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HomeMy WebLinkAbout020-1417-50-000 (2)Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, sA 5.04 (1)(m)]. Permit Holder's Name: Delta Construction Inc ICST BM Elev: Ilnsp. BM Elev: IBM Description: TANK INFORMATION City TYPE MANUFACTU E CAPACITY L S Septic �r 0 Dosing Aeration J/V V / ��+ TANK SETBACK INFORMATION TANK TO �L WELL BLDG. Vent to Air Intake ROAD Septic Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer TDH Forcemain SOIL ABSORPTION SYSTEM to Demand Ft TOWN OF HUDSON ELEVATION DATA County: St, Croix Sanitary Permit No: 617743 State Plan ID No: Parcel Tax No: 020-1417-50-000 Section/Town/Range/Map No: 20.29.19.2643 STATION Min BS HI FS ELEV. Benchmark Alt. BM Bldg, Sewer SUHt Inlet 3 , 3 Q D.. SUHt Outlet 3. Dt Inlet Dt Bottom Header/Man. N• T . 5 , � Dist. Pipe Bot. System Z, °I Final Grade 3 • 8 q /7.tp yr BED/TRENCH DIMENSIONS Width f Length No. Of Trenches L PIT DIMENSIONS No. Of Pits - Inside Ligdfd-Beptfi---- SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR UNIT Manufact r: //'� I,`41 7`0.1t i'o` Type Of System: ` a9 �`'Cyt OnN I ] 1 �- Model Num er., DISTRIBUTION SYSTEM Header/Manifold � I t Length Dia Distribution Pipes) Length Dia Spacing x Hole Size x Hole Spacing Vent to Air Intake --"� SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Onlv Depth Over Bed/Trench Center 3 �--� � Depth Over BedfTrench Edges � I�Topsoil xx Depth of xx Seeded/Sodded xx Mulched � Yes ■ No Yes �i No COMMENTS: (Include code discrepencies, persons ,�present, etc.) Location: 438 WREN LN ' n! 1.) Alt BM Description = Fd � Off 2.) Bldg sewer length = 78 amount of cover = 7 1 �� �`KS � Plan revision Required? 0 Yes �i] No Use other side for additional information. Inspection #1: VeK16 � ri ram+ :IJ Insepctor's Signature Inspection #2: l � � Cert. No. Sf}VU �1,,.1 � 3�/ .� � , r County s�oawr"r�,r� e )'::: -- � t�D Safety and Buildings Division �` I I \V/ � D "� 201 W.1Nashin ton Ave.; P.O. Box 7162 9 Sanitary Permit Number (to be filled in b}' Co.) T ��, :, `-' Madison, WI 53707 7162 . rl /,, /� F�� Sanitary P it Appli.Cat' ►.�tateTransaction "umber In acco ca with SiLS ?a80CS11<(�akli?S: i�dm. ,submission o#this form to the appropriate Gov unit is requir pripr��ppit�a �R :Application }`otms for - aze submitted to project Address (if different than mailing address) the Dcp e an o essional Servies. Personal information you provide may be us dad; oses in accordance with the Privac Law, s. 15.04{1) m), Stars. I. y l � A lication Information —Please Print All Information / J L- t�/ (%L,v .� r,�/ Property Owner's Name �� Pazcel # -�-v �.�. �- Cif v.- � � j � - so� oc� o ,� Property Owner's Matting Address -Property "7 Location � U, a y , � � n I Gout I,ot Cny S Zip Code Phone Number N� r�4 � yy z� � /, Section �/ � � circle on - Type of Building (check all that apply Lot T _L_ N; R E W or 2 Family Dwelling —Number of Bedroo �� Subdi ion Name lu� �� Bloc ,�%� ❑ Public/Commercial —Describe Use �(��� •"""' („ `E� ❑City of P�,N,,,, ❑ StatennOwned —Describe Use CSM Number ❑ Villaee of � U e Sd- _ t..J 2 Z�-ZZ � own of III. T ermit. (h ck only one box on line A. Complete line B if applicable} A- l�ew System Replacement System ❑ TreatmenUHolding Tank Replacement Only ❑Other Modification to Existing Sy plain) 5l � f Q. B• ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Num er and Issued Before Expiration- �� !�. ry •� J / IVr�" e of POWTS S stem/ � m onent/I3evice: Check all that a 1 • • on -Pressurized In -Ground �, essurized In -Ground ❑ At -trade ❑Mound > 24 in. of suitable soil ❑Mound <24 in. of suitable soil �, r�r ®lding��s� Otber Dispersal Cotnponent (explain) ❑Pretreatment Device (expl ' Ut � 4' V. Dis ersal/Treat ent Area Information: � � �/ gn Flow (,�pd) �° Design. Soil Application Raze(gpds Dispe�rsJal Area/Required (sf) Dis/persal Area `� <p �� f � pose m Elev 'on < � '� ZS J l� - � VL Tank Info Capacity in Total # of M u acturer Gallons Gallons Units ' o � � New Tanks Existing Tanl� ' .� o °'• � °j a - a. U v, � � w C7 .-, Septic or Holding Tank �.— �� Dosing Chamber � VII. Responsibility State nt- I, the undersi d ssume responsibility for installation of the PORTS shown on the attached plans. Plum is Name (Print) ber's Signature MP/MPRS Number Business Phonc Num r (' `f..t/ � Plumber's Address (Street, Ciry; m, Zip de . , Countv/De artment Use Only �V,III/. I�Approved ❑�sapproo—� �erm�jit Fee Date Issued Issuing ent /// )) Sidra � given "� Owner Reason for Denial IX. ConditiC'lt���'��,+asons for Disapproval 1. Sept!^. tank; e�tic�n lute- t�rni 3� D I �a r�� �, �-'"� Wr� t+lS�azY;�:ri cell dust all be > �_ic•�s';.� '��Ite'-ec - � +. � , ys per iYlar.ayemen! plan p�'o iue�! w Nlumde:: p,/rey�ta,)y�,Q�, � � !Ma�� 2. All RN.itfi�k recl. tee! ,ens moat uu �:.� rt, i1 E i � � /+ , au r' � ct .r• /:rdi- . ,•:: I n ref,n,.e�>I-,'�r�. e��h r„ leke lass f tb� SBA-b398 (R. I1/11) comp p or , e system and submit to the County only on paper not less tLan S r2 z Il inches in sizt ' - .,! s� W.� � „�- Al R-$�z �� System PLOT PLAN PROJECT Delta Construction ADDRESS 202 W 2nd St. Hudson Wi 54016 NE 1/4 NW 1/4S 20 /T 29 N/R 19 W TOWN Hudson COUNTY ST. CROIX SYSTEM ELEVATION 95.5/94.5' 4.5' below qrade 8/31 /17 BEDROOM 4 DATE CONVENTIONAL % CONVENTIONAL LIFT MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 891 IL BENCHMARK V.R.P. Top of 112" pvc pipe ❑ BOREHOLE O WELL *H,R,P, same as benchmark 97' 2-3' X 90' cells with >3' spacing ST A to All piping shall be ASTM SDR 30/34, within 10' of tank, piping shall be ASTM F891 Wren Lane HOLDING TANK DOSE TANK SIZE # of chambers 44 AS ELEVATION 100' Filter Lifetime Filter 8 °Io 51ope B-3 103' Vents 53' 1 lv' 58' Property Line 56' 14' >6)) Quick4 Standard of Cover Leaching Chamber with 20.0 ft2 of Area Long 12 5.6ft^2/pair of end caps 4' " Grade at System Elevation Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 8/31 /17 Owner:Delta Construction Location: NE1/4 NW1/4 S20 T29 N,R19W 438 Wren Lane Hudson Manuals Used: In -ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Leaching Chamber Cross Section 4-6. Maintanance Ad Continaerlcv Plan Signature License numq'epf #226900 System PLOT PLAN PROJECT Delta Construction ADDRESS 202 W 2nd St. Hudson Wi 54016 NE 1/4 NW 1/4S 20 /T 29 N/R 19 SYSTEM ELEVATION 95.5/94.4.5' below qrade 5' CONVENTIONAL XXX MOUND SEPTIC TANK SIZE 1255 gallons HOLDING TANK SIZE LOAD RATE • 7 Ilk W TOWN Hudson COUNTY ST. CROIX DATE 8/31 /17 BEDROOM 4 CONVENTIONAL LIFT HOLDING TANK LITT TANK SIZE DOSE TANI{ SIZE ABSORPTION AREA 891 # of chambers 44 BENCHMARK V.R.P. Top of 1/2" pvc pipe ElBOREHOLE O WELL *H.R.P. same as benchmark 2-3' X 90' cells with >3' spacing ASSUME ELEVATION 100' Filter Lifetime Filter Scale 8%Slope B-3 97' 98' 99' 100 4 3 0' 30' Pro 4 Bedroom House All piping shall be ASTM SDR 30/34, within 10' of tank, piping shall be ASTM F891 5 8' 10' Property 103' Line Vents BM* 134' Vent 53' >6„ Quick4 Standard of Cover Leaching Chamber with 20.0 ft2 of Area 5.6ft^2/pair of end caps 4' Lon a 12" 56' 155' at System Elevation Wren Lane Cross Section of Infiltrator Quick 4 Leaching Chamber Typical cross section for 2 of 2 cells Quick 4 Standard Leaching Chamber with 20.0 ft2 of Area per Chamber 5.6ft^2 pair of end plates Typical Installation Vent Grade 4" Ar:0�30/34 Septic Tank 5' Long Grade at System Elevation Spacing 5' To be >1' above grade Finish grade elevation 100.0' ,Vent 1" at System Elevation 2-3' X 90' Cells Same on other end Observation tubeNent cnampers per cell System elevations: A 95.5' r B 94.5' At end of cell n POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of LE INFORMATION SYSTEM SPECIFICATIONS Number of Bedrooms ❑ NA i Number of Public Facility Units A j Estimated flow (average) Cfgal/day 1 Design flow (peak), (Estimated x 1.5) i gal/day Soil Application Rate aUda lft2 Standard Influent/Effluent Quality Monthly average* Fats,- Oil & Grease (FOG) <30 mg/L Biochemical Oxygen Demand (BODs) <220 mg/L ❑ NA Total Suspended Solids (TSS) <150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODs) <30 mg/L Total Suspended Solids (TSS) <30 mg/L XNA Fecal Coliform (geometric mean) s104 cfed100ml iMaximum Effluent Particle Size Ya in dia. ❑ NA !Other. NA "Values typical for domestic wastewater and septic tank effluent. IAINTENANCE SCHEDULE Septic Tank Capacity r� �- ❑ NA Septic Tank Manufacturer O NA Effluent Filter Manufacturer ❑ NA Effluent Filter Model ooe 13 NA Pump Tank Capacity WIN aI NA Pump Tank Manufacturer NA Pump Manufacturer NA Pump Model p NA Pretreatment Unit ❑ Sand/Gravel Filter O Mechanical Aeration ❑ Disinfection ❑ Peat Filter ❑ Wetland ❑ Other. ❑ NA Dis ersal Cell(s) round (gravity) ❑ At -Grade ❑ Drip -Line ❑ In -Ground (pressurized) ❑ Mound ❑ Other: ❑ NA Other ❑ NA Other: ❑ NA Other ❑ NA Service Event MAINTENANCE Service Frequency linspect condition of tank(s) At least once eve every: month(s) (Maximum 3 years) ❑ NA ears !Pump out contents of tank(s) When combined sludge and scum equals one-third of tank volume ❑ NA linspect dispersal cell(s) At least once every: eve 4❑ -- month(s) earls) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: f r months) ears) ❑ NA I nspect pump, pump controls & alarm At least once every: 1_I ❑ month(s) year(s) NA 1:lush laterals and pressure test At least once every: El ❑ month(s) year(s) NA Pther. At least once every: ❑ ❑ month(s) year(s) NA {ether: NA INSTRUCTIONS !Inspections of tanks and dispersal cells shall be (Plumber, Master Plumber Restricted Sewer; PO linciude a visual inspection of the tank(s) to identify icembined sludge and scum and to check for any visually inspected to check the effluent levels in made 'by an individual carrying one of the following licenses or certifications: Master WTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must any missing or broken hardware, identify any cracks or leaks, measure the volume of back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be the observation pipes and to check for any ponding of effluent on the ground surface The ponding of effluent on the ground surface ma regulatory authority. y indicate a failing condition, and requires the immediate notification of the local IdVhen the combined .accumulation of sludge and scum in any tank equals one-third ('!) or more of the tank volume, the entire contents of {:he tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin 14dIII inistrative Code. 1N1 other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, land any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. 14 service report shall be provided to the local regulatory authority within 10 days of completion of any service event. START UP AND ! ' . t For new construction, - prior to use of the POWS check treatment tank(s) for the presence of Pei may impede the treatment process and/or damage thq.dispemal cell(s)a If high 0oncentistIons 4 are detected have the coontents of th' tank(s) removed by a septage servicing operator pnior to use. System start up shall not occur when soil conditions are frozen at ft infiltrative surface. During power outages pump tanks may ful above normal highwater levels, When power is restored the excess wastewater will b discharged to the dispersal cell(s) in oft large dose, overloading the cell(s) and may result In the backup or surface discharge of effluen To avoid this situation have the corgents of the pump tank - • by a _ • • - Servicing operator to restoring • •• . • 1 effluent pump or contact a Plumber or POWTS Maintainer to assist In manually operating the pump controls to restore normal level� within the pump tan . k. pa therwise disturb or compact the area withi Do notodrive or park Vehicles over tanks and disper§al cells. Do not drive or rk over, or o 15 feet down slope of any • • or atlrade soil absorptionarea. (sumpReduction or elimination of the following frorn the wastewater stream may 1mpr0vq the performance and prolong the life of the POWr antibiotics; baby wipes; te butts, *condoms, co*m wabse, degreasers, � dental floss, diapers; dishfactarsits; fet foundation -dra) pump)water,'.vegetabler peelings; • _ _ • v grease; herbicides; «• :s _ scisaps, e• t-: 1 • • painting prod YID pesticides, napkins;- and water softener ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to Insure that the system is propefily and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:. rw The contents of all tanks and pits shall be removed and property 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 slAii, gravel or another inert solid material. CONTINGENCY PLAN • _ • _ment system. effectsuitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption syst M. 7 e replacement am should be protected from distuftrice and compaction and should not be infringed upon by requit0d setbacks from existins; and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the noed for a new soil and site evaluation to establish a suitable replacement area, Replacement systems must comply with the rules ir at that time. X A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technologV 3 The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluaO must be performed to locate a suitable replacement am. If no replacement area is available a holding tank may be Installed a last resort to replace the failed • • Mound and atangrade soil absorption systems may be reconstructed � in place following removal of the blomat at the infit"traii surface, Reconstructions of such systems must comply with ft rules In effect at that times «WARNING» SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANW UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE O A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. Name This docxnnnent was drafted in c�mmptiance with chapter SPS 3$3.22(2)(b)(1)(d)&(t) and 3tt3,54(1), (2) & (3), Wtscorrsin Administrative Code. t ST. CROIX COUNyy SEPTIC TANK MAINTENANCE AGREEMENT AND • O'VVNE.RSH W CERTIFICATION FORM Owner/Buyer ;_ ) 9,1' Aexwwovo ULM1 • a l / - Mph' Address 'I ti., > ,,, �Ifr N iM:t•1 inl 1"1 Ift1 •.111 t' 1111', City/State Parcel Identification Number �'kf) , 1 I S LEGAL DESCRIPTION Properly Location 1�1 74 , vJ '/a , Sec�.�j , T "Z-- I N R��� Subdivision I � 1 Spec pause yes no W, Town of IL ,A V/� Lot lines identivabl"es J no t111i • ■ �1 .11 1 1■/. 11 I- 1 : 11 � t t - / t 11 • t / ♦, ■ 11 r: 1 f: 1 • 1 I • (� • • • � 11/. JI I 1 . 1 - rtionlibib • ♦ /O• Ii _ OW n,"scP=talikeverythree Years or • 1 1 ! iF1.:-• byaheensedpun4mr.I 1 . 1 ♦ 1 - I to 1" system canaffect the U1 tion of the septic Y.I. as a treatment stage n the wastedisposal1:111 owner Q.nUilr:1 .•. 1'1 1 f •vim are specified Lin, • Inn and 1 ChapterCroix• / sanitary! 1 1 1 e. 1 property owner g - - to submit to St Croix County Planning • 1 11 • t ■•a - / ■1• 1 • 1 •1 • • ' - I • • faG f IU . • 111 - 11 1 1■a • - a■ ?• 1 I • F • :1 r r n11 1 1 11 1 7" 11 •• III • /•J. •1:1III6•It ■11 1• ■jI.Mr InspecTion am pumping kir 1 the tic Y. lea d= 1/3 ftill of sludge, nk is • • • • I■ ill ti a • J i • t1Y. 1 •: I 1■ . I' ■ ■ ' Y. I • • ■ 1 1 11 ! ■1•- � ,• •■■.v1! • 1 n al I • 1 � 11 • • ■ • '•1 • 1 ): a NNW" : 1 ■ 1 Y. ♦ I _ 1 . 1 1 - • 1 I" 11 1 . ► �� 1 11,: If Y. 1 " 1 11 • • • /■1• , a • Itl.�• • 1■.' • • 11 • 111 1 • a 1 _ ! ' ■ •1 •■L" 1 1 11 1 ■ • 1 Ilt - Y9 glop W- I • 1 ' 1 that v r •• tit 1 • I d3is fo=a are tme to the best of MY/our knowledge. awl { ' ♦ • I it t 11 " t Ilii /n t1:1 /• ■ ^111:• I: ■II •--• • •'• 11 •J • /� ,jt. 'I'C7RE OF APPI,ICANT(S} DATE i■ • u.•/• a: 1.1. -• •n-. u• r ll' .ur. •- f1 •" 1• •,"/ f /' ' .Ilu• •1 1' �".: 111: r 1 11 1 / 71• K.tlt r t ttt .1 1 •v't 1 /11 1' r � • �"! it+ - .IJ 11 1 11' - In I I 1 n •: 1 �It 'PA U : L" 1 11 v Z01 , (l�v. as/os) / 6 _4� \ `N \ No BLOCK 6 \ \\ No. 49 45166 S.F. (1.037 AC) \ \ \ 1 1 .48 �N 43596 S.F. , \N (1.001 AC.) 10 587@16'55W N87'16'SS�E 75 \ \ \ \O 50 \ \ L, 45462 S.F. \ \fir. (1.044 AC.) \ \ \ sow\ \ sow I / / / 34 i I f I 1 t I I I I I I 1 I I ' �� �k more im •Heserat'•N- ri�rbn esy ys ��a3!s�,�8 Y c� $far � } 9 y t 1 ; �CI01+►! N053Qilf�t L1G�Z 1p[srt4�iais�?j'�i, i�fi��°+�5� �21 =y ,,.�f� i :?Y: � . i 1 � S 3 tlOI.L�L�N07 D'l� "s 37 ��a �?%� � �Yt.�sa9�.= a 2 3a �1. � �i�g� �r3sfz.as ��, ��: ____—i � 11 .j ® I O � �'i7i � �i `y `yy 1 +� � � a i tl� ®® ! i t 11 I'1�'�1''�II � lU � ! E f � i � � �' ' 1 �• �, a © � ` 11 I 1 ®® ���� �� �� ® ® aft �Y® ® 1 I i ® ® '1 �I ® II 1 Ij ' ® ® � ® 1 � _ ~ _ _ i 1 t I I 1 1 1 ; I I �r____�i z „- ;1 o I 1 1 11 - It �� �t it ;�1 1 [ 1 ; I 11 I 1 1 � 1 I 1 it ;1 I 1 11 � --- I� 11 _;, 11 4 II 11 I i 1 1 ;I II L I I 1 ® II � 11 11 � li 11 � i i __"'LJ � I 1 I 1 � � II 1 11 © 1 I � � it 1 � 11 1 1 z , II 4 i �� ~ I' 1 i � I 1 i I - 1 1 i I ii� 1 I � , �: �� I I � � 1 1 � .a.� • • .moo • .-� •.�I • p , . I E'd Wd�5�0t LtOZ/tE/80 Q3ltI3�3�i �60�80L6 60daS vtuvs im 'Nosarm '-N� Ny2t(il eFr `i�QOL►l NOSQ�'1{-i i.IOZ NOIl�f12lASN07 VLT.�C J W } W QL 11.t �. O° �; �•d Wd89�0T LTOZ/TE/80 Q�llI��3J e60�80L6 60daS 9ior5 im lvcscmn "rri rt3uan ss7 g �'i� e � 2 5 � � � ��0� 1� r����l 1 ��Q(i t�i; p . � � � � � �IOIi�L9NOa Pl icQ 0 O rc u ��L g'd WdE9�0T LtiOZ/IE/80 Q3itI����l �60�80L6 60deS 1 1 I I I I 1 i I F 6 �� �� �1 ,�E? Y _ L 91UY5 Iffl 'NOJ4TIN "Nl iJ32Y719EY i3'7�,;?�;7� i 3i+'re�t Y� i ! � ; u ?� % 3 0 1��..1�1^E 1"«.6 3R'Ewd�:��as .;�_ '�Y�`;`k; � La _ [ L6� � �- 3 e, 3 � f�`� 5 a i e V0117lRiJ.SNO^J V1"�Q 3�y`Fi���i6'n`;p� ;`i��Y�i�P; Y ;v 'Q '� r�`� iE!3�.:.°�K in� y� z3si:'�t�: 7 1 i n fid a Q9 O K 8 m h m ev C m i �: �; �� � N� Q mi v[; §� ya> �� $Sij -'3 �sa r� �E� o ao � A o u 4Cj �j ��c < �Y3 y S' �:� �� y� L o � � � � z a � _� � u _ � O �;� 9 � � b g'd WdE9�0Z LZOZ/ZEI80 Q3(1I3�3J �Z0�80 L 6 60 daS Z Wisconsin Department of Commerce Division of Safetyand Buildings 1147 Page 1 of 3 g in accordance with Comm 85, Wis. Adm. Code Steel Soil Service Attach complete site plan on paper not less than 8%2 County x 11 inches in size. Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel LD. = / u — _o6o Please print all information. viewed By Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ✓/e/ Q Property Owner Property Locationkd Sienna Corporation r °' Govt. Lot � .A�19 NW 19 S 20 T 29 N R 19 W Property Owner's Mailing Address Lot # Block # / Subd. Name or CSM# 4940 Viking Dr, Suite 608 S F P 6 20 2 49 `a (L The Glen 1 J City 4� a State Zip Code Phone Number City ' 1 Village e] Town Nearest Road t MN 55435 99 z, 835� zoK Hudson Carmichael Rd. ✓] New Construction Use: Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD _, I Replacement Public or commercial - Describe: Parent material Pitted outwash Flood plain elevation, if applicable na General comments P o and recommendations: System elevation 95.80ft, trenches spaced and depth to code b low grade e i a. GI, dirdn4AJ _ B l Z 44 Gm ` Boring # J Boring t Pit Ground Surface elev. 99.80 ft. Depth to limiting factor 96 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 *Eff#1 *Eff#2 1 0-10 10yr3/4 none sl 2msbk mfr cs 1f 5 9 2 10-26 7.5yr4/4 none Is osg mvfr gw na 7 1.2 3 26-96 7.5yr4/6 none ms osg ml na na C,�7) 1.2 l sys rnj0 s 94 Boring # Boring I Pit Ground Surface elev. 99,80 ft. Depth to limiting factor 96 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 *Eff#1 *Eff#2 1 0A7 10yr3/2 none sil 2msbk mfr gw I 5 8 2 17-36 7.5yr4/4 none sicl 2msbk mfr cs na .4 .6 3 36-9 77.5yr4/6 none ms osg ml na na U7 1.2 ly t q5�5 ,� ,5 Nle h SOIL EVALUATION REPORT * Effluent #1 = BOD 5> 30 <220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS< 30 Mg/L and TSS < 30 mg/L CST Name (Please Print) Signature: CST Number David J. Steel �:248956 Address Steel Soil Service Date Evaluation Conducted Telephone Number 1564 CR GG, New Richmond, WI 017 9/19/2002 715-246-5085 Property owner Sienna Corporation Parcel ID # Pending Page 2 of 3 F3 Boring # Boring Pit Ground Surface elev. 96.50 ft. Depth to limiting factor 96 in. � Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 *Eff#1 *Eff#2 1 0-9 10yr3/2 none I 2msbk mfr gw I .5 .8 2 9-24 10yr4/4 none sic[ 2msbk mfr gw 1f .4 .6 3 2424 3 10yr4/4 none sc[ 2msbk mfr es na .4 .6 4 36 6 7.5yr4/4 none cos osg mvfr cs na 1.6 5 60-96 7.5yr4/6 none ms osg ml na na .7 1.2 F7Boring # -_I Boring _ * Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L *Effluent #2 = BODS a 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or Page 3 of 3 David J. Steei CST-POWTSM Lic. # 248956 STEEL'S SOIL SERVICE Sienna Corporation NE1/4,NW1/4,S 20,T29,R19W Town of Hudson, St. Croix Co. The Glen lot # 49 1564 Cty Rd GG New Richmond, Wt 540t7 (715) 246-6200 (715) 246-5085 This soil evaluation was conducted to satisfy a zoning requirement, it many or may not be suitable for your use. The location of the test may or may not be as shown as permanent lot lines were not established at the time the soil test was conducted. Legend 1" = 40' = Benchmark El. 100.0017t 9.80Ft Page 3 of 3 David J. Steel CST-POWTSM Lic. # 248956 STEEL'S SOIL SERVICE Sienna Corporation NE1/4,NW1/4,S 20,T29,R19W Town of Hudson, St. Croix Co. The Glen lot # 49 1564 Cty Rd GG New Richmond, WI 54017 (715) 246-6200 (715) 246-5085 This soil evaluation was conducted to satisfy azoningrecluirement,it many or may not be suitable for your use. The location of the test may or may not be as shown as permanent lot lines were not established at the time the soil test was conducted. Legend 1" = 40' �.80Ft Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: DELTA CONSTRUCTION city Village Township TOWN OF HUDSON CST BM Elev: Insp, BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding TANK SETBACK INFORMATION PUMP/SIPHON I Model TDH (Lift Forcemain SOIL ABSORPTION to Ft ELEVATION DATA STATION Alt. BM Bldg, Sewer SbHt Inlet St/Ht Outlet Dt Inlet Dt Bottom wk Header/Man fist. Pipe Cover c°unty: St. Croix Sanitary Permit No: 597476 State Plan ID No: Parcel Tax No: 020-1417-50-000 Section/Town/Range/Map No: 2002901902643 BS I HI I FS I ELEV. BED/TRENCH Width L'ngth No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil [::]] Yes COMMENTS: (Include code discrepencies, persons present, etc.) Location: 438 WREN LN 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? Use other side for additional information. Date SBD-6710 (R.3/97) Inspection #1: Insepctor's Signature Inspection #2: Cert. No. CEI M Safety and Buildings Division ��� 1) 1> .� �+ K 201 W. Washington Ave.; P.O. Box 7162 �y Sani Permit Number (to be filled in by Co.) aex t�' '' . Wt 53707-7162 SE`a vN G Q B Jr`� 7 7� 74FRJZ6 sT ermit Application >� Traysactinn N �Ni In accordan Z 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are submitted to the Department of Safety and Professional Servies. Project Address (if different than mailing address) Personal information you provide may be used for sewn Purposes in accordance with the P P Law, 1 m , Sation Ps. rint L Application Information —Please Print All Information Property Owner's N Parcel # V Property Owner's Mailing Address Property Location n . `d.Q 9 a I 0 ^� w 1 c t` , . Cm> State Zip Code Phone Number Govt. Lot s0ss)) A.1 '/., Sectio II Type T 7 N; (circEoone) of Building (check all that apply) Lot Family Dwelling —Number of Bcdroo F Subdi " 'on Nam JXLor2 AV, A a P Block�/ ❑ Public/Commercial -Describe Use Nou4ir✓�, ❑ City of ❑ State Ned -Describe Use CSM Numbelr ❑ illage. of _ r % Z ` � CeM5 LAM)t/W{Q�S of III. Type of Permit: (Check only one box o line A. Complete ' e B if applicable) A. ystem ❑ Treatmen dr. Tank Replacement Only ❑ Other Modification to Existing System (explain) "Replaenli g ❑ Permit Renewal ❑ Ch% o ter ❑ Permit Trausfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV T e ofPOW I S S stall that a I ou rn G`�uads ElPressurized In. At -Grade ❑ Mound 24 ins of suitable soil El Moon <24 m, ofsuvitable soil n� ❑ Holding Tank ❑ C ber Dispersal Component (exp ') ❑ Pretreatment Device (explain) r u S V. Dis ersal/Trea ent Area Information: , t Design Flow (gpd) Design Soil Aod�pplication Ratc(gpdsf) Dispersal AreaRequired t) Dispersal Area oposed (si) Elevati n ~ _ lS J J / _O� a VL WOO Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units u c N New Tanks Existing Tanks 44 o VMoss U Ismsin W I��sVf\ Septic or Holding Tank a i•C7 r. Dosing Chamber VH. Responsibility Stateme - I, the undersigned, esponsibility for installation of the POWTS shown on the attached plans. P ber's Name (Print) Pl rgnature MP/MPRS Number Business Phone 6r PlumT ess (Street City, rate, de) - VUL County/De aliment Use Onl proved FFee DaIssu Issuin ent Signature TermAmitm rven Reason for Deniallot t6 66 DL Conditi jWVVRUR%sons,for Disapproval 1 ` tahlt; tmktic;4it filter and 'Owowu*,corittstAbesml.ices `� .rtllaliiLec *S-FF *A'ment plan provided by plumber, I' °A�l 2. u1rk'recet;>en miwtbw t �airttriried ,Hi pet >Jicabts cat / ctdinanret. 4(,IuC�IX. f a ,Mrlee.l� NK—g�% <Ad6LL _ ✓e+e. Attach to complete plans for the system and submit to the County only on paper not less than 8 vt z ] 1 inches in size SBD-6398 (R 11/11) T� Document Number State Bar of Wisconsin Form 7-2003 TRUSTEE'S DEED Document Name THIS DEED, made between David C. Loss and Randee R. Loss as Trustee of The Trust Agreement of David and Randee Loss ("Grantor," whether one or more), and Delta Construction, Inc. ("Grantee," whether one or more). Grantor conveys to Grantee, without warranty, the following described real estate, together with the rents, profits, fixtures and other appurtenant St. Croix County, State of Wisconsin ("Property") (if more space is needed, please attach addendum): Lot 49, Block 6, Plat of The Glen, in the Town of Hudson, St. Croix County, tsconsin. * * A Signature(s) authenticated on TION TITLE: MEMBER STATE BAR (If not, authorized by Wis. Stat. § 706.06) THIS INSTRUMENT DRAFTED BY: Krista M. Carlson, Oliver &Johnson, P.A., 625 Commerce Drive, Suite 119, Hudson, Wisconsin 554I6 REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 10/31/2013 08:01 AM EXEMPT # N/A REC FEE: 30.00 TRANS FEE: 234.00 PAGES: 1 **The above recording information verifies that this document has been electronically recorded & returned to the submitter Recording Area Edina Realty Title 400 South Second Street, #115 Hudson, WI 54016-1974 e # to `r714 Fil 0204417-50-000 Pazcel Identification Number (PIN) * stee Tru * Raridee R. Loss, Trustee ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. �C LU& COUNTYh) Personally came before me on O(6il i Zy t::3 , I�Jte above -named David C. Loss and Randee R. Loss. Trustees of The Trust Agreement of David and Randee Loss, to me known to be the person(s) who executed the foregoing Notary Public, State of Wisconsin My Commission (is permanent) (expires: ) (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. TRUSTEE'S DEED ©2003 STATE BAR OF WISCONSIN FORM NO.7-2003 * I ypebelow signatures.