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HomeMy WebLinkAbout161-1092-50-100Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 617896 Personal information you provide may 6e used for secondary purposes [Privacy Law, S.15.04 (1)(m)] Permit Holder's Name: City Village Township Parcel Tax No: Pat Simones I VILLAGE OF NORTH HUDSON 161-1092-50-100 CST BM Elev: Insp. BM Elev: BM Description: SectioNTown/Rangellvap No: CST BM Elev: _T�� 12.29.20.729A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic V'� I GX�5�1 4.a KS iliz'c& Dosing AerettaR W rl�cr (K , i- Holding TANK SETBACK INFORMATION M©Mm® •' • ® s • m® ,= ®M PAW VQWX� WMWM�� PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Num er TDH Lift Fr*onL Syst Head T H Ft Forcemain engh. Dist. to We SOIL ABSORPTION SYSTEM jr BEDITRENCH Width t Lengih DIMENSIONS 7P STATION BS HI FS ELEV. Benchmark 11.Itv p Alt. BM Bldg. Sewer S I let SUHt Outl t •, � S s `I t too . 06 Dt Inlet Dt Bottom Header/Man. t7 r1 7 JO q7 / Dist. Pipe Bot. System 1`446 17.0 Final Grade 1 . q / 'OI '� St Cov of SETBACK ISYSTEM TO PJK.LDG WELL LAKE/STREAM LEACHING ManutacturT INFORMATION I CHAMBER OR r Typ GCM%m ti �"~ 1 Q � 1 1 �� , UNIT Model Numbar: (l DISTRIBUTION SYSTEM S,j,,,,; J.Jj_ '-r Header/Manifold dLiffstnibution )]Pipe(s) Length I Dia I 11-engthDia Spacing z Hale Size x Hole Spacing Vent to Air Intake 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 . t Bed/Trench Edges Z r t Topsci Yes No O COMMENTS: (Include code discrepancies pars° s present, etc.) Location: 249 STATIONtLN N1 1.) Alt BM Description 2.) Bldg sewer length =, - amount of cover = J Plan revision Required? ❑w Yes No 16 I b Use other side for additional informationy Date SBD-6710 (R.3197) Inspection #1: Inspection #2: a %^ 5,,.� Evl� Insepctors Signature Cert. No. D 5AK1-20ZO —105' MAY 01 in try 2020 1a Services Division E Washington Ave010) County S . C O t ; r Cointy Mad P.O. Box 7162 WI Sanitary Permit Number (to be filled in by Co.) wx gon, D-veiopment W7-7j(2 Sanitary Permit Application Y L g State Transacum Number In accordance with SPS 383.21(2), Wis. Adm. Code, submissim of this fonA Of the appropriate governmental wit - Project Address (if different than mailing address) is required prim to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to the Department of Safety and Professional Services. Personal information you provide used for secondary purposes in accordance with the Privacy Law, s. 15. 1 m , Stats. 7;!Z 5D I. Application Information - Please Print AN Information Property O 's Name SIth" Parcel # l� -(o -Sb_ oo es — e1� s� Property era's Mailing � i a� ` rY`I N Property Location rcJ�V., Grow Lot C C � SW %wirciem City, State Zip Code Phone Number U�V50-4 I S%1 — role me) T 'Al N; R � E m W II. Type of Btulding (check all that apply) 94 or 2 Family Dwelling -Number of Bedrooms Lot k Is Subdivision Name STf�fi0Al Block N ❑ Public/Commercial -Describe Use El City of ❑State Owned -Describe Use ■■ Village of CSM Number �— ❑ To" of IIL Type of Permit: (Ch y one boa on Hoe A. Complete Use B if applicable) A. ❑ New System eplacemrnt System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Chmge of Phunbef ❑ Permit Transferto New list Previous Permit NdinberryadDue lasped Before Expiration . Owns' IV of POWTS S stem/Com nent/Device: (Cbeck all that apply) [�(Jm- in -Ground ❑ Ressunzod in-Cuwnd ❑ At-Caade ❑ Mound > 24 m. of suitable soil ❑ Mound <24 in. of suitable and Holding Tank ❑ Other Dispersal Compmrn[ lain t Devitt (explain) V. Dispersanreatment Ara [oformatio O Design Fbw (gpd) 1 Design Soil A licatim t) I Disposal Area Required (at) -ao13 Dispersal Area Proposed (st) SyElevation 00 abtt 7 To 0 a VL Tank Info Capacity in Tool # of - Manufacturer 6NewTanks Gallons Gallons Units i 11'r` t' PN . i t eg LF a 3 Existing Tanks 1W1ts*w Wt't�l ti on w a a septic or Holding Tank DOD witxK jlsa:hChaat� w P• lek VD. Responsibility Statement- 41ke unden' name m y for b."natkw of the POWTS shewa an the attacked pleat Ptum Name ) lumber's 'gram MP/MPRS Number Business Phone Nurn Plumber's Address (Street, City, State, Zip Code) l bib I)iw S �0 3 UVs11�4 VIII. ComeqTnnnhiment We Only X,Appmvcd ❑ Disapproved Permit Fee S/�% Date Issued I g Agent Signative ` ❑ Owner Given Reason fro Denial I �� INoprovaUReagons for Dhtapproval �j) e_L j- CUA,_ t,l: t*, Ar.IS 1. Septic tank, effluent filter and Fbotlt te�Q Ga- ^tt�- 4 / ew dispersal cell must be serviced raintained Q�u,yt'S �p 14.�r4t2n , by - a$ per management plan provided plumber. �1 be maintained J -tLL pigs . t'�'t^ ., 2. All setback requirements must r aaN.,�ut.yw.........-Atlrabdmpku phm car lire gveo a�Wiw'D�eitbt►�1I 1�.'MH,yl esly on Wp��laa druavtl l�arbou�ue U- SBD-6398 (R. 08/14) �, t e� *.-t-y� ��N/"P�o��l�/`��'''wri ' s b� rR. - J11Qps.t VV�rto ti a`19 Sfi afi'Le Iasi I .J�GOP� 4 °�q T40rn4 ✓,O,,W, s SU k Y,,M Sc ' I- Ewiir4y too m atiil p4tiVo I V-p � i I f-te GDN1 SI<Q C 's,; w� Pu1�C�k saS All 1% 'ruk 11 ,'`►�NGI`�J _ �l3 YAOO SfoIau r 5 Glrow�� CY ti a. nA c,�p 41 5 CONVEPd t JONAL C.OMPOWENT DESIGN Resideniai Appkafipn [la6EX AM ME PAGE Project Name: Owner's Name: Legal Di savion: 5 y S W I y s I a UVVIMII VIktAV - N. blubs�N Count': St• Clao'i\( Subdivision Name St• Gn011(, s4,06A Lot Number. S wart la NurMrer. t G l, l o g a- s �- 100 FWD t tndr=ataw bft Peke z Plat Plan Page 3 Sim S" a Cmssse=rt Pane 4 1I Fryer Specs ` POP 5 NWMmmyw Mfir� 1 Page 6 Managmertt Plan Page 7 St. Laic Cty M*s! 5 Tank Makoumm ForM page Wa "Dead P200 9 _ CSM or Plat D� LbEnma Number aaa 90 cn�6� Pt,a Number 7153�6- 4nln Signature w.s� m � saF Attsoap6oa Coa�pa.Ynt � POWTS Version to ssato�ns�,xmon. rase a 4 P 10 /0 a`I 9 5t CAI p Vh� �, S �u Y' aapg$— Page _ of POWTS OWNER'S MANUAL AND MANAGEMENT PLAN FH.E INFORMATION Owner (t�►o Permit # DESIGN PARAMETERS Number of Bedrooms 100 m) Number of Commercial Units Estimated flow (average) 0 da Design flow (DWF) = estimated x 1.5 4 v v Vda Soil Application Rate da /ft Influent/Effluent Quality (D NA) Monthly Average Fats. Oil & Grease (FOG) 5 30 mg/L Biochemical Oxygen Demand (BODs) 5220 mg/L Total Suspended Solids (TSS) < 150 mg/L Pretreated Effluent Quality (D NA) Monthly Average Biochemical Oxygen Demand (BODs) 5 30 mg/L Total Suspended Solids (fSS) 5 30 mg/L Fecal COliform (geometric mean) < 10 cfu/100mL Maximum Effluent Particle Size 1/8 inch diameter SYSTEM Septic Tank Capacity J�J66 tt ! W jrt MX D N D N Septic Tank Manufacturer Effluent Filter Manufacturer 0 DNA Effluent Filter Model $ .1 DNA Pump Tank Capacity gal 1p N Pinup Tank Manufacturer N Pump Manufacturer N Pump Model N Pretreatment Unit (D NA) D Sand/Gravel Filter D PeatFiltcr D Mechanical Aeration D Wetland D Disinfection D Other: Manufacturer: Model: Soil Absorption Component (D NA) INn- d (gravity) I ( �) �d Mound D Drip -line D Other. Vertical Distance TankBottomto Service Pad: ft Horizontal Distance T s)toServicePad: It Dispersal Unit Mfg. Mmial Number: DNA Cakmatbr: Soil Dispersal End Cap (Dispersal Unit EISA) DWF — Application Rate = Area R aired - EISA — or (Trench Width) _ # Units or Total n f Trench(s) (C-U_- .115' _ IUD - 440).J-AUJI = ls4wi�S P411 D "Design of Pressure Distribution Networks for Septic Tank -Soil Absorption Systems" Publication 9.6 (SSWMP Manual) D "ICC Flowtech Mound Component Manual" Version 1.2 D "EZ Flow Mound Component Manual" Version 8/20/2007 D SBD-10854-P (R. 1/12)"At-Grade Component Manual Using Pressure Distribution" Version 2.0 13 SBD-10705-P (N.01/01)"In Ground Soil Absorption Component Manual" Version 2.0 D SBD - 10691-P (N.01101) "Mound Component Manual" Version 2.0 D SBD-10657-P (R.6/99) "Drip -line Effluent Disposal Component Manual" Cl SBD-10706-P (N.01101) "Pressure Distribution Component Manual" Version 2.0 ❑ Other. MAINTENANCE MONITORING SCHEDULE - MAINTENANCE AND MANAGEMENT Service Event Service in cells , clean filter At least once . D 13 months D 3 Other. Inspect & pumpcontrols, alarm, pretreatment unit At least once : 13 months D 3 ears NA Flush and pressure test laterals I At least once may: D months D 3 years P NA START UP AND OPERATION: For new construction, prior to using the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If bigh concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shad aNaeev wben soil muditiom are from at the infiltrative surface. The property owner is responsible for the operation and maintenance of the POWTS and submission of requited reports. The quantity and quality of the wastewater stream will affect the performance and longevity of your POWTS. The installation of water -saving appliances and fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine or waste from water softeners, iron removal units, other clear water treatment devices and foundation drains should be discharged to the ground surface whenever possible. Note: this does not include laundry waste, showers, dishwater, etc. This system is designed to handle domestic strength wastewater; however, the disposal of food based greases, oils, vegetable/fruit peels, seeds, bones, and food solids, such as those produced by a garbage disposal should be minimized. Toilet tissue is the only paper that should be discharged into the system. Other non -biodegradable items, such as baby wipes, tampons, sanitary napkins condoms, cigarette butts, dental floss, and cotton swabs, should not enter the system. Chemicals, such as petroleum products, paint, disinfectants, pesticides, antibiotics, solvents, etc., should not be flushed into the system because they can seriously damage your POWTS and contaminate your Page of drinking water supply. Maintain a regular steady flow by spreading laundry washing throughout the week. Avoid vehicle traffic over all system components. Compaction ofsnow over the dispersal unit may cause it to freeze up. INSPECTIONS & MAINTENANCE: Inspection shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Maintainer, or Septage Servicing Operator (per the attached Maintenance Schedule). Tank inspections must include a visual inspection of the tank to identify any missing or broken hardware, identify any cracks or Icaks, measure the volume of combined sludge and scum and check for any backup or ponding of effluent to the ground surface and test all electrical equipment such as pumps and alarms. Any defects shall be promptly corrected. Exposed openings greater than 8 inches in diameter shall be secured with effective locking devices to prevent accidental or unauthorized entry the tanks. When the combination of sludge and scum in any tank exceeds one-third (1/3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with Ch. NR 113, Wisconsin Admin. Code. Specific servicing mechanics must be provided if vertical is > 15 feet or if horizontal is > 150 feet and instructions to be provided below. The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to manufacturer's specifications. Solids washed from the filter shall be retained in the tank. Filter cleaning may be necessary at more frequent intervals than stated in the maintenance schedule to keep the system operating. Alarms should be tested on a regular basis by the home owner. If an alarm sounds, contact an individual licensed to service POWTS, There is normally a 1 day reserve under regular operating conditions, however water should be conserved until any problems with the system are corrected to prevent back-up of sewage into the dwelling or surfacing. ABANDONMENT: When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to ensure that the system is properly and safely abandoned in compliance with Ch. SPS 383.33, Wisconsin Admin. Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel, or other inert solid material. CONTINGENCY PLAN: If the POWTS fails and cannot be repaired the following treasures have been, or must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soi I absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area renders it unusable. Replacement systems must comply with the Hiles in effect at the time of replacement. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may he 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 performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. WARNING!!!! SEPTIC, PUMP, AND OTHER TREATMENT TANKS MAY CONTIAN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP, OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAYRESULT. RESCUE OFA PERSON FROM THE INTERIOR OFATANKMAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS: POWTS INSTALLER POWTS MAINTAINER Name: K 'pRDM Name: Phone: I S • 3 %� . Q,, b Phone: SEPTAGESERVICING OPERATOR (Pumper) LOCAL REGULATORY AUTHORITY Name: up►tLc4 I Name: 571p )N� Phone: Phone: s 544i ��.QSS�`E�YS�31 R �S'F�.�''73B lot. e fll9de C &IMade An Fa�al i ?Ncv Mpe 1 Mb Vei Can ft E� ��...s� r it_ System A . OR r 3 It P veaof obserwvwee - - -ff -- ,: r-ey-Andk el € EISA a6r?g . a v sat per than ar Soif Aap7matt m PaL- J /g�pw3q Y L� n SFx n Fbw = • S SCQ Ar pi alion ?.�� t L � V 0- EiisA _ _ G V _ cmmtiom !'age of ST_ CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING -SEPTIC TANK This is to certify that I -have inspected the septic tank presently se ing the PPS�� rh a IJ� 5 residence located at : W, S1rJ Sec. Sd T -N, R "A�) W, =% to f Iv• ►+Iw4N,j St. oix County, Wisconsin. Upon inspection, I certify that I have found the tan and baffles to be in good cond}'tiot, and it appears to be functioning prope ly. Last time serviced 3 119a [1 a ll Did flow back occur from absorption system? Yes No ✓ (if no,- skip �ext line. Approximate volume or length of ti, Capacity: Construction: Prefah Concrete Manufacturer (if known): t� A e of Tank (if known): (Sign e) M RS (Title) atJ ao (Date) gallons minutes Steel Other as cense co Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) licensed disposer (NR 113 Wisconsin Administrative Code) or - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I- - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition .I' certify that the tank, to the best of my knowledge, will conform to he requirements of ILHR 83, Wis. Adm. Code (e for pection opening o er outlet �baffl(e�) . I Name .J� n+ pU4pQS1I�'� Signature MRf MPRS ■ + .A 1 44, A ST. CROIX COUNTY SEPTIC TANK MAII.TENANCE AGREEMENT AND OWNERSHT CERTIFICATION FORM Owner/Buyer I p TlMQ Nt S Mailing Address C a q S C 2e'lk S�'p'l oN Property Address (Verification required from Planning & Zoning Department for new construction-) City/State H vos N V. I Parcel Identification Number I I to I - 109 -a - S d - 10 U LEGAL DESCRIPTION 11 Property Location 5 �} `V. ? W Y< , Sec_} I a . T a 9 N Rau W, Tu-'a of I ` N ern s o h1 Subdivision Plat: S l �'n d �k S U b� I N Lot # s Certified Survey Map # �� , Volume — , Page # Warranty Deed # 1 O I (02-o g (before 2007)Volume '-Page # Spec bouuse D yes D no Lot lines identifiable 0 yes D no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes Proper maintenance consists of pumping our 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. Owner maintenance responsibilities are specified in §Comm. 8352(1) and in Chapter 12 - St Croix County Sanitary Ordinance. The property owner agrees to Submit to St Croix County Planning & Zoning Department a certification form, signed by the owner and by a master phnnber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wamewaner disposal system is in proper operating condition and/or (2) after inspection and punning (if necessary the septic tank is less than 1/3 full of sludge 1/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 eating that your sThe system has been maintained mulct be completed and returned to the St Croix Comity Planning & Zoning Deparmerm within 30 days of the three year expiration date. 1/we certify that all swmertc on this form are true to the best of my/our knowledge. Uwe am/are the owne(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. �1iseQDt o b d�Oo'us _ IGNATURE OF APPLICANT(S) DATE `Any information that is misrepresented may result in the sanitary permit , being revoked by the Planning & Zoning Department "•' Include with this applicator a recorded waranty deed from the Re.,gster of Deeds Ofnce and a copy of the certified survey map if reference is made in the warnwry dead - (REV. Q9/0'1) voi, y PwE 3p ST. CROIX STATION 343630 LOCATED IN GOVERNMENT LOT I OF SECTION 11. GOVERNMENT LOT 4 AND THESE I/4:0 F THE SWIR OF SECTION 12, AND THE NORTHEAST 1/4 OF THE NORTHWEST 1/4 GOB NIRN SNORE LINE TI E/IE/]] DxY ca U.SEWATS. 1929 DATUMa]°] OF "SECTION 13, T29N, R20W, VILLAGE OF NORTH HUDSON,ST. CROIX COUNTY, WISCONSIN. 1745-Ar..ORNATE Low ___________ VILLAGE _ xT]x0 L4Ms I RAISE C.MkTmX �- ___ _ _ LIMITS_ I]♦.];RATE. ELEVATION w TINU /hEME aq IIATTm EMI, FFA[el xPTl py. �9. 44� SE9v 5]'14 •E __________ IFERVUY1R.lelT ... ... ...•••••••••••••• •,• ....— ___________ _ [I• Ad INwT: OLf2 ua.x Isaa• Isa23903' 2SOOY' 5 88• S4'E 581.2E �@N 34363D c4.y Y81.69' a 33L2i' LOCATION SMETW w I ° w.T 8nw SECTION IT k x^acoT I.SOIACREa °gad• Lea ncREj/i %' <I 10 e I.x ArxEs 01101°° U y tj� �, ♦ ,� / �4r.4 SS9 ACRES _ y. R.bQ V[011Pim AINF NBu[ qwc� ti Ih,lx .tM DTI IaR WRN NI1PYys 13 °xMIIaF °' i 9 / 9 xwa(W Y� Ed . 1.904CRE5 ��' �b .` ;x `x• `.�Z . °xG00 MeD' x xes•!fw d♦TYT RAW R p .Q ^. sa.ea• a2a.06 v /.nv `�` .\` ApO, „ 'P a a.lmx D.D .C' 6 .w D� =M o IYe.//' I I IN 6 \ y9 \\• IH 4CRT5N a y x 14 V30 l3 84fAEs �.(v •' w�� S f 15t e�tl I �L499CRE5 L42 w```•_•w=``` 9 5 w 11 lanx 1: ]a• J / B `\��• Re•aJ P- �S. • L h xVt� �C6CONy da rOs.Ma a2a, pW la �p, ♦N ]a�e;W ♦'�Q T LAN Ilas♦ If f uxs b Aae•ii lwir°[ •. �b. `�w T °�O¢n o 3 LOB PORES4 29 31 $ 1� /° •l � � g ��. SunJon•3 y a n /En3ACRES 1•,q� "ROGER Ll44CRF5 3$ _' aas—>=NCIS M.N/¢Le.S.-8 y , LONG Mg :$x 33 .f s. ♦ :I,'{ gx rn4nLTs M. DadE R.L.s.-Mez G .d_ xa6.4UIpE 1 ��+fffL�LBCr••. h -^J:'° 111 KR[5 • I • i DATED TNB Y]TAELT OF ALINE, I977 111 • YaYa ggya'W aT♦b OT• a' Y A P REVISED THIS 16l] DAYOF ^4#VPGjUpST�.F1gDi� T:w 10, 1]w, T • E1.33 �T� ♦d• REVISED IGX S2GTIVN UEIFIL O IByoY♦E Iv.r- Jr ]eOU le'AO mI g OUTL Do' nl.a' ` I s 20• [) S t mldf]T T. `T �q EY0.00' Y; 0.1. IKOC \ b.8.. \\ `,ka A�Rd. rve b ual ,B N a6•LO'IB'E I - d Mo�Yvwn 4°e°.a2 _ [ DO'°ga QO4a'2g1! . Eymy M0�0\'1 �v\VI/®N / \ `,- 'AA•`�ir�Zw.N �®_Isf— __- _.FS]B_T_.LaO_O' SI_= Ba-•!a' E O_152. 0Pe RAA[AAFS N Ofy8 F2% O 26 Mob 24 ...o E% ' iMSrtj'rt®L•�S�W.�°{`A `0� t�y.c'•y"LOT/` T 16 Ho ACRES KAEs A 2 17M �, 1.82 ACRES N, O 6 _220.00' 00' PUBLIC ]ezod• 1ee•3♦•E w rd saxx .[xns, .m $ ay4A eQ�Q,6�yoe 'a 1dLT4�-- ffiIIO"---'-38100'Y( i-'20s4E--I N '[OroIW ems?\ \ BIa. '! 1.9I 1LRE8 ®/ / to m N 4 w yy uulluf Iggr_ ^ = a. \q 11I\,111 x, d ° IS w 0 19 E ° 20 :� 3 21 i 22 M �tl' 23 ♦ XI.s o '. q...yA LOS A. i 102 KRF4 2ry 101 KRE4 RR MIXXT. IO ACRfS ip III ACRE4 -p,ka „y I.�u:e II X aa•3Y'W °•�. lig A. BIe. CORNLR 4 au.. 2 Ld IQEE 11 0. Y Lr-• i NA Be�� �PaA 32 T.2Y ap a\'pad VAGT(p MT NORM IND, .r 2xd]d ,D•y I II 2EgDg. •L ,m� M4. w VA41ED MTAMONG L (I NdfN dD YESoI' E26C0' 22A00' 223E WE . WILAd LRI °1M OB•a[WY ma Aur HHO. • I3sa32' xeT31W a� f8 ."34-W ;i_a � l�sh,:Dxm• Alp/ • WTI ulS OF M aw SP T \ 51/4 WRINER SECTION CORNERSW 2 INNATTED ,kANq$. , SECTION 12 SCALE IN FEET ' $ WR1Y Ift 2 xww6T1 I 1 ImxraEx LAF Ce \ \ h • 11' 1x PIT MOWING 2SAAGEAL F[ FONO soD' ILy' d Iap' xy' • I' IRO A. NOEMOWN.GE Le4Y/11(iy rt IONp 1 \ u R Ae '^I$ o Ya a' •w rrc wElawG lm. W,Afxwn n.n°nm.a�.•°.,ewyp mynw Xn 2Y,a - //t. • w - NDTG 4L ua IL19}ppll! IN( aEEx ,MC[ m TIE Wl MU uW CCRXENs 8!a® WIX fx2a• Rdl PIL yla xaAsl lY]I.II vJC1, Wry. •wx, wl[M x 14 ao lE4en ANY xammRl OF A rwR Au AwLOI Mn8[G Cal veu. IS DCTrr a TIE Mrx°m IaE. vn°i:1, a b.w fu+TY"w1Ma+n'a•n T.. nelx Wt T1• >2• \yWYW fQ /UxrLATTEP MNOI AID: rxTd. m Mww I..,LNEAL rt W J° h IE eMD AND wiP T G ssAx ro TOM I¢xmr TxvRr er ,hL • /P'IgW ....iulos PLAN ON INS.0.) I•R T♦' IROx PI>[ WEIOXI"a LaHw/ UNNL IT. `.Iy` L_'___ rW m IaLIEe wINMnR. unux, n,..8�:wn r PLAT CONTAINS 80.1 ACRES MORE OR LEIT. -,-eN YML.e� �_ YTILIiY E4[M[xTr WIDTH MOWN. .w�M%4/A/{A•.KM7. 1VP•• /,TR T ' • smHL MONUMENT, IWUN4 Cyw�x �.�°'; wrun M Mml Anm L THIS INSTRUMENT WAS DRAFTED BY /_ IVX,,R, ATi[D No. ' SMEET I OF x sx[ETS \ 1WA* * Form- STC- 104 AS BUILT SANITARY SYSTEM REPORT OWNER ,' :! TOWNSHIP ADDRESS SUBDIVISION ST. CROIX COUNTY, WISCONSIN LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 13 SEC. T ZLN-R_W i 4 tip lk.o ,r i FFoMe u• 3C a %cPf \ V lyC � R. 1 J �3?1 _ KKAt1fe., C ��---- � - .INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used f)11>f Elevation of vertical reference) point: IUU Proposed slope at site: W SEPTIC TANK: Manufacturer: IC Sek Liquid Capacity: I JV Number of rings used: Tank manhole cover elevation! 1 • Tank Inlet Elevation: ;:)'I. Tank Outlet Elevation: ��!•�'? Number of feet from nearest Road: Front 10 Side Rear, O luO feet From nearest property line Front,( Side,O Rear,0 X, feet Number of feet from: well l➢ 0 , building: IC (Include this information of [he above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE R PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear,© Ft._ Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: V Trench: Width: 1 Length: / Number of Lines::_ Area Built: Fill depth to tap of pipe: yoll Number of feet from nearest property line: Front, Side, O Rear, Pt.,( Number of feet from well:��� i Number of feet from building: 3 1e (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Dated: Front, O Side, O Rear, 0Ft._ Inspector: _ Plumber on job: License Number: 3/84:mj DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS P.O. BOX 7969 MADISON, WI 53707 INSPECTION REPORT FOR PRIVATE SEWAGE SYSTEMS MCONVENTIONAL ❑ALTERNATIVE ❑ Holding Tank ❑ In -Ground Pressure ❑ Mound SAFETY & BUILDINGS DIVISION BUREAU OF PLUMBING 0 NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER INSPECTION DATE. frank Wallah 700 2nd S•tAeet, Hudilon, 11111 54016 Lj-y -BS- /:3v BENCH MARK Wer�m,0414M PmmI OESCRIBE If DIFFERENT FROM PLAN REF.PT ELEV.: STREE PT ELEV NE SW, Sec. 12, T29N-R20W, Vitt. ob N.Hud6on,Lo.t05, St.Cnoix Station Name oI PI. Ml' MP/MPRSW No C.—Y Lrvbry Pamrt Numpn. RichWLd Hopkins 1059 St. CnoLx 58936 SEPTIC TANK/HOLOING TANK: MANUFACTURER L10UIOCAPALITV TANK INLET ELEV TANK OUTLET ELEV WARNING LA LOCKINGCOVER t.• Z ]J �OO•a� PROVIDED PROVIDED ❑YES ❑NO ❑YES ❑NO BEDDING VENT CIA VENT MA I HIGH R NUMBEROF ROAD. ROPERTV ELL UILDING VENTTOERESH OYES ❑NO ALARM ❑VES FEE7 FROM A // LINE Z4 L'� AIR INLET /� ❑NO EARE37 DOSING CHAMBER: MANUFACTURER BEDDING 1IOUIO CAPACITY PVMP MODEL PUMPISIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED- PROVIDED DYES ONO ❑VES ONO OYES ONO GALLONS PER CYCLE: PUMF ANo caxm Ls oPERAnoNAL NUMBER OF PRO °ERT• 6uILnINc v PIo REsR (DIFFERENCE BETWEEN FELL FEET FROM LINE AIR INLET PUMP ON AND OFF) OYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LErvcTN oIAMEIER MATERIALANDMARKING or excavation. (It soil Den be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) - MAIN ONVENTIONAL SYSTEM: BED/TRENCH WIDTH^ LENGTH NO OF DISTR PIPE EPACING TRENCNEfi OV INSIDE CIA *PITS LOU. DIMENSIONS 1 k� U -� MArFy Au PIT DEP A VEL DEPTH FILL DE TH DISTR IPk DISTR PIPE I R. PIPE M RIAL p0 U N UMBEp OF R E Y WCLL BVI LOIN- V NTBELOW PIPE ROVECOVER FLEv_rpLE1 kLFV ENO -'� ,� L/J A(* 1pEFEET FROMLINE 3G AIRTG (� J/AL . NEAREST �O 7J MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑YES ONO SOIL COVERITEXTURE PERMANENTMANKF 5 OBSERVATIONWFLLS ❑YES ONO OYES ❑NO DEPTH OVER TRENCH BED pEPTNOVIRTRENC"SEU 1 DEPIN Of TOPSOIL OU O SEEUEp MULCHED CENTER EDGES F YES Z4140 ❑YES ONO OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: ,PIPE WIDTH LENGTH NO OF LATERAL SPACING AVEOEPT BEL FILL DEPTHABOVE COVER BED/TRENCH TRENCHES DIMENSIONS - MANIFOLD PVMP MAWFDLD DISTR PIPE ANIFOLOMA ERIAL NO UISTR DIB R PE DISTRIBUTION PIPE MATERIAL a MARKING ELEV, ELEV DIA ELEV PIPES DIA. ELEVATION AND DISTRIBUTION HOLE SIZE HOLEYACING COV ILLEDCORREDTLY ER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION PLANS Y ❑N OYES ❑NO COMMENTS: ERMANENT MA KRB. OBSERVATION WELLS' NUMBER OF 'PROPERTY WELL FEET FROM LINE- ]BUILDING ,t AL YES NO ❑VES ❑ NEAREST V ( t L . A- O Sketch System on Reverse Side. 11 f 7,0L/ ) �' �` Retail) in county file for audit. it DI LHR SOD 6710 (R. 01/82) APPLICATION FOR SANITARY oeggq*manr OF PERMIT LB 67) ST V COUNTY UNIFORM SANITARY PERMIT # �� eIIXISTgV,LgnOq 6 Mr1mMgELgTOnS • 5�93✓0 —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 83ix 11 inches in size. —See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS =n . .I PROPERTY L CATIO � s - •..r O� '��` �� '�5er• %ter �� Nc1/4`Sw1/4,S,TN,R ©E(Dr'W , VILLAGE LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED Z& I or 2 Family Number of Bedrooms: L/ (_] Public (Specify): NC THIS PERMIT IS FOR A: 1< New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepage Bed Ll Seepage Trench ❑ Seepage Pit ❑ Holding Tank .� System -In -Fill ❑ In -Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # L.) t, 1 '• issued El An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total Gallons of Tanks Prefab- Concrete Site Constructed Steel Fiberglass Plastic Septic Tank Capacity c1 O Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: n- 5 IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In -Ground Pressure N Total Gallons #of Tanks Prefab. Concrete Site Consvuctetl Steel Fiberglass Plastic Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE (Minutes per inch): ABSORPTION AREA REE�QUIRED (Square Feet{: ABSORPTION AREA PROPOSED (Square Feet): WATER SUPPLY: / �`a Z yG Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature: MP/MPRSW No.: Pht..one Number:) l c 10 rJ h _, rel , '" r^= at .` c_ - • S " Plumber's Address: ' Name of Designer: •Ll ''.J jl _'ti �-,J f -, ,/r, �_.,�% i-i�L-7 ���.r //i/r. �• COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: CD Disapproved /� �, �/ / ��'/� X� El Owner Given Initial v Approved Adverse Determination Reason for Disapproval: Alternate courses) of Action Available: •-•-`•�vGDwG,eo (R. orgies DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber e CSC Zo20- 070 ��(��n�am! n E Wisconsin De d rvices 1i Page 1 of 3 Division of Indus Services APR 2 S 2020 SOIL EVALUATION REPORT Ina rdance with SPS 385, VMS. Adm, Code County Attach complete sit St. Croix Coun plea =Pt1 x 11 inches in size. Plan must include, St, Croix but not limited to: v t (BM), direction and percent slope, Parcel I.D. scale or dimensions, north arrow, and location and distance to nearest road. 161.1092-50.100 Ref# 2567 Please print all information. viewed by Date Personal information you provide may be used for secondary purposes Priva Law. s. 15.04 1 m . NI ./fir ck-k 20 Property Owner Property Location ❑ Pat & Melissa Simones Govt. Lot SE % SW % S 12 T 29 N R 20 E (or) W Property Owner's Mailing Address • Lot # Block # Subd. Name or CSM# 249 Station Ln. N 05 Na St. Croix Station City State Zip Code Plane Number ❑ City ® Village ❑ Town Nearest Road ❑ New Construction Use: ❑ Residential/ Numberof bedrooms 4 Code dedved design Row rate 600 GPD ® Replacement ❑ Public or commercial — Describe: _ Parent material Glacial Outwash Flood Plan elevation lt applicable na ft. General comments and recommendations: Site suitable for In -ground POWiS with 0.5 gpd/sq/R. design loading rate. Recommended system infiltrative surface elevalon to be 97.00'. a Boring # ❑ Boring ® PR Ground surface elev. 103.67 R. Depth to limiting factor >126" in. Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ftr 'Ef#1 *Ef#2 1 D-18 multi -colored none mixedhll na ai gw 2vff 0.0 0.0 2 1852 i0yr4/4 none is Osg ml cw 0.5 1.0 3 52-80 1Oyr4/4 none s Osg ml cw 0.7 1.6 4 80-126 7.5yW4 none ffs&gr w/ cobb 089 ml 0.5 1.0 9� o / 11Y -j ❑ Boring 2❑ Boring # ® Pit Ground surface elev. 101.47 R. Depth to limiting factor >106" in. Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft' ,Eff#1 'Ef#2 1 04 10yr3/2 none sit 2fgr mvfr es 2fm1c 0.6 0.8 2 4-52 10yr4/4 none fs Osg ml cw 21mc 0.5 1.0 3 52-68 7.5yr4/6 none s Osg ml CAP2tm1c 0.7 1.6 4 68-106 7.5yr4/6 none tis&gr w/ oobb Osg ml 0.5 1.0 CST Name (Please Print) Sig ture CST Number James K. Thompson 30021 Address Date Evaluation Condluctiid Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020-M13 Aril 2 2020 715 248-7767 JtlU-eJJU (KU4/1 b) • 3❑ Boring # ❑ Boring ® Pit Ground surface slev. 101.37 ft. Depth to limiting factor >97 in. Anil Arvdieafinn Rafe Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft= 'Eff#1 'Eff#2 1 0-34 multi -colored none mixedfill na na di 2fmcf 0.0 0.0 2 34-57 10yf3/4 none Ifs Osg ml gw 2fm1c 0.5 1.0 3 57-7G 10yr4/6 none s Osg ml cw 0.7 1.6 4 76-97 7.5yr4/4 none w &gr Osg ml 0.5 1.0 ❑ Boring If ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor _ in. Soil Annlinatinn Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft' 'Eft#1 'Eft#2 ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. —ft. Depth to limiting factor in. Anil Annlinefinn Rafn Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft' •Eff#1 •Eft#2 ' Effluent #1 = BOD, > 30 5 220 mg/L and TSS > 30 5 150 mg/L ' Effluent #2 = BOD, > 30 s 220 mg/L and TSS > 305 150 mg/L pad awyd�N3 Q •iiaA4 ?v/ jods .SZ•siL� • A711 7ptpw a'}TM .49�/8'ns ' s..�P / J!-Z p,v av�JA✓ ^i'r+� a / O 9iafaS /�'wsp»�I 1�J X'�'•'�9'9s 6h r pwaw.s bST_/�%N1�