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HomeMy WebLinkAbout040-1209-90-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 589720 Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: r ity Village Township Parcel Tax No: David Zorn TOWN OF TROY 040-1209-90-000 CST BM Elev Insp. BM Elev: BM Description: Section/Town/Range/Map No: 25.28.20.994 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER i oil CAPACITY STATION BS HI FS ELEV. Septic Benchmark 1 MW 3.41143. 106 %T7 ZS Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet r •';A, °IS• 5.3 q• ~c, ~q•9Z TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. ent o Air Intake ROAD Dt Inlet I / - Dt Bottom Septic fO3 3 Dosing Header/Man. Aeratio Dist. Pipe Holding Bot. System PUMP/SIPHON INFORMATION Final Grade Manufacturer Demand St Cover r.~ Model Nu GPM 3 16 2 • T Lift FrictiTDH Ft Forcemain Length SOIL ABSORPTION S YSTEM BEDITRENCH Width 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 CHAMBER OR Type Of System: 1~ 11 1 AJA- UNIT Model Number: \ DISTRIBUTION SYSTEM Header/Manifold Distribution IX Hale 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 Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 133 GLEN LA G i 1.) Alt BM Description= 66 L# ~..1., ~ ~-Q ".,L 2.) Bldg sewer length = a 1,24 - amount of cover = M X~`~ 11 a4 Oed Plan revision Required? [n Yes ❑ No Use other side for additional information. _ Date Ins ctor's Si ature Cert. No. SBD-6710 (R.3/97) ~'rrf ~ County t .f V Safety and Buildings Division 4c y r , 201 W. Washington Ave., P Bo 162 Sanitary Permit Number (to be filled in by Co.) Madison, WI 5370 JUN 22 20i S'nrv (09)0 u-7 17Z0 ;oMMU c1~~F3'it Application Sta oCN r 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 Pro'ect Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary l purposes in accordance with the Privacy Law, s. I5. 4 1 m Stats. 1. Application Information - Please Prin formation hhhhifffif Property er's N f Parcel # Property Owner's Mailing Address Property Location Govt. Lot ^c> Cit State Zip Code Phone Number y. Section ~J^_L ~V W I,L~ 1 a// one) t r(/ T N; R ~ E og II. Type of Building (check all that apply) Lot# 1 or 2 Family Dwelling -Number of Bedrooms Subdivision Name WN~ 1xr'y" , GCai .t 1 ~w Block 15+. ❑ Public/Commercial - Describe Use ❑ City of CSM Number ❑ Village of _ ❑ State Owned - Describe Use Town of f© ne B if applicable) ete li III. Type of Permit: (Check only one box on line Wmat. A. ❑ New System ❑ Replacement System ent/Holding Tank Replacement Only ~-Other Modification to Existin yste (explain) e', I M G tz - List Previous Permit umber and Date sued B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New ~ ~ ~ ~~2/ eY, / Before Expiration Owner OT IV. Type of PO TS System/Component/Device: Check all that a ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound 2:24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (st) Dispersal Area Proposed (sf) System Elevation Xi S VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units -2 ts U y New Tanks Existing Tanks obi r/~ Lc. C7 0., P pAb /v U i7, n.s,.gCh ank O bility Statement- I, theundersignde responsibility for installation of the POWTS shown on the attached plans. PI berName (Print) Pl Signature MP ber Business Phone Number Plumber's Add" s (Street, City, State, Zi ode) I1J ~ ~ VIII. un /Department Use Unnly Permit Fee Dat Issue Issuing nt Signature - Approved Disapprove $ • ~ IV n Reason for Denia 1 a I _ a IX. Cond' Se eas~ns; fo~ Disapproval1 6 ptl~ er tint u F G+nl ) l wlJ~- dhsper• ~,i cell must all be sit is s ! noomt~nec as per management plan prwidedbyby plumber. GQ n 2 t as PW spPlloabls clods / W nWIM, tt<sir;6 d Attach to complete plans for the system and submit to the County only on paper not less than 8 tr! x 11 inches in size SBD-6398 (R. 11/11) r iJ V WIN k T w / lib ~t ,V~~ ~V~ tier ~ ~n ~ ' ~r ~y~ 7`re~s HR P ivy Cade"~`st►~+►( S -,k- New ~)t'cser te, if r CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: x'0117 Owner's Name: Owner's Address: /5 3 CD Legal Description. leO/~V J Township: County: SY., j! n 'Subdivision Name: ~Y, C5" tC A.-q /4-), Lot Number: Parcel ID Number: ~,TD`/ da~G 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 ell klmz*~co Designer/Plumber: - ~ LOY n _ License Number: Date: Phone Number Signature Designed pursuant to the In-Ground Soil Absorption omponent Manual for POWTS Version 2.0 SBD-10705-P (N.O1/01). Page 1 6 PIN At S 1 ' (k DoE l~ 'L°;l -6 i~t Y1,C) Vo IA t F", P~~ H pp * C ue;) ~ )tOSer a r LJSE _ HATES OBSERVATIONS MADE f~JC~ la~lY~'Ll~, ~ c ~ h'l,lr_€~,t I ii (rf-~t_~I~'T OV: ~ r'Vata Teplac`e RATING. S= Srt1 suitable for systern U Site urasuitablo for system t.: Jt w dl" ti rsL {~tlil BC? iN H{3t ti3rlE F~ l7P'C ax sTt 1.~ 1 J-i 1LC1) Lti-]'14NK I EC 3~°1# PJUED S_TST M!foil!wri,r1} F-1 S Flu E SEu [IS i...J t `Pr arl fl`rrl Et c,r Jl3T<r iiivti `?F t N }?,51C: ~ 11 ;,li) put , 11o. I-Ji ri iri:a ry i 3 he ntf r 463,01,V +Ii"•;P ra il~ tt F I, rflti3in r,; uate F notdp Flu ivvation, PROFILE DESCRIPTIONS IsCfT+ild+, Tt61's[, f)' ti{Tr'g 4+l'}CJt+Jt3+a"AT 7TIP7Cdk tNAff CTCF OF SOH V61 1H rHSIYt'C S.CCSIri1,TE~TC'#?j,rZ17DCifYCi{ 1 - (E w't .T. E-]r rtL -T (t) I:3EL3 t'WX IF 02SE4dVCD "SEE F-3 ^t 6r. Ciiv F L, ACK ) , ' • < <T !E-s PERCOLATION TESTS ~ I ~J ~'3 1P~7 1~1~'i(t~1@9C F T T"iol,'F C~i1T'd~,' ~ ~TFI? E s'E~- Jrdf ~ r ,I~~7Ct~Ira:tJl~ i q i'. r f 5 I -`J 1 ~ 1- I St S°_ L 1 P: t { t t l t l l h J. 1 r on 1 'LfJT PLAN: i 1 r t t a~rr~=i~~ta~ r_.t~., <.tr i f r r r3a ru t~tr3 r.a al r,6it3 73 to 5uita17 c ;ril ».1:~. Ir, llrafr, sett or ista.rc.:~s. what arE tf,,. +t'or-f ~,'~rltal ,.r 1: . >r€€ ~I .'sr'c tit31'€ s*_. ;tttr r-,; I uit"s rind 11~,Ir '-r)c ion gar t~i~~ ph,,1 Sii_ir,, Shcvv T~o~ sui a,,- r. r..t,a€tsn <It a-.,' Prorir.c and Yia ;vii SYSTEM ELEVATION s "4,j j U, ry, - * i q f 1 , v. ry I'1?' 1. r~lf '•51:.'111 f{, (~(i'I'Y I1~ i •"tl'1", 'la;it t,11, a tip "!A'- t` ))("t'lo 7 thl3 ftaiirt ywrl fI" wj it11?, i 1 ,['cord rvivl the llefho(4 sl,ecills,<i ir tno vvb sccln5in -,rra u;.tr ¢t "o=is. l.od 4, gn', dau.i re -ord,d ivl l 1h, )t~r.iti,, rn of ih,- '+4s1° :aw c~~rr~-ct to, the best r.il in. I.no"' IudIp swid t,t.li=Yf. rit ~7 t , Filters PL 525 EFFLUENT FILTER 09 ' ' L Polylok, Inc is pleased to add its new commercial filter to its existing line of quality effluent filters. The PL-525 is rated for over 10,000 GPD Alarm (gallons per day) making it one of Accepts PVC g accessibility the largest commercial filters in its extension handle class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok PL-122, the new Polylok PL-525 has an automatic shut off ball installed = . 525 linear feet with every filter. When the filter is of 1116" removed for cleaning, the ball will filtration slotsF Rated for over ~a 10,000 GPD float up and temporarily shut off the system so the effluent won't r leave the tank. No other filter on the market can make that claim! Accepts 4" & 6" ~ 5CH D. 40 Pipe ~ - PL-525 aint.nnance: The PL-525 Effluent Filter should ` operate efficiently for several years under normal conditions before requiring cleaning. It is recom- mended that the filter be cleaned every time the tank is pumped or : - at least every three years. If the installed filter contains an optional , alarm, the owner will be notified by an alarm when the filter needs - servicing. Servicing should be Gas deflector done by a certified septic tank pumper or installer. ball l when filtenfiltet-off b whr 1. Locate the outlet of the U.S. Patent No# 6,015,488 is removed septic tank. 5,871,640 2. Remove tank cover and pump tank if necessary. PL-525 Installation: 1. Locate the outlet of the 3. Do not use plumbing when septic tank, filter is removed. Ideal for residential and com- 2. Remove the tank cover and 4. Pull PL-525 out of the housing. mercial waste flows up to pump tank if necessary. 5. Hose off filter over the septic 10,000 Gallons Per Day (GPD), 3, GI Lie the filter housing to the tank. Make sure all solids fall 4" or 6" outlet pipe. If the back into septic tank. filter is not centered under the access opening use a Polylok 6. Insert the filter cartridge back Extend & Lok or piece of pipe into the housing making sure to center filter. the filter is properly aligned and 4. Insert the PL-525 filter into completely inserted. its housing. 7. Replace septic tank cover. 5, Replace the septic tank cover. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECiFiCAMOtINS Owner Septic Tank Capacity al ❑ NA fiA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer A d' ~ ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units a. ❑ NA Pump Tank Capacity al J',"A Estimated flow (average) gal/day Pump Tank Manufacturer ANA Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer ANA Soil Application Rate al/da /ft2 Pump Model ANA Standard Influent/Effluent Quality Monthly average" Pretreatment Unit ANA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD5) 5220 mg/L A$ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BODs) 530 mg/L Uln-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L _,0-NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 510° ctu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Ya in dia. -Cf-NA Other: ❑ NA Other: E],-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) { mum 3 ears) NA ❑ ear(s) Pump out contents of tank(s) When combined sludge and scum equals one-third IY3) of tank volume L>„13 NA Inspect dispersal cell(s) At least once every: ❑ month(s) ❑ year(s) xlmum 3 years D NA Clean effluent filter At least once every: 'ffmonth(s) / NA ❑ year(s) l ~'i~rS Inspect pump, pump controls & alarm At least once every: ❑ month(s) A ❑ year(s) ❑ month(s) -9--NA Flush laterals and pressure test At least once every: ❑ year(s) Other: ❑ month(s) ❑ NA At least once every: ❑ 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 512 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 4 OF 4 In-ground Gravity [Management Plan IMPORTANT: The owner of this in-ground gravity system shall be responsible for its perpetual operation and maintenance pursuant to requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this system shall be considered a human health hazard if not maintained in accordance with this approved management plan. Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in accordance with SPS 383.52 (3), Wisc. Admin. Code. Maximum DisoersaI Area Operating Limits: Design Flow a 450 gpd; BODs 220 mgL"; TSS 5150 mgL"; FOGS 30 mgL-' laMcdon Checklist INSPECT EVERY 3 YEARS o We of use o age of system o nuisance factors (i.e. odors, user complaints, etc.) o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.) o material fatigue (i.e., leaks, breaks, corrosion, etc.) o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution 1 drop boxes) o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.) o extent of ponding in distribution cell prior to dosing o dosing irregularities - if applicable (i.e., pump re-cycling, float switch settings, etc.) o electrical components - if applicable (i.e., wiring, connections, switches, controls, timers, alarms, etc.) o distribution lateral or lateral orifice plugging (measure lateral distal pressure - compare to design specification) o surface discharge of effluent or sewage back-up into structure served Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary) o Septic and dose tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis. Stats. when the volume of solids in the tank(s) exceeds one-third (1/3) the liquid volume of the tank(s) or as required by local ordinance. Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code. o Effluent filter(s) shall be inspected every 3 years and shall be cleaned when necessary to remove any accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12 months. System maintenance reports shall be submitted to the proper local government unit in accordance with SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to: Name of individual or company: Thomas Wang Phone: 715-425-9958 Local government unit; COUNTY ZONING OFFICE phone: 715-L~ -~°1,_ Local government unit address: NP N Sb l Wi ZIP: Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin. Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code. No product for chemical or physical restoration of the POWTS may be used unless approved by the department in accordance with SPS 384, Wisc. Admin. Code. Contingency Plan in the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to a plan submitted to the appropriate agency for review and approval. A failed in-ground dispersal component may be abandoned and replaced by a code-complying dispersal component in a pre-determined area of suitable soils. System Abandonment If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT 'AND OWNERSHIP CERTIFICATION FORM ~ p y Owner/Buyer Mailing Address Property Address (Verification required from Planning & Zoning Department for new construction,) City/State E 'd ev Rl/S b-4-, Parcel Identification Number ~.1I - /Q Lhg& DESCRIPTION yy-- Property Location -AE'oq ,'i4 , Sec. TN fiQTowm of _2 6 Subdivision l C ~f~ tcG . Lot 9 _ Certified Survey Map Volume , Page # Warranty Deed # Volume Page # 1 5'r Spec house yes no Lot lines identifiable ves no S'Y'STEM MAINTENANCE AND R CL YFI ATIO Improper use and maintenance of your septic system could-result in its premature tailurc 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. $3.52(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 ptunper 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. Uwe. the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards scf forth, herein, as set by the Department ofC6minerca and the Department of NaturafResources, State of Wisconsin. Certificationstating 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 arm 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 ty deed recorded in Register of Deeds Office. w7 1Vuatber of b roams SIGNATURE 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. 01;/05) 2 3 ` - S90-10, 00"L m, A x o ~ h 0 0 i ~ 2A 7 o Gi P/ 59 ~ ~1~9 ~ N N 4 \ J-C~"\ nsOp{G'C~ J-C~~ / o Ci a~°e °Le ~ U 3 5p s M~kT ~6• lol- C5 >>p` n \ ~ N~30~6'4> 4 N / a1 c 2, 9S M N 1 ~ W Ens ~ _ m 9 N 12 N w f V w m V N88°29 59"W 378,13' 10 z O ,i e @) 0 0 1ec PM, 11 w 10 w ;IN _ 100FT $0 ~ N N t~ 10'UYI{„ITY EAS~ME NT r' N Q ~ c r ~ 5 !2s 10 UTIyTY ~ Q L O C AT I ON M A P -D_ 4~ ..CC NO ACCESS 93 ,2nE ]90' ;I SEC. 25, T28N. R 20 W 377,85, 1188°49' SM x + N N88-49,52"W - - - - - - - --G"~.ENA+I Q4T ! Ak L u F ~ ~ ...R °c wav w'orw v^~~c♦ ~~J, r`m ro ROA>f 1 Nw !~c. San N88013138"U 1330.53' p15TANGES SWOWN ARE AT _ W - - R14HT A.NG1.E To l3p4,- M _ Ft G"I OF WAY UNPLATTED LANDS OWNED aY OTHERSbF GLEN MONT RbAO N n GLEN MON' r ROAD C) Cl) O n w Q r-j y o y 5, o cn (`xl= o -D 3 C ? m ci co N N r W 3 Q] C7 Q O 0 O O U Q 7 C ',:D O , O Q O O w G ~ ~ r ~ n w ~ tv :J "J r co D a !D v x r C- Ci R C b y n G• F' F''' C C'1 CD ~ w N ~ 2 N (n r cn ti T a_ 41 O O O _S w~l ~ ~ n~ ti L Ul N ~ ti~ r n_ o ~ CT n my v o LB' (AAA) d \ G 7 7 ~J Z a c~ r. O Z 00 z r.. j(D a m Q 'o N `'ti N f tC a O A R 0 Z A Ian O n ~ r' r r .ti (1 A (Z 7 O N J Z ~ N W 'p M 'Nn r n Z o o W rl) 3 N Z (D - d 'rt n CD T _ C O I~ ~ O I;: G G ti CD D n 7 7 O QN ~ Z CD 7 S (D N ~v T ~ X ~ 7.` ti ~ p w r V b ~(V O T ` 1 G 1 V Parcel 040-1209-90-000 02,'0q12006 a :34 F I PAGE 1 OF Alt. Parcel 25.28.20.994 040 - TOWN OF TROY Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): 0 _ Current Owner, C = Current Co Owner 0 - ZORN, DAVID P DAVID P ZORN 133 GLEN LA RIVER FALLS WI 54022 Districts: SC = School SP = Special Property Address(es): ' = F'rirnary Type Dist # Description " 133 GLEN LA SC 4893 SCH D OF RIVER FALLS SP 0160 CHIP VALLEY VOTECH Legal Description: Acres: 2.490 Plat: 2495-ST CROIX HIGHLANDS SEC 25 T28N R20* NL SbJV LOT 9 OF ST CROIX Block/Condo Bldg: LOT 09 HIGHLANDS Tract(s): (Sec-Twn-Rng 40114 160114) 25-28N-20W Notes: Parcel History: Date Doc # Vol/Page Type 07!2311997 11291159 WD 07!2311997 816, 407 07!23!1997 693!54 2005 SUMMARY Bill Fair Market Value: Assessed with: 103679 232,700 Valuations: Last Changed: 07/22!206- Description Class Acres Land Improve Total State Reason RESIDENT',AL G 1 2.400 53.707 171,000 NO Totals for 2005: General Property 2.490 53,000 171,000 224,000 Woodland 0.000 0 0 Totals for 2004: General Property 2.490 53,000 171,000 224,000 Woodland 0.000 0 0 i 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 , AS ROIL"f' SAPJ!'I'~"+ItY Sy'Sl"H.M REPOiJ7' ^l - - OWNER ~ ~ - - TOWNSHII' SEC. ,~•-J 1 oi: _ \ - 11 _C__ lJ ADDRESS ST. C:ROIX COUNTY, WISCONSIN i Z~7~ SUBDTVISION C 4, fx LOT 1 OT P (.AN V f !'W Distances and dimensions to III(,(-,t Sl[OW EVERYTHING /D L , .r b ~f.2y INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used _ Elevation of vertical reference point: 1- Proposed slope at site: SEPTIC TANK: Manufacturer : ,40- c c 4 t Liquid Capacity.: ! , 1 Number of rings used: - - Tank manhole cover elevation: Tank Inlet Elevation: - _ Tank Ontlet Elevation: Number of feet from nearest Ftoticl: Front, 0 Side, - O Rear, 0_ From nearest property lint--1'rc,n t ,0 F' O il+ rlr , O - Number of fi a-  (Include weir building: this information of the d-I VC Plot hl,in}( - 1-e c:.rel1 J i mr n s i nr , r u r; t, r.!< 1 Liquid Cal)p city: M:niuCac'Lurer: - Pump Model' _ pump/Siphon Manufacturer: Bottom of tank elevation: Elevation of inlet: Gallons per cycle: p,_;ml> ut C switch elevation: P,lurm Switch Type: - - - - - - - - Alarrt Manufacturer: - - . property line: Front, C)Side, ORear, 1.t cr k-01 Cc -t Crom nearest Nu;tlh `,umber of feet from well: - - f Nui-her of feet from bui Id ing: (include distances on plot plan). ,,oif. A}i50KP LION SYSTEM Bud: Trench: _ - - 0 Length: Number of Lines: Area Built Width: _ fill depth to top of pipe: - n Side O Rear, O Ft _ Nom},ter of feet from nearest property line: Front, ~J Number t feet t rout well: ! .I~-1 - - - ;Tanner of feet from building: - - - hide ,distances on plot plan). SKEPAGF, P I'1' Diameter: - - Sir Number of pits: - Liquid depth' Bottom of seepage pit elevation: Area Built: Hai either a drop box O or distribution box O been used on any of the above. soil ahsurbt-ion sytems? (Chick one). HOLDING 'L'ANK Capacity: ~ - - Manufacturer: Number of rings used: _ Klevation of bottom of tank: _ - El evat ion of inlet: O Sid' Ohear, 0Ft.-_ Number of Ceet from nearest property line: Front, , Number of feet Crom well: Number of feet from building: Number of feat from nearest road: - Alarm Manufacturer: - : - - - Inspector I' 1 umb e r on job: Dated. - L i censc' Number-  0 11,6 " : ~11 i I DEPARTMENT OF INDUSTRY. INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & IAUMAN NELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P U Box 7969 BUREAU OF PLUMBING VADISUN, WI 53707 LXXCONVENTIONAL ALTERNATIVE 51nIr PIenID N-1, I I I I asSlgnnf I Holding Tank 7 In-Ground Pressure . Mound ✓.-F N11T HOLCEN ~AD:)RFSS'")F PERMIT HOL'JEH INsP F!':TION [AT= Clavton Welch RR#I, Box 203, Beldenville, WI ~Q 1-3 dirt Iv'• j" IE hCH V4R< IPr"-aw-r rr4rrrcr r:,,~11 DE (-R BE IF I) IF FE HE hT =""V PL-.REF, PT EL V.. f:ST 14-1 vl L_LV NE SW, Section 25, T28N-R20W, Town of Troy .u r~•P.unh«, - - L''6'.•r. ~.':/n, - - - 1'..rn-Il~u Tom Wang i 3231 SL. Croix 54976 SEPTIC TANK/HOLDING TANK: ti i~`JJF%•C TVH ER -Q r•.r_ I ABLL LC'SK IN'3 l'v OV'ER L I'. L C; J1F,".C lil JTAIIK INI FT FI IV TANK IrIJ', I I I'll' QQ v Lc PROVIDED mub - j YES F-INU DYES ❑NO eEDDIVG v :)IA v •.t,, Fr' N U R OF ROAD: PR OPER-Y 'NE-L ENT To FRESH J J FEET FROM LINE ! a N INLLr YCS NO _IYES 1N(~ NEAREST I lJ / DOSING CHAMBER: .:LJI;FA;:'l! R F H RFFIDIN:-, _I(]UIC_',P4('IT': aIIVP Ii-, DEL PIL V P,S I P H`I M A% 1. F:. t ' I J A F 11 'NAnh INC.. AREL I"1CK INf: COVER PROYUED PROVIDED _LL DYES - NO _ L_ YES__ NO -YES ,ENO rurvaNUL:IN HI I.StivLRAtlov4t NUMBER OF vH.1v:RTV LL ELIL:Nr vLN1-LSFnrsH GAONS PER CYCLE II)IFFFHFNCF HFTVVFFN FEET FROM L Ain INI FT PUMP ON AND OFF, _YES El NO , NEAREST SOIL ABSORPTION SYSTEM. Check the sail moisture at the depth of ploaving Enc rH :4tE rLR cTf r.;_ :i .o a ;.N. rr, FORCE or excavatlDr. Ilf soil Can be rolled into a wire, r.onshuF:uun shall cease until the soil Fs dry erinugh tO COntlrTUC-) MAIN CONVENTIONAL SYSTEM: ji_`IITI NO IF _1 '_:IH VIF`E '-~A'_ r. LI_': LII h$I.)F [)la PI TS LIOU L: BED/TRENCH rHFNCHES at na PIT uEVlu DIMENSIONS S S J L - v4FI :ia I'_1. CE VT.I '"TR VIrE DIS'R ~PF OISTR PIPE MATFR141 NU Uf 5 I NUMBER OF Pq OPERTY WFII RIM DIN! VENT Tr' FRESH :~f,l i. vv P iv Rf1VE C.I ViEZ E L`.:' FI:•1' rv l Alll N:'_T FEET FROM 1 f C 7_ Z l Z NEAREST--w f f (y ✓ l N10UND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- ❑ Y ES N meets the criteria for medium sand TIONS MEASURED. ~IU OIL COVER I'-F1 R; - vFRM4hEhtrnARKFRS d-.;F s'4TFTI - J1vE- ' ❑YES ✓NO ❑YES LINO I77VT1- -i',-FN "F~rlc. 8E'.) \'FI: TFEr•: f',H F'~~;~ r'.I l~) I'. .i 1; iI:F I) `,II nFI: '.111 1:111 L~ i_1 `JI L{J ED~F_11 YES L- No ❑YES L-1 NO ❑YES []NO PRESSURIZED DISTRIBUTION SYSTEM: :J'F~T I• Iir.l "II NO UI I_a ILN:.L :>F`4(;IhG ''-,H EL D- HBEL014'PIPF FIII DEPTH AP:,VF C!'VFfI BED/TRENCH TRENCHES DIMENSIONS V,' NI=JL:) PUTAP MANIFOLD 1-I15TI= VIVL MAhIF :I n 47.47E 9tAY' NDDISTR. FIFE DIS rR BUTION PIPE MATERIAL & MARKIryG E. E!ELEb CIA L_L PIPES D1A ELEVATION AND DISTR IBU1 ION _ INFORMATION HCLE SIZF IH'"I L E SPA CI 111, DHILLFFl f1il•1111: r !VI_f+MATERIAL VFF- CAL LIFT CORRESPONDS TO APPRO'VFI: F L,,"S YES LINO DYES _ LINO 171 14 L- ' NITS: P FRMANFNT rAARKFRS - 06SERVATICN HELLS NUMBER OF I'HUVLHTY [OVILLIL B ILDINI COM FEET FROM uvE 46 we I __YES - NU IYFS -GNU 1NEAREST-----. _ q 7 V4 1 0 Sketch System (in - Retain in county file for audit. Reverse Side. _ • $ Su}N AT~R _ TITLE DILHRSBD6710) 1R.01/821 j . - APPLICATION FOR SANITARY PERMIT ©CQUNTY (PLB 67) uVIFORM SANITARY PFRr,11T # -OU inousl l av u,~uw e.•uu.var aeeaTrcns -Attach coi•iplete plans it accnrd with s. H 63.05, %Vis. Adm. Code =or -he system, un paper not less than 8"Ix 11 inches in size. -See -everse side for instructions for completinq this application, PLEASE PRINT PROPERT OWNER MAILING ~DDRESS C. a T~i I &k le 80 X03 e sy~-f IV Ile PROPERTY LO TION My: 1/4SGJ1/4, S Tod N, R 00 E (or} ILLAOl G COT NUMBER BLOCK NU113CR SUBDIVISION NAME NEAREST ROAD, AKF OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED 1 or 2 Fa IrriIy Number of Bedrooms: Public (Specify): THIS PERMIT IS FOR A: New System Tank Replacement ❑ Repair Replacement Soil Absnrption System Revision L Privy L-1 Alternate System Recurimxt on Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepage Red A*i Seepage Trench Seepage Pit (-l Holding Tank - System-In-Fill I_ In Ground Pressure J Vault Privy ❑ Pit Privy Existing, For Which A Previous Peri,iil Is On File, Permit # ssue(jAn Existing System That Has Beer Inspected And Is Compliant As Far As Soil Conditions. Total #oz Prefab. Site GeJ ons Cunstructed Stee' Fiberglass Plastic Tank; COnf:rete Sep- c Tank Capacity )L) Lift Pump T nkrSipnon Chamber Holding Tank ciowity Vanufacturer: P• ~~5 P Q S - IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: Mound In-Ground Pressure Tbta # of Prefah Site Steel Fibernlass Plastic Gallons Tanks Concrete Constructed Scpuc Tark Capacity l ift Punip'Siphon Chamber Wr`UfacturL-r: PERCOLATION RATE A3SORPTION AREA ABSORPTION AREA iMinutes per inch): REQUIRED (Scuam Feeti: PROPOSED ISruare Feet:$ 'WATER SUPPLY: Aj~~ 3 560 500-5- r'S RJ Private ~ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Jame f Plumber IPrintl:r Signature MP,'P.1PRS1q No.: phone Number: '4 Plumh.r's Addreys: Na esigner ~22 COUNTY/DEPARTMENT USE ONLY Signature bf Isswng Agent: Fee: -)at Disapproved - Owner Given Initial /s 141/ Approved Adverse Determination I Reo Son for Disapproval: Alternate coursels) of Action Availahle DILHRSt3D-6398 i P x!82: DISTRIBUTION: Orlgiral t.. ^.nunty, One Copv To. Bureau A Pit nibiry, Cc,nrr, Plum`°r INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To oe co"nplete arcs aCl:wrdte the permit appl ca.iun rn.ist i-1clrinF. 1. Pi;,iperty owner's name and corplete legal description, oluase circle the app-ohr ate municipal government unit, (whether LW s s n a city, village or town}; 2. hidica-e specifically %-~hat type of use is $er pd, if public is clwc'<ed inr.icate tyre o' rise (i.e. 10 unit apartment, 30 seat restaurant, erg.}; :3. Complete the b1cI fo- conventional or alternate system depend ng on system type, check a'J apprcp-iatF boxes nr ranks. 4. Indicate the design perculatior rate isterl on tht~ 115 sr.:il l.'s. r.por: the tl .[W-IN of Srluare feo? regiwed by code and --e number of square feet to be installed; 5. Complete the section on ,voter sw:Piv, 6. PRINT the name Of the master olurnbe, or ma;-e lire iher resirctec v.,hw II instal thr. sys'_crn, c rclu e appropriate lict -se classi- fication, place your license number in the space provided and s.gn the permit in the signature block; 7. Please place the plumhers business phone number in the blank provided, if there is a problem or questiur, this will speed review of the permit, 8. Change of owrFr~h p or plumber requires a Sanitary Permit Transfer Form 167-T} to be submitted to the county prior to installation. Failure to curnp.y -wll void the sanitary permit. 9. This hermit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A never perrtiil vv It be n,--!I, i f ih^rrr s chap n: ~;r matt'- i :,aec:a*r r "Ir,;:,, 'numl;er of hedrnnm~, etc.l, lnca-inn (-f *he sys depth of the system, I, 11. All revisions to this pt'- 12. A complete plan including a plot plan, dr;r 13. Hori7nntal and vertical elevation reference 14. Pining detail including pipe size, separating distances, distances between beds i` appropr d-c, %i k ocatio•,s. e`tl_,ent li le from tankfs) to system, building severer and vent observation pipe(s). 15. T•'c' pc='rm t -ij na aqe'-t nla'V requiir~ a cioss Sy_'c-ion dl'ao,inq of the et+ went clsf.osal System. TO THE OWNER: This is valid for two years. Changes in your bnrldury plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact Vour ]oral code administrator or the Btwr au of Plumbing, DILHR, State of Wisconsin. Form- S T C 100 Owner u1 Property ti Lv c~ Lncritiun u1 Property '4 SU !L, Section _~s RX W Township Mailing Address Subdivision Name p Lot Number -I Previous Owner of Property Total Size of Parcel Date Parcel Was Created L9 ~ aZ Are all corners identifiable? ~ Yes No Include with this application one of the iollowin : .Certified Survey Map .Deed .Land Contract, or .Other Legal Document which describes the property PROPERTY OWNER CERTIFICATION I (We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information torn, by virtue of a warranty deed r co,d in the Office of the County Register of Deeds as Document No. and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Register of Deeds, as Document No. SIGNATURE O wNEA SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED X11 r~ . • ~Y S T C. - 105 r Y SEPTIC TANK MAINTENANCE A(;REEMENT St. Croix County 0 A l1 l•1 N I..1< / it 1_I Y j" I, Q~' - - I(OIJTL/BOX NUMBER Fire Number ~ I i W, ']'own of Ti~of EZ_ :;t c' ruix County, Subdivision ST E~~C1st- l_ut_ cumber II111rr011Cr u 6 C allll III aiIItCnaIIcC oI- your ;'Cptic yc;ti'lll ~lUJil rt'tiull In its premature failure to handle wast.u5. Proper nlaiuteuanCe call- lists of pumping out the septic tank every Lllret- years or souuer, if needed, by a licensed septic tank pmp_er. What you put into Ltle system can affect the function of Lile septic tank as a treat- ment stage in the waste disposal system. t. Croix County residents ula~ be eligible to rct•eiVc a grallL fur a maximum of 60% of the cost of replai,rm~•rlt of a faiIing system, which was in operation prior to July 1, 19/8. 5t. Croix County accepted this program in August of 1980, with the ra(luirement that owners of all new systems a6ree to keep their systems properly maintained. ['he pruperty owner agrees LO subulit to St. Croix County "l.oning a certification form, signed by the Owner and by a master pluulber, journeyman plumber, restricted plumber or a licensed pumper veri- tying that (1) the on- site wastewater disposal system is in proper operating condition and (2) after inspection and puulpiIIg (if nec- essary), the septic tank is less than 1/1 full of sludge and scum. Certitication form will be sent approximately 30 days prior ro three year expiration. 0 F I/WE, the undersigned, have read the above reyuiremellLa and agree to maintain the private sewage disposal system in accordance will ;x the standards set forth, herein, as set by the Wisconsin Depart- 1U ment of Natural Resources. Certification form must be completed arid returned to the St. Croix County Zoning Office within 30 clays ut the three year expiration date. 1CNED__ - D A T E St. Croix County '/,oning Of tice 1'.0. Box 96 Hammond, W1 54015 I 715-796-2139 or 715-425-8361 Sign, date and rt:Lurn to abovt- tddrt tiff v. N o viwm~ w~cc^'30 X10. ~ ~ ~ 7~ Br (D 7 a3 ~0° ow m 0to C<r 0 cCww~,7cK Go ~ la Z O cD a CD CD 0 O i 7 c o Q 0 0 cD w 0 m ca ~10 o co xm aN A - CD 3 to 19 : CD ~ 0 0 0 0 O " 03a 0-.m w C' 3 0 K c co w z c W V f~ F CA N - m CD 0 2.a-, N Co (D CD U o .0. c Q O < M cr. m~~ 0Dc ' O 0 _ w f1 A C c w ~ o m 0 &:E Q w Qco sCL w' N C N • j N CD N m m m N Z New :E5 v a = nm0 3~NmNa a w v -+ol 0 w 0 -C Cf) ww a ac c, g m f C fT1 CD oa~W~? A~ CD m N - N " l< 0 ~00 ~,o^ m~ a y N u' i D co w w Qo f ccn am o m CD M. m E fD N o cv m a~ N c~ K(Q m 3 g 0• n 0 +n t0 7 to W A tD O 7 CL C 1 ; N C -i C w cD 7 0 d =r c ? a+ n p, °C: 3 o m O 0 0 e w aS• _nw 0 0 y v a 0< 3 o v \ J `'.r) (7F AbO P,,R~RY(,T OF REPORT ON SOIL BORINGSf D ETY & BUILDINGS ARC , ff AND P.O. BOX 7969 PERCOLATION TESTS (115} DIVISION HUMAN RELATIONS DISON, WI 53707 (H63.090) & Chapter 145.045) .0 ✓/,jC O 1 d LOCATION SECTION _ C- T -04YNSHIPrR9U~tit'tPALTTV_ -LOTt(+~0: QLK. . : SUB VIS,f NAME: z )1/a 1/4 / N/R E T (crri W _ COUNTY: OtvNEH'sTe,1YCf?'S NAME: AIUNGADDR SS: ~ USE _ • DATES OBSERVATIONS MADE FBN0_E_D9RW._- COMM RCIAL DESCRIPTION: PRO DESCRIPTIONS: PER ION TESTS: 'Residence New 1-7 Replace - J RATING: S= Site suitable for system U= Site unsuitable for system 07NVFVIlO'JAL hIOl1ND IN-GRO(.NI)PHESSURC:SYSTFPI-IV-FILLHOLDING TANK:RECOMMENDEDSYSTEM: (optional) oS au s EIS ❑u as Qu os,u If Percolation lestsare NOT required OFSI(;N RAT[: - 11 any portion of the testnd area is in the under s.H63.09(51(b), indicate: ' ` F nodplain, indicate Floodplain eluvation: PROFILE DESCRIPTIONS BORING TOTAL D PTH TO GROUNDbvATER-III CHARACTCR OF SO 11 livITH THICKNCSS .COLOR, TEXTURE, AND DFP I H NUMBER DEPTH MV. EI-EVATION OBSERVED [ST- HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK) 1 1v.-, T B 1 B- -=l to PERCOLATION TESTS ir T D=PTH 'RATER IN HOLF I TEST TIME { CROP IN WATER I FVEL-INCHES to RATE 1`0 Nt1Tf_!i".' ~NL7)MFIER INCHES AFT ER SWELLING INTERVAL-MIN. t----Pc:R npt Pert-u p R___p PAR INCIL" P P- P- - LP- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori zontal and vertical elevation referero! points and show their location on the plot plan. Show the surface elevation at all borings and the directinn and percent a( land slope. -r~ _ - SYSTEM ELEVATION yIC i Z ~j eeg t 711 ?S TRp mil"[ IS Lb ~ Cta, g Is , l~~?,-~•~.D tv . 3D6rW. OF T)it cE L~6- 2ty 1 1 _C v y j - gter, utat Lh . i 10% 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures cr-0 metf ccis specifier it r„' A, sccnsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belia NAME (print) TESTS VJFRF COMPLETED JN. ADDRESS: ~ ~ - - CERTIFICATION NUNIREH PHONE NUMBER(optiov i CST SIGNATURE:  DISTRIBUTION: Orig;nal and one copy to Local Authority, Property O,,vner and So I L,--. ~:II.4RSBG-G3::5 (R. C, .^n ;!I I i',; FR