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020-1128-20-000 (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, s 15 04 (1)(m)I Permit Holder's Name City Village Township Danny & Nelwyn Jenson TOWN OF HUDSON CST BM Elev Insp BM Elev IBM Cescrobon TANK INFORMATION ELEVATION DATA Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG '."ent ic/ar Mate ROAD Septic Dosing Aeration Holding PUMP/SIPHON INFORMATION Number Head t to W SOIL ABSORPTION SYSTFM Dt Bottom Grade ELEV BED/TRENCH DIMENSIONS Width Length No Of Trenches PIT DIMENSIONS No Of Pits Inside Die Liquid Depth SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR UNIT Manufacturer Type Of System Model Number DISTRIBUTION SYSTEM Header/Mamfoltl Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipets) Length Dia Length Dia Spacmg ovt� �.vv arc x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth of xx Seetletl; Sodded roc Mulched Bed; Trench Center Bed/Trench Edges Topsoil I Yes ❑ No _ Yes No COMMENTS: (Include code discrepencles persons present, etc ) Location: 472 PARK LN 1_1 Alt BM Description= 2 ) Bldg sewer length = - amount of cover = Plan revision Required? L—] Yes [' No I Use other side for additional information SBD-6710 (R 3/97) Date Inspection #1 Insepctor's Signature Inspection #2 Can No S-in► as i — � 1400 E Washington Ave t]oay t C F U i r , 25 202 P.A. Box 71+4 Medime-WIM747-716t ) PCWA �°r NaoBcpobe3$eambyCa) & 33$3T N A ]cation '` gwEe®m of y IVp®L �""l` emw'`�bw b.aoad.eewjlb this heaps aro�ed ptab N�AppTiefaa isc%r #aleawcd POWlS as sd b the Dqwbti of ad Pif®aml Savioes. Praamal iimrfim ym pmvide mq be mW for sernadwy Adbeat(far-- mihng add—) m amwimm with the Pdwaw IsR: 1 SbR �� e L Sfwwaliam-pleaaePYiaiAYLtwwa6� P'°patyOelYa Noe Pattrlt ftpet Oy0 sMa PatperyLoc's ql a PI)n L p'(�C h, �� VR.J�o lk 7. C�ajd/e N 1410101,011 S d N 1 1 V I l� '[3i 1 13I E W —'-- 1L Type of Buffi mg (check 9 dwA apply) tact 17ar2FaoalyDwdtiag-NonbarofBadtaoaa B)oek J� YYY//// StbdniaPmNa ' I. �s "QS t 1 )>,.Il I �"• f+ AO ❑ PublWCo.=W-Dewrbe Uss ❑ Qty af ❑ Smk Owned-Detabe UM .CSM ❑ VNw f Nobar —�� BTa of UI)SGw IIL Type of Fermib (Cbeck mly aw box tm it A COnq*Ie 6e R Irnppilabie) ❑New Sysem Sda= (] Tieaft,=dHOk5; Tank Rcp!®t Only O Ome►[odifi mbm b K Sys (aR'—) B- ❑PaaRReaewal Bef a E:pmfim ❑pcnwx m QBm�geofPlomber ❑PtamitT=isk:rto New Owter LstPteviom Ptree Noba r.dD!ltmed 1V. etmwn (ieckandea a ❑Pte�dbiaomd QA"bade DMd>24o.da4blesnd GMmmd<Mdafaele61eaa7 ❑ilkwmg-ruk ❑OitsDeptad CamI ,( (e>plae) readce t Aaef i*w=Rfiat: gt Sal Appi-b- O.i Mgcm I AmRapkd (s() �S Am Paipesr'(SO Syate•�w �13z CO :7T cwadtyin Tad tdCaOCoin, UedaS_�T..b ,, i'B'aT aT� m t 341� of v VR Qapawiity SNOWS sl- 4 The awdvaIl a:wme sapeiity for 001111IMNIM aftbe P'OWTS aMwe r• the alcarled pba PbtmbdaNaee (Pr's) a1MMPRSN�c Boe>a{bmeN®bv PIPWAWS Ad&= Ci% Z* ) Q7D 1i �u w S' s6� VIK U hY J`, s Pki Re S 1 D"h=ed �e Dail �� 6` ZO Z »L p l C• SYSTEMOWNE 3) pkl -f Jf�_� ((��Q_� [ 1. Septic tank. effluent filter and ll B S T tCj dispersal cell must be serviced I maintained as per management plan provided by plumber. 9 Ail setback requirements must be mamtamed as per applicab;e codekIN"IYaprteadasdwale' araawtbaac+..q..bwp.Ps>.tlsee.aysaureieb.is 11d�ir'riQ SBD 6398 (R, W14) K-•e- x to ma, w.� C4e ^ �- .t, PF IVA i`ri-e; LOCFt 10�/ .A �'ifLa5��5 0 = 8lma�6)tS Wieua. 300I100 C040 f3eJMARk � off" Sip Goa 10 0. Pak k 16bb 50 Lpo(z L+ic.'(�tP�S aaaga� T ��ICopy (.:ONVE-N- ONAL COMPOWENT DESIGN R m MUFT,. Ai D Tn-LE PAGE owners aum ti' II Ly- tv ,11y S i I I:A, Tom: 0 ubStib:! LOUTAT SQ. c, kc" L 5ubdiveim Mavw 1' A (L, i W munter oab- I I d8 ao lu- ()OD rage I Page 2 Samf am ale Pbt pmm Page 3 s skkq a V-mm- Pzo® 4 Pap 5 - FtaT SpEms R aanse filfmma$' Page fia ran Page 7 SL Crate Cis -tQW¢ Tank NttFan1t Page 8 wm� Deed Page 8 CSM a- PL-1 I%I y- Z O:..:iz JA R Des 20 D M)G J �.� 71S�S6-rltx e ffiNuso.�b 3n6At C j4MUO rw poWTS VMBrMn2�5BD-7Q7dnP pp� -pict? 4�� LJ'vruR 300�100 COM60 16bb 9p� STrfi'` oo d� ISDK4Lh�� ' IJo 0 O OIlwPO s , ■ �n g 3x $� � ciJ� py%j h as �hbMhvu � f3eamrlkk l off' s�'pke �m Dou+'nttsk L'ic,MPR5 daa9a� T L a**M- vham4 jr Samade -40 FWV�Et-� Uft V---ft C�Plo J a ,,P Leacxwe itgwrosm ;feF9 Or Obserj2fflon Pine r i 'imfz� f I I TIMIch 2 1 � 4, _(2'n� z ;s 'lia`:'is-�I E�Q€3LTmFN77i -,,"e a.,t � '� if �� gpd Desian _ 7 soya : 8`�'EUSA _y _ I R ST_ CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING -SEPTIC TANK This is to certiflY that I have inspected the septic tank presently ing the AN �v Q I In � �f IV S 0 N . ,se residence located at: Sec_T=N, R_W, Town of up$ bh} St_ oix County, Wisconsin. Upon inspection, I certify that I have found the t and baffles to be in good cond'tio , and it appears to be functioning prope ly. Last time serviced j �a Did flow back occur from absorption system? Yes_ No% line. Approximate volume or length of time: gallons _ Capacity: Construction: Prefab Concrete _ Steel -Other Manufacturer (if known): Age of Tank -'W known) � (h R 4�Aa 96 (Title) (License Numbe (Date) (if no, skip minutes Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes)' licensed disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank conditic certify that the tank, to the best of my knowledge, will conform to requirements of ILHR 83, Wis. Adm. Code cept L"rinspection opening outlet baffle). Name &V Signature MP/MPRS or I Page _ of POWTS OWNER'S MANUAL AND MANAGEMENT FLAN F" INFORMATION Owner I mfluAW' 4S1,I4 Permit # DESIGN PARAMETERS Number of Bedrooms 100 Number of Commercial Units Estimated How (average) O Design flow (DWF) = estimated x 1.5 (aC t Soil Application Rate galtda fft" InHu�f/E loem Quality (13 NA) Moodily AvuaW Fats. ()it & Grease (FOG) < 30 mg(l. Biochemical Oxygen Demand (BODO <220 mg1L Total Suspended Solids (IS.S) < 150 aaWL Pretreated Effluent Quality (O NA) Monthly Average Biochemical Oxygen Demand (SODS) < 30 mgfL Total Suspended Solids (TSS) <30 mWL Fecal CMifosm (geome7ac mean) < 10 cfuf100mI. Maximum Effluent Particle Size 118 inch diameter DRpersat Unit MfgJMedel Number - SYSTEM SPBCMCATIONS Septic Tank Capacity gal 13 N Septic Tank Ma rdhotmer o NA EfucaR Filter Mani fwiti er (3 N Effiacffi Filter Model ❑ N PUWTaukcqacky gad a NA pump Tank mmuditcamear O N Pump Manufacturer O N Pump Model O NA Pretreatment Unit (O NA) a Sand(Graved Filter 13 PeatFfltea O Mechanical Aeration O Welland O Disinfection O Otba: Manufacnaer Modd: Soil Absorption Component (O NA) 0 In -ground (gravity) O In ground(presnuized) Cl At -grade O Mound ❑ Drip -line O Other - Vertical Distaince, Ta akBotram to ServicePad: It HortzooialDistance Tank(s)toScry Pad: ft NA Calculations: Sod Dispersal End Cap (Dtspersal Unit EISA) DWF— ARRliration Rate - = Area Reamed - EISA = or (Trench Width) _ # Units or Thal Length of Trrnch(s1 O -Design of Ptesstae Distribution Networks fur Septic Tank -Soil Absorption S}stems" Publication 9.6 (SSWMP Mnncal) O "ICC Flowtecb Mound Component Manual" Version 1-2 O "EZ Flow Mound Component Manual" Version 8/202007 13 SBD - 10854-P (R- V 12) "At -Grade Component Mammal Using Pressure Distribution" Version 2.0 43 SBD-10705-P(bL01101)-In Ground Soil Absorption Component Manual" Version2-0 O SBD-10691-P (14.01/01) "Mourn Component Manual" Version 2.0 O SBD-10657-P (R.6/99) "DriP-hoe Effluent Disposal Component Ivlanaar O SBD-10706-P (9.01 rol) - teatne Distribution Component Manual- Version 2.0 ba txs! �. at m usI L_ t,a . _y .ss s Service Event Serviceirregraeucy call(SL cum filter At least once 13 months 13 3 yews (3 Other ffi caonok, alamn, Pretreatment unit Am least once - Elmonths 133 Cl NA Flush and test At least once - ❑ months a 3 years O NA START UP AND OPERATION: For new construction, prior to using the POWTS check treatment tankks) for the presence of Painting Products or Mho chancats that may impede the treatmnent process and/or damage the dispersal eell(s). lfbighooncetetrattionsaredetectedbave the orintemaof the tad(s) removed by a septage servicing operator prior to use. SystemstartupsbARotacaw wim red evens are [tuna at the: ui5thative stertaee. The property owner is responsible for the operation ail mainteuence of the POWTS and submission of required reports, Ilse quantity and quality of the wastewater stream will affect the perforce and longevity of your POWTS. The inseailarion of water-Gaving appliances and fixtures along with prompt repair of Yaks redrnces the wastewater volrone. Also the bane 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. Nate: this does not include laundry waste, arownts, dishwater, them This system is designed to handle domestic strength wastewater, however, the diisPo nd Of food based grew, oils, vegetable/fnmit Peels, seeds, bones, and food solids, such as those produced by a garbage disposal shaakl be minimized. Toilet tissue is the only paper tbat should be discharged into the system. Other ram -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, train, disinfectants, ctants, pesticides, antibiotics, solvents, etc., should not be Bushed into the system bacasthey can seriously damage your POWTS andcontarainatevour dn°h°g,stipph'- tiSa�taiasteynU:crmdygowr,y�;.,a.�._ - —�_ Pane-- .W anent¢.CBmQscvtrnoinowovetthedispersalUMMilyCOUSCAMfiet=11D- INSPECTIONS & MA_RITENANCE: Iaspecbm shall be made by an individual c rtymg one of the following licenses or catifications: Master Plumber, Master Ph®ber Restricted sewer, POW'IS Maintainer, or Septage Savicmg Operator (per the attached '✓'a —aace Schedule). Tank inspections mast include a visual -inspection of the tank to identify any missing or broken hardware, zemL'S err. k; &= or leaks, measure the coI-ome of combined sludge and scum and check for any backup or ponding of effluent to the ground sarfax and test all electrical equipment such as pumps and alarms. Any uiefects shall be promptly corrected. Exposed openings greater than g 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 Sc~ Servicing Operator and disposed of in accordance with Ch. NR 113, Wiscansm Admin. Code. Specific servicing mechanics must be provided if vertical is >l5 feet or if hotimmal s >150 fax and instructions to be provided below. The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to manufactutWsspecifications. Solids washed hum the filter shall be retained in the tank. Filter ctearung may be necessary at more frequent intervals than stated in the maintenanceschedule to keep W e system operating. Alarms should be tested on a regular basis by the home owner_ If an alarm sounds, contact an individual licensed to service P OWTS, There is normally a 1 day reserve under regular operating conditions, however water should be conserved until any problems with the system we wed to prevent back -rep of sewage into the dwelling or surfacing. ABANDONMENT- When the POWTS falls and/or is permanently taken out of service the following steps shall be taken to ensure that the system is propel- and safely abandoned in compliance with Ch. SPS 383.33. Wisconsin Admire. 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 other treat 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 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 rules in effect at the time of replacement O A suitable replacement area is rut available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be Dialled as a host resort to replace the failed POWTS. Cl The site has not been evaluated to identify a suitable replacement area Upon falser of the POWTS a soil and site evaluation most 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. 13 Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions ofsuch systems mustcomply with the rules in effectat that time. WARNING!.„! SEPTIC, PUMP, AND OTHF,R TREATMENT TANKS MAY COATIAN r.MIAL GASES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP, OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAYRESULT.RESCUE OFA PERSON FROM THEINTERIOR OFATANKMAYBEDVMCULT OR UIQOSSIBLE. ADDITIONAL COMMENTS: POWTS INSIALLEI l p POWTS MAINTAINER Name: 'lry, 9151, hrQ1 lC ppthec: SBPTAGE SERVICDNG OPERATOR er LOCAL REGULATORY AUTHORrIY Name: V r\\lyu` Name: /ii tr•%% C Phone: l.t' I C J P Phone: 3 1. Force Main: Diameter Length Flow rate Friction loss 2. Total dynamic head: Min. supply pressure Vertical lift Friction loss Total dynamic head = 3. Pump selection: Jenson Pump Chamber Calculations 2" 50' 35.00 gal./min.+ 1_29' (50'K2.58 ft./100') = 1.65 ft. 0.00' (fotcemain discharges to 4" pvc header & gravity feeds into trenches) 8.25' (P.C. bottom = 88.00',Off float — 88.75', highest forcemain invert = 97.00' ) 1.29' 9.54' Manufacturer & Model number: Zoeller BN 53 Pump will discharge approx. 34 gpm (a 9.54' `I'DH (Flow Velocity 3.67 ft./second) 4. Fluid Flow Calculations: (i FO flow through PVC pipe S/B >2 ft./sec & <_ 5 ft./sec.) V— (0.408N34Gpm)=3.46gpm 4 5. Dose chamber manufacturer & capacity: Wieser Concreter')CC;allon pump chamber, liquid depth 37.00" �� 20.28 >;alJinch (75036 Qal actuaq Maximum dose volume: (450gal./5doses/day)+(.164)(50')-9820gallons per dose Tank component is properly vented Wieser Concrete Ca cit700- ea Volume 20.28 Dose Tank Information Manufacturer Gallons gal/inch Dimension Inches fig' 2.001 Gallons 436.04 40.56 A B C9L24 D 9.00 182.52 Total 37-001 750.36 3" rt t Alarm Manuafacturer SJ Rhombus Tank Alert Alarm Model Number SJH 1011421 Pump Manufacturer I Zoeller Pump Model Number I BN 53 Forcerrein diameter 2 in. Weep hole or antr siphon device Nap off elevation ft 88.75 Dose tank elevation M 88.00 s —I 20 15 4 PUMP PERFORMANCE CURVE MODELS 53155157/59 TOTAL DYNAMIC HEAD/FLOW PER MINUTE EFFLUENTAND DEWATERING MODEL 53/55/57/59 Feet Myers Gal. Liters 5 15 43 163 10 3.0 34 129 15 4.6 19 72 9prt-0If Head: 19251L(5.9m) f 1 20 30 1 40 1 GALLONS I UTERS ` —f FLOW PER MINUTE 4 v_ CONSULT FACTORY • . SPECIAL APPLICATIONS cycleVVatiable level foat switches available. c Amailldtge with special cord l .1 of 16,26, 36 and r Duplex -. L _: --ate •_ sr coom saftoow so" 1Fafa mom be& C" LL Wwamsim 11s 1 MID or 1 Y Y N0366f M575B -115' 1 Ilon 9.T 2 3tr4f5 Y Y ' 9N5.8 115 1 Ado 9.7 Y Y • Bw 115 1 Ab ILT N Y • BEB,w me 1 Aib 4A Y Y D53adf D570 130 1 Ado 4A 1 Y Y B5855f E774i9 2M 1 Non U 4 3tr4A9 Y Y qNb owbmdewehfld mw SELECTION GLADE 1. IrAegW*d opwWmdmodmnio9l %vb* no edarla1.4 Iecow 2 Swo mn" bael foal sAifdl a d>Ide pbWjbKc wrbhb fowl loerfwdCk Fbkrb F1r0M. 3 Modwilal d wndar'YPar 1OW2 a 10-W?a 4.SaeF0712faM nlodeld9edrba1Aialdx. 5. Wbbb bwi aalkd aNch iO4M ued w a aA6d adfre►w. wrb 9eclficd Aiemflo; Mm(4) kd oyAm Faitenelmmaddfu.IZee1rP• •� 1"°9AB lxsWNWn of co o*pmhzf nifwr es and wfin9.hWE be dow hYe 4.dfid S,dddAUnd,..FYDr88;Yedw"Afnofw,FWW;SLowrb 1pe®lle.F110487;2W8de Plwee Ilcened.keMdan. All ekddtalead esbb•cud" elwYdbe Mawed lneloam the S NOW POWCawe ft mi 9pimK F110T12 mod r.oiM NdbW �adllc Cad. pEC) .M tM Ooafpedomf 9ddy.no fh.11h Act rysFul. RESERVE POWERED DESIGN For ufuaial condfam a reserve saMy kcw a aWmered iMD tle doign of emy Zoeller pLEV- `oo w rfrfrdae+sa.. e I41:o+fA Nv 4om-1r91.. ,�drr/!)'/g1W -s w Aw- �. PUMP !O. /"°q Trax ~ /P... ® CopyApM 20W Zoeller Co. A# rWfB marled. Dose Conventional Septic System Management Plan Pursuant to SPS 383 54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with SPS 382-384 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD-10705-P (N.01/01). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Boumeester at (715) 760.0117 or the St. Croix County Zoning Department at (715) 3864680. Septic Tank Septic tank servicing mechanics comply with SPS 383.54(1 )(e). Septic tank to be located within 150' of service pad, with bottom of tank to be n 15' below service pad elevation. The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall he removed when the sludge and scum in the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must he replaced. Exposed access openings greater than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthonzed entry into the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Pump Tank The pump (dosing) tank shall be inspected at least once every two years. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent filter is installed at the pump discharge, it shall be inspected and serviced as necessary. Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface within and above the system and will promote frost penetration during cold weather months. Influent quality into the system may not exceed 220mg/L BODS, 150 MGiZ TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will he eliminated by installing anew soil absorption cell to bring the system into proper operating condition. I I I Wisconsin Departrnent of Safety, and Professional Services Page 1 of 4 1 Division of Industry Services SOIL EVALUATION REPORT In accordance with SPS 385, Wis. Adm. Code County Attachcomplete site plan on paper not less than 8 12 x 11 inches in size. St. Crook Plan mist include, but not limited to: vertical and horizontal reference pant (BM), direction and percent slope, Panel I.D. scale or dimensions, north arrow, and location and distance to nearest road. 020-1128-20-000 "2620 Please print all information. Raviewed by date Personal information you provide may be used for secondary Pdv Law, s. 15. t m . Property Owner Property Location d Danny 8 NeWyn Jenson Gov. Lot NE % NE '% S 17 T 29 N R 19 E (or) W �I Property Owner's Mailing Address Lot a Block # Subd. Nine or GSM# !, 472 Park Ln. 16 Na Park View Estates City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road Hudson VA 154016 I (651)303-8514 I I Hudson ❑ New Construction use: ❑ Residential I Number ofbedrooms 3 Code derived design flow rate 4N GPD ® Replacement ❑ Public or commensal — Describe: ' Parent material Glacial Outwash Flood Plan elevation if applicable na R General comments and recommendations: Site suitable for In -ground POWfS with 0.7 gpd/sgAt design loading rate. System infiltrative surface elevation to maintain gravity flow = 91.50' (8.W below grade). Installation of pump chamber recommended to facilitate shallower system installation of 96.50'. Boring # ❑ Boring ® Pk Ground surface elev. 99_97 ft. Depth to limiting factor >748 in. Cnil Annll Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots G D� -Ef1#1 -Eff#2 1 0-26 muii colored none siusl fill na nit na 2fm , 0.0 0.0 2 26-41 7.5yr4/6 none Is 089 di cs 1vf 0.7 ''��i 1.6 3 41-80 10yr4/6 none s Osg di gs - 0.7 1.6 4 80-146 10yr5/4 none gr s 059 dl - - 0.7 1.6 a Boring # °BoHing ® Pit Ground surface elev. 100.20 ft. Depth to limiting factor>144 in. c,ll AvilI r-�hm Rafc l Horizon Depth In. Dominant Color Munsei Redox Description Qu. Az. Cont Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft' 'Elf#1 `Eff+f2 1 0-10 10yr3/3 none sit 21gr mvfr cs 2vf,fn 0.6 08 2 10-18 10yr4/4 none sl tmsbk mvfr av lvf,fm 0.4 07 3 18-28 10yr4/4 none Is Dag ml ar tvf 0.7 1.6 4 28-81 10yr5✓4 none grs 059 ml cs - 0-7 1.6 5 71-144 10yr6/4 now grs Dsg ml - - 0.7,E 1.6 i I - rmrwm ai = a n > an < 270 rmn n.nn roc > %ri < 1 sn .nnn * Pm.m � = n n CST Name (Please Print) Signature CST Number Jaynes K. Thompson 30021 Address* Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane Osceola WI 54020-5413 May 12 2021 15 248-7767 ! SBD-7 (R04/l5) Boring # ® Boring 3❑ ❑ Pit Ground surface elev. 1 W.45 ft. Depth to limiting factor> 147 in. Rnil Ar n.Iknfinn Rath Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont Color Texture Structure Gr, Sz. Sh. Consistence Boundary Roots GPD/Ft2 `Eff#1 `Eff#2 1 0-10 10yr2/1 none sil 2fgr ds cw 2vff 0.6 0.6 2 10-20 10yr4/4 none sl tmsbk ds M 2vff 0.4 ' 0.7 3 20-30 7.5yr4/6 none Is Osg dl cs lvff 0.7 '�� 1.6 4 30-68 10yr4/6 none s Osg di gs - 0.7 1.6 5 6&147 10yr5/4 none gr s Osg dl - - 0.7 1.6 i ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. _ ft. Depth to limiting factor_ in. —1 Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 •Efl#1 •Eft#2 I a ❑ Boring ❑ Pit Ground surface elev. _ ft. Depth to limiting factor _ in. Cnil Aev�lirafinn Rafe Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 `Etf#1 ,; •Eff#2 Effluent #1 = BOD, > 30 5 220 rtg/L and TSS > 305 150 ng/L ` Effluent #2 = BOD, > 30 5 220 mglL and TSS > 30 S 150 mg/L a, 8 .: addo."of sad. ate= �. 1 91rt�t gii3�g4 1/ U �d.F •/� 1 ucd sroG'a�•.•x: � Laem;. /n,f s6A&Au- i .�OW�¢✓B/�tOEroY/I �TL PaX'L�• LeE/G P/<d aFR...t'de�El� AE'i'y'o,wfr JZT19rG,Qflcaj -rl�l Afgod"n,56j 'no�kG.I X P� �a.To-�ve•xo-an . SoF3 ST. CRo NTY SANITARY SYSTEM OfficeFilOffice�ce Use Only OWNERSHIP/ADDRESS FORM Created 2/2021 Community Development Department will utilize this information to provide the property owner with information regarding operation and maintenance of your new or replacement sanitary system! This information will be provided as part of our ongoing efforts to protect public health, your well, groundwater, surface water, property values, and county resources. Once approved, this completed form and educational information will be sent to you by email. OWNER/BUYER INFORMATION Owner/Buyer _ Mailing Addre: City/State/Zip Phone Numbe Email Address Parcel Identification Number ©W> - 11 :8-' Q ' 00 Q (found on the property tax bill) Property Location �!r 1/4 Subdivision Plat Certified Survey Map # NEW SYSTEM: LEGAL DESCRIPTION 1/4 , Sec. T ,.Ili ✓ .1-, R Y W. Town of N 4DS e)Q , Lot #. Volu Page # Warranty Deed # '% 19 *30 6 (before 2006)Volume I , Page #__`— Number of bedrooms Spec house 0 yes 0 no Lot lines identifiable 0 yes 0 no OFFICE USE ONLY New Property Address ' A- (Verfication of new address required from Community Development Department for new construction.) (Staff Initials) (Date) This form must be submitted with oil Private Onsite Water Treatment System (POWTSI applications. New System: Include with this form o 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. Community Development Department - Land Use Division 715-386-4680 St. Croix County Government Center 715-245-4250 Fax cdd0sccwi.gov 1101 Carmichael Road, Hudson, WI 54016 www.sccwi.aov Wisconsln Department of Commerce safety and Building Division GENERAL INFORMATION Personal information you provide may be used for TANK INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) [Privacy Law, s.15.04 (1)(m)l TYPE MANUFACTURER CAPACITY Septic i c r (/ /0 O Dosing Aeration Holding TANK SETBACK INFORMATION PUMP/SIPHON INFORMATION Manufacturer L jjmamd M Model Number 4adonS TDH Lift tam H DH Ft Forcemain Le Dist. to wdi 6Ys71 �e1:r.Ys7:7 O II U7: !.Y'691 � ,S STATION BS HI FS ELEV. Benchmark oozs - Alt. BM Bldg. Sewer St/Ht Inlet Ht Outlet �1 rZ r 3. Dt Inlet Ot Bottom Header/Man. If Dist. Pipe ystem ` sal St Cove / 2 SEDRRENCH Width Length No Of Trenches PIT DIMENSIONS No. Of Pus Inside Die. Liquid Depth DIMENSIONS SETBACK SYSTEMTO PIL JBUDG WELL LAKE/STREAM LEACHING Manufacturer. INFORMATION CHAMNEROR Type Of System >3s >aS / �sd IT Mudd Number 91619 N 1:1111 1410116f&I1 a„ HeadenfManifold Distribution x Hole Sae x Hole Spacing ant to Ak InWke Plpe(s) LengthDie length Die Spacing SOIL COVER . pre..,,ra S...t...,. nnn. vy M.nrnd Or At noada Svstems Only Depth Over Depth Over xx Depth of zx Seaded(Sodded xx Mutoned BedlTrerch Center Bedlrmnch Edges Topsoil Da Yes ®No w Yes ❑f• No COMMENTS: (include code discrepancies, persons present, etc.) 1 OL Inspection Location: 472 Park lane Hudson, WI 54016 (NW 114 NW 114 17 T29N R191W) ParkA" 1Est/ates Lot Prarcel No: 17.29.19.597 1.) Alt BM Description = yJf P` hf4 we e^ 4f r4 AI 2) Bldg sewer length = / - amount /o�f cover = 1 �r Y I.{IGC S �/4 C fCP 3.' 60-N/L �uQ s i� 90aE1 5 e Plan revision Required? U Yes o Use other side for additional informabo D L L / SBDe710 (R &B7) Ode q epctofs Si na re Can. No. M County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN In accord with 15.04 St Croix County Sanitary Ordinance ZONING OFFICE Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER [Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road Hudson, WI 54016-7710 (715)386-4680 Fax (715)3864686 Attach complete plans for the system o t less than 8-1/2 x 11 inches in size County Sanitary Permit # ❑ C I o Pr s application b 0-2 4, 7 I. Application Information - Please Print all Information Location: Property Owner Name r m La 114 /4, Sec "1 \ 1 ,� —n- V\ -Z-- I I I �I '-L N. R E Property Owners Mailing Address co ST CWIX w Lot Number Block Number -1 - �L L �(t iii ty, State Zip Code a Number '`� Subdivision Name or CSM Number kAe)5a -1. 1 sa7,I� C-k r1L—I •E 3 jc I Type of Building: (check one) - amity ❑ Village own of 1 or 2 Family Dw lhng - No of Bedrooms: ❑ PubliclCommercial (describe use): es t Road I )L L- ❑ State awned If. Type line of Permit: (Check only one box on A Check box on line B if applicable) Parcel Tax Number(s) /7t • r ���i(( A) 1.QU � Repair � . ❑ Reconnection 3.❑Non-plumbing . pRejuvenation , Sanitation _ O - 0o0 B) Permit Number Date Issued ❑ State Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) X Non -pressurized in -ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In -ground ❑ Holding Tank ❑ Single Pass ❑ Drip Une ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other V. Dispersal/Treatment Area Information: A.7 (r E',PiST 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4, Soil Application Rate 5. Percolation Rate 5. System Elevation 7.4Mwt•Grade O �S Required Pro'ese0. 2 (Gals./day/sq.tt.) (Min./inch)9� eO Q Elevation pP•So y o A ORyw&7i5 .7 / VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic / L'-5 0-New Gallons Tanks �» Concrete slructed glass Existing I Tanks Tanks wlese„ ct%e it 0 1 fJ L ❑ ❑ ❑ ❑ 2 ? T 7 ❑ ❑ ❑ ❑ ❑ II. Responsibility Statement I, the undersigned, assume responsibility for repair/reconnenctiomlrejuvenatiorYnstallafion of non -plumbing forthe POWTS showmen the attached plans. A license is not required forterraliit repairorthe installation of nor -plumbing sanitation system. PI bees Name pnnt) r, uL13(�2iC(�.T Plumbers Si atu-re (no amps): 1lut ' MP/MPRS No. zz375 Business Phone Number ?IS G �r�s Plumbers Address et, (StreCity, State, Zip C e) 0S I�so s a ,, •) III. County Use Only Disapproved Sanitary Permit Fee Date issued Issm Agent Sign (No stamps) Approved Owner Given Initial Adverse rZs. p �i Determination IX. Conditions 91 A rovallReiison kfor Dl ae roval: n n y n� . OC. p�s.ww1L leer is b�S +. CB+�XfSG t�N �oc�A��� wi $ c16iX 211"1"1 . j /� iv�v„w..X`Bvv. C5ir �r! r s rpce�,cDt aQQsw ` us PX-- ' � tar •� W 1 v, Q. tL.vA S big � - r - k` � T Owe, %v XL�Pl'f�E GYb�'E7�, ,c��orCE',v oP S�?Tcz�D 6u7' VF 5&-)0T7c 7 '- To �. E(�i'srn�G— 4 Wisconsin Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings Page / of Z 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 percent a", scale or dimensions, north avow, a d distance to nearest road. Please print a Penona7lnlormation you provltle may be u s ndery *-ses (P , s W04 (1) (m)). county 5q. 6^o/ )t' Parcel I.D. n 2-O • d'IIYy O 2 O • //1 d R 'awed by Dale 4, Property Owner Ktaw tu \/ OAV to ZA `E l roperty Location ,,--'' vt. lot Nut 1!4 ��1/4 S 7 T 2 IN I9 E (w W Property wne Or's Mailing Address y7Z �i},PK 1-,v.sT cox cl # /Ce Bock # Subd. Name or CSM# p°KU/E!� �STATEs Ciy Stale ZIP Codrl. ,Phorre gFPrC .1 � Co 'A' q9 ❑City ❑Village ®Town Nearest Road yv�So.� Pf�P� ��v . ❑ New Construction Use: Residential / Numb-erofS6s 3 Code derived design flow rate Sb GPO ❑ Replacement rf❑ Public or commercial - Describe: Parent material - �QeEgf/g Flood Plain elevation If applicable N�/� ft. General comments --�-� /OESS '0V&R S-y vOy o07•- /,vi} S, • and recommendations: 00 GF Boring If rt❑s Boring Q ,I aL Pit Ground surface elev. ��•� h. Depth to limiting factor I'0 in. Soil Ap Ication Rafe Horizon Depth In. Dominant Color Munsell Redox Description Ou. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/flz 'Eff#1 •Ef/#2 0-& 10W 313 1— LS /.wf R �� C S f .7 /• Z 2- �O•/ /oYie3 — SL s-r- ,C . 4e c5 / S / •b /o R Zf'SK .I«f•/• 25 -- . s .g SS /o R S. Dl S . OU r- 5 — ? Z D loyx sAl— S. o - J' 7 / `I2. ❑ Boring# ❑ Boring W-10`f'r{ ❑ Pit Ground surface elev- ft. Depth to Ilmlting factor In. Soa Application Rate Horizon Depth In. I Dominant Color Mansell Redox Description Ou. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Bounds GPD/fts 'EH#1 'EfM - emuent a1 = Bvu,, > 30 < 220 mg/L and TSS >30 _< 150 mg/L ' EBluent #2 = BODs < 30 mglL and TSS < 30 mg& CST Nama (Please Print) Signature CST Number 21 RO SERT L1BCC LT- z•2-4375 Address Dale Evaluation Conducted Telephone Number 3/ -0/ -2/5•386•818s Ulbrich( & Assoclatee Private Sewage Consultants �• GD DF_ 655 O'NeII.Rd. / 7 Sr✓ ��22 � S� S���Z2 skew 91015 'elm Uogpni4 'py IIeNA SS9 94uglrou.0.6s.es elenNd semopiw 914o1)QIII SL '00/ .1,ClOd �o Lr01lof/ 19h i SST aoa - 111 Wisconsin Department �-LU Division of Industry Sery Serv7)I'�MMkRjmipt I a �X.� Page l of 4 IL EVA6UAZ U2f-P RT laW4ordan with SPS 385, Ws Adm. Code County Attach complete site Ian o p p 8 1/2 x 11 inc es in size Plan must Include, St. Croix but not limited i vertical a (BM), irection and percent slope, Parcel I.D. scale or dimensions, northd otfl ff= to nearest road 020-1128-20-000 Ref#2620 Please print all information. R viewed by Da e Personal information 2ou provide may be used for secondary purposes Pnva Law s 15 04 1 m ZpL Property Owner Property Location ❑ Danny & Nelwyn Jenson Govt. Lot NE % NE Y. S 17 T 29 N R 19 E (or) W Property, Owner's Mailing Address Lot # Block # Subd Name or CSM# 472 Park Ln 16 Na Park View Estates City State Zip Code Phone Number ❑ City ❑Village ®Town Nearest Road Hudson WI 54016 (651)303-8514 1 Hudson ❑ New Construction Use ❑ Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD ® Replacement ❑ Public or commercial — Describe Parent material Glacial Outwash Flood Plan elevation if applicable na It General comments and recommendations Site sui ble for In -ground POW7S with 0 7 gpd/sq/ft design loading rate System infiltrative surface elevation to maintain gravity flow = 91 50' (8 95' below grade) nst^ allation if pump chamber commended to facilitate shallower system installation oj96 50' Pi x/ VQ.:r�a I19- �iQ-(ut Sn 11 Boring # ❑ Boring ® Pit Ground surface elev 99 97 ft Depth to limiting factor> 146 in r-- Horizon Depth In Dominant Color Munsell Redox Description Qu Az Cont Color Texture Structure Gr Sz Sh Consistence Boundary Roots sun ucauon I<are GPD/Ft2 1 0-26 multi colored none sill fill na na na 2fmc 2 2641 7 5yr4/6 none Is Osg ill cs 1 of 3 41-80 10yr4/6 none s Osg ill gs - Z71 80-146 10yr5/4 none gr s Osg dl - - i-i3- G i— Boring # ❑ Boring ® Pit Ground surface elev 100 20 ft Depth to limiting factor >144 in SoilA7lication Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots In Munsell Qu Az Cont Color Gr Sz Sh •Eff#1 0-10 10yr3/3 none sil 2fgr mvfr I cs 2vf,fm O62 10-18 10yr4/4 none s1msbk mvfr av lvf,fm 04L 18-28 10yr4/4 none Is Osg ml M 1vf 0.74 28-81 10yr5/4 none gr s Os ml cs - 0.7-1.-144 10yr6/4 none gr s Osg ml0.7 �— i o _--- --- --... - .uv 11-- v,' -v-14-G„u,JJ. JV�IJV IT L ease Print) CEPaulsEonLake Signature CST Number JThompson — L� 30021 A ate Evaluation Conducted Telephone Number 3Lane, Osceola, WI 54020-5413 Ma 12, 2021 715 248-7767 SBD-8330 (R04/15) 3 Boring # ® Boring ❑ Pit Ground surface elev. 100.45 ft Depth to limiting factor > 147 in. Soil Anolication Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu Az Cont. Color Texture Structure Gr. Sz Sh. Consistence Boundary Roots GPD/Ftl 'Eff#1 'Eff#2 1 0-10 10y2/1 none sil 2fgr ds cw 2vf,f 0.6 0.8 2 10-20 10yr4/4 none sl 1msbk ds crr 2vf,f 0.4 0.7 3 20-30 7.5yr4/6 none Is Osg dl cs tvf,f 0.7 1.6 4 30-68 10yr4/6 none s Osg dl gs - 0.7 16 5 68-147 10yr5/4 none grs Osg dl 0.7 1.6 Soo Boring # ElBoring ❑ Pit Ground surface elev. k Depth to limiting factor _ in. Soil Aoolication Rate Horizon Depth In Dominant Color Munsell Redox Description Qu Az Cont Color Texture Structure Gr Sz. Sh. Consistence Boundary Roots GPD/Ft2 •Eff#1 'Eff#2 C Boring # ❑ Boring ❑ Pit Ground surface elev. _ ft. Depth to limiting factor in. Soil Anohcation Rate Horizon II Depth In Dominant Color Munsell Redox Description Qu Az Cont Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/FF •Eff#1 •Eff#2 E Effluent #1 = BOD, > 30 5 220 mg/L and TSS > 30 5 150 mglL ' Effluent #2 = BOD, > 30:5 220 mg/L and TSS > 30:5 150 mg/L i qq 5 m /o,&.56,t4e. Assctmed e 14W - ex' (6rd. a 5.'d,•n�, Elul. = /az3i.' '7 tole � PYi3[r /ab M �3 .SGOG'GL �!1 Se,/¢✓a/eeoE:on,p,� Luca&d/p�yo. se�t'e. ♦ EX/s&� grate e(e�! tit ^ �y � /itL wY n Sen son �f7Z ParrL,t. �/udsv�,cJ/. SS<D/G Let/G Pk�efRv�dewEs�E. 0 nEY9AFYt;S.c.J7,T.s5'rl.,.P.rdw. Py +yos0-/rss-zo-an 0. 3owQ Soil Evaluation Notes Danny & Nelwyn Jenson property Pcl. #020-1128-20-000 A Soil & Site Evaluation of this property was completed by James K. Thompson, Dep't. of Safety & Professional Services Credential #30021 on May 12", 2021. Soil color, texture, consistence, and Redoximorphic features were evaluated and recorded on the attached Soil & Site Evaluation Report in accordance with Chapter SPS 385, Wisc. Administrative Code. The evaluation of the site included evaluation of 2 backhoe excavated pits and 1 hand augured evaluation. The parcel contains approximately 1.42 acres. The purpose of this evaluation was to determine the suitability of the site to accommodate a POWTS installation to replace the existing dispersal cell consisting of two drywells that currently serves the residence located on the property. The results of the evaluation indicated that soil suitability is uniform throughout the site, with suitable depths of soil -- 144" - 147". Soil pits 13-1 & B-2 were evaluated to a depth of approximately 8' by direct observation, while the deeper soil characteristics at those locations were determined by use of a hand auger extending down through the bottom of the backhoe pits. B-3 was evaluated by use of a hand auger. The elevation at the infiltrative surface (bottom) of the drywells — 88.09' or 148" below grade. Determination of soil suitability to a depth of 184" to allow the continued use of the drywells was not obtainable within the scope of this evaluation. Pg. 4 of 4 45".TCouNTY NO. 633837 STATE SANITARY PERMIT TOWN AND/O PREVIOUS NO, IVISION (2) NISCONSIN STATUTES (a) The purpose of the sanitary permit is to allow installation of the private sewage system described in the permit. (b) The approval of the sanitary permit is based on regulations in force on the date of approval. (c) The sanitary permit is valid and may be renewed for a specified period. (d) Changed regulations will not impair the validity of a sanitary permit. (e) Renewal of the sanitary permit will be based on regulations in force at the time renewal is sought, and that changed regulations may impede renewal. (t) The sanitary permit is transferable. History: 1977 c. 168; 1979 c. 34,221; 1981 c. 314 Note: If you wish to renew the permit, or transfer ownership of the permit, please comact1he county authority. ISSUING OFFICER - DATE UNLESS RENEWED BEFORE THAT DATE POST IN PLAIN VIEW VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION SBD-06499 (RI1/20)