HomeMy WebLinkAbout026-1153-09-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 430547 0
GENERAL INFORMATION State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)J.
Permit Holder's Name: City Village X Township Parcel Tax No:
RFK Construction I Richmond Townshi
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
d C S+ r_". -� t .
�.� Ic,v. = l C ✓�4 a► 19.30.18.
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark �
c ,-- u
U V
Dosing ( U V Alt. BM
Aeration - -• _� Bldg. Sewer U
i
Holding St/Ht Inlet
St/Ht Outlet 3 - /
TANK SETBACK INFORMATION - 2
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic , !� �� , . Dt Bottom
Dosing Header /Man. %Z
Aeration Dist. Pipe
Holding `'- Bot. System s W
S-E / 1. -4< 9 qS_
PUMP /SIPHON INFORMATION Final Grade ?• 0 �2 • 3
Manufacturer Demand St Cover
GPM
Model umber 17. lb
TDH Lift Fffction Loss System Head TDH Ft
(3-1 13 t 9 .0
T r'fz?
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM '� (,.off 1.7 Y .S o1r*� -
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS '3 1 0-1 :J' C' — ✓ $
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR 13 i v a
Type Of System: i t N oT NIT
Model Number: c
DISTRIBUTION SYSTEM - +r
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s) _...___._.__
Length 9 Dia 4 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 1 Bed/Trench Edges Topsoil
`3 77 _ j q Yes ] No Yes No
V� a��
t 4 .� f- P
COMMENTS: (Include cote Q§c replcies, person �° Inspect on #1: 0- / `f / U 3 Inspection #2: / i___
Location: 1497 92nd Street New Richmond, WI 54017 (NW 1/4 19 T30N R18W) Glen View Lot 9 M IN / Parcel No: 19.30.18.
tS
1.) Alt BM Description e- — sewer length= c , ..
= -,� g, na l4eer �'^��'' a.,�s + o
9 g 7 p ` � y� 6e'# 0 1
2. Bldg ct , 5 � - �` i�-� / /5 ` 1 ¢(� ✓ c� b �
amount of cover = �� r 1 Cpr�t ''� Sl n r S l- ✓ 1 G LP 6" lG (rl ° P
Plan revision Required? LJ Yes k No �a� G 3 I'I ✓S.
� � �
Use other side for additional informati __ - - -
Date Insepctor's Si nature Cart. No.
SBD -6710 (R.3/97) CkC /9 z �/ .� -eM
RECEIVED
NOV 1 200
Sa ety and Buildings Division Comity
m S ST. CROIX C U091 WTlaldisOn ashington Ave., P.O. Box 7082 rd J
` I ��O NING O FICE , WI 5370? -7082 Sanitary Permit Number (to be filled in by Co.)
(608) 261 -6546
De artment of Commerce
State Plan I.D. Number
Sanitary Permit Application In accord with Comm 83.2 1, Wis. Adm. Code, personal information you provide
may be used for secondary purposes Privacy Law, sI5.04(1)(m) Project Address (if different "Mailing address)
I. Application Information - Please Print All Information
Property Owner's Name Parcel # t # �J
Property Owaei s Mailing Pro tion
'/., b, Sec ' n
Zip Code Phone Number
(ci e).n.
Tt� N; E r
II e of Building (check all that apply) Xz, ?xr' S .W n
Su ivi 'on Name M Number
2 Family Dwelling - Number of Bedrooms
❑ Public/Commercial - Describe Use 1
❑ State Owned - Describe Use ❑City ❑Villag wnship of
III. f Permit: (Check only one box on line A. Complete line B if applicable)
A ' New ystan ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New
List Previous Permit Number and late Issued
Before Expiration Plumber Owner
IV. ! of POWTS System: Check all that appl
ess urized in -Ground El Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter 11 Constructed Wetland 11 Pressurized
round [] Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ Q�
Recirculating Synthetic Media Filter g Clamber ❑ Drip Line ❑ Gravel -less iaii ' Dis ersaV I Treatment Area ormation:
Design Flow (gpd) D esign Soil Application RauKgpdsi) Dispersal Area Required (sf) ti Tank Info Capacity to Total Number Manufacturer el Fiber
Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tan Tanks
Septic or Holding Talc
Aerobic Treatment Unit
Dosing chamber
VII. Responsibility Statem - 1, the undo ed, assume responsibility for installation of the POWTS shown on the attached plans. ) 7-
P 's Name (Pont) Ztrre MP/MPRS Number Business h ne
ne u
Plumber's Address (S
j2_� 1J 4 City, S Zip e) `J
J 0/ 2-
VTJ I artmea (U e Onl
Approved C1 Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuin gent Signature Wo Stamps)
Surcharge Fee) 2 �_ /
❑ Owner Given Reason for Denial
IX. Conditions of Approval/Reasons for Disapproval 3)
SYSTEM OWNER: '�/ - l ` l `� - -
efflue filter and .fin a4
1 Septic tank, efflue Q�-�"�
P
dispersal cell must all be serviced serviced /��intained
as r management plan provided by plumber.
p 9 P
2. All setback requirements must be maintained
as per applicable code /ordinances.
Attach complete plans (to the County only) for the system on paper got Ins than 8112 111 Inch" In size
SBD -6398 (R. 08/02)
P T PLAN
PRO;FCT RFK Construction Inc. ADDRESS 1390 Neal Ave N. Lake Elmo MN 55042
1 /4 NW 1 /4 S 9 /T 3 W TOWN Richmond COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 11/8/03 BEDROOM 3
CONVENTIONAL >00C IN -G D PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE
1260 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 872 # of chambers 28
BENCHMARK V.R.P. Top of Steel Fence Post � M-4' ASSUME ELEVATION 1 00' Filter Zabel A -100
❑ BOREHOLE O WELL *H.R.P. Same as enchmark
SYSTEM ELEVATION 99.2/98.0 4.5' below qrade
Alt. B — Top of Survey Iron @ 97.0' Plans Designed Using
Vent Conventional Powts
Manual Version 2.0
>6 „ Standard Biodiffuser
Leaching Chamber
a of Cover with 31 ft2 of Area '� Scale is 1" = 40'
H 6' Long 1111 unless otherwise
0 34" Grade at System Elevation noted g*
AM 4 1
Vents 5
20' 20'
T
11%
Slope
Pro 4
Bedroom
House
B -3 2 -3' X 88' Cells with >3' Spacing
45' o
00
O �
Vents B -1
30'
C f
30'
kd id 275'
498' Property Line
P T PLAN
PRO, f CT RFK Construction Inc. ADDRESS 1390 Neal Ave N. Lake Elmo MN 55042
1/4 NW 1 /4S 9 /T 3 W TOWN Richmond COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 11/8/03 BEDROOM 3
CONVENTIONAL )00( IN -G D PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1260 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 872 # of chambers 28
,BENCHMARK V.R.P. Top of Steel Fence Post ASSUME ELEVATION 1 00° Filter Zabel A -100
❑ BOREHOLE O WELL •H.R.P. Same as enchmark
SYSTEM ELEVATION 99.2/98.0 4.5' below qrade
Alt. B — Top of Survey Iron @ 97.0' Plans Designed Using
Vent Conventional Powts
Manual Version 2.0
> 6» Standard Biodiffuser
° of Cover
" unless otherwise
Leaching Chamber
x with 3 1. 1 ft2 of Area Scale is 1" = 40'
0
E2 6' Long 11
�° 3 4" Grade at System Elevation noted
if
AV
Vents 5
20' 20'
T
11%
Slope
Pro 4
Bedroom
House
2 -3' X 88' Cells with >3' Spacing
a
45' a.
0
00
Vents B -1
30' -1
30'
275 Ji
498' Property Line
Wismirisin Department of Commerce SOIL EVALUATION REPORT Page of
Division of Safety and :�vildings
in accordance with Comm 85, Wis. Adm. Code �
County
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must ° C f, t
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. e ' wed by ate D
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). �I
Property Owner Property Location
4 - J.. S d '- Govt. Lot 11At UJ ' /4 S T_3() N R E (o 6w)
Props Owner's Mailing Address Lot Block # Suubb'd. Name or r M#
City tate Zp Code P one Number City ❑Village 10 Town Nearest ,Road
Wx 1
New Construction Use:A Resident 6k/ Number of bedrooms � Code derived design flow rate � GPD
❑ Replacement ❑ Public or commercial - Describe: _ --
Parentmaterial [�GCsZ`(c/rX-���✓ Flood Plain elevation if applicable � ft.
General co mments
rb 5�� ys✓ s� f�� ��� % � � ¢� � � �
and reco
Boring # n Boring
a Pit Ground surface elev.�ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff'•
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
Z / J
O'-
Boring # Boring /
® Pit , Ground surface elev. ft. Depth to limiting factor �in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f?
in. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff #1 •Eff#2
0 - SL a
✓ r
3
y 1 z
Effluent #1 = BOD > 30 220 rng/L and TSS >30 < 150 ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date Evaluation Conducted Telephone Number
1008 192nd Ave, New Richmond, WI 540 �_. —02 715- 246 -4516
i
Property Owner _ Parcel ID # Page of FT Boring # �l Boring
Pit Ground surface elev. ft. Depth to limiting factor � � - in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2
g ' S '
`
o,4 q9• ZO
?
F—I Boring # ❑Boring
❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2
Boring # O Boring
F7
Ground surface elev. ft. Depth to limiting factor in.
❑ pit
Soil ADplication Rate
Horizon Depth Dominant Color Redox Description- Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2
Effluent #1 = BOD > 30 220 mg/l. and TSS >30< 150 mg/L ` Effluent #2 = BOD <_ 30 mg/l_ and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777.
SBD -6330 (8.6/00)
Soil Test Plot Plan
Project Name Lakes and Hill Development Shaun
Address P.O. Box 10598
White Bear Lake Mn 55110 CS #226900
Lot 9 Subdivision Glen View Date 7/18/03
1/4 N W 1/4S 19 T 30 N /1318 W Township Richmond
Boring Q Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of Steel Fence Post
System Elevatio 99. 2/98.0 *HRPSame as Benchmark
Alt. BM Top of S y Iron @ 97.0'
Scale is 1" = 40'
unless otherwise
noted ,�
M.9
Please note: survey was not A
completed at time of testing, M
setbacks from lot lines may Please Note: Tested area
change. Installer must verify y not be suitable for
all lot lines and setbacks des' d building area.
before installation. Check stem location
102' , before a avating.
100
104'
5' B -2
I
11%
5 , Slope
B -3
45'
B -1
30'
30'
175'
498 Property Line
0-
Soil Test Plot Plan,
E': ject Name Lakes and Hill Development Sha; F � 1
Address P,O, Box 10598
White Bear Lake Mn 55110
( _1CSTM #2269 r 0 2003
Lot 9 Subdivision Glen View Date 3
1/4 N W 1/4S 1 9 T 30 N /R W /
Township Richmond
Boring 0 Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of Steel Fence Post
System Elevation 99. 2/98.0 *HRPSame as Benchmark
Alt. BM Top of Survey Iron @ 97.0'
a Scale is 1" = 40'
0
unless otherwise
noted
Please note: survey was not A
completed at time of testing, M
setbacks from lot lines may Please Note: Tested area
change. Installer must verify may not be suitable for
all lot lines and setbacks desired building area.
before installation. Check system location
102' 100' before excavating.
104'
5' B -2
11%
5 , Slope
B -3
45'
B -1
30'
30'
275'
498' Property Line
Maintenance and Contingency Plan for a Septic System
Maintenance Plan
1. Septic Tank is to be pumped once every 3 years.
2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in
order to extend the maintenance interval of the filter.
3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of
the cells.
4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system.
5. The owner agrees to save this plan.
6. Do not plant trees nor park nor drive over system.
7. Watershed is to be diverted away from system.
8. Discharge into system is not exceed those required as per Comm. 83
Contingency Plan
1. If system fails, determine cause of failure, use alternate area and install new system or
install system at a lower elevation.
2. Replace any other failing components as needed.
Plumber: Shaun Bird 715- 246 -4516
St. Croix County Zoning 715 - 386 -4680
Pumper Tom Mondor 715 - 246 -5148
Shaun Bird #226900
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT`
AND
OWNERSHIP CERTIFICATION FORM
i
owner/Buyer
Aw, /V /czZ�/7w.� MIJ
Mailing Address / --0
Property Address
(Verification required from Planning Department for new construction)
City /State Parcel Identification Number
LEGAL_ DESCRIPTION
Pro ,l - W, Town of l
Property Location 1 /., /•, sec. T- N L21*("
P rh' S
/� ' P�
Subdivision .��r /-�
Lot # ,�•
Certified Survey Map # , Volume / , Page # g
/ Page #
—2& Warranty Deed # %' �57S —3 . Volume
Spec house yes ❑ no Lot lines identifiable �s ❑ no
SYSTEM MAINTENANCE
Improper use and maintenanceof your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
master plumber, journeyman plumber, restrictedplumber or a licensed pumper verifying that (1) the on -site wastewater disposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
day a three y eypiration date.
SIGNA: URE OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
th operty described above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNA F APPLICANT DATE
* * *s *s
Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * **
** Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
U 2 9 5 1 P 19 3 - 7 , e+5'gs3
STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH
REGISTER OF DEEDS
Document Number WARRANTY DEED ST CROIX CO., WI
RECEIVED FOR RECORD
This Deed, made between Hillvale Development Limited Liability 11/06/2003 11:30AN
Partnership Grantor,
and RFK Construction, Inc.. WARRANTY DEED,
Grantee. EXEMPT #
Grantor, for a valuable consideration, conveys and warrants to Grantee REC FEE: 11.00
the following described real estate in St. Croix County, State of Wisconsin TRANS FEE: 951.00
(if more COPY FEE: ce is needed, please attach addendum): CC FEE:
Lots 5k 9, 7 29, 30, 31 and 41, Plat of Glenview in the Town of PAGES: 1
Richmon , St. Croix, Wisconsin.
Recording Area
Name and Return Address
N AT 03 (0
030 - 1056 -30 -000
030- 1055 -90 -000; 030 - 1055 -95 -000: 030 - 1056 -20 -000:
Parcel Identification Number (PIN)
This is not homestead property
(is) (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this day of November 2003
* * Hillvale Development Limited Liability Partnership
AUTHENTICATION /�. ACKNOWLEDGMENT
Signature(s) STATE OF lam—_ )
raCV L- Tamer ) Ss.
Not �/ Pub '� County )
authenticated this day oT'
m ate or I COnsin Personally came before me this day of
November , 2003 the above named
Hillvale Development Limited Liability Partnership
*
by Richard Nelson
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person(s) who executed the
authorized by § 706.06, Wis. Stats.) inst m and ackn wle a same.
THIS INSTRUMENT WAS DRAFTED BY //
Attorney Kristin Ogland * U /L
Hudson, WI 54016 Notary Public, State of
My Commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.) I )
J
* Names of persons signing in any capacity must be typed or printed below their signature. Information Professionals Co., Fond du Lac, WI
STATE BAR OF WISCONSIN 800. 655 -2021
WARRANTY DEED FORM No. 2 -1999
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EP
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