HomeMy WebLinkAbout026-1153-43-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No: 453386 0
GENERAL INFORMATION (ATTACH TO PERMIT) 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 X Township Parcel Tax No:
Hometown Remodelin , Inc. I Richmond Township 026- 1153 -43 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
T 7 , f
/ ~ ' C C P-) - ?j 19.30.18.1181
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
[�osirtLT Alt. BM
357 16Z
Aeration Bldg. ewer �[ 7
Holding St/Ht Inlet L 17
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic 7 / AA 19 ) I Dt Bottom \ \
Dosing [— Header /Man.
I (J - z i
Aeration Dist. Pipe 16-35 C l z
Holding Bot. System
. 11 . Z % 1 ,d (p
r
PUMP /SIPHON INFORMATION Final Grade '
Manufacturer Demand St Cover
GPM W Z.� / l r C r
Model Numb
TDH L Friction Loss System Head Ft
Forcemain Leng ist. to Well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width i Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
3
DIMENSIONS / cl L � � ` \
SETBACK SYSTEM TO V � P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR t J r
Type Of System: e 1 f, 3 / / )+ l - / I � UNIT K �
t L} u1 Model Number.
� I a
DISTRIBUTION SYSTEM -= _ i
Header /Manifold �� Distribution x Hole Size x Hole Spacing Vent to Air Intakci
cap 4 Pipe(s) \ VQ�� - �Lc v�
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 eeded/Sodded xx Mulched
xx S
Bedrrrench Center Bed/Trench Edges \ Topsoil °' 0
Yes No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 1498 192nd St New Richmond, WI 4017 (NE 1/4 NW 1/4 19 T30N R1 8W) Glen View Lot 43 Parcel No: 19.30.18.1181
1.) Alt BM Description
2.) Bldg sewer length
- amount of cover = 4
I
Use other side for additional information. C J
Plan revision Required? [� Yes �'v� - IC I I � I
SBD -6710 (R.3/97) Date Insepctor's ignat a Cart. No.
i _ -
County
Safety and Buildings Division
lv 201 W. Washington Ave., P.O. Box 7162 , Cro
Madis ��Oi��i�� on, Wl 53707 - 7162 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce (608) 266 - 31
Sanitary Permit Application State Plan LD. Number
In accord with Comm 83.2 1, Wis. Adm. Code, personal information you pro ' / V
may be used for secondary purposes Privac La Ll1 .0 f 1 m Project Address (if di nt than mailing address)
1(.. �......: �.._
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1. Application Information - Please Print All Inform tion
Property Owner's Name Parcel # Lot # Block #
Property wner Fs Mai Address Propgtt anon
City, State t Zip Code Phone Number ' AZ, na '/., Section 19
o0wd hl R - 5S- /2S ((q$) circle one)
11. Type of Building (check all that apply) T ?�1 N; R_T —
G;Or'or 2 Family Dwelling - Number of Bedrooms 3 ubdivision Name CS.M Number
❑ Public/Commercial - Describe Use
t J
❑ State Owned - Describe Use c b IS - T, C w � _ ❑City_ ❑Village 0lownship of�
111. Type of Permit: (Check only one box on ne A. omplete line B if applicable)
A. p<ew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B• ❑Permit Renewal El Permit Revision [I Change of El Permit Transfer to New
List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV Type of POWTS System: Check all that apply)
_
k Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter U
Constructed Wetland Pressurized In -Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter �)
Recirculating Synthetic Media Filter Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain)
V. Dispersal/Treatment Area In rmatioo: l2 / / ",Ig o - i ptF/ 4e.-s a63 /./V T S. r C _W K+7T ez. s A.
Design Flow (gpd) Design Soil Application Rate us ea uu s Dispersal Area Proposed (st) System E;lecation
SI Q 9 d. 0. &BS/ 24 S.4 E..z 4.1. _ 9S,SU
VI. Tank nfo Capacity' Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Septic or Holding Tank Tanks Tanks
Aerobic Treatment Unit
1
Dosing Chamber
VIL Responsibility Statement - 1, the undersigned, assume responsibifiX for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's Signature MP /MPRS Number Business Plrone Number
•4 4e// ZZ � 03 6 b/2 PGs -5,47
Plumber's Address (Street, City, State, 'p Code)
VIIL oun /De artment Use On ___ __
proved ❑Disapproved Sanitary Permit Fee (includes Groundwater D Issued ring Agent 'ignatuue ( mps) ~ i
Surcharge Fee) i /3 0 / /
❑Owner Given Reason for Denial -- //" `r
IX. Condi �ti n on�s of Approval/Reasons for Disapproval O /� /
6 Y 0
1 Septic tank, effluent filter an y, 1Gti
dispersal cell must all be serviced � ,{, / malntain 4 l� � �� �, •Q
as per management plan provided by plumber. / S�/S%j'� 411�
26 All setback
as put applicable ans (to the County only) for the system on paper not less than 81/2 x I 1 inches in size l
SBD -6398 (R, 01/03) A
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T e partment of Commerce SOIL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County C ' n
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must `
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcei I.D. 2 0 /000
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. OZ �� �� J
Please print all information, eD ate 'n Personal information you provide may be usedior secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property oca i /
0 -4 S Q ,'�' f/t Govt. Lot vv, �!R !1/4 S /� T N R E (o W
Prope Owner's Mailing Address Lot # Block # Subd. Name or C-
6) S-
City
/)[ torte Tp Code P one Number City ❑village XT o Nearest Road
New Construction Use:A Residential / Number of bedrooms Code derived design flow rat GPD
❑ Replacement ❑ Public or commercial - Describe:__ --
Parent material ( l.� sZ`�J r) �/ Flood Plain elevation if applicable _ ft.
General comments
ments
and recommendations:
Boring # ❑ Boring
® Pit Ground surface elev r_O'Ift . 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
0 3/2 ---- --
S' -2 `�
3 �
1Z 9 Boring # Boring ,y ��
Pit Ground surface elev. AG ;" 1 Depth to limiting factor Ll 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
s L S t L
2 - L All CL 2 t
Effluent #1 = BOD > 30 1 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Sig CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date Evaluation Conducted Telephone Number
1008 192nd Ave, New Richmond, WI 54017 �� 0 715- 246 -4516
�3
Property Owner , Parcel ID # Page of
137 Boring # ❑ Boring
pit Ground surface elev. ft. Depth to limiting fador�_/ in• Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDR
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
T rks G 1 '� •`
ST
Boring # ❑ Boring
❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2
0 g
B oring # Borin Ground surface elev. ft. Depth to limiting factor in.
❑ Pit Soil Application Rate
Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Effluent #1 = 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 -8330 (R.W00)
i
' Soil Test Plot Plan
Project Name Lakes and Hill Development Shaun Bird
Address P.O. Box 10598
White Bear Lake Mn 55110 CSTM #226900
Lot 4 3 Subdivision Glen View Date 7/18/03
1/4 N W 1/4S 1 9 T 30 N /R W Township Richmond
F1 Boring Q Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of 1/2" Pipe
System Elevation 96.2/96.0 *HRpSame as Benchmark
Alt. BM Top of 1/2" Pipe @ 99.7 Scale is 1" = 40'
unless otherwise
noted
Please note: survey was not
completed at time of testing,
setbacks from lot lines may Please Note: Tested area �
� change. Installer must verify may not be suitable for c
all lot lines and setbacks desired building area. 04 before installation. Check system location
before excavating. o
H
0
a�
0
a�
a
o
N
Not enough slope to establish contours
B -2 B -1
45' 45'
1% 30'
Slope
-3
20'
449 Alt
200' B.M.
10 455' Property Line
Conventional Septic System Management Plan
Pursuant to Comm 83.54, Wis. Adm. Code
General
The conventional septic system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall be maintained
in accordance with component manual SBD- 10567 -P (8.6/99). All local and/or state rules pertaining to system maintenance
and maintenance reporting shall be complied with.
Septic Tank
Septic tank servicing mechanics comply with Comm. 83.54(1)(e). Septic tank to be located within 150' of service pad, with
bottom of tank to be 5 15' below service pad elevation. The operating condition of the septic tank and outlet filter shall be
assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in
the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR
113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are
not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be
needed to maintain less than 1/3 scum and sludge accumulation in the tank. The outlet filter shall be cleaned as necessary to
ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank
that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be
serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water
tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of
service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater
than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank.
No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank
abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS
component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If
such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings
Division.
Soil Absorption Cell
Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should
be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for
vegetative maintenance) over the system is not recommended. Soil compaction may hinder aeration of the infiltrative surface
within the system and will promote frost penetration during cold weather months. Cold weather installations (October -
February) dictate that the system be heavily mulched for frost protection.
Influent quality into the system may not exceed 220mg/L BODS, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not
exceed maximum design flow specified in the permit for the installation.
Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the
owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring.
Contingency Plan
If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the
system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by removing
biologically clogged adsorption and dispersal media and replacing said components as deemed necessary or by installing a
new soil absorption cell to bring the system into proper operating condition.
Questions on the operation or maintenance of the system should be directed to installing plumber, Mike McDonell at (612)
865 -1927, or the St. Croix County Zoning Department.
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner /BaFur o cj*? A t" ock I art e.. _ - --
Mailing Address 1739 .?ewe/ Zriile, [.JC&d / m/� SS /ZS 1 �
Property Addres/ - r
(Verification required from Planning Department for new constr t n.)
City /State Parcel Identification Number O ZCQ' / /S3 - `/3
LEGAL DESCRIP , / /Fj
Property Location '/4 , '/4 ,Sec. j 3 4 N R�W, Town of
Subdivision ��'► tOi� Lot #
Certified Survey Map # — , Volume y , Page # _
Warranty Deed # ?cP (O 7i , Volume J � �O , Page #
Spec house 01 ❑ no Lot lines identifiable Vyes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix County Zoning Department a certification form, signed by the owner and
by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (I ) 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 fall 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
Department within 30 days of the three year expiration date.
— ( _C0l -/_ oy
SIGNA 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 the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
— onz U4"-_-y1y - & /i ?105(
SIGNATAE OF APPLICANT DATE,
* * * * ** Any information that is misrepresented 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 and a copy of the certified survey rnap if
reference is made in the warranty deed.
9BP 1�3 - 7 r=p6, 1 aa
KATHLEEN H. WALSH
STATE BAR OF WISCONSIN FORM 2 - 1999 REGISTER OF DEEDS
Document Number
WARRANTY DEED ST. CROIX CO., WI
RECEIVED FOR RECORD
This Deed, trade between Hillvale Development Limited Liability 06/1712004 10: 40AN
Partnership Grantor, WARRANTY DEED
and H_ ometow Remodeling, Inc. EXEWT #
Grantee. REC FEE: 11.00
Grantor, for a valuable consideration, conveys and warrants to Grantee TRANS FEE: 131.70
the following described real estate in St. Croix County, State of Wisconsin COPY FEE:
(if more space is needed, please attach addendum): CC FEE:
Lot 43, Plat of G1enVlew in the Town of Richmond, St. Croix County, PAGES: 1
Wisconsin.
Recording Area
Name and Return Address
ton ,
026- 1153- 43-000
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 June 2004
* * Hillva Development Li mited Liability Partnership
s *
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF )
County )
authenticated this _ _ day of _
Personally came before me this _/ day of
-_ June 2004 the above named
Notary Public p
"% � De elo ment Limited Liability Partnershi
* - --
TITLE: MEMBER STAT
(If not, _ to me known to be the person(s) who executed the foregoing
authorized by § 706.06, Wis. Slats.) Atary, and a o edged the same.
THIS INSTRUMENT WAS DRAFTED BY
Attorney Kristina Ogland ^ ^y
Hudson WI 54016 _ _ ic, State of
�! My o issi is ermaner?t. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.)
* 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 -2D21
WARRANTY DEED FORM No. 2 - 1999
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