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Home My WebLink About026-1126-02-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 600353 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: Derek Carlson TOWN OF RICHMOND 026-1126-02-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: G5r 12.30.18.763 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURE CAPACITY STATION BS HI FS ELEV. Septic l e~ 3 S Benchmark . Dosing C Alt. BM • ' ~r 17 L n Bldg. Sewer z- -94, Yo SZ Holding St/Ht Inlet + 1 9•g TANK SETBACK INFORMATION St/Ht Outlet TANK TO ,P,/L WELL BLDG. ent Air Intake ROAD Dt Inlet Septic 39 Dt Bottom Q.1 6 41 Dosing Header/Man. r( lp.6 71112, Aeration t Dist. Pipe Z Holding Bot. System -7-4- 1444 O PUMP/SIPHON INFORMATION Final Grade .1 16D Manufacturer GPmand St Cover o ~ 7 J (v Model Number 6 O TDH Lift - Friction Loss System Hea A TDH 6,qt r Forcemain Length Dia. if Dist. to well SOIL ABSORPTIOI`j SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMEN IONS No. Of Pits Inside Dia Liquid Depth DIMENSIONS 3 vv ~ ~ \ SETBACK SYSTEM TO P/L BLID WELL LAKE/STREA LEACHING Manufacturer: r7 a L INFORMATION CHAMBER OR 4:5 Allor~7 Type OfA Jyste~ ~ q /66 1 26 ` UNIT Model Num 66 DISTRIBUTION SYSTEM Aemi _5 ( (04-(04- ~c = Header/M nifol ~I Distribution ix Hole Size x Hole Spacing Ve to Air Intake Length Dia Length Dia Spacing Pipe(s) \ \ ` SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over jxx Depth of jxx Seeded/Sodded r Mulched Bed/Trench Center Bed/Trench Edges Topsoil 3 b -gip No Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 1667 WATERS EDGE DR / It7Oj~ 1.) Alt BM Description= ~h~ CoAJP.~. r aGJG~ d I~ 2.) Bldg sewer length = ' GI +~6 f•• - amount of cover ,;P3 a, Plan revision Required? ❑ Yes No I / 3 7 Use other side for additional information. / SBD-6710 (R.3/97) Date nse 4ig e Cert . No. V h 0 A f d ~►p 4 ,0° C~rft. v ~ Q V Y ~ s ~ A County 11 Safety and Buildings Division JV-. Gfa X M L S 201 W. Washington Ave., P.O. Brix 7162 " Sanitary Permit Number (to be filled in by Co.) Madison, WI 37 71 4y Sanitary Permit Applicat, State Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission oftpi~ ' ~3 .rate governmental unit is required prior to obtaining a sanitary permit. Note: Applicatie- " GZQ , eed POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal infi ~ 9 provide may be used for secondary PUTP2WS in accordance with the Privacy Law, s. 15.04 1 m , Stats, 1~4~tW Ct t/~i1~e I. A lication Information - Please Print AllInformation to Property Owner's Name / Ld / Parcel # tR Soh az6 - //Z6 - oZ- o 0 0 Property Owner's Mailing Address / RC~ r'76w/~ Ciiv/~ Property Location Govt Lot Z City, State p / Zip Code Phone Number /C r ~ fj /h a h ~ Ll/2 y®I `J s E il1N/ Section ~ circle on 17. Type of Building (check all that apply) Lot T 3 o N; R E rV4 oqmj or 2 Family Dwelling - Number of Bedrooms .2 Subdivision Name (S Gd [/f/6$ E~1 ❑ Public/Commercial -Describe Use Block # o J "sue-- p OLI ^ ❑ City of ❑ State Owned - Describe Use I7 / CSM Number ❑ Village of 3 ~"55 - \ ~ T_~P rlo 5 J?Townof R/G41"oket III. Type of Permit: (Check only ne box on line A. Complete line B if applicable) 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 ~G c N. T e 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) d) Design Soil Application Ratgpdsf) TDi Required (sf) Dispersal Area o 7Chamberr Ills Trea ent Area Information: po (sf) System Elev • Capacity in # of Manufacturer Gallons Units /0,1y toe.1E Sts ~~a a New Tanks Existing Tanks / 0.ank ~~Cr jG~ D /?0 immik $,Do / "t7 VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Si~ --l MP/MPRS Number Business Phone Number toe" Plumber's AddreA (Street, City, State, Zip Code) H. un epartment Use Only Approved Permit Fee Da ssu Issuin gent Signature El Own , ven Reason for -Demal IX. Condi easons for Disapproval . rk, t~1 t:: 3) Ge,,~ Q~'wri~ ZdlB 1~ ft per •'l pain WW4dV1 by 9hnW. are. t-- 2. A~w+ninaa.,r:,alrjr:.~ ftPW,.:d1,.~ Attach to complete pleas for the system .it sub t to the Coaa`only oa p per not less than 81/11 lathes is size n f n SBD-6398 (R. 11/11) 1& /nZoo 3 ~j r Z, ~j y~ e}'gAti r ~j 4 b0 ~lQ, F d1 e,,~ e~C . T7 Z J CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Derek Carlson Owners Name: Derek Carlson Owner's Address: 1451 Red Hawk court New Richmond WI 54017 Legal Description: SE 1/4, NW 1/4, Sec 12, T30N R18W Township: Richmond County: St Croix Subdivision Name: Waters Edge Lot Number: 2 Parcel ID Number: 026-1126-02-000 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: Countryside Plbg & Htg License Number: Date: 03/28/2018 Phone Number (715) 246-2660 Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT Psge of Project Name: Derek Carlson No. of Cells ~o Per Cell 3 ft Cell Width Total No of 6a ft Cell Length 3 v v sq ft EISA Per Cell 3 ft Cell Spacing Sv sq ft Total EISA Manufacturer Model Laying Length EISA Rating Infiltrator EZ1203H-5ft 5.0' 25.0 ~EZ12031-1-10ft 10.0' 50.0 Gravelless Leaching Unit Manufacturer: --4 /1 Gravelless Leaching Unit Model: tZ /26 3N- /a Typical Cross Section Finished Grade It Observation Pipe with approved cap or vent Soil Backfill ::`:>c:.::.,::., Geotextile Fabric ft Infiltrative Surface 12 in ~ I ft Limiting Factor i ,36 in Slotted and Anchored Vent/ //O Observation Pipe with Cap Plumber/Designer Signature: Countryside Plumbing and Heating License Date: 03/28/2018 i PAL 10 ~lox.rInc. Innovations in Precast, Drainage Zabel• PL-525 Effluent Filter & Wastewater Products A Division of Polylok Inc. PL-525 Filter The PL-525 Filter is rated for 10,000 GPD (gallons per day) making it one of the largest filters in its class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok PL-122, the Polylok PL-525 has an automatic shut-off ball installed with every filter. When the filter is removed for cleaning, the ball will float up and temporarily shut off the system so the effluent won't leave the tank. Features: 1/16" Filtration Slots • Rated for 10,000 GPD (gallons per day). Alarm switch 4 r"~ (Optional) • 525 linear feet of 1/16" filtration. i • Accepts 4" and 6" SCHD 40 pipe. Accepts 1" PVC Extension Handle • Built in gas deflector. • Automatic shut-off ball when filter is removed. • Alarm accessibility. Rated for 10,000 GPD • Accepts PVC extension handle. PL-525 Installation: Ideal for residential and commercial waste flows up to 525 Linear Ft. 10,000 gallons per day (GPD). of 1/16" Filtration Slots 1. Locate the outlet of the septic tank. 2. Remove the tank cover and pump tank if necessary. Accepts 4" & 6" cz:~ 3. Glue the filter housing to the 4" or 6" outlet pipe. If SCHD 40 pipe the filter is not centered under the access opening use a Polylok Extend & Lok or piece of pipe to center filter. 4. Insert the PL-525 filter into its housing. 5. Replace and secure the septic tank cover. Certified to NSF/ANSI Standard 46 PL-525 Maintenance: The PL-525 Effluent Filters will operate efficiently for several years under normal conditions before requiring cleaning. It is recommended 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 t, Gas Deflector needs servicing. Servicing should be done by a certified septic tank pumper or installer. Automatic 1. Locate the outlet of the septic tank. Shut-off all 2. Remove tank cover and pump tank if necessary. 3. Do not use plumbing when filter is removed. 4. Pull PL-525 cartridge out of the housing. 5. Hose off filter over the septic tank. Make sure all ' solids fall back into septic tank. 6. Insert the filter cartridge back into the housing making L sure the filter is properly aligned and completely inserted. outdoor iltero Alarm Extend & TM Polylok, Zabel l & & Best filters accept Easily i nstalls alls 7. Replace and secure septic tank cover. the SmartFilter® switch and alarm. into existing tanks. Polylok, Inc. 3 Fairfield Blvd. Wallingford, CT 06492 Toll Free: 877.765.9565 Fax: 203.284.8514 www.polylok.com 8MWORWA 31U 99- 9-5~C-008 Z \ :8nOd-1SOd ova 00/00", 00 3iba 05Lti9 °~aoa ar~adw Ol AMH Sf~ 9lL£M -lvnNVW 3I1d3S - ^3a W :anod-38d .o-,l-.t. t .~vos d~ -~.a r~vao 31303000 13531M = p \ NM-009/00ZIdW in o w it r I LLJ Uwf U Q Ir J z0 < m 0 W O J ~ J W C O w to a U it x F= a a a- 2 LA ° w rJ toa tro p 4 n f (,7 m F r tri for U Z 0 a w O tr m < 0 o o z ® ZZ f"! O w °M rQ pQm z ow:r.W WmM 0 3 LL ° > G w o °oo Vi,w < < < Z Q U Q a C p 0 U a. O CST r- mm~WW UU o WZ Zm 0 a d g 0 o Q o x In U) to top -CO CO < < < w m ° to v~ Y < a 00 LL. s pO °~tin (A► mtJi~ MN O <Ua=. ik ~U = Ne pl_~I- rQa Win pi W a.\ ZZ x~ C~ W r7coa w Op ! O Zti Z inw0 ~U ZO O Q ca••tor OmiZwmU r F2N O OAF w~ ►¢-f' in F-: D OR 'S ~a N MO & F-F ••3°z ~VY p~W Q w ~ W UW °OW °p m F to J~ ~t=M:0 ~o o in ooh d ° a. Xx nw U ~Y ~<po<Ww°wcy a~rva ° U ° aWo X 20 z Z3mU2xJ~m= r r ° Z U oLL. LLI J J J M ° Y z in <C Z Z Q J FZ<- O LLJ I H r < U z > Opp u62 d %t M a z I ( I i ~-I~i~I I: LLJ :I I f t f ! LLI I, i I I II I' II I( 04 i ! N to fli 14 _ 1 0 11 p «9s I. ~ ~I w w m w r ( r I N r ui I II°C14 ~1 II i' 1 1~' o I ~ I U a i I < F Z - < M u ab3a w «96 SV «£S in x z a r Septic-Dose Tank Cross Section And Pump Performance Specifications M Tank Manufacturer wieser i Pump ManufRChm _ GOULDS Tank Model Number 1200/800 LP Pump Model Number EP04 Total Tank Capacity 2,000.00 Alarm Manufacturer SJ ROMBUS Max. Bury Depth 8.00 Alarm Model Number PS PATROL Switch Type - - IFLOAT Filter Manufacturer POLY LOCK - - Total Dynamic Head (TDH) - Feet Elevation Head 5.00 Distal Pressure Network Loss _ Minimum Pump Performance- Required Force Main Loss `Q 55_00 GPM ti 5 00 Ft TDH _ .00 > Total Outlet Manhole Min. 4" Above Grade With Manhole Min. 4" Above Grade / Locking Device. Inlet Manhole With Looking Device < 6" Below Grade Sealed Watertight Securely Mounted ' Weather-proof Junction Box WO ft. Finished Grade -0 41 - Depth of Cover Vent Above Min. Grade Disconnect Ft With Vent Cap Means ,e~ <<s<ss<s s's <'s •ss '~'~'i se'~iTS,s• s ss s < Outlet Outlet Filter - Inlet j---- Inlet Basle Switch Settings and Reserve Capacity ~ y.» 4 4 Tank Volume = GPI Weep -r- <'< Hole i Dimension Inches ! Volume Gal. B (reserve) A 18 400.32 (alarm) B 2 Off Elevation C 44.48 >t► ~ ~ Ft ; (dose) C 7 155.68 < ' < Bottom (dead)- D 11 2_44.64 D Elevation Total ; 38 845.12 Ft GENERAL INSTALLATION: The septie/dose tank is bedded and back filled in accordance with the manufacturer's product approval specifications. Maximum depth of bury as specified by the manufacturer may not be exceeded without prior approval. Manhole covers exposed to grade have an effective locking device (padlock) installed Piping at the inlet and outlet is of approved material, connected to the tank with watertight fittings, and laid on stable soil to pre nerd settling or sagging. The force main is sleeved with 4" Sch. 40 PVC to bridge the tank excavation and the sleeve is sealed watertight. Electrical service complies with NEC 300 and Comm 16.28 WAC. 02/05 W Page of Wastewater METERS FEET 10 i 9 30 r w" , 5 GPM 8 _ 2.5 Fr 25 V 6 20 } 5 O 15 Q 4 O EPOS i 3 _ 10 2 EPO4- ~ i 5 1 oL o 6 0 10 20 30 40 50 GPM 0 2 4 6 8 10 12 m3/h CAPACITY MODEL INFORMATION mum I - Mini Float Switch ! Cord 'Discharge Minimum: Minimum' Minimum Maximum Shipping Order No. HP Volts Amps BrCircuit eaker Phase We Length Connection On Off Basin Solids Weight Level Level Diameter Size Ibs/kg EP0411 Plug / 10' Ph" Manual Manual 15" 20 / 9.1 No Switch EP0411A ( i Piggyback! 1 10- - Wide Angle 1'h" 12" 6" 15' 21 / 9.5 115 12 20 EP0411 F Plug / 20' 1'h" Manual Manual 15" 20 / 9.1 4 No Switch EP0411AC Piggyback / 20' 11h" 12" 6" 15" 2119.5: Wide-Angle i EP0412 1 No Swit h 10 1'h' Manual Manual 15 3/i" 20/ 9.1 230 6 10 - - - - EP0412F No Swit h 20' r 1'h" Manual Manual i 15" 20 / 9.1 - - - - - - EP0511 F , Plug / 20 1 1h' Manual Manual 15" 22 / 10 { 115 13 20 No Switch EP0511AC .5 Piggyback/ 20' 1,k„ 12" 6" 15' 23/10.4 Wide-Angle L _ EP0512F 230 i 6.5 10 Plug No Switch 20' 1'h" Manual Manual 15' 22 / 10 PAGE 41 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of 'L- FILE INFORMATION SYSTEM SPECIFICATIONS Owner ~GR! v1/2~ o EEffluent Tank Capacity /ZF1s al ❑ NA Permit # Tank Manufacturer ❑ NA DESIGN PARAMETERS Filter Manufacturer O NA Number of Bedrooms ❑ NA Effluent Filter Model ~ZS ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity al ;&NA Estimated flow (average) #Co v al/da Pump Tank Manufacturer NA Design flow (peak), (Estimated x 1.5) al/day Pump Manufacturer in NA Soil Application Rate - gal/day/ft' Pump Model NA i Standard Influent/Effluent Quality Monthly average" Pretreatment Unit tNA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Flier Biochemical Oxygen Demand (BODE) 5220 mg/L JkNA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) e}NA Biochemical Oxygen Demand (BODE) 530 mg/L ❑ In-Ground (gravity) ❑ In-Ground (pressurized)) Total Suspended Solids (TSS) 530 mg/L ANA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 5104 cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y. in dia. NA Other: ❑ NA Other: ❑ NA Other ❑ NA i_. '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: 3 13 month(s) (Maximum 3 years) ❑ NA Ak ear(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: E3 month(s) 3 .0 year(s) (Maximum 3 years) ❑ NA Clean effluent filter ❑ month(s) At least once every: A ❑ NA ~ ear(s) Inspect pump, pump controls & alat least once every: earn(s) ❑ NA 13 Flush laterals and pressure test t least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ mo m1t s le ( ) ast once every: ❑ 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 i sand p pe 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 (Y) 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. START UP AND OPERATION Page Z of Z For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat, foundation drain (sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or. must be taken, to provide a code compliant reTcA ant system: 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 she 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. alua ' o ing ~ank b e a. ~Ra~-!18 rT~ 9=a~2 Co~v57xct~t o ❑ 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 ,,rr POWTS MAINTAINER Name 6.,n Dt A'~i Name Phone 2 4!.0 Phone ..2r(• Ll~o SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name ~ Name S C I 20/lfl~ Phone/.s ' ~y6' Phone 1 S- 3 ~Co- (o This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer V..J Mailing Address &4, Ce- c.A S4,mI_ Property Addresk {,(a6-7 4=TCAt-z ~fLl~s` (Verification required from Planning & Zoning Department for new cons 'on.) City/State 91 CIZ) Parcel Identification Nwnber ~Zb - I Z LEGAL DESCRIPTION Property Location Vi , t4Ar , Sec. 17- , T 1b, N R t15 W, Town of " CJA nn,c~ Subdivision k4 It Lot # Certified Survey Map # Volume Page # Warranty Deed # { S39 1 Volume Page # Ayr Spec house y no Lot lines identifiabl 9~yes)o SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could insult 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 the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Ownermaint maintenance you pm into p responsibilities are specified in §Comm. $3.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 113 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a w my deed recorded in Register of Deeds Office. Number o bedroo SIGNATURE OF APPLICANT(S) DATE ***Auy information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. OS/05) .A "°•'~••~S PRl N36 ply •Q1n► NVId 1f103HV1S ar VlsNoDsw.'Uhro:) !oY] is'avo>w,,mioNnoi +a~+ ® NOSINVO - 3003 S831VM 'Z 101 ivIYW iR X- -N.-m NOLLOf12llSN00 HOIa2130 LL J \ \ O 2 _ _ \ Jul mn~ 693 W \i ~ \ \ \ \ \t EI aN \ \ ~eo TSB 1 \ \ I r ci R ~ / I / - ree~_ / a f N o ! J / O 10h / / 1 \ S1HO i v 69S v O~ - awl 3g m Wisconsin D'epartmentof Industry, SOIL AND SITE EVALUATION.REPORT~ Page 1 of 3 Labor and Hiuman Relations Divsicn of Safety & Buildings in accord with ILHR 83. e$ COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Flan ~e, but` St. Croix not limited to vertical and horizontal reference point (BM), direction and % of slo s ~ ale oARCEL711. D. # Q Z dimensioned, north arrow, and location and distance to nearest road, , 3 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATIO REV EWED BY DATE •O PROPERTY OWNER: PROPERTY,ILQCA ION Derrick Const. Inc. G&T. LOT SE 1,/4 NW 1/41S12 T 3 ,N,R 18 :~E (or) W PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK# SUBD. NAME OR CSM # WAX-"rS 6 (it-) 1505 H 65 ake CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE ZTOWN NEAREST ROAD New Richmond, WI. (715) 246-2320 Richmond 140th. St. [x] New Construction Use [ Residential / Number of bedrooms 4 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd/ft2 .8 trench, gpd/ft2 Absorption area required 858 bed, ft2 750 trench, ft2 Maximum design loading rate .7 bed, gpd/ft2_-trench, gpd/ft2 Recommended infiltration surface elevation(s) 96.50 ft (as referred to site plan benchmark) Additional design / site considerations na 7 t! Parent material outwash lood plain elevation if applicable ft S =Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U =Unsuitable fors stem KI S ❑ U CAS El U 7 S ❑ U ® S ❑ U as ❑ U ❑ S ® U SOIL DESCRIPTION REPORT hej CbrA2,~o On -X~ T--~( 11?XM-4. Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1... 1 0-10 10 r 3 3 none I 2msbk mfr 9w 2f . 5 .6 • S . . 2 10-37 7.5 r 4/4 none scl 2msbk mfr if 1 ( • Ground 3 37-96 7.5 r 4/4 none cos os mvfr na na .7 .8 elev. 100.4 ft. Wl ~c o S - - Depth to limiting factor + Remarks: Boring # mfr cs 2f .5: .6 1 0-12 10 r 2/2 none I 2 2 2 12-36 7.5 r 4/4 none W if 3 36-96 7.5 r 4/4 none cos omvfr na na .71 .8 Ground elev. 100. ft. Depth to limiting factor Remarks: CST Name:--Please Print Gar L. Steel Phone: 715-246-6200 Address: 1554 200th. Ave. Richmond I 54017 Signature: Date: 5-30-2000 CST Number: m02298 l PROPERTYOWNER Derrick Const.- Inr- SOIL DESCRIPTION REPORT Page 2 r of 3 PARCEL I.D. # pending Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouxeiry Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 1 0-14 10 r V3 none 1 2msbk mfr cs 2f .5 .6 S 2 14-34 7.5 r 4/4 none scl 2msbk mfr if .4 .5 } Ground 3 34-96 7.5 r 4Z4 none cos osq M1 na na .7 .8 elev. 100.4 ft. Depth to limiting factor +96" Remarks: Boring # 1 0-10 10 r 3/3 none 1 2msbk mfr cs 2f .5 .6 4 2 10-21 10 r 4/4 none sit 2msbk mfr if .5 .6 .5 Ground 3 21-43 7.5yr 4/4 none scl 2msbk mfr 3w if .4 .5 elv. 100.4 ft. 4 43-96 7.5 r 4/6 none cos os ml na na .7 .8 Depth to limiting factor +96" T-F: Remarks: Boring # 1 0-12 10 r 2/2 none 1 2msbk mfr 9w 2f .5 .6 S 2 12-25 7.5 r 4/4 none scl 2msbk mfr w if A .5 5 Ground 3 25-48 7.5 r 4/4 none sil I_2csbk mf i na .5:: .6 J. elev. 4 48-96 7.5 r 4/4 none cos _ j os mvf r na na .7: .8 100.5 ft. - Depth to limiting factor +96" Remarks: Boring # Ewa Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) - - I PROPf RrYOWNER_ Derrick c anitf Tom_ SOIL DESCRIPTION REPORT Pape,. ofd PARCEL LD. sf` yendina Boring # Horizon Depth Dominant Color Motdes Texture Structure GPD/ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Roots Bed rends 0-14 10YX 3Z3 - none -L- 2mabk 3 2 .5 r 4/4 none sci -Zmkbk mfr if .4 .5 11.4 R. ~-t ]Cons~ Ground elev. . } D epth to lffdng +961, Remarks: Boring # 1 0-10 110yr 3/3 Wane 1 2msbk mfr cs 2f .5! .6 .5 4 2 10-21 10 r 4/4 none sit 2msbk mfr if .5' .6 .y. Ground 3 21-43 7.5 r 4/4 none sci 2msbk mfr gw if .4 .5 100.4 ft 4 43-96 7.5 6 none cos ml na na .7` .8 t~ Depth toIor ~y l factor +961, Remarks: Boring # 1 0-12 l r 2 2 noose 1 2mebk mfr 2f .5 .6 .1` 5 2 12-25 7.5 r 4 4 none sci 2msbk mfr v if .4 .5 round 3 25-48 7.5 r 4 4 none sil 2csbk mfi na .5 .6 ,S G elev. 100 5 ft 4 48-96 7.5 r 4 none cos mvfr na na .71 .8 D" to 1 dro)dng r factor ^I A +96" i Remarks: Boring # L3 Ground ! elev. It Depth to drang fecdor Remarks: SBD,8330(R.0&'Q2) J , c STEEL'S SOIL SERVICE Gary L. Steel Derrick Construction, Inc. 1554 200th Ave. CSTM2298 SE4NW4 S12-T31N-R18w New Richmond, WI 54017 MPRSW-3254 townof Richmond (715) 246-6200 lot #2-Brushy Mound LaKE This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. The location of the test may or may not be as shown as permanent lot lines were not established at the time the test was conducted. N 1"=40' ~-BM.= top of 1" pvc pipe @ el. 100.00' Alt. BM.= top of 1" pvc pipe C el. 100.40' n~ V 2 2 -a7G L Zcc/ V ,O "NYIw I O C A61 ~ P-er"X'i ofy- cIL c Gary L. Steel 5-30-2000 /9 ~k 9 x x 999.4 X 9963 LOT J ° 4343 Q.FT. 2.17 CRES / 993.5 B- O x B-1 I 992.7 6-5 -4 8-3 O x B-3 B-5 41 P94.5gO1 LOT ~aDtA 2.4 X UMI 9OF DRAINAGE EASEMENT YOH i x 7002' SQ.FT.~~ i 031 / 2.23 ACRES 991.3^B-2 25 O B3 B-4 - / -4 4 14.4 ~Q B-3 B-5 / 2 / 89462 S FT•x ~ ~ 9s?205 ACRM-5 B( / O + V/ r ~ r r M 99 0 ; 990.5 100 YEAR FLOOD ELE\ x ' AS SHOWN ON A 1981 ,x I -LOT--5 8~4 DRAWN BY THE CORP! ?98 8 99077 S • Q O ~ 2.27 ACRES g 3 B-2* , 8=01 • ~ B _ x L T~ a B-- 999.7 ~ `n O B-2 ` Building Setback Line (100' from R. 0. W) (75' from Shoreline) -IMINARY PLAT OF BRUSHY MOUND LAKE J0