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HomeMy WebLinkAbout026-1294-45-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 579065 GENERAL INFORMATION 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 Township Parcel Tax No: Oevering Homes Inc. TOWN OF RICHMOND 026-1294-45-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 28.30.18.1527 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark DZing , Alt. BM Aeration Bldg. Sewer - i. _ Holding St/Ht Inlet TANK SETBACK INFORMATION SUHtOutlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. t } C Aeration Dist. Pipe G=:~ r 1. Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer „ Demand St Cover GPM i , Model Number TDH ift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width e Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of System: CHAMBER OR r UNIT Model Number: -DISTRIBUTION SYSTEM Header/Manifold ID istribution ix Hole Size IX Hole Spacing Vent to Air Intake Pipe(s) Length- 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/Trench Edges Topsoil Yes No 2 Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 1153 132ND AVE 1.) Alt BM Description 2.) Bldg sewer length = ( - amount of cover Plan revision Required? ❑J Yes ❑ No TJ Use other side for additional information. _ t J SBD-6710 (R.3/97) Date Insepcto Signature Cert. No. otiv W County ,3 • f and Buildings Division G /Z Ld I.1-, 9 ri. 01 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) _7P P AU 0,?) 201,FtAadison, WI 53707- 1 s ~ (v 77 'ts~f` { yw ST. CR IX COUNTY Sanitary Permit pp i tion ransaction N fiber In accordance with SPS 383.21(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 rojeet Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary J153 1 3 2 -b A ✓L purp oses in accordance with the Privacy Law, s. 15.04(1)(m), Stats. 1. Application Information - Please Print All Information Property Owner's Name Parcel # Property Owner's Mailing A dress Property Location \ ; y cc L. i s L J - V J l tJk&) o Gk, CLS All - Govt. Lot 15Z 7 City, State Zip Code Phone Number L-J , Jr" /a, 56 /a, Section - circle one) j T 36 N; R I~ Eor4~1) IL Type of Building (check all that apply) Lot # 1 or 2 Family Dwelling- Number of Bedrroo s Subdivision Name ❑ Public/Commercial -Describe Use ❑ City of ❑ State Owned-Describe Use CSM Number ❑ Village of R Town of Ad t~Ct~ III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ PermitTransf er to New List Previous Permit Number and Date Issued Before Expiration Owner 7 t u IV. Type of POWTS System/Component/Device: (Check all that apply) v V-Non- In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil f S g Tank Other Dispersal Component (explain) ❑ Pretreatment Device (explain) ❑ Holding V. Dis ersal/Treat ent Area Information: Design Flow (gpd) Design Soil Application Rat gpdsf) Dispersal Area Required t Dispersal Area Proposed (s System Elevation u Co 3S~ ~'7 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units p o v New Tanks Existing Tanks / ~t ❑ a~ It cl: a`U rn ~ ~C7 a Septic or Holding Tank L) C e L Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) f r \ " J1Plumber's Signature MP/MPt'RS Number Business Phone Number Plumber's Address (Street, City, State, Zip Code) 4L L eN, (C<- VIII. oun /De artment Use Only Approved sappr Permit Fee DateZsued Issuing A Signature o ~7j~ . as $ 15 n en Keason for e 'al IX. Condit' seasons for Disapproval n , 1. Septl Yank, effluent filter and 3 dt ~ e e( ~ p ~ , G~-~ ~ .dispersal cell must all be services 1 mainiaineq I as per management plan provided by plumber. Ov~n2pc..J_ (,J I 1~- ~Q'A 2. AJI'setbeck requirements- must be maintained as per applicable code / ordinances. 1 A-~/ e Atlach to complete plans for the system and submit to the County only on paper not less than 8 1i2 x 11 inches ' size ,I) t j, PC_ 4--, In~- , j ~F,l Z SBD-6398 (R. I I/11) ~ B po ~-T"- Wisconsin Department of CommerSOIL EVALUATION REPORT Page of Division of Safe and Buildi in accordance with Comm 85, Wis. Adm. Code County ST. CROIX Attach complete site plan on paper riot,( Ahan $11 x 11 inches in size. Plan must include, but not limited to: vertical and fiertzotSiarreference point (BM), direction and Parcel 1. 26-1 4-45-000 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Revi d by Date Q J~ Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). tJ / / V Property Owner Property Location OEVERING HOMES/ALI PERRY Govt. Lot SW 1/4 fE 114 28 T 30 N R 18 E (or) )WW Property Owner's Mailing Address Lot # Block # Subd. Na or CSM# 1153 132ND AVE City State Zip Code Phone Number city Village ■ Town Nearest Road NEW RICHMOND WI 54017 ( ) 132ND AVE R New Construction UseE] Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD 11 Replacement Public or commercial - Describe: Parent material OUTWASH Flood Plain elevation if applicable ft. General comments RECOMMENDED SYS. ELEV. 97.3 and recommendations: 1 Boring # 11 Boring ❑ Q Pit Ground surface elev. 100.0 ft. Depth to limiting factor 122 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr_ Sz. Sh. *Eff#1 'Eff#2 1 0-9 IOYR3/3 -0- SIL 2MSBK MFR W 1F •6 1.0 9-24 1 OYR4/4 -0- SL 1MSBK MFR CW .6 1• 3 24-44 7.5YR4/6 -0_ LS OSG ML CW N/A .7 1.6 4 44-122 7.5YR5/6 -0- LS OSG ML CW N/A .7 1.6 r F-1 Boring # n- Boring , Pit Ground surface elev. ft_ Depth to limiting factor in. Soil ~Eplicafion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 `Eff#2 I i Effluent #1 = BOD$ > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signatur J CST Number ROBERT HARDINA ? 824825 Address Date Evaluation Conducted Telephone Number 477 170TH AVE TURTLE LAKE WI 54889 715-491-5039 HARUINA SEPTIC SYSTEMS -..._.-MPRS/CS`I` 824825 7 n - Ks is a.rz..z> L..:1 'f to E -;e~ i~a<f ~ v f ~ 1' 'p t p _ e C# J W n a l HARDINA SEPTIC SYSTEMS _ MFRS/CST 824825 PL7:::3a cjAjkq, 110 _ t f ` - G r- - - - - - - - - - - 0 ri go, f J i t I CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name:_ c~,~ Q y Owner's Name: `~r>`;~;>✓r: ~p, Owner's Address: ~f_5 I r~ ~t3E Legal Description: `j' z,J 5c / ti 1 C Township: iC Ni{Y iP► IS County: Subdivision Name: '64 ~ufdw,x,j~ AC ce-S N7 OS" Lot Number: 7 S Parcel ID Number: '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 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber: 'n NA e-D- JAr#.t4 License Number: 9CAe~S Date: ?g- !5 Phone Number `~/~f/JSLl Signature ~ Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 ARDINA SEPTIC SYSTEMS MPRS/C.ST 824825 >rALLQ:Z> Q _ _ ~Ro~Q~EJ - ~ coo n ~~LJT 1 - kA m T~, w 1 Soil Absorotion System Cross Section ft 4' Schedule 40 Final Grade PVC Vent Pipe ft 9 With Vent Ca'n Leaching Chamber f- 5Uft System Elevation ft I' ft Soil Absomtion S tem Plan View % ft 5 { i ft j t ft Leaching Trench 1 Vent Or Observation Pipe Chambers mum 4' Dia. Trench 2 Header Leachina Chamber Specifications Manufacturer And Model iI Ciz i 4-n'Tc-W- Chu i r EISA Rating dL sq ft per chamber Soil Application Rate gpd/sq ft y SZ, gpd Design Flow + 7 Soil Application Rate T -1C.' EISA = St? Chambers 2 rows of / chambers each. r Page of wfetime [:7j1-1 i filter Installation and Maintenance Instructions Installation Step 1 dry fit the filter case onto the outlet pipe going to the drain field. Ensure it is centered directly under the access opening. (if outlet pipe is already in a fixed position, additional pipe may need to be added) Step 2 If utilizing the additional single side support and the two bottom supports: While the case is still dry fit to the outlet pipe, measure and cut 1"schedule 40 pvc pipe to the length needed to extend from the hubs that are pre-molded into the case to the side wall and the inside floor of tank. solvent weld pipe into the hubs that are pre-molded onto the case. Step 3 Solvent weld the case to the outlet pipe. Insert the filter cartridge into the case pressing down on the cartridge until it locks into place at the bottom of case. Step 4 if utilizing avertical read switch: Insert switch into the hole pre-molded into the top of the filter. Press straight down until it locks into place Maintenance 1) Remove the access lid of the tank. Note: To ensure undesirable solids do not exit the tank and into the drain field, the tank should be pumped out until the level of effluent is below the outlet level of the tank. 2) To. remove the filter cartridge from the filter case, pull up firmly on the handle of the cartridge dislodging it from the case. (if utilizing a vertical read switch, removal of switch is optional) 3) Using an ordinary garden hose, rinse the filter cartridge ensuring all visible septage material is removed. 4) Place the filter cartridge back into the filter case pressing down on the cartridge until it locks into place. 5) Place the access lid back onto the tank ensuring it is secure. Lifetime filter has a lifetime limited warranty: Lifetime filter LLC warrants the filter will be free of manufacturing and workmanship defects during normal use for the period of time the original purchaser owns the product. Lifetime filter will provide a replacement filter in the event that the original filter was not damaged during the installation or maintenance process. Damage to this product caused by accident. misuse or abuse will not be covered under this warranty. Improper care or malfunctions resulting from product not being installed, operated or maintained properly will void this warranty. Lifetime filter assumes no responsibility for labor charges, removal charges, installation or other incidental or consequential costs. Contact. mikePlifetimefilterlk.com Phone: 502-7242731 AND OPEFaTtG,~ - - :T: RT UP -_n} si toi ih•: presence of p°in'ing produc?s i.r treatm• ni \ I .Gnstn c cn, y rcr ro uses of the FO TS check r I r-ntrsVcnS rr9 def.?Ci h3.H the cCf::?,-:::. i;'"'~~ :~l•~ tra=tn'.-_flt r:rQCd;; and!or dc.ingC the CT high CC7n fc}y(=ill0ved (rj 3 >=ptage serAcin~ Crt:•r:.icr pi of Cif us!. - fi!:rative s:rt-ca. - .uGl ter. 'rL SiSEII noL Gi.Ct_=r '~rP~t-t 511 COr"➢d lifOnS ?ft', CiCc°n et ih9 c n r V. I.' ' r_bGV© ncrn, al In % . the c {Ils1 a ,ij1 ti C:''}:IJa r sis. art _t _ .'(s) to one larga dose, overlo .:Jini! ili i o e tl: rr 'mp tart.): Y this ha,-,", ha,-,", L{~'~ Content- t ih•31c.1t , l;tlr.,•-,contact Plu,W-er or F01'J I j .i_Ia6u.Cr iU t t :Itw.l:: ~f&: tJ t t^~..:i:: `l:ter.^.t t .J':°l5 '::i[ii".n pUfi J ;vnk. V t c ri':o cr DO no, dii-:e or I:ark avlor, c•r oti:c r: a a;urb co ;,p to r vl:icies -v~r tnn i's and isp r;al s v :n slow 01 any nncund or at-grade soil absorption 3r.'3a_ IB improve t!:a periofmance slid CrC4 j the f) 0--1- i cif t7a fc !Cc'• :ins from the s v:zs •rJater:realnt may _ - n2ricn c ! n :r zi' l.r^.i JF. f5; d•~n i."'..f iJ:l Wit; rCr •,,TC- ~n:i~iG'i0.5: rv-V y v=ines; c,,- r i9 btSLf S; CondGmS; Canon Sv1a65: 1• herhicid~ met craF.s: _ ;•-.t!~jticn ,;;'in (sun'p aril?) .^:ester: fruit and veg°tai,la pee.in;s; ,,;~ulina; ,real.3, apkins; tampons; and water so;tr-.r.er brine. prc(,Ucts; p-sticidca; sanitary n CiE'd „ ,`,c elf: ; GAM'S fails and;Cr is permanently taken out of service ttto following stays si:a :~rop r:,V nd s:;;"ply abandcned in ::omplianca with chaptar Comm 33.33, Wisconsin Administrative Code: o All piping to tanks and pits sins!) be disconnected and the abandoned pipa openings seated. n i h Conte, is of ail tanks and pits shall ba removed and properly disposed of by a Saptage Servicing Opgraior. i mid the :L.'~ CF'~4•..' o ;,wsr pumping, all tanks and pits shalt t3 excavated and removed or :heir covers remc•ve7d Y 3pi1, ;ravel er ano ih-r inc.rt solid mat_rial. ( r>xi i I~iG1- iGY PLAN _ b•a r or must i e tai e:~, to protiue a !i til2 Owl3 fails and ca.,nOt b9 rapa:red th•3 tollov,,ing measures have rca.!a:°_incnt system: •A suitable rac-l-cement ar'oa has been evaluated and may be ut15--atd for the locaton of a rdpiaue-ine i syst°i I. Tha•replacament area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed strtJctura, for lines and walls. Failure to protect the.r?pl.acement area ,osult in the need for a nay'.' soil and site evaluation to establish a suitable replacement area. Replaca-ment systems r-nus: comply with the rt:l°s in effect at that time. A suitable replacement area is not available du° to setback and/or soil limitations_ Earring advpnr as to PC- technology a holding tank may be installed as a last resort to replace the failed POWTS. LI The sate has not been av2luated to identify a suitable raplacarnent area. Upon failure roi the aa is F VJ 1 a `o] ~~nd Liz-2 tari e a!uation must bo performed to locate a suitable replacement area. If no replac-rnent a IYtay be installed as a last resort to replace the failed POWYS. r•.1ound and at-grada soil absorption systems may be reconstructed in place following removal of the biom.:t at Tn infiltrative Surface. Reconstructions of such systeins must comply with the rules in effect at that tiani--- C 1.1JAWNING> > SEP-pC, PUMP ARID OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSt=S AND/OR INSUFFICIENT OXYGEN. DO r'OT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUh7STANICES. DEATH MAY RESULT. RESCUE OF A PF-P ;ON FROTO THE INTERIOR OF A TANK MAY BE DIFFICULT OR tr,,IPOSSI6Lt-. F.DITioNALCOMMENTS POWTS INSTALLER POVJTS MAINTAINER Name Nam- , ~i as T - f r-- / A Phone -Phone - - 2 . L c&nTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTkORn-Y C 3A,) Names Pheno - --ion - er Cc:-n.'n 83.22(2)(b)(i)(d)&(f1 and 83.54(1), (2) Fi (3), M-scomin Adrtl i3tr3t^:6 C~je. i rws docur~ni'>ti'as drsic~3 in ccin},li~rwa ~ h ch..p•. srsTl=r.~ ~,~ccfr-ICaTtcr~s _ - - - Al P~ +z e-~ - - - c t.,r_:r rt'~t~"1 T - ` r-lanuttuf~r ~~J1^n~'- 'no _ Z nlt 1J 4. A:;-1 S j t a=ffl+ i C t 1Cy _ it i r I .t) 1 L c n 3 (E-hD i <220 nnn,'L C! i:A (Tt._,) L 'hC~fl l. L c~Q 111;~~-~ ~llds t { 5" } <up L7 h~A Cl Ar C lie J r - - ;~?~r~i n ririU r^r,~ri} ~1G1 rfull(?C);r~l ❑ C?rrp ~ It;a t t 1 y. in Xa. C~ r'A - - - CJ HA in-i .v. (>C1C E ,~iC rii{[}°I;i_ iNTEr;An;CE SCIiEDUC= erric,' re~qucnc/ - . _ SeN.iC3 Evestt - U r71tJr1£h(S) § 1 ,.l y t least Inct "A JNS'' r( ~rtS} d lv,:} oft o , _ _ ^ ,r,1;.B•n~d :,wjq and •curn oGu-I. or C'h' _ ~ rr is) I LJhon _ , r~ r710nth(•`.} »rs) a1.m,lrt ( 103st onto Fe-fl F1 n.yr rC - ,~t IY3at GnC9 eiy: =t) C _ _1t•,r• It ,icl - 1770nifT(5} i C1 dl lz.5t . CR,3 av_ ent,: - r I c - nt rnp PUMP GVR"(:~1 IS At i ~f,C3 HvCrf: Q 'near(s) -1..l (:7 L.fi 1. f',"~ r.~~:!~r? ESL rat ie .S - JA ❑ lon-'h(s) feast CRCt wary [-1 Ye~t(s) r t f 1 1 , t r,1F11;1,vicE NSTiWCTIONS r.arr inr oi1~ of thcp i o%'Jn t II r tietis Sha;l be mado by an ;R~Induai t 3 r 5 r^ I J Up r r I; ~epiat~t p _tcr,ns Of tanks and disl;Crsal ~R ber; h1aster Ctor; E=OtTJTS Maintainer; S Cr ^ ?lumber Restricted Sewer; pt~iNT~~ [nom( t,)--l or bro} an hardwart'-, Ir `'~,fy 'f Cr . r, 'Writr any m;asirtg 5~ ' f 1 :(s} to i~;c~ -c`~ up or pnr ding of r i'iri nt on ie gr~ f ;f bans must includ a visual sled of the- tat+F y c ` ~ Wed sludge e and scum and to checi: far any b rr lavel•~ in ,ho obser- ation pip s and o Lh c{ 1,r _fr pci, fnc - Ilr=j 'JCir. ma OT COtl',C~ r,;rl ices n';aY indlcatt, a t :.l~ing ron~iltlo? _I11.~ ~,sp~-rs~l ceil(sl snai§ be visually ,r,spoctF.:r~ to cf,PCI: ti^,a of£.ue co 1 ht' partding of, rffkjent nn the ground surfa t,tl.") alJ ~ rfaGC T t~ E.ISi a f t 07 ~h8 Qic_ Ori -l ~;o''re tra ,-n "t tl n Oi the l~Ca rf,~~ pryuXh ty. _ rr1'iitt3 n ~tIfIC t rrrr,r h 1 1 r ~ nr;'~-third cr 01 tPt e d -n11at!on of sludge and scum in any tank equ2,• ,n ccordancc~ ti, tM, F y r? hs ce;t15{R 1 ' a" 1 ,,icing cpceratcr and disposed o` cntents of t,to tank ,hall be removed by a Septage 5.r Fu"S:'',i,iS, 'n AdminlstraJve Code, o-rLiatr en r L!2 dinq but not limittA to the sarvicing of effluent filteiS Ci~fT', } r~^!TS Pv1a nt.nlner. rvices, inclu , 3n e Is of 512 months, shall ha performed by a Certifi d FO , ts and any servicing at inteNa r .ginv serti'ic,~ aven*. t,^z.f req:.'{atory a,lrhorn, v ~,atriut 10 days cf cantPlot§on o r-.~r~'1 (.S;t)t} ,_ip Ivy. - (eport St1 ~3i( L)J ,.^.rOViC76d 't4 i, t RECOVED ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT ST. CROIX COUNTY AND :~OMMUNITY DEVELOPMENT' OWNERSHIP CERTIFICATION FORM Owner/Buyer FO C C-01" L L C Mailing Address 7 C CA,! Q / C~t.t Ai !C_lCf 4YC,j, ~L l 7 3 L-'11 Property Address 115 .a I ' ,;IA3 At Q (Verification required from Planning & Zo I Department for new construction.) City/State j Parcel Identification Number LEGAL DESCRIPTION Property Location 5t L/4 , .5 C-, '/4 , Sec. r ' , T '(1 N R ~S W, Town of " j 1 C F1 1-1 Subdivision Plat: ~ LVrl <:-:s lC (-E ~~IG'~ ~ 3 , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # (before 2007)Volume Page # Spec house n yes r no Lot lines identifiable Ali yes n 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 (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/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. Uwe certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms IGNA URE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 09/07) ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 0 Mailing Address y,, r Property A ddress (Verification required from Planning & "Zoning Department for new construction.) City/State Parcel Identification Number e) `a, q LEGAL DESCRIPTION Property Location 5 ti' '/4 '/4 Sec. , T ,:30 _N R-19 _W, Town of tC 1 M cyJ t~ Subdivision Plat: PL A l C C Wt ,LE S , Lot # `I . Certified Survey Map # , Volume , Page # Warranty Deed # (before 2007)Volume , Page # Spec house F1 yes F no Lot lines identifiable yes F1 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 (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/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 are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms r !J l~l t 5 SIG URE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department- Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 09/07) LO;LOP 34 rri 7.90 acres 7, 62 GC,'-es 52,75J sq- ft, 70,659 s ft. AS, 4 G.Z,Y 7J.f 7- W T C.?_2 _ . ~ S82-4273B ~ t482-4f 3B E 0 z 46 S 1.96 acr fto 1.79 acres 1.74 cores 8-,1' 77,876 sq ft. 75a 74 1 s q. ft. ~ ~ 5;0' Ed"MOnt for Prairie Cr= Potion 9 SV89'50'27*E AT °5 E80,09 39.196' q~ ~}6 C7 a 600. 00 1. 96 VE ll V14 acres 85, J98 sq. ft. ' - r Monument. of Record N89'50'27"E 450.26' 0 . Pip 0 00 18" Iran Rebar 03 Ibs. per linear foot. All acres P _ m.P... m. ®t..» ~ ...°At ~ f8. e•@ C3~ _ae._. ~ r°sa-~ ~ ~ r _ _ r~ • m E 4 E O - sgg~a6y ~ N rv Z d V O -j82 ?fig C o w Z ,f c~ p Z 8 j H ~ LL a ~ z X03 i ~ uw ov J ¢ m ¢ w m'^, 3pE 3 p c J I p~~ w Z b° ¢ ¢ I._g c a m se Mks I J I - I I ICI I'.I I I 1 - I r i I I i ~ I _o.z s~.s3ssnai noo ~.ei it FET I . I I I I II II I I I I If 10 I I I I _ I I I I' QII O I I .a e II I-_-_-_ I I II~ I I o~ I I I I ~A~p II I u. I I I I- I a I I V I I I" ° a I I e L__________JI II 4~ - -J a I 10 II f~L I- I I I I . _ J r m . I..rt I I 11 ~ ° ' I I ..¢s-ni I I I I I . IR I~ I I I ~ I I I ~ I' I I I I I I I -w~ - I ~ II o I 'r o.x a. sassnH~noo~~.e~ i I 50~ I I II r I I I L ~OP ~y7 chi 3a im ~a - - E g k 5a N - - - - - - - - - - - - - - - ii ° o ~za 4QO E . w p o c > M w _ a LLJ ff~ _ - U a i:- p~ r v J ~l N m pw a3Ey pa § C yw z \I z > a a~ ~ 5 gg 33 p 5 gC ud$€@S °$~t.€ u§ k$fzm gam, O e Cw ~ 2 LL> j I 30 0~ ~ °w 5 w ~z as i I m I I I ~ I I of I I C\ fo s I Ob ; 3 I - - - - - - - - - - - - - - - - i~ - ae f z ~ I R~ ,a <El .o I a v, o I'd" 1 O O A + I I 5 - - 4~ I a~v~ vN.c~n~e _ I gN I m ~ I I I I if 0 I Sm to ]f - - - - - - - - - _ - _ - _ - _ - _ - - I alo I v I I I ' I Ezui.»aJ~lmn I Irv, i. ~,]iinen I ~a3 z~ ~e gxh gm4 B Wisconsin Departrtlent of Commerce SOIL EVALUATION REPOR-h Page Division of Safety and Buildings in ac cordanu with Conan W3. Wis. Adnt Code, -1 County P-1 Attach complete site plan on paper not less than 8 1/2 x 1 1 include, but not limited to: vertical and horizontal reference point (B~iy,, drrectiar~ rid Parcel I.D. i V f )J ocation and distance to neaiest road.; l✓'' percent slope, scale or dimensions, north arrow, and, 0 2- - - - - - - Rev'owed by -Duty Please print all information. / Personal information you provide may be used for secondary purposes (Pnrac/ law, 15»0'1-(1) (m)). f'ropertyOwner Property l LocationGL~ (CUctvlrl Pr ott)..114`t -114SaTN R E(ar) µ l_oparty Own(/}e-"r'/s Mailing Address ( } Lot E;lock Sufxi. Name or CSM// /p.T~ 1 2 1u~ i" 1-~1 ICZ 1 0 r 1-C. f ~Wl d P✓ S~ -A C f C* City State Zip Code Phone Number City E) Village (9 Town Nearest Road,-, F lK R P.-1 7 c 4, a ►•j c 3 " ~Z 1 New Construction Use: Residential / Number of bedrooms _ Code derived design flow rate GPD Replacement ❑ Public or commercial - Describe: Parent material _ C>t.-? ~.r 3+ ry Flood Plain e'evation if applicable _ _ _ . ft. General comrttents T 5 Y s-r and recommendations _((r;{,(t~.(,Q,..~~1.. 1 Dy .r/ ~IU.{(!"/: J,.-_. (,LPL?L-~?i'. ~~L:7„✓ ri?../.-J,rr';'C, ,l.'`.'i/1~' L ~ Boring ; Boring # Pit Ground surface elev. ft. Depth to limiting factor Soil At plicdtion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ff in. Munsell Qu. Sz_Cont. Color Gr. Sz. Sh, 'Effff 1 Effl/7_ 444- '77 Boring # ❑ Boring i{ N, p t Pit Ground surface elev.' ft. Depth to limiting factor in. - - Soil Application fate Horizon I Depth Dominant Color Redox Description Texture Structure ConsistenceT Boundary Roots _-GPDrfP in. Munsell QU. Sz. Cont. Color Gr. Sz. Sh. Effl/1~_Eff#2 - j t r, _ Effluent #1 = BOD$ > 30 < 220 mg/L and TSS >30 < 150 mg/L Effluent V = BODE < 30 mg /L and T SS < 30 mall - e T Name (P~lease p,r Signatur CST Number (:~a 1 7 _q ~ dress Date Evaluation Conducted Telephone NurnLer Property Owner Ger y, )A T S'Y1 Ak Parcel ID # _ Page _i;;R_ of _Y- Boring # ~q L] Boring I 13 F-31 A Pit Ground surface elev. ! I'ly Y ff. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f? In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Etf#1 'Eff#2 1 04 /0Y6 rn 5 h ~ m-~r C~ a , $ 10Y6 N e n `1 m 5 " i C W 3 F'y- w s N~ S . s Yn L CLJ 1v-~ -8 7 SIB '~L~ tim L , -1 ❑ Boring # ❑ 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/ff In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ❑ Boeing # ❑ Boring ❑ Pit Ground surface elev. R. 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 = BOD6 > 30:< 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD, < 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. WD•2330 (R.M) Y r ~ 4 j Ig f t 1. . , . , , 4 an . _ YY r _ ~ I ,.,Y . . . y -.nom . 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