HomeMy WebLinkAbout040-1189-60-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
211
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:
Rolling Hills Development, % Steve Fox I Troy, Town of 040-1189-60-000
CST BM Elev: Insp.BM Elev: BM Description: Section/Town/Range/Map No:
36.28.19.839
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg.Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing Header/Man.
Aeration Dist.Pipe
Holding Bot.System
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
Model Number
TDH Lift Friction Loss System Head T DH 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
SETBACK SYSTEM TO P/L JBLDG IWELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: UNIT Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Ti3istribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia I 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/Trench Edges Topsoil
Yes 0 No Dj Yes 0 No
COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2:
Location: 828 County Road MM River Falls,WI 54022(SE /4 NW 1/4 36 T28N R1 9W) Oak Ridge Acres Lot 86 rcel No: 36.28.19.839
1.)Alt BM Description= ��— /�G(L° �'�� ��d� P� P1 tG t'Oik'
2.)Bldg sewer length
-amount of cover
_ _
- S 1;1:L T A.dl.t�.
r
Plan revision Required? ® Yes o ,
Use other side for additional information.
SBD-6710(R.3/97) Date Insepo rs Si re Cert.No.
1
% Sanitary Permit Application ST.CROIX COUNTY WISCONSIN
with Chapert 12 St.Croix County Sanitary Ordinance PLANNING&ZONING DEPARTMENT
C �S Personal information pro ide may be0us1 used for secondary purposes ST.CROIX COUNTY GOVERNMENT CENTER
�+ Road
Hudson,WI 54016-7710
(715)386-4680 Fax(715)386-4686
nm G plans for e s ss than 8-112 x 11 inches in size.
OM ', ary Permit#211 ❑ Check if revision to previous application
I. Application Information-Please Print all Information Location:
Property Owner Name
114 NA114,Sec
Z6111019! Y /7 1 N, R E(or)
Property Owners Mailing Address Lot Number Block Number
P-0- 80
City,Staten Zip Code Phone Numer Subdivision Name or CSM Number
�c�sai✓ /6 GS/-� 3�-� �`/6 410 A, krj c- -4ceeS
If Type of Building: (check one) y =ity ❑Village mown of 7-el
1 or 2 Family Dwelling-No.of Bedrooms: 1 ^ `
❑ Public/Commercial(describe use):
❑ State-owned Nearest Road' nn
11.Type of Permit: (Check only one box on line A. Check box on line B if applicable) A
Parcel Tax Number(s)
A) 1J&lTe—pair 2.❑ Reconnection 3.❑Non-plumbing 4.[]Rejuvenation YO —//e�Go
Sanitation -00c) J
B) Permit Number Date Issue
-State Sanitary Permit was previously issued
IV.Type of POWT System: (Check all that apply)
Non-pressurized In-ground ❑ Mound 24 in.suitable soil ❑ Mound:s 24 in.suitable soil O Mound A+0
❑77nd Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line
❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass jR*Other
❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating PIA M JO
V.Dispersal/Treatment Area Information: —,ft A P f
1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application Rate 5.Percolation Rate 6.System Elevation 7.Final Grade
RequiredeF.�� (Gals.lday/sq.fi.) (Min./inch) Elevation
U Ina
Mae VI. Tank Information Capaicty in Gallons Total #of Manufacturer Prefab Site Can- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks
#G T IF I I 4r I ❑ ❑ 1 ❑ 1 ❑
0,0 / W C Si- 1 ❑ ❑ ❑ ❑
VII.Responsibility StatementOO 7S8 �0-fd
I,the undersigned,assume responsibility for repair/reconnenction ejuvenation/instailafion o7 non-plumbing for the POWTS shown on the attached plans. A
license is not required for terralift repair or the installation of non-plumbing anitation system.
Plumber's Name(print) Plumb ' i at. r o amps MP/MPRS No. Business Phone Number
Plumber's Add r ss(Street,City,State,Zip Code)
C 2c 4-J=
o ZZ
VIII.County Use Only
LDe s Sanitary Permit Fee /D;t Is ued Issuin gent Sig4stam pproved wner Gi nitial se J 5
enn ination l/
IX.Conditions of Approval/Reasons for Disapproval:
SYSTEM OWNER:t.' Septic tank,effluent fitter and
dispersal cell must all be-services/maintained .` S
as per management plan provided by plumber. �-
t All sc�li;requirements must be maintained
as perappkabieecode%ordinances.
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285 COUNTY ROAD SS EXCAVATING
RIVER FALLS, WI 54022
800-828-3723 715-425-6200
715-425-8466 FAX
2/25/2015
This is to certify that I have inspected the septic system presently servicing the
3 bedroom residence of:
Rolling Hills Development
828 county road MM
Town of Troy
Saint Croix County WI
PIN 040-1189-60-000
SEl/4,Nwl/4, sec36, T28N, R19W
Upon inspection I have found the septic tanks/baffles to be in good condition and the
system appears to be functioning properly, except for the constricted 4" cast iron pipe
that is scheduled to be replaced 3/2/2015.
System details
1000 gal precast septic tank circa 1970 --pumped 2/25/2015
1000/750 gal septic/pump tank 2002 --inspected 2/24/2015
Zabel a-100 filter 2002 --cleaned 2/24/2015
Gould Ep04 2002
Non-mercury float switch 2014
2 trenches 1 l chambers each 2002
Michael B Rodewald
MPRS #931394
i
i
ST CROIX COUNTY
SEPTIC TANK MAIN7MANCP AO RBEMCNT AND
OWNM'f1P CBR CATION FORM
i
F.
DOaVMtNT NO. STATE.OF WASCONSIIY FOAM I
THIS SPACE RUERVED r0R RP.CORDDIC DATA
281427
THIS INDENTURE,Made this.. 23rd,-,... day of_.._. •4uquet REGISTERS OFFICE
A.U,19. 5._,between.__.Dennia..R. �7ChultT..mnd.:;3ndrq_C. ,chult�, •T.CROIX CO.,WIS.
hueband and...wlfe faa..joi.nk_tgnant15 2!T..,
i Rec'd for Record this
t .... �_. ... .. ---...... ...-_ .__part of the first part.nil I it y Ot MD 19__
AUI p t,
ies
�1Ntood. L (leasbY anal FJChard 1', Toy, ap tenon'n i n-
_._
aeHwteYnyo.ed.
r t parties _.nf the riecond pi rt._.....__......_... ..__. _... _.. _.. RETURN TO
r F i
W I t in e R R e t h,That the said part..i es..of the Grist part,for and in consideration
of thesumof._.Three, Thousand-Tito 171in,ir-„3 i:frY_Dollarr " no[100
....
to .thpC1..-. .in hand paid by the said part i01 of the second part,the net cipt nh,nof i,hen I" C
confessed and acknowledged,ha Ye_.._given,granted,bargained,sold,remised,released,aliened conve Ye 1 and roof m d end t N tl ` pre - t:
do_.._....give,grant,bargain,sell,remise,release,alien,,onvey and confirm unto the said parts"S of the u c,nd putt I to o:and a"gns
forever,the following described real estate situated in the County of ��:).. �`�'. - and strte of W'i„on,in,to-wit:
Fart o` �7r� of 1.;,t of "rct rihrd fnl;n-
r.
Conrnenr.,, at 17.' corn„r of lot 1 a',, ' it! in re
180 feet? thence ,. 192.F fee ire, 0
of ('a, Pid0a Drive; thence .?0 3q�.._, 'o }lac; n '
J
i
P1 r•vpn.._, zi f i..^d an'i r t t
(It,Nt•CE,SARV,Cc)v�tf'vt,t off REVI.utit,SID ) .
r with o a 1 an Singular the h,nditunitutn and ,t tw tu, r H—c its belong ng or in ,n +,.e'ppert,ni,e .ui I.dl thr"'tat,
ToQethe all d g t I
right,title,interest,claim ordemand dthe„ld p,rt..1 %„f the Grt pot,,aher in l,+,n ,,ruin,,tits
of,in and to the above bargained prim. nd their h-edo.nnen t,.,nd pp-teu.m— k
To Have and To Hold the acid p utu,cv n. ;da„e,b it.I wit+tl„ h,and t,, nt, nd ,ppw t,n n u v,.th, -.,GI p.i,t - ,f•I r
second p.,rt,and to t?1P,i..l u,d g s VORf%1,k
And the sold. ...P,II:S r. �.�-> _. .., :�� -. ?.' . _9Y'
for.. _... . -tL'F.1S ___ . -hci ere,ut r t,i ul�ni�„tr.n r do r„cen m t,r.u,t 1.0 gain u I -tgre, t.,-,nd :I
with the w,id partle6 of the second part,_-_ t ^�_ heir, end i—g-,1h it the tune of the cn,c-ding end d,l"”, of these prey nt,
ra._.._.._well seized of the premises:dotes de”r,h(d..i.of.,go,..I.pun•,perfc,t..,b,uluti,and ind,ic,,•iblc r.taic n(inhe ri to orr
in the law,in fee simple,and that the same are free and,le,r frou, it in,umhre ii,u1,atccer
and that the above bargained premises in the quiet;uol th, "id P.,rt:.., of the,u,enl part,
against all and every per—m or rkersons lawfully claiming th, +,hnlr"r.u+p p,ot Nu roof. ..-.... wlll[„rcc,r AAARRAN I AN O 1)I 1 11 1)
In Who—Whereof, the raid I',rti49 of Qt, fo.t p:,,, h.r•!C• _h,ryun to n,a his od.` .+r I .d slit, :i••
t,
day [ _FI ... _.-.,A. D., t9_C�
_
SIGNED UANU SEALED IN PRESENCE OF
C) �1-Y&A
STATE OR WISCONSIN,
Ss.
Fierce _._County. -
Personally came before me this. 23rd day of ”+'t3vet _ _ _. A (2, to F
the above narned... ._.De.nni's R._"chlltz and.£andra,C' :,ch.t-_?.z,., r' +_Enacts
...._. ..... -- ..-.-.... ..-. ...___._. _._.. ._.._..._...._.._
to me known to be the personwho executed the Il�o)Pa nd acknowledged the ame.
a ..
t —J u r n
NOT V .
fi
This Instrument drafted by -./Notary Public..... .. ..... .._.County Wis.
_�• Fiance
_.,Z.a,.F...M11LZ.}Ce_. �OYrifly....flt...l.a1d....... '..�]Y�ir�., J •` My Commission (Is)._.po-rManpani-.......__............
River Feller Wisconsin
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d taa Mwmss,yaetttt+sr witeema M 00"a.
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