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Home My WebLink About030-1037-50-100 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Coun Safety and Buildings Division t Croix INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitmPg3m No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). E Permit Holder's Na me: C] City ❑ Villa e ❑ own of: State Plan ID No.: er, Troy St. �oseph Township Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.: 1-40 030 - 1037 -50 -100 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic �/� �2 Benchmark (, PLO /0 d v - 6 Alt. BM Aeration Bldg. Sewer I ' trove D Ing S t Inlet ,6 1033 TANK SETBACK INFORMATION 0/ Ht Outlet 9 Z 0 -a TANK TO P/ L WELL BLDG. A I to ntake ROAD Septic 7 3s� 7 35 Z ' Z NA A Header / Man. Ae on NA Dist. Pipe tt) r �' .17 Z, o Holding Bot. System c /0' a/ too I6.L/ v f PUMP/ SIPHON INFORMATION Final Grade ? �'� �� Yz U-Q ulacturer errand St cover Model Number PM TDH Lf Friction m TDH Ft L oss ea Forcemain Length Dia. Dist. To SOIL ABSO PTION SYSTEM -3d 4 0�j (Qer5 BED / ENCH ) Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIME / 3,35 Z - I DIMENSION SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEAC ING ctur r: INFORMATION Type of A B ode umber: System:' t 7 DISTRIBUTION SYSTEM Header / Manifold r Distribution Pipe(s) �, r x Hole Size x Hole Spacing Vent To Air Intake � Length Dia. _� Length � 3• P Dia. 4L/ _ 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 E] Yes El No E] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: 1 / LS/oo Inspection #2: Location: 1096 Mound Drive, Hudson, WI 54016 (NE 1/4 NW 1/4 11 T29N R19W) - 11.29.19.125D -Lot 1 1.) Alt BM Description = 4 << S i cove y) z eac)s a� C�Vw 4iefs wr%rc i s fo (leA s4ad o � 3 2.) Bldg sewer length = 3.5 - �( 4M 6tr >/vu �o�ov�'de ror✓�e�c� 5�`l�� N /a.��as_�u: /r< - amount of cover = -2 yz 3. / / �rofs. ) �hC( �- /Utz 6u45 Plan revision required? ❑ Yes I No Use other side for additional inform6tion. q 2 Op SBD -6710 (R.3/97) Dat Inspector's Si nature Cert No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: I e , , i f f f E 3 i F m _ k } a m� V v ; 8 f { 3 x p . � 3 � 9 .. .......m .. ., - ., ,.... &., mm .... ,m£-� ..... . i G e o ie. , t u , .,.., .... l V t e � f E a 3 a d t � 2 r I vm. i , 2 i t i fl � f i e .rt , , i I IA 1.4 U 0 1 '1 too Ul co I V A 9. IL th W% UJ .gym � ' � � t� Q V1 OA 4V w 1 M �, � � �� - ?, OCR U v .12 £0'd S600t0S^z9,ic NOIIOIA"'31210ISI-3- Wd 9T:z0 00-61-d3s 0% AA&U ).A hK. I Sanitary ermlt A Iication Safety &Buildings Division rIn accord with Com Wis. 201 W. Washington Ave. ..lconsin See reverse side for instructions for completing this application Madison, WI 53707 -7302 PO Box 7302 Personal information you provide may be used for secondary purposes Department of Commerce (Submit Completed form to County If nc. [Privacy Law, s. 15.04(1)(m)] state owned.; Attach com lete plans (to the county copy on{ ) for the system, on a er not less than 8 -1/2 x 11 inches in size. (aunty State Sanitary Permit Number Cheek if r ' ' revious application State Plan 1. D. Number 51, fro,' K 3a 30 12 �# i Application Information - Please Print all Information °� Location: erty Owner Name r Property Location 1/ p Z_ �_ • � 1 L ! /virf 1 /4N�I /4,S T N,Rr/E o 6 W Property Owner's Mai mg Address J 4 1yr i Lot Number Block Number City, State Zip Code Phone tj5 /X -- Subdivision Name or CSM Number f 1'�i iij SOH wt 54D 0 N e�fiv oil ✓0 1.2 f='538 II Type of Building: (check one) / , ❑ City �( 1 or 2 Family Dwelling -No. of Bedrooms: V ill ag e of J Sep ❑ Public/Commercial (describe use): • State -owned III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road Motes" A) 1. %New System 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Addition to Parcel Tax Number(s) System Tank Only Existing System 0 B) Permit Number Date Issued A Sanitary Permit was previously issued ( IV. Type of POWT System: (Check all that apply) PLNon- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V Dispersal/Treatment Area Information: i `d` t!" ur - 1. Design Flow (gpd) 2. DispersalArea 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch /01.0 ; Elevation VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information G allons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks I I Z 53 0 12,E - l (A� s ma c.. f,1,4 ❑ ❑ ❑ ❑ t -0- 1 ❑ ❑ ❑ ❑ VII Responsibility Statement I, the undersigned, assume responsibility for in stallation of the POWTS shown on t hed plans. Plumber's Name (print) Plumber's Signa � we (no tamps): M RS N �z,� Z Business Phone Number 71 5 v��it -u T 6m . �� . 2Z��7� � Plumber's Address (Street, City, y State, Zip Co / 73 Aqp E VIII County/Department Use Only f I ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) 'Approved ❑ Owner Given Initial Adverse Surcharge Fee Determination IX. Conditions of ApprovWl /Re ons for Disapproval: 'f -V"— �o� �� at-Ce. e.,.'� S' Se. y i►�5 cY S'� �..� ^e 5� we ow% . b .�... AA J_ p, code_ Al % . SBD -6398 (R. 07/00) AUG-25-2000 14�02 RENEWAL BY ANDERSEN G51264�� P 02/02 Vl CJO tV m cr- Ln LAJ Ln QA HI�JON ' ' � � � � TOTAL P.02 � X. IN- GROUND WORKSHEET IN- GROUND WORKSHEET A. SITE CONDITIONS Evaluate the site and soils report for the following: • Surface water movement. • Measure elevations and distances on the site so that slope, contours and available areas can be determined. • Description of several soil profiles where the system will be located. • Determine the limiting conditions such as bedrock, high groundwater level, soil permeability, and setbacks. Slope - / % Occupancy: One- or Two - family Dwelling, # of bedrooms - Public Facility Depth to limiting factor - >/30 inches In situ soil application rate used - 7 gaUfl /day B. DESIGN WASTEWATER FLOW (DWF) One- or Two - family Dwelling. DWF =150 al/da /bedroom x # of bedrooms g Y = 150 gal/day/bedroom x 6 # of bedrooms 6 00 gal/day Public Facilities. DWF = Sum of each wastewater flow per source per day x 1.5 gal/day x 1.5 = gal/day 20 of 28 1 C. WIDTH AND LENGTH OF THE DISTRIBUTION CELL. 1. Determine the design loading rate (DLR) for the site. From Table 83.44 -1 or -2, Wis. Adm. Code, select the effluent application rate for the most restrictive soil horizon in contact with the distribution cell that matches the soil conditions. The effluent application rate selected from Table 83.44 -1 or -2, Wis. Adm. Code, is the design loading rate (DLR) for the site. /0 9� DLR gpd/f e /1 2. Determine the distribution cell area. Calculate the distribution cell area by dividing the daily design wastewater flow (DWF) by the design loading rate (DLR). Distribution cell area = DWF _ DLR Distribution cell area = 660 gpd _ , Z gpd/ff Distribution cell area = Q •Z�i 7� I fF �... 3. Select a width (A) for the distribution cell. The width of the distribution cell cannot exceed 6 feet. A= ft 4. Determine the distribution cell length. Calculate the distribution cell length (B) by dividing the required distribution area by the distribution cell width (A). B = Distribution cell area _ A B= fe- ft B= ft 21 of 28 AUG -25 -2000 1402 RENEWAL BY ANDERSEN 6512644080 P.01/02 �.. G North N TD St. Croix River CL Hwy 35 0 Carmichael = rn Hwy 35 y W C � m c v CL N a wisoon m oqpmwt of Comm" SOIL EVALUATION REPORT Page 1 of 3 Dlvisiau of and eutidings b ce with Comm 85 Ws. Adm. Code In accordance County St. CRoix Attach complete slue plan an paper not leas ten 8112 x 11 Inches In at m. Plan must Irckm1e, but not tinned 1a: varticai and horbmtel reference point (BW direction and parcel I.D. t . scale or dirnerWons north arrow, and location and distance to nearest read. 030 - 1037 - - 000 Please Pd it aft infor,"A bm R by p Deb Persmrwr ir*cmueon you Provide moy a used forssoondoy pUrposM (Privacy Law. s.1 5.04 (1) (m)). Pmpedypwm PmpertyLocation Troy Rubenzer GWA Lot NE 114 NW 19 15 11 T 29 N R 19 R(or)w Ply 0mWs Address Lot # Block # Subd Nerve or CSM# 1096 Mound Dr. 1 na csm City State 4P Code Number ❑ City ❑ Village ®'town Nearest Road Hudson, WI 1 54016 (51 264 -4080 St. Joseph Mound Dr. ® New Construction Use: ® Residential / Nwnber of bedrooms 4 Code doWed design lbw rate 601 GPD 13 RepWcWF rrt ❑ Public or commwciel - Desafbe: per„ outwash Flood Plain elevation if appila" n a fl Generet corrownts and reonxnrrrerrdatiorrak trenches starting C el. 101.00 spaced to code 3,50' below grade D F7 ® Pit Ground surface slay. 103.85 R Depth to *ni&v factor +1 in. Boll Rate Horimon Depth Dominant Color Redox Desaription Ttydt" Strtx kre Consistence Boundary Roots Gpoff in. Munsell Qui Sz. Cont, Color Gr. Sz Sh. •EW1 •I.= 1 0 -12 10 r4/3 none sl 2m r mvfr cs 2f .5 .9 2 12-2E 10yr4 /4 none sl 2msbk mvfr gw if .5 .9 3 26-120 7.5yr4/6 none co s Osg ml na na .7 1.6 � o Bodrrg 105.15 ] ph Ground awRao. etelr. fi. peptl, be Itrrritir,q +120 ;n soli tiaM H xkm Depth Danrlmt Redunr Description TWAM shmium Consmanoe soux+dary Roots GPD4F In. Maws" Qu. Sz Cont Color Gr. Sz. Sh. 'Efd11 'EM 1 0 -14 10 r4 3 none sl 2m r mvfr cs 2f .5 .9 2 14 -3 7.5 r4 6 none ms Os ml qw if .7 1.2 3 32-110 7.5yr4 6 none co s Osg ml na na .7 1.6 • Eflltm t fa'1 = BOO > 30 220 n*L and TSS >30 _< 150 nV& #2 x 130. S mWL and M < 30 nV& CST Name (Please P" a Number Gar L. Steel �' 02298 Address Dale EvaNattior► ondCmftd Telsphons Nunter 1554 200th. Ave., New Richmond, WI. 54017 8 -8 -2000 715- 246 -6200 I property owner T. Rubenzer ParoelID# 030- 1037 -30 -000 P age 2 of 3 ❑ Boring # ❑ Boring 3 ® Pit Ground surface elev. _ 29,6 ft. Depth to limiting factor +120 in. Soil Applicatlon Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/If in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 'Eff#2 1 -14 0 r4 3 none sl 2mcfr mvfr Cs 2f .5 .9 2 14 -32 .5yr4/6 none ms Osg ml gw if .7 1.2 3 32 -12 7.5yr4/6 none Co s Osg ml na na .7 1.6 F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soo ication 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 # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to liming factor in. Soft Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Etf#2 Effluent #1 = BOD, > 30 = 220 mglL and TSS >30 150 mglL ' Effluent #2 = BOD, < 30 rng/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- 2648777. sen.a;w ptAW) STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 1 Troy R- New Richmond, WI 54017 MPRSW -3254 NE4NW4 S11- T29N -R19W (715) 246 -6200 town of St. Joseph lot #1 -csm N 1 =40 BM.= top of 1 11 pvc pipe C el. 100.00' A1t.BM.= top of 1" pvc pipe C el. 103.15' le y Pt '' tQ fOC'4— Gary L. Steel 8 -8 -2000 y 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 "S t&%' Sanitary Permit Number 333 a Number of Bedrooms Design Flow - Peak (gpd) Estimated Flow - Average (gpd) Septic Tank Capacity (gal) 25' Soil Absorption Component Size (ft') Type of Wastewater Domestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) 2, 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. 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 r Management Plan for a Septic Tank and Soil Absorption Component 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 r s t. Management Plan for a Septic Tank and Soil Absorption Component 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. 3 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. (2>S/ — 3 86 —1 Co 8 Z 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 Des i n Specifications Sanitary Permit Number Number of Bedrooms Design Flow - Peak d o Estimated Flow - Average d 5_00 Septic Tank Ca acit al /05 3 Soil Absorption Component Size ft 14, z Type of Wastewater Domestic Table 2. Soil Absor tion Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Com onent Design Flow - Peak d I2 .7 Maximum. Influent Particle Size in NA 1/8 Maximum BOD (mg/L NA 220 Maximum .TSS m /L NA 150 Maximum FOG NA 30 Table 3: Maintenance Schedule Septic Tank Inspect and /or service once every 3 years Outlet Filter Should inspect once a year and clean 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. 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 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 Management Plan for a Septic Tank and Soil Absorption Component 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. Plantings of deep - rooted trees and shrubs directly over or within ten feet of the I component should be avoided since root intrusion into the component may obstruct wastewater flow. czw`i; i j c (, � - 1S e-4 2 S Safet ofBui D ivi s i o n SANITARY PERMIT 4I Bureau of Building Water System! 201 E. Washington Ave. In accord with ILHR 83.0` m. Co P.O. Box 7969 �? Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the sy / i on p ii� un than 8 112 x 11 inches in size. Sf cv-v r k • See reverse side for instructions for completing this apple ation ° std ' anitary Permit Number ST G �, 3 ?3 0 COUNTY The information you provide may be used by other government agency progrVms. % ck it revision to previous application IPrivacy Law, s. 15.04 (1) (m)I. ZomNGOIFF M e Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL IN I --= Property Owner Name --_ _rdpVd v"a u 6 eL. ze N 114 5 11 T 29 , N, R / 9 E (or W Property Owner's Mailing Address Lot Number Block Number Z4 S W I — Cit State Zip Code Phone Number Subdivision ame or CSM Number V" 0,Z' M v1 d zS ( 6 esv`cr� d V� Z 5'3$ II. TYPE OF BUILDING: (check one) ❑ State Owned it Iyy // Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms Tow OF � - Jb s h /U&A.AAd 0r1 vQ, III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) — � fi ZA,,19, IO'D 4 00 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1 New 2. ❑ Replacement 3. ❑ Replacement of 4, ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System ----------------------------------------------------------------------------------------------- B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 %Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION WSTEM INFORMATION: U 5� 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rat 6. ystem Elev. 7. Final Grade ,L k 50 Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft_) (Min./inch) 99.9 9 Elevation 4i a '4 wu Fee y9.9 Feet Capacity VII. TANK in g allons Total # of Prefab. Site Fiber- Exper- INFORMATION g Gallons Tanks Manufacturer's Name Concrete ruct steel glass Plastic App New Existin strutted Tanks Tanks Septic q Holding Tank Dl,/V Q ! iW9 R] ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber I ❑ I ❑ I Eli ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage s stem shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: q4o Stamps) M RSW No. XZt 2. Business Phone Number: Plumber's Address (ITreet, City, State, Zip Code): / r 1 ,►2 g leaa�r ,t� s4�'7 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) 'AApproved ❑ Owner Given Initial surcharge Fee) Adverse Determination oZoZ� '/ ZceO X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: if - 5 opy To: Saf y & Buildings Division, Owner, Plumber ,� r -- . INSTRUCTIONS 1: A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 -3815. To be complete and accurate this sanitary permit application must include: I_ Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair_ V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan,.drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. �! M p- C . 0 W CA LA 144 CL :Z i LrI kA o / J `� Y tA x Ci 4. A 6 � 1' Wisconsin Department of Industr SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COU 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 4rWion and % of slope, scale or PARCEL I.D. it dimensioned, north arrow, and location and di aXl- n_Qateo i6ad. 030 - 1037 -30 -000 E REVIEWED BY DATE APPLICANT INFORMATION -PLEAS ALL IM FORMAt N -7 I ' PROPERTY OWNER: ':,�, /11r r PROPERTY LOCATION Donald Nestrud �J , GOVT. LOT NE 1/4 NW 1/4,S 11 T 29 ,N,R 19 f (or) W PROPERTY OWNERS MAILING ADDRE _ r i LOT # BLOCK # SUBD. NAME OR CSM # 1194 42nd. St. s1O X98 f 1 na I csm pending CITY, STATE ZIP ER []CITY [ [MOWN NEAREST ROAD Hudson, WI. 54016 '��. 6 `� St. Jose h Moun Dr. [x] New Construction Use [ :4 Residentia �toxo ii 4 [ ] Addition to existing building Replacement [ ] Public or coibe Code derived daily flow 600 gpd Recommended design loading rate .7 ed, gpd/ft gpd/111 Absorption area required 858 bed, ft 750 trench, ft Maximum design loading rate _j bed, gpd/ft gpW Recommended infiltration surface elevation(s) 9q. It (as referred to site plan benchmark) Additional design /site considerations tenches spaced to code 3.50' below surface grade Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN GROUND PRESSURE I AT - GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem I U S ❑ U as ❑ Ll I CAS ❑ U ®S O U ®S ❑ U ❑ S ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tmnch 1 0 -9 10yr2 /2 none 1 2msbk mfr gw 2f .5 .6 2 9 -18 10yr4 /4 none s i t 2msbk mfr gw if .5 .6 Ground 3 18 -84 7.5yr4/4 none co s Osg ml na na .7 .8: elev. 1 .o ft. Depth to limiting factor +8 4" LI y, �h Remarks: Boring # 1 0 -12 10yr3 /3 none 1 2msbk mfr gw 2f .5 .6 r .2 `€ 2 12 -27 10yr4 /4 none sil 2m sbk mfr gw if .5 .6 f }:> 4 3 27 -80 7.5yr4/4 none Co sl Osg ml na na .7 .8 Ground elev. 1(�0 . lt. Depth to limiting factor +80 V rt•rt Remarks: CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200 Address: 1554 200th. Ayew, New Richmond WI 54017 Signature: Date: 11 -25 -98 CST Number: mO2298 PROPERTY OWNER ' Doanld Nestrud SOIL DESCRIPTION REPORT Page 2 of a PARCEL I.D. # 030- 1037 -30 -000 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bojxky Roots GPD /ft .................. in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trees ................. .................. 1 0 -9 10yr2 /2 none 1 2msbk mfr gw 2f .5 .6 3 2 9 -20 10yr4 /4 none sil lcsbk mfr gw if .2 .3 Ground 3 2 7.5yr4/6 none ms Osg ml na na .7 .8 elev. 1 Depth to limiting factor q y o ?io Remarks: Boring # 1 0 -15 10yr2 /2 none 1 2msbk mfr gw 2f .5 .6 2 15 -28 10yr4 /4 none sil lcsbk mfr gw if [-2 .3 LU 3 28 -82 7.5yr4/4 none co E Osg ml na na .7 .8 Ground elev. 103.9 ft. Depth to - limiting factor +82 Remarks: Boring # 1 0 -8 10yr3 /3 none 1 2msbk mfr gw 2f .5 .6 5 2 8 -17 10yr4 /4 none sl 2mgr mvfr gw if .5 .6 3 17 -84 7.5yr4/4 none co Osg ml na na .7 .8 ................... Ground elev. 1 02 . B ft. Depth to limiting factor q 6+4 Remarks: 3 sit lens- mot.7.5yr5 /6 -non contiguous in H -3 Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) s STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 Don Nestrud New Richmond, WI 54017 MPRSW -3254 NE4NW4 S11- T29N -R19W (715) 246 -6200 town of St. Joseph lot #1 -CSM N 1 =40' BM.= top of SE lot stake C el. 100 Alt. BM.= top of tel. ped. C el. 98.50 a� x � l ot0 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM ,wner/Buyer 12 Mailing Address 24x Property Address o M ouni d -� (Verification required from Planning Department for new construction) City /State ' U��SDYI Parcel Identification Number 03 0.3-7 - - d LEGAL DESCRIPTION _ roperty Location 1 1 A, i /, Sec. T _aN -R—ffW, Town of Subdivision Lot # �_.• Certified Survey Map # I.C�T C�OVI Volume 2 , Page # Warranty Deed # , Volume , Page # Spec house ❑ yes V no Lot lines identifiable L yes ❑ no S YSTEM 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. 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 Zoning Office within 30 o the three ear expirra Sate. b /2t SERIURE OF PLICANT ATE 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 rty d 'bed above, by virtue of a warranty deed recorded in Register of Deeds Office. 7,4 & 4 / — / 0 SIGN OF 4PLICANT DATE * *s * ** An y information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** t* 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 i / DO i VO 1505PAGE 73 . 621756 STATE BAR OF WISCONSIN FORM 1 - 1999 KATHLEEN H. WALSH Document Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI This Deed, made between Donald J. Nestrud and Virginia M. RECEIVED FOR RECORD Nestrud, husband and wife as joint tenants 04 -24 -2000 11:40 AM WARRANTY DEED Grantor, and Troy L. Rubenzer and Kimberli K. Kramer - Rubenzer, EXEMPT N husband and wife, as survivorship marital property CERT COPY FEE: COPY FEE: TRANSFER FEE: 120.00 RECORDING FEE: 10.00 PAGES: AGES: 1 Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Part of NE '/4 of NW '/4 of Section 11 -29 -19 described as follows: Lot 1 of Recording Area Certified Survey Map filed April 29, 1999 in Vol. 13, Page 3633, Doc. No. Name and Return Address 602261. The RiverBank P.O. Box 188 Osceola, WI 54020 030 - 1037 -30 Parcel Identification Number (PIN) Together with all appurtenant rights, title and interests. This is not homestead property. jdx) (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and ordinances of record and will warrant and defend the same. Dated this z y day of , 2000 4 -11 4 x z * * D nald J. Nestrud * * Virginia M. Nestrud AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ) ss. St. Croix County ) authenticated this day of 7i d ay of Per Wally came before me this y 2000 the above named 40 ��i�� Do Id J. Nes rud and Virginia M. Nestrud _ . . bp s '. TITLE: MEMBER STATE BAR OF WISCN �nd (If not, : Co , n� t e nown to e p r on(s) who executed the foregoing _— 2. u nt and w t o sa e. authorized by § 706.06, W is. Stats.) p THIS INSTRUMENT WAS DRAFTEVY . , �7j��`� Q to Q Priscilla R. Dorn Cutler �� I'V{�11�y`1 \ 1 1 tary Public, State of Wisconsin Osceola, WI 54020 ��Nlum ►� a My Commission is permanen . (If n ,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 Company, Fond du Lac, WI STATE BAR OF WISCONSIN 800 - 655.2021 WARRANTY DEED FORM No. 1 - 1999 e. A. r C� o k 1 CERTIFIED SURVEY MA�� LOCATED IN PART OF THE NE 1/4 OF. THE NW 1/4 OF SECTION 11, T29N, R 19W, TOWN OF ST. JOSEPH, ST. CROIX COUNTY, WISCONSIN. CURVE DATA NUMBER RADIUS CENTRAL ANGLE CHORD BEARING CHORD LENGTH ARC LENGTH TANGENT TANGENT 1Q 150.00' 50'49'43" N38'40'45.5 "W 128.75' 133.07' N13'15'54'W N64 Q2 200.00' 06'32'53" N60'49'10.5 "W 22.84' 22.86' N64 N57 Q3 117,00' 50'49'43" N38'40'45.5 "W 100.43' 103.79' N13'15'54'W N64 ® 233.00' 06'32'53" N60'49'10.5 "W 26.61' 26.63' N64 N57'32'44'W OWNER 0 DONALD J. NESTRUD 1ti' VIRGINIA 194 2ND EE RUD HUDSON, WI 54016 S �: LOT 1 C. NW COR. " � - ----------------------'s= M - g � ' VOL. 2 PC. 538 SEC. 11 �V� g,,� " --- - - - - -- t------ - --- - - - - -- N1/4 COR. ^589'57'29 "E S89 "E SEC. 11 1317.92' \� 1317.92 L NORTH LINE OF THE NW1 /4 0 6 z 00 4- r Cl LOT 1 = w w S � 3.432 ACRES ^T 1 ° w N �n 3.058 AC. EXC. RW n '.t u - w 133,199 SO. FT. 1 z 3 m N89'50 "W 601.76' w z ^' 298.19' 269. 4' r w w 3'.�- 567.83' 33.93' w = w LOT 2 3.172 ACRES Do: t � 138,180 SQ. FT. �, c , w ° �- 3 N 3.001 AC..EXC. RW A l ;�jj y Li im 130,724 SQ. FT. t z D J i co S89'50'14 "E 655.65' 1 �, Z2� (6 u') a 621.72' 0 , 33.93' ` w o z q co LOT 3 "' Z o! 0 3.425 ACRES CD ao 149,185 SO. FT. N Ala (/) N 1•255 AC. EXC. RW w v N N 1 141,768 SO. FT. 33.93- , 1 7 . 675.3 4. S89 °50'14 "E 709.25' 33 } I UNPLATTED LANDS � ; '; ) w ~z 1b Q CY ; e Z jO z ww Z LEGEN ALUMINUM COUNTY SECTION CORNER = MONUMENT FOUND O V X 24' IRON PIPE SET WEIGHING 1.68 LBS. PER LINEAR FOOT SCALE IN FEET 1 = 200' ........... 100' ROADWAY SETBACK LINE 200 0 200 400 — x — x — EXISTING FENCELINE