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HomeMy WebLinkAbout032-2176-21-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Building Division St. Croix INSPECTION REPORT sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) 579083 Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. State Plan ID No: Permit Holder's Name: City Village Township Parcel Tax No: Baillargeon Properties TOWN OF SOMERSET 032-2176-21-000 CST BM Elev: I C) Insp. BM Elev: BM Description: _ Section/Town/Range/Map No: CST 12.30.19.1506 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER ,'S CAPACITY STATION BS HI FS ELEV. Septic r~ Benchmark (~J► eS e„r- r It, 1600 71 a Ibl..3 99'. 3 n• Pb la 'I ~Z L Alt B,M,s 6.A- :15 Aeration Bldg. Sewer 5.65 iQa. Holding SUHt Inlet 5.8'8 /ao.yZ TANK SETBACK INFORMATION St/Ht Outlet (0,15 lDt~. 1 ! TANK TO E P/~ WELL BLDG. ent o Air Intake ROAD Dt Inlet Septic NA- I t -->/5 Dt Bottom I'f Z ~ Dosing Header/Man. Aeration Dist. Pipe lt7.3 !613 9 Holding Bot. System ll•3 45 ,E PUMP/SIPHON INFORMATION Final Grade ~•I 1 ~'~.,N. eJit S.&S (o Manufacturer Demand St Cover t' GPM Ie,~- G Z.S~S 1e3. 7 Model Nu TDH Li FrictiojLoss System Head H Ft Forcemain Length Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length ! No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS Is115 7, ! lto-e-l /f 1-~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufact rer: INFORMATION Type Of System: ~ ~ o L CHAMBER OR Z. ~!6 y) C6 ,tiJ~• --A4 a O g UNIT Model Number:G DISTRIBUTION SYSTEM 4-ed41-Q_ Header/Manifold 11 Distribution x Hole Size x Hole Spacing Vent Air In ke ~y / Pipe(s) ~~4 S Length O Dia T Length Dia Spacing ~ 6~~ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Q on so Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center S Bed/Trench Edges Topsoil Yes 0 No 0 Yes a No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 1601 83RD ST 1.) Alt BM Description = A i (C t/6Je.L-- CL06:A,'5 G L~lfc. 4--6 2.) Bldg sewer length = 23 - amount of cover = 7 it / Y av` Plan revision Required? ❑ Yes No Use other side for additional information. SBD-6710 (R.3/97) Date Insepctor' ignature Cert. No. f County Safety and Buildings Division f 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) Madison, Wl 53707-7162 COUNTY A OMMUNITY DEVELOP any pp S TransactionN lmbgr_ t Permit A lication In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate govemmen is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to act Address (if different than mailing address) the Department of Safety and Professional Servies. Personal infomtati ou provide flay be used for secondary purposes in accordance with the Privacy Law, s. 15.04(1) m , stab. IV I 1. A lication Information -Please Print All Information Property Owner's N e 1,71 Zi ZZ Cr CJ (3 47 Property Owner's "ailing Addrres J Property Location f , 0 7y &1a71e ja,:e4r cJ Govt. Lot I City,, State _ Zip code Phone Number L- yy S Section ;_X017 ? //7(circl1es N; R( o an II. Type of Building (check all that apply) ~ Lot T J0 # Subdivision Name ❑ 1 or 2 Family Dwelling - Number of Bedrooms j Ca ~ e (`IrA Block # e i ~~*71ef J GGG~~~"' ❑ Public/Commercial -Describe Use ❑ City of 0. CSM Number ❑ Village of ❑ State Owned -Describe Use ❑ Town of III. Type of Permit: (Check on one box on line A. Complete line B if applicable) e A. ji~New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only Other Modification to Existing System (explain) B. ❑ Permit Renewal- ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. Type of POWTS S stem/Com onent/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 ersal/Trea Ent Area Information: Design ~ d) Design Soil Application Ra dsf) Dispersal Are~eq~ fit) Dispersj Area Proposed (s System EJgv~ / 0 S-0 P VL Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units „ a New Tanks Existing Tanks , J n ' = Y a y °'p m as Y+ Ya a cg rn J5 'w 5 w Septic or Holding Tank 1006 %L° e, - Dosing Chamber v VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Prinj) Plumber's Si MPIMPRS Number Business Phone Number ~r(' a/-^ e ll 2313l 71r-Zy~_3zo3 Plumber's Address (Street, City, State, Zip Code ` VI Coon /De artment Use On Permit Fee D Issu Issuin t Signature Approved prove j,~ w teen Reason for ial $ f -7.5' ~ yl r Ix. Condi s for Disapproval Zon;'/`` 1. c a uenAbrand 1'IO I S L,, j~ .C-1~ Pt1.f dispersal tali must all be servW l'maintained pi br1 ti`V~ 7 ~ ~ ' es per mIllAgement plan provided by plumber. v J 1 'LLkusE rrlairttaiti8d T'C Attach to complete plans for the system and submit to -the onnty only an r not t than 8 A/z z 11 'inches size SBD-6398 (R. 11/11) Eras►aY.~~` ' OWNER Page 3 of 3 Name Pa.( Brian Parnell Address S "lS"S eye CST 231314 S°ncsse~y2S Date Benchmark 1 Y2 S~~e~ e CL / A Benchmark 2 74e e ❑ Soil Boring U _ Suitable Area 1 40' Scale l i i l ~ I!~, i I r I 1 f i l l I I I s i l i l , I I I~ I I ( I f i i- ITIKI i r I i I~ I! r i l i( { i i l l{ i l i l i i! I 63 I i I I i ( i I I i I a f r I I I f I I' I I I i i~ i I I i II 0~ { I l i a l i I I~ ~ D ~i i ! ~ . { o S~el ! 1 I i { I . ! i ~ Ip f i i I 1 ! ,1, 1 I I I r I / { r i ~ I i I 1f ~ 1 ~ Tl I i I I 2i I I l 1 ~ ~ I 1~ i 1 ~ 1 ~ I i t f i! i! I ~ r i ~ { l~l{i ~ Ilil ' !I III I I I s I i i Q;M 6 V I CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE foes Project Name: Owner's Name: C 16 11e7 Owner's Address: Sc~ - ~~5~~ y e , Legal Description: S~/ `J~ ~C C lz -772 6 AI Township: County: 5- 6, ref' e ~S~~fes Subdivision Name: Lot Number: 21 Parcel ID Number: Z~ 600 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 r 7(V1,,4e11 Designer/Plumber: r V f License Number: Date: / /Sr Phone Number Signature - - 61 Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 OWNER Page 3 of 3 Name V,~r Brian Parnell Address 5- -153 ~Le CST 2;.314,y, Sc~~e~ ~Z 425 Date A Benchmark 1 'V601 YZ ~i S~ e CL A Benchmark 2 -ro '*X Soil Boring Suitable Area 1" = 40' Scale _ I /I s f I h4 l IT hi I I 4 ~ I IT a e ~ n g z I e 1 /16( S ~ -5-~f " f _ro- C~ Z z ~l/z~ r s 5 Z3 ~re `4 ~~SU= ~3 12 o_7 - - SOIL ABSORPTION SYSTEM DETAIL I GRAVELLESS LEACHING UNIT Page of Project Name: l l G F ea., t A l ~s /0` No. of Cells Per Cell 3 ft Cell Width .Z2- /0- Total No of it Cell Length T7170~ sq ft EISA Per Cell ft Cell Spacing S~ sq ft Total EISA Manufacturer Model Laying Length EISA Rating Ior Q12031-1-5ft 5.0' 25.0 EZ1203H-10ft 10.0' 50.0 P ~ fob Gravelless Leaching Unit Manufacturer. Gravelless Leaching Unit Model: ~2 N ~Z /2 3h`' ~a ~3 Typical Cross Section Finished Grade ~ ft Observation Pipe with approved cap or vent ~.w ■ <;:;>:>:::::-:•;;>::•>:;::::;.<_ s: Soil Backfill :::f Geotextile Fabric /ft Infiltrative Surface ,2 in ° I I / 7ft Limiting Factor in Slotted and Anchored Vent/ Observation Pipe with Cap ■afflfff f■aar!la....■/aw=......................................... Plumber/Designer Signature: G License 0 Date: I P OI 2InL INSTALLATION INSTRUCTIONS ^ W4m "of P*M hr. PL-525/PL-625 FILTER INSTALLATION INSTRUCTIONS Center filter 7 with opening l ' . Rol ~'r ,,LYti' N#SY'F~ e. u Addir~at pl. £ " ` forc~ten Glue Step 1: Step 2: Step 3: (A) Locate the outlet of the septic tank. (A) Before installation, place the (A) Glue the filter housing on the (B) Remove tank cover and pump tank filter housing on to the outlet pipe. outlet pipe. if necessary. (B) Make sure that the housing (B) Insert the filter cartridge in the is positioned so the filter can be 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 1 21 1 it T ~ 4 1 -"t-y IN .•'--5 c,.,~,-. a <:_t? . •r ,tea r~ .3f2."i. a... ?'s. T2.»,. '~,.•.;s._ ~r:`~^ -'2a -,yu, '2' ~T-e-E,:asS~ .g u",- -~~~'i . ~1.. N.. Step 1: Step 2: Step 3: Locate the outlet of the septic tank. (A) Remove tank cover and pump (A) Insert the filter cartridge back DO NOT USE PLUMBING if necessary, into the the housing making sure (B) Pull the filter out of the housin WHEN FILTER IS the filter is • properly ali hed g 9 (C) Hose off the filter over the septic tank and completely inserted. USE RUBBER GLfSVES` ` Make sure all solids fall back into the (B) Replace septic tank cover ~NH1=f CLEANING FILTER septic tank. i POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner ~m Septic Tank Capacity l0 © al ❑ NA Permit # Septic Tank Manufacturer /re.S ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer p / Ct~G ❑ NA Number of Bedrooms 3 ❑ NA Effluent Filter Model 1 52.E ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity al ❑ NA Estimated flow (average) al/day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) YSD gal/day Pump Manufacturer ❑ NA Soil Application Rate 7 al/day/ft2 Pump Model ❑ NA Standard Influent/Effluent Quality Monthly average` Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODS) 5220 mg/L NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) <_150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BODd 530 mg/L p.ln-Ground (gravity) ❑ in-Ground (pressurized) Total Suspended Solids (TSS) S30 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coiiform (geometric mean) 5104 cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y. in dia. ❑ NA Other ❑ NA Other: ❑ NA Other. ❑ NA f 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: 13 month(s) (Maximum 3 ears) ❑ NA Iff ear(s) y Pump out contents of tank(s) When combined sludge~and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) 11 NA ,year(s) Clean effluent filter At least once every: 2 ❑ month(s) ❑ NA .l-year(s) At pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA ❑ year(s) At least once every: ❑ month(s) ❑ NA _ ~s= `atera[s and pressure test 13 year(s) At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined .accumulation of sludge and scum in any tank equals one-third (Y3) or more of the tank volume, the entire . contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of X12 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. 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 seated. • 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 G 4F/n Name ,1 1 Phone Z c/-7 -,?2 02 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone This document was draftee c::-p:iance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(7), (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.norma( 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 Name Phone 0 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone This document was drat-tat c1-;:.9ance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK hfAD TFL ANCE AGREEIvENT AND 0-W-N7FR.SIT CERTIFICATION FORM Pro Get, UX, O'er: Buyer, n 10 • i,✓l ~"yv z /4 ~1~~ U wog i'►12 V~~- to TL/~a1li Address , --j to ?rope-t` Address o ~ rd 5 ~-Z o (Teri-ication rem from Planning & Zoning Depm=AW for new construction.) Parcel Identificaion Nmnber 032. - 2116 • 21 - 000 City/State ~ v LEGAL DESC_RIPTIO,N- ProPeriy Location g._ Sec. I T _VN RL~--W, Town of (M eJS a ~ - Subdivision Plat:~,eb I e-~ C - , Lot# Z Certified Survey Map # , Volume Page # Warranty Deed (before 2007)Volume Page Spec house)(yes i01 no Lot sines ideatifiablekyes 0 no S ST M MARN NANCE AND OVYWER CERTMCATION Improper use and main er ance of your septic system could result m its premature failure to handle wastes. Prager 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 asked the function of the septic tank as a treatment stage in the waste disposal system. tawtter maintenance responsibilities are specified in §SPS. 383352(1) and in Chapter 12 - St Croix County Sanitary Ordinance. The property owner agrees to submit to St Crow County Piamiing & 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 ua._stewater disposal system ism proper operating condition and/or (2) after inspection and pumping (ifnecessary), the septic tank: is less than U3 fiill 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 Safety And Professional Services and the Department of Natural Resources, State of WI-isconsin. Certification stating that your septic system has been maintained must be completed and retained to the St Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that. all statements on form are true to the best of my/our knowledge., Uwe am/are the owner(s) of the property descn'bed above, by virtue of :76ranty deed recorded in Register of Deeds Office. 3 Number of bedrooms IGNATE; OF APPLICANT(S) DATE ***:Any information that is misrepresented may result in the sanitary permit bemQ revoked by the Plannmg & Zoning Department include A= this application a recorded warranty deed from the Reamer of Deeds Once and a copy of the certified survey map if reference is made in the warranty deed. ,rREV. 04/1.Z) D= D; Y n O K W Q W J ~ ~(Y Z z ° W o G>~. * R g 6 z IN- W z .i R . C Q O -Q ~a p o O _ 2w:N° p CJ z0 C) Q. y (Y0 L W LL) 4~ O Q CG 1 N Ln N W N W U 1. N o N 0- -C uj a CL 4, 0 C) 6 > > Q D O Z ,f N f6 i C 0 4~ E 8 O • ` N t $ O ( Naj N o rn\ ~ qq n CD cu S I L tS 0 I L N C` ft!( 3 Q p o 0 'y- R I ~cn3oou I ~ • ,6COS£ 3„ZS.Sb,O0S as I~ pp Q W N N FL Z a z r I OOT a u cc 32 Z I W I vcoi mow I I N O I I 'o ~ 1 I N W I I M W 00 z y N 1 0o > 00 i ,OT N = I z z ,OOT %-4 1 .4_! CR - (n w W X Q °o W 54 a pW 0 U) ~.bF ? 02 m w N .66-6£Z M„ ZS.S'1.00N U ¢J o JL33HIS MISS to N ~ -oj gam"( N0. i 570.18' M n ~I - N Di W ~I LOT 9 ; I I 3.0 ACRES N 0 ~ I C.B.A. = 2.3 ACRES Q W N c l LOT 16 C 1 j~ 3.1 ACRES W ® ® C.B.A. = 3.1 ACRES - ' ~ I I I ® al 575.47' ' N ' N ® LOT 17 N 3.0 ACRES 0 C.B.A. = 3.0 ACRES 642.67' 388.95' : LOT 18 ®SO ACRES '6' W/OE C H..A = 2.4 ACRES c V M T W C N N LOT 19 N 41 r~ Qy 3.0 ACRES Q r N C O.B.A. = 2.7 ACRES C9 L B.O. = 926.4 3 d of ® 563.71' 291.23' i LOT 20 3.0 ACRES r r G BA. = 23 ACRES r L.B.O. = 926.4 r r t; ' r C.B.A. = 1.9 ACRES 71.48' 336.96 S89°34'47W 372.54 LOT 22 ® 3.0 ACRES j W ~ r L CQ 16 N LOT 21,- ® OD M 3.0 ACr ES (h w (it D.B.A. = 3.0 ACRES W W@L. ~9 p~o ea~"3g- N O p ny 0 . . . . • . . . • . . . . . . . . • N Z FIELD C.B.A. = 0.96 ACRES POLE SHED HOUSE DRIVE EXISTING DRIVE ~ 160TH AVENUE ~ 1319.70' m S89°1 4'08"W 223.78' m u i. S89'1 4'08'W EXISTING CENTERLINE m SOUTH LINE OF THE SW1/4, SECTION 12 't In IK TIERS: DEVELOPERS: Parcel 032-2176-21-000 03/26/2008 04:58 PM PAGE 1 OF 1 Alt. Parcel 12.30.19.1506 032 - TOWN OF SOMERSET Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 01/28/2004 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - TI MAGNUSON ENT INC TI MAGNUSON ENT INC 1638 83RD ST NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 1601 83RD ST SC 3962 NEW RICHMOND SP 1700 WITC Legal Description: Acres: 3.000 Plat: 09-099-LAKESIDE ESTATES 1/22 032-04 SEC 12 T30N R19W PT SW SW LAKESIDE Block/Condo Bldg: LOT 21 ESTATES '04 LOT 21 (3.OOAC) Tract(s): (Sec-Twn-Rng 401/4 1601/4) 12-30N-19W SW SW Notes: Parcel History: Date Doc # Vol/Page Type 11/10/2005 811724 2925/680 WD 01/28/2004 752813 9/99 PLAT 08/22/2003 736985 2385/383 WD 09/27/2002 692047 1991/540 Rp mor 2008 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 08/10/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.000 60,000 0 60,000 NO Totals for 2008: General Property 3.000 60,000 0 60,000 Woodland 0.000 0 0 Totals for 2007: General Property 3.000 60,000 0 60,000 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 ~ 'u;t :t Opt-&/ ~ rJ y&-,-f57 • (le PfjR P&mez-Op yE.v 7- CIO To-Ai ~•9•vSE•v ¢o Cv ~tl.4~iv ST ~FV Cv~.vG-, ~.v. sso 66, (a SI• 3 88 /la od Wisconsin Department of Commerce SOIL EVALUATION REPORT Page ` of 3 Division of Safety and Buildings In accordance with Com 185, V C Attach complete site plan on paper not less than 8 112 x 11 inche in size Plan must Include, but not limited to: vertical and horizontal reference point ( M), direction and Pam 4 I.D. percent slope, scale or dimensions, north arrow, and location and istanc4 t j4ea Aroj40 Please print all Information. Re Y. Date Personal Information you provide may be used for secondary purposes (P !L: ST. i2 ( Il Property Owner rope) S RAbt J"e'FF) Govt. Lot 1/4 114 S /A T30 N R ~9 ~ (or) W P rty Owner's Mailing Address Lot # Block # Subd. Name or CSM# ad~ iO ~-07L.21 b w, City State , Zip Code Phone Number ❑ City ❑ Village (Town Nearest Road iG~ii~/o vt~ cv/. Syo/ 7 ( 7/5) 2- Y6 • SM6 -T`" 160V New Construction Use. Residential / Number of bedrooms 3- Y Code derived design flow rate y ~0 o U GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material /~&,A Flood Plain elevation If applicable ft. General mm comments and recortnm dataons: /7 it/, r,6-5 rev 4A.-) 1,V • y.~O U.tJf~ 7'R&4" &A-,, r Sys /,-P 4Pi/v I- /t'4 T-JSF` o . 4 ~ Z a Boring # Boring Pit Ground surface elev. 7 1.3 0 ft. Depth ro limiting factor M. Sol Appitaflon Rate Horizon Depth Dominant Color Redox Description Texture SUuct re Consistence Boundary Roots GPD/fF In. Mumsel tau. Sz. Cont. Colo Gr. Sz. Sh. 'Eff#1 Tff#2 / o -S /o R ,3/3 - L 2 f ,t? I'ip cs a f . f/ . 4 Y? 3 Cs 7C y 3 1.2-2,1 /o 0? ,T srL sd 'r.,, f,e ezu / . Z .3 7. S YR Sic L 17'W AV I's - . Z . 3 y v s 1-,4 O( S e.5- 5' a • po 7.5 Y/? 7 0•e 7sytsY - S /JC~ l . y . G F - 1 Boring # Boring / / • 3 D ~I Pit Ground surface elev. _ ft. Depth to limiting facto d in. Soil ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f! In. Munsell tau. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 I 0' !o /&q Xe y/ - SG Z f sbK 40v iP w 31t 'S" .7 2- -1& /o YiP y 2 f s6A- i►~►~iP c 5 2 • s . 8 3 6•26 ?-5'YRy Cs - .7 Z /0-W S1411 S 0 07- r DIP- S ' Effluent #1 = BOD > 30 < 220 mg1L TSS >30 < 150 mg/L ' Effluent #2 = BOO < 3o mgn, and TSS < 30 mg/L CST flan (Please Print) - - Signature CST Number f, -P37- Address Date Evaluation Conducted Telephone Number Ulbricht & Associates '03 71..5. 77.Z• 3 y~fZ 2812 10th Ave. Spring Valley, WI 54767 419/S g See For issuance of permits and designing Contact: Ulbricht & Associates s~/sue sic C, / Registered private wastewater consultant and plumbers 2812 10th Ave. yG!> /SGIJ SE~• Z- Spring Valley, WI 54767 ? 715-772-3442 . ORIGINAL 7- z l Z 3 Property Owner _ Parcel ID # Page of 31 Boring # ❑ Boring 70 Pit Ground surface elev. ft. Depth to limiting factor FO I,. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDAf° In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 0.// /o he 3 Af a fR w 3 I - Y . b 1~0 /D f• 3 -00 7 S yR 2 f5b4 o o f s n-,~~ . S d. s ,.Q • 7 i- Boring # ❑ Boring - ❑ Pit -Ground surface elev. ft. Depthto limiting factor In• Application Rate Horizon Depth Dominant Coibr Redox Description Texture . Structure = Consistence Boundary Roots GPD/IF In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring # ° Boring ❑ Pit Ground surface elev. ft. Depth to Iimltin9 factor In. Soil Applicalkn Rate Horizon Depth Dominant Color Redox Description. Texture Stricture Consistence Boundary Roots GPDM In. Munsell Qu. Sz Cont. Color Gr. Sz Sh. '0101 'Eff#2 Boring a Boring # ° ~ Rate ❑ Pit Ground surface elev. ft. Depth to limiting factor In. ~ IGPDff Dominant Color Redo cription • Texture Structure Consistence Bourxiary Roots Hori zon Depth 'E'Ef1#2 In. Munsell z. Cont Color Gr. Sz Sh. EE Effluent #1 = BOD` > 30 220 nxft and TSS >30:n 150 mgll ' Effluent #2 = BOD, < 30 nV& and TSS 30 mglt. I 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. seo 1130 (R.6w) ~3 4.9~~DM~¢,J L D T~ Z ~ Z 3 Property Owner _ Parcel ID # Page of Boring L] Boring 3 ~ y' •7~ 9a Pit Ground surface elev. _ N. Depth to limiting factor > in. Soli lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDt f In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 o * ll / o y2 3 fiP w 3 . y b Z to I SQL, cs Z • 3 3 o jo 7.S yR SiG. 2 fsb,~ ~,2 ccJ / • -s y 10. 3 715SG / f5h . /u i iew a----s O /a s ~•r-~cP . s d ..I oQ.Q 7- F1 Boring # ❑ Boring ❑ pit Ground surface elev. 1t. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Colbr Redox Description Texture Structure - Consistence Boundary Roots GPD/ff In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 I Boring # U Boring ❑ pit Ground surface elev. fl. Depth to limiting factor In: Soil Application Rate Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPDM In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 a Boring # ❑ Boring ❑ Pit Ground surface elev. R. Depth to limiting factor M. Soil Application hate Horizon Depth Dominant Color Redo ascription. Texture Structure Consistence Boundary Roots GPDM In. Munsell Q z. Cont. Color Gr. Sz. Sh. •Eff#1 *Eff#2 Effluent #1 = BODE > 30 < 220 mg1L and TSS >30 < 150 mglL ' Effluent #2 = SOD, < 30 mg& and TSS < 30 nVIL 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. seo eno ~t.NOOI T 20 ;VV, Lo T' Gi.v~ ( LA 1 N CojeAA ~ 0 D- o to l' z 0 3 1/0 qq D ~ x.10 \I J 'O u' • 0 v Tor of For issuance of permits and designing Contact: Ulbricht & Associates Registered private wastewater consultant and plumbers 2812 10th Ave. Spring Valley, WI 54767 715-772.3442