA1NER Name COU >� G Id Name Phone . ?il j fe Phone 71S-- 2 Pe • ?l!O SEPTAGE SERVICING OPERATOR(PUMPER) LOCAL REGULATORY AUTHORITY Name /s .4 f,� •� Name S'('. GHQ t 20�JIIc1 Phone ;7/S" S- Xd.2 Phone This document was drafted in compliance with chapter Comm 83.22(2)Ib)(1)(d)&(f) and 83.54(11. (21 & (3), wiscunsin Administrative code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer l v l41n"�Y- i Mailing Address 1-74-Z' -. S4<). Property Address U(Verificationrequired ft m g&Zoning Department for new construc ' ) City/State `���- f 1 Pafcel Identification Number Ci — Z I'2..4a - 3a - ado Q LEGAL DESCRIPTION Property Location "G /�►`� % Sec. --r-1 , T N R-ZO W,Town Subdivision Certified Survey Main# Volume ,Page# Warranty Deed , Volume , Page# Spec house yes no Lot lines identifiable es no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature faihme 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 s?' 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 113 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. Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s)of the property described above,b}virtue of a wawa deed recorded in Register of Deeds Office. Number of bedrooms SIGNATURE OF S ICANT / t ) DA1.T�E_l__�_ '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 neap if reference is made in the warranty deed- (REV.08105) z s a 3 ¢ F i } b t. RAW WN, say XF,W1191%,101 "on"Wo 051 on- s UNPLA TTED LANDS • o NrSyr. K r7S,t96-C Lit sy Id / s u � a � a T law a 00 r r = m � s � o m CrJ r 16 op �► Waconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 bivision of Safety and Buildings in accordance with Comm 85,Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size.Plan must County St.Croix include,but not limited to:vertical and horizontal reference point(BM),direction and Parcel . 3 �42a percent slope,scale or dimensions,north arrow,and location and distance to nearest road. Please print all information. Revie ed by ,,/ Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). C�N/V n' Property Owner Property Location Quest Development,Inc. Govt. Lot E 1/2 114 SW 1/4 S 25 T 30 N R 20 E❑(or)❑W Property Owner's Mailing Address Lot# Block# Subd. Name or CSM# Suite 150 10700 Old County Road 15 28 Birch Park City State Zip Code Phone Number ity E]ViIlage ■ Town Nearest Road Plymouth MN 1 55441 1 ( 7¢3-595-9512 County Road E oNew Construction Use[D Residential/Number of bedrooms 3 to 4 Code derived design flow rate 45 PD F1 Replacement Public or commercial-Describe: rt `,;, . Parent material i.oess over ont wash sands Flood Plain elevation if applicable °x?' A. General comments and recommendations: This site is suitable as a below grade conventional syste a , Aj w # F7] Boring# ❑ Boring , •t.„_ 0 Pit Ground surface elev. 103.90 ft. Depth to limiting factor >96 in. ''' '..AI,• i, ate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots /ft' in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 1 0-8 10yr2/2 sil 2msbk mfr cs 2f .5 .8 2 - 6 7.5 r4/6 s Osg ml - - .7 1.2 F Boring# ❑ Boring 98.70 >96 Q Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 1 0-8 10yr2/2 sil 2msbk mfr es 2f .5 .8 2 8-19 1 r4/6 sil 2msbk mfr cs if .5 .8 3 19-42 10yr4/6 sil lmsbk mfi cs - .2 .3 4 42-96 7.5 r4/6 Y s Osg ml - - .7 1.2 *Effluent#1 =BOD >30<220 mg/L and TSS>30<150 mg/L *Efflu --160D,:<30 mg/L and TSS<30 mg/L CST Name(Please Print) Signature ��_� CST Number Thomas C Nelson 227387 Address Date Evaluation Conducted Telephone Number 1432 120th Street,New Richmond,WI 10/23/01 715-246-2454 } L� Quest Develo 2 3 Property Owner Q ment.Inc P p Parcel ID# age of FTI Borin # Boring — g 0 Pit Ground surface elev. 103.65 ft. Depth to limiting factor >96 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'Eff#1 -Eff#2 1 0-11 10yr2/2 - sil 2msbk mfr cs 2f .5 .8 2 11-30 10 r4/6 - sil Imsbk mfi cs - .2 .3 3 - 7.5yr4/6 - s Osg ml - - .7 1.2 ❑ Boring# El Boring M Pit Ground surface elev. ft. Depth to limiting factor in. 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 ❑ Boring# 13 Boring F-1 Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application 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 Effluent#1 =BOD,>30<220 mg/L and TSS>30<150 mg/L 'Effluent#2=BODS<30 mg/L and TSS<30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330Test(R.07/00) 3S3 Q u v 150 OtA 1 b � 690 III = 3Ui 103,13 u Opt �k / c, P45"Z9 i N 6 - LOT- To B& 1-S.S 1*6Al E-49 + N,6tv P/'iv 67Xj s7-1;v&- ?/mss -> c�,v r . T- 0SO • 203 � • LO • � �� 0 34 2.0,3 ,5O 0zrV G-�'GC�vS�`� MASTS 030 20 ?k OOV 0 3 d . Z v /10 , 70 - OM Ulbricht&Associates 7 Private sewage Consultants O'Neil0 3O 2 _7/57 Hu dsan,Wis. 54016 . 3 -P G • ?/S' s 7i 5 • 7*7 • 3 y4{Z- FAOtr�� s 1 1 12- (1 � i 8279721 Document Number Document Title TX:4229230 1007035 St. Croix County BETH PABST REGISTER OF DEEDS Occupancy Affidavit ST. CROIX CO., WI RECEIVED FOR RECORD A - 01/23/2015 10:01 AM P-om Zt IG Aoo LAt mAs L'• Wom Z'c IC. EXEMPT #: Name -(Owner) Typed or printed REC FEE: 30.00 being duly sworn , states, under.oath,that: PAGES: i He/she is the owner/part owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume Page Document Number 61°i4G 1227 St. Croix County Register of Deeds Office: Recording area A parcel of land located in the rG ',�f theSV�C'/< of Section° i, T3!o N Name and Return Address —R_W, Town of � St. Croix County, Wisconsin, being duly described as follows(Include lot no. and subdivision/CSM or detailed legal LON I1-� D �� description): ©3 a --2-12-tv --$o -(0Q D Parcel Identification Number(PIN) As owner of the above described property, I acknowledge that the private onsite wastewater treatment system (POWTS)serving this residence is sized for a S; bedroom home or a design flow on5o gpd. Design wastewater flow(DWF)is calculated assuming 150 al./day for 2 individuals/bedroom. A maximum oftG occupants are permitted based on the DWF; there are currently occupants living in this residence. Therefore the POWTS serving this residence is code-compliant at this time. However, I understand that if the number of finished bedrooms or the number of occupants exceeds the DWF, the POWTS may be subject to premature failure and/or will need to be modified to accommodate the increased wastewater flows and/or contaminant loads. I also acknowledge that I will make this information available to any future parties interested in purchasing this property. D \ Dated this day of Jf AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) )ss. authenticated this da of St.Croix County. ) -Z \_nom Y Personally came before me this y of.J� IL©E S the above named AAT TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the person(s)who executed the foregoing (If not, instru&anoWledge the same. authorized by§706.06,Wis.Stats.) THIS INSTRUMENT WAS DRAFTED BY: Pamela Quinn. Land Use Specialist Community Development DeDartment Notary Public,State of Wisconsin (Signatures may be authenticated or acknowledged. Both are not My Commission is permanent. If not,state expiration date: necessary.) Date: V. "THIS PAGE IS PART OF THIS LEGAL DOCUMENT-DO NOT REMOVE" This information must be completed by submitter: document title.name&return address.and PIN(if required). Other information such as the granting clauses,legal description,etc.maybe placed on this first page of the document or maybe placed on additional pages of the document.Note: Use of this cover page adds one page to your document and$2.00 to the recording fee. Wisconsin Statutes,59.43.