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Home My WebLink About030-1099-90-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 514988 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Smith, Thomas H. I St. Joseph, Town of 030 - 1099 -90 -000 CST BM Elev: Insp. BM Elev: BM Description: „ ' Section/Town /Range /Map No: ` ' 33.30.19.359A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS H{ I FS ELEV. i Septic T.n. Benchmark Alt. BM �► f E Z. Aeration Bldg. Sewer L '13 �p j � 9. 9 1 S Holding _ St/Ht Inlet - �' �E . � 9w•65 5.35 �!l • :� TANK SETBACK INFORMATION St/Ht Outlet S. `�� •' TANK TO - P/L WELL BLD7�. Vent to Air Intake ROAD DtInlet Septic / / f Dt Bottom Dosing Header /Man. �, e✓ �+ �I.I Aeration Dist. Pipe - 7• tb I, Holding __ = �'` Bot. System �.a Final Grade` �G PUMP /SIPHON INFORMATION Manufacturer Demand St Cover . , � GPM k Model Numl; r TDH Lift Friction Loss System Head j' TDH Ft Forcemain Length Dla. - ist. to Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS w .ti - _. SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION :I; CHAMBER OR � Type Of System:. M , 26 A ;1 A UNIT Model Number: DISTRIBUTION SYSTEM : t.v / - -; �7 `�? 4 -e. Header /Manifyld $ I Distribution x Hole Size x Hole Spacing Vent to it In / a Pipes) ` y '3 rr t- (cJ.�� Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over j Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center A Bed/Trench Edges \.. , Topsoil \4 _Tt� yes No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 588 125th Ave Hudson, WI 54016 (SE 1/4 NE 1/4 33 T30N R19W) NA Lot jt ," j Parcel No 3.30.19.359A 1.) Alt BM Description - �' * i ibt i c c4' f'Cb"b.. F5 d- SL 2.) Bldg sewer length =.�'� �/ , /� �• �> - amount of cover = � C...E �.a.4�.. C, .; � - � `f `eF ►, � . ...., o „; 41 Cl� revis Plan Req Use otherside foradditionalin �No formation. f L_ Date Insepctor' Signatu Cert, No. SBD -6710 (R.3/97) t cornmerce.Wi.gov afety and Buildings Division Coum 5 . 201 W. ington Ave., P.O. Box 7162 �J I tucleperilment r sco dison, WI 53707-7162 Sanitary Permit Number (to be filled in by Co.) Sanitary Permit Application StateTransactionN r In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: lication forms for state-owned POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal info secondary �-- purpo in accordance with the Privacy Law, s. 15.04(l)( m , S p� /�5 J11, I. Application Information - Please Print All Property Owner's Name Parcel # ` r i S S(8 03 D - 9-fJ Pr ops Owner's Mailing Address pper&j Location 355 # ST. 2 a 1 . _ . . Y Govt. Lot City , State Zip Code 41/ E' /a Section .67- 7 / � T � N; R (dtrcl on EW ype of Building (check all that apply) Los # II Subdivision Name Family Dwelling - Number of B _ �wCQIM�. Block # ❑ Public/Commercial - Describe Use ! ❑ City of CSM Number ❑ Village of ❑ State Owned - Describe Use own of w 234 r III. Type of Permit: (Check only on6 box on line A. Complete line B If applicable) FB. ❑ N ew System ement System 11 Treatment/Holding Tank Replacement Only 13 Other Modification to Existing System (explain) List Previous Permit Number and Date Issued ❑ Permit Renewal ❑ Permit Revision El Change of Plumber ❑ Permit Transfer to New Before Expiration Owner IV T e of POWTS System/Component/Device: Check all that appl Non - Pressurized In -Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑Pretreatment Device (explain) V. Dispersal/Treatmient Area Information: r Design Flow (gpd) Design Soil Application te(gpdsf) ispersal Area Requi sf) Dis real Area Propo y�tem ElevB 'o g'o VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units ! ft5 New Tanks Existing Tanks & :� rn w C4 Septic or Holding Tank Dosing Chamber VII. Responsibility Statement - 1, the undersigned, assnm osibnuy for instanation of the POWTS sbown on the attached plans. Pl ' s Name (Print) Plumber' ro MP/MPRS Number Business Phone Number < z� 4 � LTIJ �� Plumber's Address (Street, City, State rp Code) / , ) - 7 VIII. Coun /De artment Use Onl Approved ❑ $erm Dat I ued Issuin tint Signature ven Reason Denial / 5 u , IX. Conditftp� p> UWl1s for Disapproval �` Ot q. /� 1. Septic tank, effluent filte and l ) e dispersal cell must all be aPrvk es /maintained as per management plan provided by plumber. G p e 2. All setback requirelnerits must be maintaihed Aus eh to complete plans for the system and submit to the County only on paper not less than 8 14 11 Caches h► du SBD -6398 (R. 01/07) Valid thm 01/09 PRO OT PLAN JECT Tom Smith ADDRESS 588 125th Ave Hudson Wi 54016 SE 1/4 NE 1/4S 33 / T N/R 19 W TOWN St. Joseph COUNTY ST. CROIX MPRS Shaun Bird 226900 9/12/08 3 DATE BEDROOM CONVENTIONAL XX IN -G ND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA # of chambers 46 ,BENCHMARK V.R.P. Bottom of Garage Siding ASSUME ELEVATION 100' Fi lter BE Filter ❑ BOREHOLE O WELL * H. R. P. Same as Benchmark Well is to meet all SYSTEM ELEVATION 89.4/88.0 4.5 below qrade setbacks required by WDNR WE" 20 ' Scale is P = 40' Plans Designed Using Old tank unless otherwise 125th Ave is to be 40' noted Conventional Powts pumped a� d Manual Version 2.0 buried Existing 3 Overflow Bedroom ' House A clean out is to be ' installed as per code' ; Vent 120' > 6» Quick4 Standard -W 30 of Cover Leaching Chamber with 20.0 ft2 of Area 4' Long 12" 5.8ft ^2 /pair of end caps 3 4" Grade at System Elevatio Garage 30' B.M. ST Q 20 25' 2 -3' x 94' cells with >3 spacing - Vents 45' 15' 45' 100' B ,,2 B4 20% Slope 300' 1320' Property Line ]COPY OT PLAN PROJECT Tom Smith ADDRESS 588 125th Ave Hudson Wi 54016 SE 1/4 NE 1 14S 33 j/TN/R 19 W TOWN St. Joseph COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 9/12/08 BEDROOM 3 — CONVENTIONAL XX IN -G ND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA # of chambers 46 IL BENCHMARK V.R. Bottom of Garage Siding ASSUME ELEVATION 100' Filter B EST Filter ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark Well is to meet all SYSTEM ELEVATION 89.4/88.0 4.5' below qrade setbacks required by WDNR wF11 20 ' Scale is 1" = 40' unless otherwise 125th Ave Plans Designed Using Old tank is to be 40' noted Conventional Powts pumped and Manual Version 2.0 buried Existing 3 Overflow T Bedroom House A clean out is to be 5' installed as per code Vent 120' >691 Quick4 Standard -W 30' of Cover Leaching Chamber with 20.0 ft2 of Area 4' i:::::�Grade Long 5.8ft ^2 /pair of end caps 3 4" at System Elevatio Garage 30' * ST B.M. O ' 2 2 -3' x 94' cells with >3 spacing 20 5' Vents 45' 15' 45' 100' B -2 B -1 20% Slope 300' 1320' Property Line Wisconsin Department of Commerce IL EVALUATION REPORT Page of Division of Safety and Buildings in actor a . Comm 85, Wis. Adm. Code County . - L Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must / include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arro and location and distance to nearest road. 0 -3 0 "- P/ease print all infor7�1r'�E Revi ad by D Personal information you provide may be used for ndary purposes (Privacy �w, s. 15 (1) (m)). Property Owner Pro erty Location 'Tb>, SEP 1 5 2008 Go . Lot St✓ 1/4 g 1/4 T, 3 ON R ` E (o W Property Own r s Mailing Address ST. CROIX COUNTY Lo # Block # Subd. Name or CSM# 0 ING OFFI City State Zip Code Phone Number City ❑Village wn Nearest Roa New Construction Use. sidential / Number of bedrooms Code derived design flow rate GPD Replacement n ❑ Public or commercial - Describe: Parent material (7 U �'"Z! J a-4 - Flood Plain elevation if applicable General and recommendations: `�i ��/�, /� J System Type / . /7 >1/LJ� System Elevation F T1 Boring # o ❑ Boring 4 Pit Ground surface elev. ft. Depth to limiting factor in. Soi Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff# #1 1 •Eff#2 22 3 a-// b , s v r, � "g # ❑ Boring t t'1�1 o L ' y Pit Ground surface elev ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Etf#1 I 'Eff#2 z o 7V -#0 4.0 Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mglL ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Si CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 54017 �� D 715- 246 -4516 Property Owner _ Parcel ID # Page of F-31 Boring # ❑ Boring �–Rit Ground surface elev. ft. Depth to limiting factor Ll / in. SoiI lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDAf in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 11 s O 1 i 0 y� 70 T F-1 Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil — Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring # ❑ Boring F ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon 'lepth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ' Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Ef fluent #2 = BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777. SBD -8330 (RAM) Property Owner _ Parcel ID # Page of F_31 Boring # ��• ring 1 i t Ground surface elev. ft. Depth to limiting factor in. r*EffM#1 l Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDKf in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#2 rt o y > L/) (� i y� F-1 Boring # F1 Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 F-1 Boring # E] Boring 1:1 Pit Ground surface elev. ft. Depth to limiting factor in. Soil ication Rate Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence. Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Etf #1 •Eff#2 " Effluent #1 = BOD > 30 1220 mg/L and TSS >30 150 mgA- ' Effluent #2 = BOD < 30 mg/_ and TSS < 30 mg1L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 -264 -8777. SBD48330 (RAW) Soil Test Plot Plan Project Name Tom Smith Shau ird Address 588 125th Ave Hudson Wi 54016 C #226900 Lot ----- Subdivision -- ------ Date 9/12/08 SE 1/4 NE 1/4S 33 T 30 N /1319 W Township St. Joseph Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Bottom of Garage Siding System Elevation 89.4/88.0 *HRPSame as Benchmark WEll 20' 125th Ave 40' Existing 3 Scale is 1" = 40' Overflow T Bedroom House unless otherwise 25' noted 30' Garage 30' B.M. 20' 94' B -3 45' 15' -f- 90' 45' 100' B -2 B -1 20% Slope 300' 1320' Property Line my Maintenance and Contingency Plan for a Septic Systsin Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Effluent filter is to be cleaned once a year Please note: a larger filter Is being installed In o rder to extend the maintenance interval of the filter. 3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of the Delis. 4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system- 5. The owner agrees to save this plan. 6. Do not plant trees nor park nor drive over system. 7. Watershed is to be diverted away from system- 8. Discharge into system is not exceed those required as per Comm. 83 Contingency Plan Option #1. if systemfails, determine cause of failure, use attemate area and install new t replacement area. biomat, Option #2. nstall system at a lower elevation, by removing charnbers, removing and in new system. Option#3. No adequate area is suitable for replacement area, and system elevation cannont be lowered. install holding tank as last resort. 3. Replace any other fail! . N components as needed. Plumber: Shaun Bird 71 5- 246 -4516 St. Croix County. Zoning 715- 386 -4680 Pumper Tom Mondor 715- 246 -5148 Shaun Bird #226900 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWN ,RSHM CERT InCATION FORM Owner/Buyer _ � n , =- `� �►,� �Jrl S �z5 Mang Address Property Address nt for new construction.} (verification required from Planning & Zonm o Department G q City /State Parcel Identification Number 3 0- 10 LEGAL DESCRIPTION c� 1 J 3 O N RAw,Townof Property Location �� 1/ S /a ,Sec. T Lot # Subdivision 'Volume Page`# Certified Survey Map # .� ,Volume J t� Page 7 'Warranty Deed # Spec house yes no Lot lines identifiable Do SYSTEM 11iINTENAN E AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to "mdleu��-�� u pm into a licensed maintenance consists of pumping out the septic tank ovary three Years or sooner, if need b y owner maintenance the system can affect the functionof the septic tank as a treamient st in the waste St. Cro County Sanitary Ordinance• responsibilities are specified in $Comm- 8352(1) and in Chap 12 _ to submit to St. Croix County Planning & Zoning Department a catfication :form. silted by the The p ° agrees lumber or a licensed Pumper verifying that (1) the on -site owner and by a master plumber, journeyman Plumber, restricted p n and pumping (if necessary), the se0c tank is wastewater disposal system is in proper operating condition and/or (2) after inspectio less than 1/3 full of sludge. agree to maintain the private sewage disposal system with the Uwe, the undersigned have read the above requirements and t of Natural Renounces, Srate of Wisoansin- standards set forth, herein, as set by the Department of Commerce and the Departmen Certification staring that your septic system has been maintained must be completed and returned to the St Croix County PIamiing & Zoning Department within 30 days of the three year expiration date Uwe that all statements on this form are true to the best of my /our knowledge. 1twe am/are the owners) of the � per ; y above, b of a' ty deed recorded in Register, of Dads Office...... SIGNATURE OF APPLICANT(S) DATE Any information that is misrepresented may result in the sanitary permit being revoked by the Planning 8t Zoning L * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed - owv. t18 w r Y.,, 1509PAu 477 ��s KATHLEEN H. WALSH Document Number QUIT CLAIM DEED REGISTER OF D ST. CROIX CO. , WI RECEIVED FOR RECORD 05 -10 -2000 9:30 AN THOMAS H. SMITH, Grantor, quit claims to THE THOMAS H. QUIT CLAIM DEED SMITH REVOCABLE LIVING TRUST, Grantee, EXEMPT # 16 CERT COPY FEE: COPY FEE: the following described real estate in St. Croix County State of TRANSFER FEE: RECORDING FEE: 10.00 Wisconsin: PAGES: 1 An undivided one -third (1/3) interest in: Southeast Quarter of Northeast Quarter of Section 33, Township 30 North, Range 19 West, except the land shown in the Certified Return to: Survey Map recorded in Vol. 4, Page 929. D. Peter Seguin Mudge, Porter, Lundeen & Seguin, S.C. Southwest Quarter of Northeast Quarter of Section 33, Township 110 Second Street, PO Box 469 30 North, Range 19 West, except that part conveyed to Richard Hudson, WI 54016 and Rosalie Ostendorf, recorded in Vol. 408, Page 220 and except the part conveyed to Jerome Anderson and Phyllis J. Anderson, Tax ID # 030 - 2005 -80 -000; recorded in Vol. 536, Page 153, and except that part conveyed to 030 - 2005 -40 -000; Ervin J. Schauer and M. LaRae Schauer, recorded in Vol. 449, 030 - 2004 -95 -000; Page 426. 030 - 1099 -50 -000; 030 - 1099 -90 -000. North Half of Southeast Quarter of Section 33, Township 30 North, Range 19 West, except the part deeded to Ervin J. and M. LaRae Schauer, recorded in Vol. 449, Page 426, and except that part conveyed to Floyd E. and Marie M. Nestrud, recorded in Vol. 441, Page 59, and that part conveyed to Donald L. and Loretta E. Kooiman, recorded in Vol. 457, Page 269, and except the Plat of Oak Knoll. Southeast Quarter of Southeast Quarter of Section 33, Township 30 North, Range 19 West, except the East 20 acres and except the Plat of Oak Knoll. All recording references are to the records in the Office of the Register of Deeds for St. Croix County, Wisconsin. This is homestead property. Dated this 3 •-4 day of �21 !/ , 2000. (SEAL) Thomas H. Smith AUTHENTICATION ACKNOWLEDGMENT Signature of Thomas H. Smith authenticated this _ STATE OF WISCONSIN ) day of . �S ��i 2000. )ss COUNTY OF ST. CROIX ) Personally came before me this day of TITLE: MEM13EK STA BAR OF WISCONSIN , 2000, the above named Thomas H. Smith, to me know to be the person who executed authorized by §706.06, Wis. Stats. the foregoing instrument and acknowledged the same. THIS INSTRUMENT DRAFTED BY: D. Peter Seguin, Attorney Mudge, Porter, Lundeen &c Seguin, S.C. Notary Public, State of Wisconsin 110 Second Street, PO Box 469 My Commission (expires): Hudson, WI 54016 (Signatures may be authenticated or acknowledged. Both are not necessary.) -Names of persons si in an capacit should be t or prmted below their si ptures. QUIT CLAIM DEED t