HomeMy WebLinkAbout030-2108-90-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
395279
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:
Wagner, Dan St. Joseph Township 030 - 2108 -90 -000
CST BM Elev: Insp. BM Elev: BM escription:
qq I
j
Q V
TANK INFORMATION I ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic O u V Benchmark 3 Q
_I
Dosing Alt. BM
/a3 0
Aeration Bldg. Sewer
Holding St/ t Inlet S r
TANK SETBACK INFORMATION St/ t outlet 0 5
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic � � � � � � � / Dt
Header /Man.
3 9� .
Aeration Dist. Pipe < < to 3 G
`P< ' `` 2 S-
H6lding Bot. System L 4. y3
PUMP /SIPHON INFORMATION Final Grade
P--
acturer Demand St Cover k
- - - - - -- GPM
Model Number
TDH Lift. Friction Loss stem Head TDH Ft
Fbrcemain Length Dia. Dist. ell
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 /_ 1, L
SETBACK SYSTEM TO V P/L JBLDG IWELL LAKE/STREAM L G Manufa rer
INFORMATION Type Of System: / b r CAM ER R
� odel Number:
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
q Pipe(s) Dia Spacing
/ / & r .L Y0 ✓
L L
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 I Fig Yes [W No A Yes � No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:�/ / 3 / 0/ Inspection #2:
Location: 1198 64th Street Hudson WI 54016 (NE 1/4 NW 1/4 3 T29N R19W) Buck Hill Lot 13 Parcel No: 03.29.19.903
1.) Alt BM Description =� B
1) 114 1. dl Al 41
2. Bldg ewer le = L '�l s41 G"I-e
9 9 � -� �PP «tS S e afelw - t b t/
- amount of cover = 7Zy" r J g � 4, ( f
3•�06�e ✓va4 P "res ins7VV �✓ r i+. al
a G 1r
Plan revision equired . � Yes No
Use other side for additional information.
ate nsepctops Si na Cart. No.
SBD -6710 (R.3/97)
(A �knr �sav UGY o �t
f i%,,... 0 -" i 9ra z��-
l ! 9 8' `� 8,5
*; Sanitary Permit Application Safety & Buildings Division
In accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave.
`� scc�nsin See reverse side for instructions for completing this application Madison, WI O B 7302
Personal information you provide may be used for secondary purposes
Department of Commerce [Privacy Law, s. 15.04(1)(m)J (Submit completed form to county if not
state owned.)
Attach complete plans (to the county copy only) for t p p 9r t less than 8 -1/2 x 11 inches in size.
Coun State Sanitag Permit Number ❑ c vision to p16ru 9s a lication State Plan I. D. Numbe��
le-
I. Application Information - Please Print all Information. RLCEIVFH Location:
Property Owner Name _ ; Property Location
Oc h 1' r --� r 7 Z .� 1/4/!/k/1/4, S Tp� , , x"
Property Owner's Mailing Address ST C,49Qx r, Lot Number Block Number
,[
lo- COUNTY �A�
Ci , Stfle Zip Code P), Number i Subdivision Name or CSM Number
II. Type of Building: (check one) ❑ City
'l9./ 1 or 2 Family Dwelling - No. of Bedrooms ' / ❑ Village
• Public /Commercial (describe use):_ ► � /��, Y3 - V 1 KTown of
• State -Owned �5)1 sow 5 Z
--�7a ��C / n �� Nearest Road
/ l /i�!(>rH / ' ��"l� � Parcel ax Nuin r(s�2
III. Type of Permit: ( Check only one box on line A. Check box on line B if plicable) 77V 77 /Q -Q
A) 1. JKNew 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to
System System Tank Only qa3 Existing System
B) Permit Number Date Issued
❑ A Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
, O�Non- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
G'�CQ C
V. Dispersal/Treatment Area Information: e
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elev ation 7. in Grade
Required Proposed Rate (G ./day/sq. ft.) (Min. /inch) lev
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
^ ,c Tanks Tanks
5 - e ' �o/ iL �C 6Bti �i�c S r ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
VIII. Responsibility Statement
I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plum s Name (print) Plumb ' Signature (no stamps): MP PRS No. Business Phone Number
.41 /y 4� 4��- 7
Pljobees Address (Street, City, State, Zip Co
4��"11- 469n
IX. County/Department Use Only
❑ Disapproved Sanitary Permit Fee ncludes Groundwater Date Issued Issuing Agent Signature (No stamps)
Approved ❑ Owner Given Initial Adverse Surcharge Fee)
Determination
X. Conditions of Approval /Reasons for Disapproval:
TVrrsupl (. 1�, forte rb�} ;-�, �'�A,,ymcrease in wastewater loads (added bedrooms) may result in a non - compliant septic system, and the
sy*vw v"V nave to be mouiiieu w mecL ,u,�ent codes.
2 ui smuac,Ks to system and residential structure must meet applicable code requirements.
�. Effluent filter to be installed and maintained per manufacturer's recommendations.
4. Property is zoned Ag- residential — only one principal dwelling is allowed on this property.
SBD -6398 (R. 07/00)
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Wisc6*sin ,Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3
s UbDr and human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St. Croix
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. 030- 1008 -95 -000
APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION ED Y DATE
?
PROPERTY OWNER: PROPERTY LOCATION
Steve Hennina GOVT. LOT NE 1/4 NW 1/4,S3 T 29 N,R 19 iE (or) W
PROPERTY OWNER':S MAILING ADDRESS LOT # I BLOCK # SUBD. NAME OR CSM #
1182 61st. St. 13 na Buck Hill
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE NTOWN NEAREST ROAD
Hudson, WI. 54016 (715 549 -6094 St. Joseph I C.T.H. " E "
[x] New Construction Use [ x] Residential / Number of bedrooms 4 [ ] Addition to existing building
I ] Replacement ( ] Public or commercial describe
Code derived daily flow 600 gpd Recommended design loading rate .5 bed, gpd /ft gpd /ft
Absorption area required 1200 bed, ft 1000 trench, ft Maximum design loading rate _ bed, gpd /ft trench, gpd /ft
Recommended infiltration surface elevation(s) _ 96.67 ft (as referred to sit pla benchmark)
Additional design / site considerations na G • (off (o "1 T�
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable for s stem KI S ❑ U [2S ❑ U [RS ❑ U I E] S ❑ U CAS ❑ U ❑ S ❑cU
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots D /ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Nd
1 0 -10 10yr3/3 none 1 2msbk mfr cs 2f .5 g
2 10 -25 10yr4 /4 none sil lcsbk mfr gw if .2 1 3
Ground 3 25 -75 7.5yr4/4 none ms Osg mvfr gw na .7
elev.
1 4 75 -88 5yr4/4 none sl 2csbk mfr na na .5
Depth to lv
limiting d
factor 5 ' D �'-
+8g" Z
Remarks: Z
Boring #
1 0 -9 10yr3 /3 none mfr gw 2f np
2> 2 9 -31 10yr4 /4 none sil lcsbk mfr gw if .2 ,3
3 31 -82 7.5yr4/6 none ms sOg mvfr .aa `, - - n — d--4 .7 {'Z (,Z
Ground
elev. r
1 00.3 ft.
I f
Depth to
limiting -
factor
oix -:z
+82, sT
CIO
1 n
\ - zc)w
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200 ,
Address: 1554 200th. A New Richrrjon W1 54017
Signature: Date: 7 CST Number: m02298
i
PROPERTY OWNER Steve Henning SOIL DESCRIPTION REPORT Page 2 g f r 3
PARCEL I.D. # 030- 1008 -95 -000
Depth Dominant Color Mottles Texture Structure Consistence Y Roots
/
Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. T
1 0 -13 10yr3 /3 none 1 2msbk mfr yw 2f .5 .6 g
- 10yr4 /3 none sil lcsbk mfr gw if .2
2 13 3
Ground 3 22 -36 10yr4 /4 none sicl lcsbk mv fr mfr gw if .2 r na 3 'j
elev. 4 36 -84 7.5yr4/6 none is Osg na .7 8
1 I •L
Depth to
limiting
factor
+84 ,,
Remarks: {
Boring #
1 0 -12 10yr3 /3 none 1 2cpl mfr cs 2f .5 g
4 2 12 -28 10yr4 /4 none sil lcsbk mfr gw if
2 ': .
3 28 -85 7.5yr4/4 none ms Osg mvfr na na .7 (.Z
Ground
elev.
1
Depth to
limiting 5�
factor
Remarks: iL
Boring #
IN ....:::...:::::: 1 0 -14 10yr3 /3 none 1 2cpl mfr gw 2f n
ryi•:....
2 14 -39 10yr4 /4 none sil lcsbk mfr gw if .2 3
3 39 -80 7.5yr4/4 none ms Osg mvfr na na .7 LL
Ground
elev.
1
Depth to
limiting
factor
+80"
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
t
STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 New Richmond, WI 54017
MPRSW -3254 Steve Henning 715 246 -6200
NE4NW4 S3- T29N -R19W
town of St. Joseph
lot #13 -Buck Hill
N
1 11 =40 1
BM.= top of 1 pvc pipe @ el. 100'
Alt. BM.= top of 1 pvc pipe el. 99.80' ►'
CAS � ��
1 , 3z 5�
p
f
Z �o
.. h
Z
` cy� t3•�
2n
r
2p4
This soil evaluaiton was conducted to
satisfy a zoning requirement, it may
or may not be suitable for your use.
The location of the test mayor may
not be as shown as permanent lot lines
had not been established at the time
of testing.
Gary L. Steel
7 -10 -98
Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In- Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWTS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
10567 -P (R.6/99).
Table 1: System Design Specifications
Sanitary Permit Number 3
Number of Bedrooms
Design Flow - Peak (gpd)
Estimated Flow - Average (gpd)
Septic Tank Capacity (gal)
Soil Absorption Component Size (ft 3 7!5
Type of Wastewater Domestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow - Peak (gpd) ?
Maximum Influent Particle Size (in) 1/8
Maximum BOD (mg /L) 220
Maximum TSS (mg /L) 150
Table 3: Maintenance Schedule
Septic Tank Inspect and /or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years /
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the septic tank and outlet filter shall be assessed at least
once every 3 years by inspection. TfK o tlet Iter shall be cleaned as necessary to ensure
proper opg ho n. The filter cartridge 'sTV5'unof 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
Management Plan for a Septic Tank and Soil Absorption Component z)
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole 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 one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
Management Plan for a Septic Tank and Soil Absorption Component 3 l
Plantings of deep- rooted trees and shrubs directly over or within ten feet of the
component should be avoided since root intrusion into the component may obstruct wastewater
flow.
n�
'/.
3
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be liken, to provide a code compliant
replac"ri system:
C7 A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed svvcwre, lot (Ina and wells. Failure to protect the replacement area will
result In the need for a new soil and site evaluation to estabilsh a suitable replacement area. Replacement systems must
comply with the rules In effect at that time.
O A suitable replacement area Is not available due to setback and /or soil ilmltatlom barring advances In POWTS technology
a holding tank may be Installed as a last resort to replace the failed POWTS.
* The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be perfonned to locate a suitable replacement area. If no replacement area is available a holding tank may
be installed as a last resort w replace the failed POWTS.
D Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the
inflitrative surface. Reconstructions of such systems must.comply with the rules in erect 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
IMPMUR1 F.
ADDITIONAL COMMENTS
(POWTS INSTALLER ( POWTS MAINTAINER
Name Q; N a me
Phone _ --7 ( I Phone
SEPTAGE SERVICING OPERATOR (PUMPER LOCAL REGULATORY AUTHORITY
Name A>iency Zon ' n
Phone r R fho nt —
��oe -1
900- zz t - s' 2t z_ l
lk ST CROIX COUNTY
` SEPTIC TANK MAINTENANCE AGREEMENT
M
AND � o.^
OWNERSHIP CERTIFICATION FORM
Owner/Buyer /'I D e r o.7" y —
Mailing Address o i• . e r A. aL9 iwl
Property Address 4
(Verification required from Planning Department for new construction)
a lo8 C)
City /State Parcel Identification Number 0 I o —
LEGAL DESCRIPTION /
Property Location ' /a, �'/4, Sec. � , TN -RW, Town of J
Subdivision Lot #.
Certified Survey Map # , Volume . Page #
Warranty Deed # Volume Page #
Spec house ❑ yes A no Lot lines identifiable N yes ❑ 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 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 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
days of the three year expiration date.
S ATURE OF APOLICANT 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.
S ATURE OF AOLICANT DATE
* * * * ** 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
VOL 1663PACE294
645749
STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH
Document Number WARRANTY DEED REGISTER OF DEEDS
Sr. CROIX CO., WI
This Deed, made between Bradley M. Blomquist and Heidi J. RECEIVED FOR RECORD
Blomquist, husband and wife, 06-19 -2001 3:00 PM
WARRANTY DEED
EXEMPT N
Grantor, and Danny P. Wagner and Joanne M. Wa gner CERT COPY FEE:
Husband and Wife COPY FEE:
-- — -- TRANSFER FEE: 129.00
— - -- -- -- RECORDING FEE: 10.00
-- --_ — — PAGES: 1
Grantee.
Grantor, for a valuable consideration, conveys to Grantee the
following described real estate in St. Croix County,
State of Wisconsin (ifmore space is needed, please attach addendum):
Recording Area
Lot 13, Plat of Buck Hill in the Town of St. Joseph, St. Croix County, Name and Return Address
Wisconsin, TOGETHER WITH an easement for ingress and egress as set EDINA REALTY TITLE
forth in that certain easement dated July 28, 1998, recorded August 10,
1998, in Vol. 1347, page 161, as Doc. No. 584732, St. Croix County, 400 SOUTH SECOND STREET
Wisconsin. HUDSON, WI 54016
1318721
030 - 2108 -40 -000 - `
Parcel Identification Number (PIN)
This is homestead property.
(isl Q$,�tdQ
Exceptions t warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this `�1 � - day of March 2001
• + Bradley M. Blomquist
+ Heidi J . Blo ui t
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
) ss.
- - -- St. Croix County )
authenticated this day of �y
— Personally came before me this day of
March 2001 the above named
Bradley M. Blomquist and Heidi J. Blomquis husb and
wife,
TITLE: MEMBER STATE BAR OF WISCONSIN - --
(If riot, to me known to be the person(s) who executed the foregoing
instrument and acknowledged the same.
authorized by § 706.06, Wis. Ststs.)
THIS INSTRUMENT WAS DRAFTED BY
A ttorney Kristina Ogland Notary Public, tale of Wisconsin
Hudson, WI 54016 My Commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.) a 1_�11 O !�_- )
• Names of persons signing in any capacity must be typed or printed below their signature. m Prore,ai - 1, Company, Fond W Lac, VA
S'rATE BAR OF WISCONSIN Notary � 800-655-2
WARRANTY DEED FORM No. 2 -1999 Stat of Wisconsin
B&i oara J. Burke
02/05/2001 16:53 7153863210 ROGER HETCHLER PAGE 07
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