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HomeMy WebLinkAbout032-1055-10-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 578988 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: Lindberg, Elliot Somerset, Town of 032-1055-10-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 1-60 A4 1 CST 21.31.19.272E TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER ; ^ 7S CAPACITY STATION BS HI FS ELEV. i Septic T-rt. Z Benchmark Alt. BM 5.13 9G- o - po ~ b k. SZS !5"11 Aeration Bldg. Sewer -7-4/41 93. a Holding St/Ht Inlet g 93 TANK SETBACK INFORMATION St/Ht Outlet rI 2 - 7 J TANK TO t . P/4 WELL BLDG. ent t Air Intake ROAD Dt Inlet Septic 1 35 n TL Dt Bottom ` Dosing Header/Man. q.~~ 9i• Lit Aera on Dist. Pipe 9.9z 9i• z4 Holding Bot. System /61 V 76. 3 elk PUMP/SIPHON INFORMATION Final Grade yr -7 C1 (o . -5 Manufacturer Demand St Cover GP /O ! / •b Model Numb C• TDH Lift Friction Loss 1 System Head 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 q Z I -I _ J~ ~ SETBACK SYSTEM TO CJ P/L BLDG WEEL/L`Axl LAKE/STREAM LEACHING Manufacturer: Ez /a~ INFORMATION CHAMBER OR Type fSystem~~OJ~n~1 1-. 75 A/~ t/► Al UNIT ° Model Number. G/LJZ 4 DISTRIBUTION SYSTEM 4-q= / $r Header/Manifold Distribution ` x Hole Size x Hole S sing Vent o Air I aka Pipe(s) pl Length Dia Length Dia Spacing ` d r S SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center ` 1-7 Bed/Trench Edges Topsoil Yes Efl No Yes No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: Inspection #2: Location: 484 208th Ave Some..rrset, WI 54025 (SE 1/4 NE 1/4 21 T31 N R1 9W) NA Lot 3 Parcel No: 21.31.19.272E 1.) Alt BM Description= OL" O 2.) Bldg sewer length - amount of cover = ! ~ / Plan revision Required? Yes No q G Use other side for additional information. SBD-6710 (R.3/97) Date Insepctor's i nature Cert. No. r county { r Safety and Buildings Division C t 0 D JUN I ) 2015 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) ^f M n, 15 7- ST. CROIX COUNTY S 7F_9 8'$ 'OMMUNITYDSVELOPM! Y Sanitary Permit Appli on State Transaction Number In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Pro"ect Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary _purposes in accordance with the Privacy Law, s. 15.04 1 m , Stos. dr-, Al -F L Application Information -Please Print All Information Property Owner's Name Parcel # //;or o32- WS"-lo-ooo Property Owner's Mailing Address Property Location 8y_20 "ckVC ,279 GovL Lot City, State , Zip Code Phone Number p S' E y,~ =ig Section 56 01 Crs -ef _-r S y~ 5~ 0 / yl _ Z -7p - Z 13 (circle one T ~ R Wi II. Type of Building (check all that apply) Lot # N, N 9 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name ©k o4 Bloc 11 Public/Commercial -Describe Use ❑ City of J ~ ❑ State Owned - Describe Use CSM Number ❑ Village of Town of rF D v'►+ a ft El -e -7 L,) ez o~ c5 MC AI II III. Type of Permit: (Check only one box on line A. Complete line B if pplicable) A. New S ❑ ystem Replacement System ❑ TreatmenVHolding 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 a 6:1-7- a tsJ IV. Type of POWTS System/Component/Device: Check all that apply) ~6, Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ er Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersal/Trea ent Area Information: Desig~nn Flow (gpd) Desigr~ Soil Application Rate(gp fl Dispersal Area jequind (sf) Dispersal Area P1' ed s S 66 7 Fs- 7 ( ystem Elevation 00 , o© gyp, of VL Tank Info Capacity in Total # of Manufacturer , Gallons Gallons Units o New Tanks Existing Tanks w 0 aU ti y vi wt7 a Septic or Holding Tank f-~ 1 Sp e Se Dosing Chamber J VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber' Signature Wft,,V S Number Business Phone Number $rtl4^ ~Gin~/( VC- 23/3r~/ /S'Zi7 ~Z0; Plumber's Address (Street City, State, Zip Code) l92 awe 50oleri-er 2 S oun epartment Use Only ued Issuing t Signature Approved Perjm~itt Femme Date p e eason for Deni $ ► /J ' ~ IX. Condi ,'p 49FA easons for Disapproval $eptic`tank, emuientfilterarid' 3) ror~, A-J dis . rsal cell must all be seryless I'malntained AWL as per management plan provided by plumbar. 2. A s4ack f*40crrterits must bee tnaintainbd. W' l as perapplicablo bode / ordinances. r Attach to complete plans for the system and submit the County only on r not than 8111 z 11 inches in re D f bd 3(~jT-- G, ILG. SBD-6398 (R. 11/11) ~Q.r~` i l 11'~ l ' G a Cr b f- (3 zi ILI \~{J~t~G;'~C/?~ `W ICsc✓-~L tf - Sic - i CAS /0, ' . 017- - - - - - r-, _ ;o - CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Owner's Name: } ~d erg Owner's Address: , ~~tti y e Legal Description: 5 eG 2 9 Township: e~".S"- County: S C / d S Subdivision Name: Lot Number: 3 Parcel ID Number: 0 32 /40 -00 o Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing Page 4 System Cross-Section Page 5 Filter Specs Page 6 Maintenance & Management Plan Page 7 Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat 2-3131K Designer/Plumber: l3f n (t 14l/ License Number: Date: Phone Number 0? Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 . ~ ~ i t j ! f I i r z ( 1 i I T3 ~l zY 41 t t M t l NC Oe { i ~rG f e 1 ~ ~ i ~ O { ~ ~ ` _ ~ ~ _ ~ _.-_-7__ _a.... ; 'C(/OV S 4/~ 1 I c 1 I E ( ~r i t i i ' 1 1 - ; FZI . t t _ I i 4- 00- i , -4-41 . o~ j__ - f i- f - - i -4-4- i i , ~ , s11 I ! ~ i I t a . ; i ! I i d i ; f 1 1 i ! ~ F + d ~ y S : j d # ? y i 9 i ~ t ~ j ! i a ~ ~ zr i i F s f i ! 5 4 ' ~ f f # i f i ~ q} t i 1 - i s 1 1 f P f S I~ ' i i f F ~ i ~ ! a 7 i 1 I : f { 4-4 ' ~ ~ 1 f } f ~ f 1 t } • ( i i ~ f f 1 ~ p s} i i r ~ ~ } 7 7 ~ ? a - - I t r 1 t j . ,t ` A 0 14~ ~r/y 5~~, ,PC k y ;Fe~ Rao-2 r V06 d l X- . D 9 9 Ica ~ Aa/ - x yacfo ~ ~ 1.2 S.Z. 8 P/(2,7/1 J ~2 ~rJg/ W ifPSf/ 2 O Ala,~ fH~1Ece C~r~s ~oo , tO; qoo 2 : S~ Z iz a3 910 c ~rZ Z ~-o lie / SOIL ABSORPTION SYSTEM DETAIL/ GRAVELLESS LEACHING UNIT Page-of Project Name: d 02 No. of Cells / Per Cell ft Cell Width Total No of 2 / Z ©j H' /0 9 ® it Cell Length q p sq ft EISA Per Cell ft Cell Spacing q 00 sq ft Total EISA Manufacturer Model Laying Length EISA Rating Infiltrator EZ1203H-5ft 5.0' 25.0 EZ1203H-10ft 10.0' 50.0 Gravelless Leaching Unit Manufacturer: f~~tl~ tos Gravelless Leaching Unit Model: c' 7, /2 O3 - /O' ~J Typical Cross Section Finished Grade Observation Pipe with approved cap or vent •:::;'>::':•:-:.:-:<:.:•:.:•>:->::.>:<':.: Soil Backfill •:<:<;:;:<>;>;;> :<:.->>a:<..:. Geotextile Fabric Eft Infiltrative Surface 12 in (I g-16 ft Limiting Factor in Slotted and Anchored Ventl Observation Pipe with Cap Plumber/Designer PfumberlDesigner Signature: - License 3 / y Date: aL]~~,~ INSTALLATION INSTRUCTIONS ` " ^ MW*n of PL-525/PL-625 FILTER INSTALLATION INSTRUCTIONS f Center filter with opening A-Z 8-10 UN 7 t Z~ ~ I ON r ~ z ~ ~a°ina( pl ~ GIUP. Step 1: Step 2: (A) Locate the outlet of the septic tank. (A) Before installation, lace the Step 3: (B) Remove tank cover and pump tank filter housing p (A) Glue the filter housing on the on to the outlet pipe. outlet pipe. if necessary. (B) Make sure that the housing is positioned so the filter can be (B) Insert the filter cartridge in the housing, making sure the filter removed from the tank for cartridge is properly aligned and maintenance and service. completely inserted in the housing. MAINTENANCE INSTRUCTIONS to § 10 1, L 4 ~ x- .~.s axe _ x3~ ' Step 1: Step 2: Locate the outlet of the septic tank. (A) Remove tank cover and Step 3: ~ , ~ if necessary. pump (A) Insert the filter cartridge back into the the housing making sure WHEN FILTER IS REMOVED (B) Pull the filter out of the housing. the filter is properly alighed (C) Hose off the filter over the septic tank and completely Inserted. LWHER- Make sure ail solids fall back into the (B) Replace septic tank cover CLEANING FILTER septic tank. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity ❑ NA 2s"O gal Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer o L v k ❑ NA Number 7ofBedrooms "7 ❑ NA Effluent Filter Model PL ,S`2.5- ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity gal ®NA Estimated flow (average) d0 gaf/day Pump Tank Manufacturer ® NA Design flow (peak), (Estimated x 1.5) 66D gal/day Pump Manufacturer. &NA Soil Application Rate 7 gal/day/ftz Pump Model w ®NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ® NA Fats, Oil & Grease (FOG) <30 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODS) <220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) <150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) n NA Biochemical Oxygen Demand (BODS) <30 mg/L J In-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) <30 mg/L O NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) <104 cfu/100m1 ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size in dia. ❑ NA Other: 13 NA Other ❑ 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 ear(s) Pump out contents of tank(s) When combined sludge and scum equals one-third of tank volume ❑ NA inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA ,9. year(s) Clean effluent filter At least once every: ❑ month(s) 3 49-year(s) ❑ NA 'aspect pump, pump controls & alarm At least once every: ❑ month{sl _ ❑ year(s) ❑ NA aterals and pressure test At least once every: ❑ month(s) ❑ NA ❑ year(s) At least once every; El month(s) ❑ NA Other-. ❑ year {S) ❑ 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 focal regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (%3) 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. 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 replacement 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 f,ra' &lne Name Phone 7/5__2'/7-3Zo3 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone This document was draftct - z lance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. START UP AND OPERATION Page of 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. 0 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. :ONTiNGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement 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. iDDiTIONAL COMMENTS OWTS INSTALLER POWTS MAINTAINER Name r,~C" cz jne It J Name Phone 713--2`~7-3Zo3 E Phone EPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone S „ 3,:rr(.A his document was drats= -dance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK A AINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owmer/Buyer Mailing Address z O '8 ProperlyAddress So w ` , J~_ (Verification required from Planning & Zoning Departmdent fornew constrn,ction-) City/State f6 Le, s' Parcel Identification Number 0.5 2 Go 0 LEGAL DESCRIPTION 2~- 7Z Property Location s V. , 1Y V. , Sec. Z t , T" J N R 9 W, Town of Subdi'vii sio12 ,Lou ~r Certified Survey Map # , Volume , Page # Warranty Deed l , Volume , Page # Spec house yes no Lot lines identifiable yes no SYSTEM MAIN'ICENANCE AND OWNER CERTTFICATTON lnproper use and maintenance of your septic system could result in its pimaw fad 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 Pm into the system can affect the function of the septic tank as a treatment stage in the waste disposal system Owner mranntenance responsibilities are specified in §Comm. 83.52(1) and in C after 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 ;xastm ater 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- L'-,-e, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the s:azdaz us set forth, herein. as set by the Department of Commerce and the Dint of;vatraal Resources, State of Wisconsin- Cer,a cation stating that your septic system has been maintained most be coapieted and returned to The St Croix Comrty Plasmmg & Zo-ning Department a-ithin 30 days of the three year expiration date- Vrve certify that all statements on ' form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of 76ranly deed recorded in Register of Deeds Office. Number of bedro e ~1 D I r~ SIGNATURE OF CANT(S) DATE -y information that is istepresented may result in the sanitary peanut being revolted by the Planning & Zoning De=rEment. -with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey neap if :e7z7ce is made in the warranty deed. o3SIA3b tct,?-99Z-9T4 XVi 3nN3/\V H Hi ~4Canri~ SZ00SIM' SOZ OS 00L=04 ELOZ 6LlsnJnH 031V0 t9t2;-99a-5T/, Hd 060 w NYI3 NIMa3 A13 a 13va T00t9 IM `AlaLUy X001IM N HOf 00t =..t 133d NI 3IVOS g `s . 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" W Bt'SC£ 3.SO,by y~V se, Z ~ 6 ? Z w oo¢ 0z2 sbr j co wN0 ",I a) > 14,1 N" I 0 Z~ QI-I j Z~ X~ \ ~ -~I -1 w W O V V `0/ r 0 a QI C) $ Nei o 0 - -N o U. M qZ 2~ J o€z 8 W I I a s Q/ :c~dF' r a z LL c z w ~N~V ~I~I I yr ' 10 ~Z°rz Z 3EM ¢ e / Za- w C U Q 'YQJ vy x > 14 w (0 LU 6S/ ¢wX U) ^~00' ~ Q/ /oOG z 3 a a OO r IL W 020 f' M z (w31S~,S 31VNQ1000 Q 3 ~"~G N, 100 XO80'1S1-M,S£,Z£,008 ONIbV39 V 0 0/L3N 3H1 dO bIL3S 3H1 d03NIl 1S3M L'` N010n.dO t,43N 3H1d03NII 0 J 1SV3 3H101030N3b3d38 3W SONkN39 J 4 r Parcel 032-1055-10-000 09/30/2013 12:26 PM PAGE 1 OF 1 Alt. Parcel 21.31.19.272E 032 - TOWN OF SOMERSET Current 1K ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner 0 - WILCOX, JOHN H JOHN H WILCOX 490 208TH AVE SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description SC 5432 SCH DIST OF SOMERSET SP 1700 WITC Legal Description: Acres: 4.727 Plat: 1170-CSM 04-1170 032-82 SEC 21 T31 N R19W 4.727A IN N1/2 SE NE Block/Condo Bldg: LOT 03 LOT 3 CSM VOL 4/ 1170 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 21-31N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 871/490 07/23/1997 696/44 2013 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/12/2010 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 4.727 31,900 0 31,900 NO Totals for 2013: General Property 4.727 31,900 0 31,900 Woodland 0.000 0 0 Totals for 2012: General Property 4.727 31,900 0 31,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ail F TRA 13 M M SM M 4 A O z ❑ 0000 0000 01300 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ _ 0000 O06 _ r=oc 0 EH tlm A _ A D 'a 2 M 11 _ < yea ® D ~ 690==- - i ; p ( i Z OO f li a o 000 ®®o o ❑ I I - ~ m I III a Q] I t _ I m Z tl 1 1; ;111 iI tl ~ I 1 ;II _LIJ I tl ii 1 " ' a-H M t stn `J .tad ~B. a I A m i `off b a ~ b'r2a Aw lt'xli A 2/6 BENd BEV01 2/6 O m $a :q IT7 gg - I imZ r r a ~ ~ ' - LA X-10, 0 W r r 1 1/6 r 'Z z ~ o V m V - ~ 5N IE "q g c o ® ~ 0 x~ ~z l g g ow arr ~6•rsr,nl s6e6 rAno d+ 14 -0 718- IX-5118, A a MM-n C ~mc x ZC~ - oom m 26' 42' ` 16 14' i ~ II ♦J A D ~ D I A 1 u I I _ N 1 ■ 1 ~o Fy 1 I ♦1 I - I , - 1 I j i i J6'Xf I ~Q\ co $M o m i xo' croon m, Y p - m - mx'na GO s~ ~ I IN c ~r--------- ,i,, R c 2/6 I u ~ I Q BMM OR , . A ~ 7N xA 1 i D = I , 5 a a I , - I ~ 1 1 1 1 1 1 I I XT. 1- 4 Z' i S' _ 11'-1 t/2" 8'-5 x , m. n, , to' r,noR zl i$ o , I I ~ I I , 4♦ 1 - BARN OR O ' ~ °i 1- ~ t(ml , I i i i I I ' I i$ I ~ I I 31-IC6' OM-1 76-1a6f1' OM .76'Y68' OM-2 CU s ,AI I l ~ r r 3/22/15 BUILDER h OWNER MUST VREI Y ALL N .IKT qFR\/IrFq I I ( GATE: /V..CMCIABIC CI7CC .I,,,zC IM.11A.IC V6consin SOIL EVALUATION REPORT #2140 Department of Commerce in accorda wi85, is. M. Code Page 1 of 3 -Division of Safety and Buildings Steel's Soil Service County Attach complete site plan on paper not less than 8/2 x 11 inches in an mus St. Croix include, but not limited to: vertical and horizontal reference point (BM), direc i percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. Z as~~/ ~,1 ' Z ' Please print alJLtafdrmgVLD iewed DG~at U-CJ J Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). u A '~1/►"~ / Property Owner 20113 Property Location John Wilcox Govt. Lot na SE1/4, NE1/4, S21, T31 N, R1 9W Property Owner's Mailing Address CROIX COUNTY Lot # Block # Subd. Na a or C~SM# 490 208th Ave 3 na CSM , City State Zip Code Phone Number City Village Town ea t Road Somerset WI 54025 651-303-1709 Somerset 208Th Ave New Construction Use: m' Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement Public or commercial -Describe: Parent material outwash Flood plain elevation, if applicable na ft. General comments Conventional system, new system elevation 96,80ft, replacement system elevation 91.94ft. Trenches spaced and depth to code. 1 and recommendations: t1Gz~ F-11 Boring # Boring i Pit Ground surface elev. 99.80 ft. Depth to limiting factor 120 in. Soil Application Rate Horizon Depth ` Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Efr#1 *Eff#2 1 0-4 10yr3/2 none I 2msbk mfr cs 2c 0.6 0.8 2 4-36 7.5yr4/4 none Is osg mfr CS lc .7 1.6 3 36-120 7.5yr4/6 none ms osg mfr na na .7 1.6 ~ I i Fil L.- Boring # Boring Pit Ground surface elev. 99.80 ft. Depth to limiting factor 120 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Efr#2 1 0-4 10yr3/2 none I 2msbk mfr cs 2c 0.6 0.8 2 4-40 7.5yr4/4 none Is osg mfr cs lc .7 1.6 3 40-120 7.5yr4/6 j none ms osg mfr na na .7 1.6 I j _ * Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 rng/L * Effluent #2 = BOD5 s30 mg/L and TSS <30 mg/L CST Name (Please Print) Signa re: - CST Number David J. Steel 248956 Address Steel's Soil Service Date Evaluation Conducted Telephone Number 1699 150th St New Richmond, WI 54017 8/30/2013 715-760-0347 SBD-8330 (R.07/00) Property Owner John Wilcox Parcel ID # Page 2 of 3 ~ Boring F3 Boring # ✓ Pit Ground surface elev. 96.40 ft. Depth to limiting factor 120 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Mansell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-4 10yr3/2 none I 2msbk mfr cs 2c 0.6 0.8 2 4-68 7.5yr4/4 none Ifs osg mfr cs 1c .5. 1.0 3 68-120 7.5yr4/6 none ms osg mfr na na .7 1.6 JO (O Boring F4~ Boring # pit Ground surface elev. 97.60 ft. Depth to limiting factor 120 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/W in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. j *Eff#1 *Eff#2 1 0-4 10yr3/2 none I 2msbk mfr cs 2c 0.6 0.8 2 4-36 7.5yr4/4 none Is osg mfr cs 1c .7 1.6 3 36-120 7.5yr4/6 none ms osg mfr na na .7 1.6 Boring D Boring # 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/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 i * Effluent #1 = BOD5> 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. Steel's Soil Service SBD-8330 (R.07/00) STEEL'S SOIL SERVICE 3 of 3 David J. Steel John Wilcox 1699 150th St CST-POWTSM SE1/4NE1/4,S21,T31N,R19W New Richmond, W154017 Lic. #248956 Town of Somerset, St. Croix Co. Direct 715- 760-0347 CSM Lot 3 Fax 715-246-0318 This soil evaluation was conducted" to satisfy a zoning requirement, it may or may not be suitable for your use. Legend N 1" = 40' f '25-6' ♦ = Benchmark Ele. 100.00 ft I Top of 1" pvc pipe 9 =Alt Benchmark Eli 100.00 ft Top of 1 " pvc pipe ,~of9rG,~ = orings Boring Elevations BI = 99.80 ft B2 = 99.80 ft B3 = 96.40 ft B4 = 97.60 ft 3 4~ 75/ I C) Z' • indicates iron pipe round N W W * Indicates 1" x 24" iron pipe weighing 103 lbs./lin. ft. set Z UNPLATTE D LANDS h _j _-0 S 00.34' 07 "E 573.60' I Nd. C C.F__ O VM E 6NE NE 1/4 W • W V, 0 O X O 1482.00' 8' 33.01- 290.28 685.20' N 33.02 323.30' O ~I .30' .6 1 - I M to F- (A I M W 01 L W LL. W LL. W W N N ~ z0 OI 0) O U. tl~ N Ir pi 0: d F- > ~aN a d. IN Im ucnc~ca _ W Q N F d l n V U) W a O W Z Q N Q N O 0 F- = y Q-I c0 N N 4M (Of I M - V It O M al znG3 w<0Wa OnInnO W} QZ- ~2W o UQ W -J ~u'-~M- O ti Q z W N N a Ot m=Z C13W ( W Q M-~~ ° U V _ W O V O st n 0: 0 W N N J LL M z a: U;j M I O. J Z O or Q O 1— N \ M 0 u~ m zn 3 m 3 1- N W O~ J W v m _ Z ~ N n m Q t0 ~ . ~ N M O I N _ z ' \ d N 2.01' 46"E Ole. J \O o W O N 344.67' ~O. 20\~'~ 3 wl mrnc~ M J in in in S 00. 25'38" E F '~~s in f- z CD m n 1 1 0.18' Fi a l Q v st a O I- r • • • O ca U. 000 p a mmm N IT a 0 `t a (j,)' M to -9 i 0 Z I - v v et n < O v! N 0 M W p OI 0 M N st N to O Z N No Z M Mto st ° I ~m- n a 'l WH O -W00 0 'T N 0 Hn0's0 0a U. V IL CYWn 0 M Nc'N a0' stMM _ M t I W F- w eo W D' ~N NQ M iV' 1- _ O z 0~ M U M -j Q I t0 J DL A 0 st 0(0 c0 ~ ~ O t<f O Q J N fp 'M .M OD n (,.m O v n.l n M d' - V (A Q to M O N z to CK is „ Q M M M - O 0) aN F N o -NM 0 ` OD Y f- W st Q cc M v, f•• N 0 Z F- O QD z J Q x 0 D V MMN O - O W CJ O Z M N 000 17' 10" W 676.56' CK- 3 3 3 W LINE SE 1/4 NE 1/4 a ~t stet State of Wisconsin) W N N N County of Pierce) o L I, James L. Murphy, Registered Land Surveyor, do hereby 01e certify that by direction of the Owner, Glen Wiese. I z W O = have surveyed and divided the lands sh "Al It 11 U V) N N " _ _ _ accordance with official records, Ch r,16Wft ns i J N W; o st Statutes and the Ordinances of St. ounty; * '&at w (D i~ r~ o o a the above map and description are £ t;%de , MXTec% % ~ a m U za o n v 0 0 representation thereof.' MURPHY I o. - o M a °D 0D m °m Dated: 20 April 1982 c 70. S 1 0 4 z ' RIVER FALLS, r~ H ./tpj WISC. Obi _ LAND Vol. Page_jL-7o James L. Murphy •ulsuoaslM 'Aunoo xlo.zO •}S '.ps,zawoS jo uMOy ''~saM GL 820 H W 'ul.aON 6C dlttsut4OL `6Z uoP-aaS 30 10 ~s-e9t4aON auk 3o h/L gseaigqnoS auk 3o q-.zsd d VW JSAMS QSIdIDEO [r1► ` or I i of Y- t}y', j m «s m N ~ - 3 ¢ ~ N ~ N' m ' I . U 0 1. E r 'map A A A r C7 m C A O W ti V r A A A r T m O O W (fl m? A d. ° m ° o fn. < m o m m m. ( m~ (m~ o O o? % o can 0 ~.°-.N O O ~ ~ J fD 2 y f7i N m 'p. p y ~ °Z N N -1 ~ G lD 2 N F n m A '7 2 m y^ N m -1 m p 3 3 'm Z 3 _ MY m W 9 m° a y 2 f N n a n m 3 v v ? 3 CL O l m» J ~ C~ N F d N Ul A ° y O A N Q fmll ~ O < `mG N m N N p~j N m ~ °m O 0 ~ m. 3 a W y3~' p V ~ Qv ~ h - ,7 o m m^ m omn iJao cn y ~ x