HomeMy WebLinkAbout020-1314-50-000Wisconsin 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 I City Villaqe Township
William and Jeane B Derrick Trust
TANK INFORMATION
TYPE
MANUFACTU R r
S
CAPACITY
Septic
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO
PIL
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
3 7t
2c�71
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
*Langth
Fricti
n Loss
System Head
TD
Ft
1,10ia.
1DisT to Well
SOIL ABSORPTION SYSTEM
TOWN OF HUDSON
ELEVATION DATA
STATION
BS
HI
FS
ELEV.
Benchmark
95 . C)
Alt. BM
3
tP3, oi�
Bldg. Sewer
`D Z
SVHt Inlet
SVHt Outlet
43
Dt Inlet
Dt Bottom
Header/Man.
l
I I
Dist. Pipe
Bot. System
I
2
• Z-
Plrlai-fT'3tle
I 3
)Z-S/
87yo
St Cover
3.3
/0 3, aZ.
1'v,' �'n�—
l3.zJa
IrX,.3z
�•75
�gt3of
F)yw
7J.
!. 7Z-
54--7r5 -r7.6 -/L 7.5 t2 10icg
BEDITRENCH
DIMENSIONS
Width
Length
No. Of Trenph�
2
PIT DIMENSIONS
No. Of Plts
Inside Dia.
Liquid Depth
SETBACK
SYSTEM TO
P/L
BLDG
WELL
LAKE/STREAM
LEACHING
Manufacture 7, /� d
INFORMATION
Ty --Of
CHAMBER OR
UNIT
YY
Of System:
a
f Zo
.
7/e o
�_—
Model Number
L z how
DISTRIBUTION SYSTEM
Header/Manifold
�
Length 2C-` DIa
Distribution
x Hole Size
Ix Hole Spacing
Vent to Air Into
-7
Pipe(s)
Length DIa Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over
Bedfrrench Center �%� / _
Depth Over I t
Bedfrrench Edges ' ' —7
xx Depth of
Topsoil
xx Seeded/Sodded
xx Mulched
o
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 758 CROSBY DR — DbitY V A40 fY 16- -�•pm (f'xds
1.) Alt BM Description = 1� ) { COV-�f . ]`
2.) Bldg sewer length = 26 � � V� h V Yl QI1CR-� • fovil"i eft ,A
-amountofcover=71t° eN { f t �LI- i r l 5-Ff +v4-c;,-y,4
ork.
Plan revision Required? Yes ND� '
o ii� / O(�
Use other side for additional informatio I (o__
SBD-6710 (R.3197)
Date Jn_Ins pctors Signature Cert. No.
_ -76 / re W tA� I 01�5 lJ1A7)-t4 -�
SAN -auao — Ild 6
ihv+r9iw - .
Safety and Buildings Division
County
ST CROIX
` �_
201 W. Washington Ave., P.O. Box 7162
Sanitary Permit Number (to be filled in by Co.)
a
�.�
Madison, WI 53707 162
(30goa
DED
PEE
��n e Applieari
State Tmrrsach°°Number
In accordance write S S 3 (�f,1 Code, submission of this form�AWWte governmental unit
Project Address (if ditforenl than niading address)
is required prior to ob utary permit. Note. Application forts for state-owned P itted to
the Department of Sa ety and Profes oonal Servies. Personal information you provide may be used for secondarIll
purposes in accordance with the Privacy Laws 15.04(1)(m),Siats.
]SH CROSBY DRIVE
1. Application Information — Please Print All Information
Property Owner's Name
Parcel 4
WILLIAM AND JEANE B TR DERRICK
0Q0-1 314 -$o - oca
Property Owner's Mailing Address
Property Location ^ 8 a q . j q. ISqT
41
758 CROSBY DRIVE
Gort. Lot
SW NW 28
'/., Section
City, State
Zip Code
Phone Number
WOODBURY MN 55129
(circle one)
T 29 N, R 19 E or W
11. Type of Building (check all that apply)
Lot n
Subdivision Name
IX I or 2 Family Dwelling- Number of Bedrooms 4
5
r
5*.
Block
❑ Public/Commercial Describe Use
❑ City of
❑ State Owned Describe Use
❑ Village of
CSM Norther
ei Town of HUDSON
ZoIV E
111. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A.
® New System
y
❑Replacement System
❑ Treatment/Holding Tank Replacement Only
❑Other Modification to Existing System (explain)
B.
❑Permit Renewal
El Permit Revision
ElChange of Plumber
El Permit Transfer to New
List Previous Perin Number and Date Issued
2� ,ntlr } Z F10 WS
'i`
Before Expiration
Owner
IV. Type of POWTS S stem/Coin onenUDevice: Check all that apply)
✓) Non-Pressunzed In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound> 24 in of suitable sod ❑ Mound <24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component ex lam) ❑ Pretreatment Device (explain)
V. Dispersal/Treatment Area Information: S
Design Flow (IV
Design Sorl Appli ion Rat gpdsf)
Dispersal Area uired (sf)
Dispersal Area Argpdeed (sf)
System Ele ahon
600
.4
1500
1500 ✓
8091
VI. Tank Info
Capacity in
Gallons
Total
Gallons
q of
Units
Manufacturer
Qo,� IO L 5 2
7
a
i
u'g
a
New Tanks
Existing TanksLZ
L V
Sephcor Holding Tank
WIESER
1250
1
WIESER
Dosing Chamber
VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the PO WTS shown on the attached plans.
Plumber's Name (Print)
PI 's Sigma
MP/MPRS Number
Business P one Number
TIM DEYOUNG
J
664713
'%jam 416 it
Plumber's Address (Street, City, State, Zip Code)
321 WISCONSIN DRIVE NEW RICHMOM WI 54017
Vlll. County/Department Use Only
Approved ❑ Disapproved
Permit Fee
Ssp p , O
Dow Je 1Is-1ssued
ZA
12l I
Issuing Agmt hue
El Owner Given Reason for Denial
1
IX Conditions of Approval/Reason for Disapproval 3 Urw SYS,-Ntyy,v p tJ0LW0V\S Q (oN tDr�s 1✓V
SYSTEM OV",FQ f[�a �1i-74cGkd CtbS5 SCC.`�'IvO VV.
1 Septictank^tfilterand OVtf
disc' -sal - be Serviced, / maintained N)VS� tee. 't1i111"'w'r�
aS per rl 11 l )t ppan provided by plumber.
Adair to comp top a a submit io the Couurs oily on paper not lessan ths ra x l l inches im siu
sy5� 1t[Iew•e11✓ Ctt-Co
y%u.5+ bt Pre5rrV'fd .
SBD-6398(R. II/II) jp) lis$�-fsYWr TO �f`OviC1'0 5Y7'4r rf'1 %'hal%'t 7"c Y1 Q✓1('� !!"1of'Ntfd:aa
0
ef,-D
�19 " 404-1 s�
i s✓,�aC7 isSo�p
��
! 18
1
( r
f
@1 T� 89 -T3 96 TN 91.
1b1%41 r�il /o- .✓/�.r.w ��l:oo c✓Fin i/14�.�i'� �cncL.$
Y{1Dit T T.crok� S9 iDclow gvr4a,
Project Name:
Owner's Name.
Owners Address:
Legal Description:
Township.
County:
Subdivision Name:
Lot Number:
Parcel ID Number:
Designer/Plumber:
Date:
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
WILIAM AND JEANE B TR DERRICK
WILLIAM AND JEANE B TR DERICK
4429 DORCHESTER DRIVE WOODBURY MN 55129
SW NW SEC 28T29R19W
HUDSON
ST CROIX
ST . CROIX ESTATES
5
020-1314-50-000
Page 1
Page 2
Index and title
Plot Plan
Page 3
System Sizing & Cross -Section
Page 4
Filter Specs
Page 5
Maintenance Information
Page 6
Management Plan
Page 7
St Croix Cty Septic Tank Maintenance Form
Page 8
Page 9
Warranty Deed
CSM or Plat
Attachments: Soil Test & House Plans
TIM DEYOUNG License Number:
12/03/2020
Phone Number
664713
(715)246-2660
Signature
Designed pursuant to the In -Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01)
Page 1
py Be
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7
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cid, only,
If you us.[e, 'I e 4
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r
SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT Pape 1 011
Project Name:
n /I
4ey7-f
U 71f k r
4
No. of Cells
7.5
Per Cell
3
ft Cell Width
30
Total No of 10
75
ft Cell Length
50
sq ft EISA Per Cell
3
ft Cell Spacing
1500
sq it Total EISA
Manufacturer Model
Laying Length _ EISA ftaOnIE__
Infutraw
EZ1203H-5ft
5.0'
25.0
EZ120311-10ft
10.0'
50.0
Gravelless Leaching Unit Manufacturer:
EZ1203H-10FT. EZ 1203H - 5FT
Gravelless Leaching Unit Model:
INFILTRATOR
Typical Cross Section
Finished Grade 99 ft
�—Observation Pipe with
approved cap or vent
..
Soil Backfiil
".�Geotextile Fabric
_a Infiltrative Surface
,2 in o
___ O Limiting Factor
12 in Slotted and Anchored Ventl
7 ' Observation Pipe with Cap
.........................................................................
Plumber/Designer Signature: ;7�—
License g: 664713 Date: DEC 3 20
_4" (10.16 cm) BALL
TRAVEL
5.78 14.7 cm —
6.5" (16.51cm) SEALED BALL
MATERIAL - HOPE
POLYLOK PL- 525 - 625 CUTAWAY
33.02 83 9 cm
20.71 152.6 cm i
HOUSING
FILTER CARTRIDGE MATERIAL -POLYPROPYLENE
MATERIAL - FILLED POLYPROPYLENE
BALL PUSH ROD SECTION A -A
FACTORY INSTALLED
MATERIAL - FILLED POLYPROPYLENE
4" AND 6" FACTORY OPTIONAL BUSHING
INTALLED PIPE OUTLET (FOR 4" THIN WALL PIPE)
MATERIAL - PVC PART NO 30142 R
OR OPTIONAL FLOAT SWITCH
(FOR 110 MM. PIPE)
PART NO.30142-EUR
WLP1250-MR
TANK SPECIFICATIONS
DIMENSIONS:
WALL: 2 1 /2"
a" CAST -A -SEAL
BOTTOM: 3"
4" CAST -A -SEAL
"
MANHOLE: 24" I.D. PRECAST CONCRETE RISER
- - --
HEIGHT: 52 1/2"
`
LENGTH: 10'-0 1/4"
WIDTH: 7'-0"
_ m`LkQ
y
BELOW INLET: 41"
f
LIQUID LEVEL: 36"
i
WEIGHT: 8,810 LBS.
a ��a
INLET AND OUTLET:
�.
FILTER OR
4" CAST -A -SEAL BOOT OR EQUAL GASKET
BAFFLE
INLET AND OUTLET BAFFLE AND FILTER:
i
WISCONSIN, SEE DETAIL #10
___
(OTHER STATES SEE CHART)
LIQUID CAPACITY: 34.81 GAL/IN
TOP VIEW
HOLDING TANK:
OUTLET HOLE PLUGGED
ACTUAL CAPACITY: 1,323 GALLONS
LOADING DESIGN: 8'-0" UNSATURATED SOIL
INLET
N
N V
in a
TANKS ARE
OUTLET
I I N
1 M a I d U m
---------------------J
TANK CAN BE USED AS:
SEPTIC / HOLDING / PUMP OR SIPHON
COVER: MIX DESIGN p8 (NO FIBER)
TANK: MIX DESIGN #10 (STRUCTURAL FIBER)
CUSTOMIZED TANKS:
FOR CUSTOM TANKS CONTACT WIESER CONCRETE
REVIEWED BY
REVIEW DATE
DRAWINGS SUBMITTED
FOR APPROVAL
APPROVED BY:
APPROVAL DATE:
PRODUCTS NEEDED BY:
0
r
a
e 3
m
OF 1 I
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2
FILE INFORMATION
Owner WILLIAM AND JEANNE B DERRICK
Permit A
f •T�9 Tci `1 T :7�\ T, I ai3
Number of Bedrooms
4
❑ NA
Number of Public Facility Units
❑ NA
Estimated flow (averagel
400gal/day
Design flow (peak), (Estimated x 1.5)
600
al/da
Soil Application Rate
.4 al/da /ft'
Standard Influent/Effluent Quality
Monthly average*
Fats, Oil & Grease
(FOG)
530 mg/L
Biochemical Oxygen Demand
(BODs)
5220 mg/L
❑ NA
Total Suspended Solids
(TSS)
5150 mg/L
Pretreated Effluent Quality
Monthly average
Biochemical Oxygen Demand
(BOD6)
530 mg/L
Total Suspended Solids
(TSS)
s30 mg/L
❑ NA
Fecal Cofforn (geometric
mean)
:0 0' cfu/100ml
Maximum Effluent Particle Size
Y, in dia.
❑ NA
Other:
❑ NA
Values typical for domestic wastewater and septic tank effluent.
TI\PYid;f6� T�T3.T�T.T3lTlr
SYSTEM
Septic Tank Capacity
1250
gal 0 NA
Septic Tank Manufacturer
WIESER
O NA
Effluent Filter Manufacturer poly IpcK
❑ NA
Effluent Filter Model
525
❑ NA
Pump Tank Capacity
al XI NA
Pump Tank Manufacturer
LXNA
Pump Manufacturer
IXNA
Pump Model
IR NA
Pretreatment Unit
OCNA
❑ Sand/Gravel Filter
❑ Peat Filter
❑ Mechanical Aeration
❑ Wetland
0 Disinfection
❑ Other:
Dispersal Cell(s)
❑ NA
X In -Ground (gravity)
❑ In -Ground (pressurized)
❑ At -Grade
❑ Mound
❑ Drip-Une
❑ Other:
Other:
0 NA
Other.
0 NA
Other:
❑ NA
Service Event
Service Frequency
Inspect condition of tank(s)
At least once every:
3 0 meaontrlsi s(Maximum 3 years)
❑ NA
Pump out contents of tank(s)
When combined sludge
and scum equals one-third ( ,) of tank volume
❑ NA
Inspect dispersal cellls)
At least once every:
3 ❑ monthX yeararlsl (g) l (Maximum 3 years)
❑ NA
Clean effluent filter
At least once every:
❑ month(s)
1 X year(s)
❑ NA
Inspect pump, pump controls & alarm
At least once every:
❑ month(s)
❑ year(s)
tjCNA
Flush laterals and pressure test
At least once every:
0 monthisl
❑ yearlsl
X NA
Other:
At least once every:
❑ month(s)
❑ year(s)
Other;
X NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector, POWTS Maintainer; Septage Servicing Operator. Tank
Inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal call(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one-third (Y) 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 chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
Page Z of v
START UP AND OPERATION
For new construction, prior to use of 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 high concentrations are detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal call(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain Isump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
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
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative 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 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
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures 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 soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS,
r a►
❑ 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 CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name COUNTRYSIDE PLG AND HEATIN Name PAUL R KOEHLER
Phone 715-246-2660 Phone 1 715-246-2660
SEPTAGE SERVICING OPERATOR (PUMPER)
Name POWERS SEPTIC SERVICE
Phone 715 417 1429
LOCAL REGULATORY AUTHORITY
Name
ST. ckn ( 211Aimi
Phone
-7/S- 3FC10- (o CD
This document was drafted m compliance with chapter Comm 83.22(2)(b)(1)(d)WO and 63.540), (2) & (3), Wisconsin Administrative Code.
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer Jeanne B Tr Derrick %WM Derrick
Mailing Address 4429 Dorchester Drive Woodbury MN 55129
Property Address 758 Crosby Drive
(Verification required from Planning & Zoning Department for new construction.)
City/State
Hudson WI
Parcel Identification Number 020-1314-50-000
LEGAL DESCRIPTION
Property yLocation S1-� v., N�/< ,Sec.28 , T 29 N R19 W, Town ofHudson
Subdivision Plat:.St. Croix Estates
Certified Survey Map #
Warranty Deed # Dz 1 Q7
Spec house ❑yes[Zho
, Lot # 5
Volume , Page #
(before 2007)Volume , Page #
Lot lines identifiable Byes❑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 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. Owner maintenance
responsibilities are specified in §SPS. 383.52(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 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 113 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 Safety And Professional Services 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 Planning & Zoning Department within 30 days of the three year expiration date.
Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the
property described above, virtue of a warra^ deed recorded in Register of Deeds Office.
Number of
12/02/20
DATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.."'
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.
(REV. 04112)
�°
FRONT ELEVATION
1�
__ __v_a_m
REAR ELEVATION
asTMN&s
NG Of IPLS
Muhlenp'h &
Assn sales
�g
NSMCw'S DIRM
NC OF YPLS
MuM1lenpoM1 &
Assocmtes
.u� s
DdTxe I 2 e..,
UL
.-S SO 1 RCH O a n
Kn e'
mmNo x Y
ea
I�✓u)
II
(�
MAIN LEVF"L PLAN
2506 SQ FT
f98 SQ. FT. 4—SFASON
2704 SQ, FT. TOTAL
1/4 ^— 1'-0"
m
Jul
M—
C.- - =�Wlm1mlm
RIGHT SIDE ELEVATION
114"=f - 0
------ - -----
---------- ---
— loomw - VFF'
--- ------ -- ------------- -------- -- - -
--------- ------------- -
i LEFT SIDE ELEVATION
Dsfl cflw DIsal
NC OF LPS
O
C4
04 �
cc C)
Q Zz
w
ROOF PLAN
TYPICAL WALL SECTION
TL _
^Nry ��Iup% • �
SECTIONg2
cxur xrr ••� I — I ti.? r -
❑ r '� SruIIAY
I �-
SECTIONp3
1/4"-1'-O"
asm�rn� oE'ra;
MC Cf MMS
Svvtin.�S28
fallo Nd�San, Eg}At*o-
5 Sfi, Cry Ilk
�j- yap �� P, pc, a �I , o0 00
�m top Of Ste -ins k/yet Qro& 9S'
AIT prf, = -( poli' an P`
s�
rs i
wiscor-r_oepar_.nent ofIndustry, SOIL AND SITE EVALUATION REPORT 'Paof 3
!, _.r end Human Relations - ge e
Division of Safety & Bwldinos \1I
Attach complete site plan on paper not less thane 1/2 x 11 inches in size Plan must include, but
� St. Croix- -.;_- N
P CEL I D f, Ii-
r�97
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or
dimensioned, north arrow, and location and distance to nearest road.-•
APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION
DAT
PROPERT�YOW/NER�
PROPERTY LOCATION �.
Jo Ud Chllot '�
GOUT LOT gy 4 j�j V4,S 2 o) W
PROPERTY OWNER S MAiI.ING ADDRESS
LOT N BLOCK #
SUED NAME OR CSM N
527 Cc. Rd. #UU
5 na
St. Croix Estates
CITY,ZIP CODE pHONENUMBEB52
dson,
❑CITY ❑VILLAGE DOWN NEAREST ROAD ,7 C +
WZ. 54016 7 ) .3U
Hudson, Crosby Dr.
I ] New Construction Use [ )I Residential 1 Number of bedrooms 3 [ ] Addition to existing buildin� -
(] Replacement [ ] Public or commercial describe)
Code derived daily flow 450 gpd Recommended design loading rate .5 bed, gpdM2 .6 trench, gpdm2
Absorption area required 900 bed, 112 750 trench, ft? Mvirrum design loading rate • 5 bed, gpd/ft2 .6 trench, gp(L t2
Recommended infiltration surface elevations) 95.20 ]as refened tot �Re plan benchmark)
" lit %AG _
Additional design 1 site considerations na �t ��v . '5"
Parent material outwash Flood plain elevation, If applicable na ft
S = Suitable for system
CCNVENTIONAL
MOUND IN GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
I 1
U = Unsuitable for system
16S ❑ U
RKS ❑ U M ❑ U I )99 S ❑ U ❑ S Z:] U ❑ S g] U
Boring #
1 ..
Ground
elev.
97.5 ft
Depth to
limiting
factor
+84"
Boring #
A..2s
Ground
elev.
97.9 h.
Depth to
limiting
factor
+84"
SOIL DESCRIPTION REPORT
Horizon)
Depth
in.
Dominant Color
Munsell
Mottles
Ou. Sz. Cont Color
Texture
Structure
Gr. Sz. Sh.
ConsistencelBotndary
Roots
GPD/ft
Bed ITrench
1
0-9
10yr3/3
none
sl
2msbk
mfr
gw
2f d
2
9-27
10yr4/4
none
sl
2mgr
mvfr
gw
if
0.6 Al
3
27-84
7.5yr4/4
none
Fs*
mvfr
na
na
6
i
(o
VcvLf
h
a
o
c�
)�
�s6h
�,uLax
Remarks:
1
0-10
10yr3/3
none
1
2msbk
mfr
gw
2f
2
10-24
7.5yr4/4
none
sl
2msbk
mfr
gw
if
o.b Yq, o
3
24-54
7.5ry5/4
none
f s
Osg
mvfr
9w
na
.5
4
54-84
7.5ry4/6
none
Co S
Osg
na
.7 b
Zml:na
3E4
Ce
Fiomarlrc• v
a
M
M
PROPERTY OWNER John Rauchnot SOIL DESCRIPTION REPORT
PARCEL I.D.# pending
Bonng #
3
Ground
elev.
98.76 ft.
Depth to
limiting
factor
+84,
Boring #
4
Ground
elev.
99_2 ft.
Depth to
limiting
factor
+88"
Boring #
5
Ground
elev.
98.5 ft.
Depth to
limiting
factor
+861,
Boring #
Ground
elev.
fl.
Depth to
limiting
factor
Page 2 of3_
Honzon
Depth I Dominant Color
in. Munsell
j Mottles
Cu.Sz.ContColor
Texture
Structure
Gr. Sz. Sh.
!Cons�stencelBourievIRootsI
GPD/ft
Bed Trench
1
0-9
10yr3/3
none
1
2msbk
mfr
gw
2f
1 .5
.6
2
9-20
10yr4/4
none
sicl
2msbk
mfr
gw
if
.4
.5
3
20-511
7.5yr4/4
none
sl
2msbk
mfr
gw
na
.5
.6
4
51-84
7.5yr4/6
none
is
Osg
mvfr
na
na
7
.8
I
iI
I
Remarks:
1
0-11
10yr3/3
none
1 2msbk
mfr
gw
217
.5 .6
2
11-28
10yr4/4
none
sicl
2msbk
mfr
gw
if
.4 .5
3
28-54
7.5yr4/4
none
sl
2msbk
mfr
gw
na
.5 .6
4
54-88
7.5yr5/4
none
If S
Osg
mvfr
na
na
.5 .6
Remarks:
1
0-11
10yr3/3
none 1
2mabk
mfr
gw
2f
.5 .6
2
11-28
10yr4/4
none
sic
—?m
mfr
gw
1f
.4 .5
3
28-86
7.5yr4/4
none sl
2msbk
mvfr
na
na
5 6
I
I I
I
Remarks:
Remarks:
SBD-8330(R.05r92)
r ♦ ♦ 1
PROPERTY OWNER John Rauchnot SOIL DESCRIPTION REPORT Pape 2 of
PARCEL I.D.1 Pending
Boring #
emu'
3
ems.
Ground
elev.
)8.76 ft.
Depth to
limiting
factor
+840
Boring #
4
Gto M
elev.
99_2 ft.
Depth
few
+ 8"
Boring #
Ground
elev.
98.5 ft.
Depth to
6mititg
+86"
Boring #
Ground
elev.
1.
Depth to
Nmiting
factor
Horizon
Depth
in.
DominantColorI
Munsell
Mottles
Ou. Sz. Cont Color
Texture
I Structure
Gr. Sz. Sh.
l8ttrtlaylRoots
GPD/ftz
1
0-9
10yr3/3
none
1
2msbk
mfr
gw
2f
- eo
2
9-20
10yr4/4
none
sicl
2msbk
mfr
gw
if
.40
3
20-51
7.5yr4/4
none
S1
2msbk
mfr
gw
na
4
51-84
7.5yr4/6
none
is
Osg
mvfr
na
na
.7
Remarks:
1
0-11
10yr3/3
none
1
2msbk
mfr
gw
2f
I:mod,
2
11-28
10yr4/4
none
sici
2msbk
mfr
gw
if
.4 `
3
28-54
7.5yr4/4
none
s1
2msbk
mfr
gw
na
.6"
D.6 1.0
4
54-88
7.5yr5/4
none
f S
Osg
mvfr
na
na
.5 ,.Flo
Remarks:
Remarks:
C7
L
Gary L. Steel
CSTM2298
MPRSW-3254
FIE
II
N
1"=40'
BM.= top of !"
Alt. BM.= nail
STEEL'S SOIL SERVICE
John Rauchnot
SWQNWq S28-T29N-R19W
town of Hudson
lot #5-St. croix Estates
steel pipe @ el. 100'
in tree C el. 103.9'
�/-�1-3-95
1554 200th Ave.
New Richmond, WI 54017
(715) 246-6200
Q
CT--aaao -371
Wis. Dept. of Safety and Pro sional ye9z 4 NZO SOI EVALUATION REPORT
Division of Safety and Buildi
Paw I of 4
Attach complete site plan on a�'Or1at1 •+ prne nt es in size. Plan must
include, but not limited to: ve = onzonlal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information.
Personal information you Provide may be used for secondary purposes (Privacy Law, a. 15.04 (1) (m))
Cou
ST CROIX
Parcel I.D.
020-1314-50-000
Reviewed by
Date
Property Owner
WILLIAM AND JEANNE B A DERRICK
Property Location 11 El
Govt. Lot SW 1/4 NW1/4 S 28T 29N R 19E (
Property Owner's Malting Address
4429 DORCHESTER DR
Lot #
5
Block #
Subd. Name or CSW
ST CROIX ESTATES
City State Zip Code Phone Number
WOODBURY i MN 1 55129 ( )
ity []Yllage LTown
Nearest Road
CTY RD UU
E' New Construction Use] Residential / Number of bedrooms 4 Code derived design flow rate
Replacement Public or commercial - Describe:
Parent material OUT WASH Flood Plain elevation if applicable
General comments
and recommendations
600 GPD
ft.
6❑ Boring # Boring
0 pit Ground surface elev. 90.3 fl.
Depth to limiting factor 86 in.
Soil Application Rate
Horizon
Depth
in.
Dominant Color
Munsell
Redox Description
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
onsistence
boundary
Roots
GPD/fl '
1111#1
1f#2
A
0-20
10 YR 3/3
- - -- --
LS
I 0 M SG
ML
GW
2M
.7
—Lai'
B
_20.48
7.5YR5/4
---------------- ----------
SICL
3MBK
MVR
GW
2M
.4
.(5'
C
48-86
7.5 YR 4/6
--- ----- - ---- ---------
F S
5(b"ft
ML
GW
-----
.5
1.0
2�
G
Boring # Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Sob Application Rate
Horizon
Depth
in.
Dominant Color
Munsell
Redox Description
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
onsistence
Boundary
Roots
GPDIft '
11#1
ff#2
�iownr x = ow .w : c" mcyL ano i bit >ju < 1 ou mg/L • Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Prmt) �J Sgnature�7 / CST Number
Address / �/� �` c�/'� Gbh
Date Evaluation Conducted Telephone Number
SBD-8330 (RI1/11)
WS. Dept of Safety and Professional Services SOIL EVALUATION REPORT Page ] of 4
Division of Safety and Buildings
in accordance with SPS 385. Wis. Adm. Code
Attach complete site Ian on any ST CROIX
p p power not less than 8 12 x 11 inches in sire, Plan must
include, but not limited Im vertical and horizontal reference point (BM), direction and Parcel I.D. 020.1314-50-WO
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all Inlonnation.
iewcd Date
Personal Informerlon you Provide My be used for secondary purposes (PrrvMy Lar, s. 15.04 (1) (m)). 07 � � I � Z ) -j -Z
Property Owner Property Location ❑ El
WILLIAM AND JEANNE B A DERRICK Govt. Lot SW 1/4 NW1/4 S 28T 29N R 19E (or) W
Property Owner's Mailing Address Lot* Blocks Subd.Nemeorr-SMq
4429 DORCHESTER DR 5 1 ST CROIX ESTATES
City a Zip hone umber ity village • own Nearest Road
WOODBURY I MN 55129 ( ) CIY RD UU
0 New Construction UseQ Residential I Number of bedrooms Code derived design flow rate600 GPD
0 Replacement Public or commercial- Describe:
Parent malenal OUT WASH Flood Plain elevation If applicable 11.
General Comments
and recommendations:
L
6 I Boring* u Boring
1_J Q pit Ground surface elev. 90.3 f1. Depth to limiting factor 86 In. IT
Horizon
Depth
in.
Dominant Color
Munsell
Redox Description
pu. Sz. Cont Color
Texture
Struclure
Gr. Sz. Sh.
onsistenca
ndary
Roos
GPD�t '
f1*1
ir*2
A
0-20
10 YR 3/3
-------
LS
0 M Sr,
ML
GW
2M
,7
1.0
B
2048
7.5YR5/4
--------
SICL
3MBK
MVR
GW
2M
.4
.6
C
48-86
7.5 YR 4/6
----------
S
ML
Gp
__
S
1.0
II
tD
_ 1 Boring U Boring G] R
® Pit Ground surface elev. r27 Depth to limiting factor �/ �— in. Application�
Horizon
Depth
in.
Dominant Color
Munsea
Redox Description
Ou. Sr. Cont. Color
Texture
Structure
Gr. Sz. Sh.
.onsistence
Mary
Roots
GPDIft '
fit
MZ
2
ore �
1 5✓ --.
5L
!. M 5,0r.
0-1*
� L✓
1 �
(,
L
�L
6.1�
f�
1/
/ 7
�mwm *1 z ouu > du < "u mgti and T55 >30 < 150 mgrL • Effluent 42 = BOD < 30 mg/L and TSS <30 mg/L
CST Name lease P' / umW
(P Signature/r /i/Q� Z 2•� 4%�e�
Address Date Evaluation Conducted Telephone Number
-p a Oec, /7 ` � 7/S-2s-V-Z149
SB134330(RII/11)
r
SCALE:
0 50 100 NORTH
ELEVATIONS SHOWN ARE
NAVD 1988 DATUM.
�496.2s'
986.84
957.20
U1
T.O.H'. 946.670 -
944 380 1
X 945x I
�soIL TEST AREA 95'
76'
29
996600:53
365' 9581.7
0�.
.0
0
C)
co
LOT 5 71
944.4 '7--
X 9S3.1 62.
52'
2.44 ACRES 2. 9 M
1 0
-7 106475 SF 947.5 96 U
020-1314-50-000 1 958.9
958 1 1 / OT.O.H. 962.88 LEGEND
.7X,
-T.O.p. 962.62 --WOOD HUB SET AT 10'
OFFSET, 15- OFFSET, OR ON
BUILDING EXTENSION
(D z
ALL EXTERIOR BUILDING CORNERS IY O <
'r.42'
MARKED WITH PIN FLAGS. -j
FOUND IRON PIPE PER PLAT OR AS NOTED
TO.H- TOP OF WOOD HUB ELEVATION
TO P.- TOP OF IRON PIPE ELEVATION 'E
0
UTILITY EASEMENT (IJ LLJ
Cn
X.944.4 EXISTING SPOT ELEVATION y
<
F-
SETBACKS (n
LLJ
50'FRONT ME I.- LLJ
10 SIDE MIN,25' TOTAL (D V) T Lf)
25'REAR W ::)
.. ........ ?5 0
Tyk o
W
DOM (n
1, Ty R. Dodge, Wisconsin Professional Land
Surveyor, hereby certify that this Stake -out
Plan was prepared by me or under my direct LLJ C:)
supervision and is correct to the best of my
11/25/2020 knowledcLe and behaf.
1 'i'OF 1
'10010,