HomeMy WebLinkAbout040-1262-90-000 t /* i
Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM County: St. Croix
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information ou rovice may be used for secondar p urposes [ Privacy Law, s.15.04 (1)(m)]. 370323
Y P Y rY P p [ Y ()( )l•
Permit Holder's Name: ❑ City ❑ Village p T n of: State Plan ID No.:
Miller, Sam Troy Township
CST BM Elev. : - Insp. BM Elev.: BM Description: Parcel Tax No.:
16 6 r 0 r 040 - 1262 -90 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ZS d Benchmark Z ID. Z U
D Alt. BM
Aeration Bldg. Sewer
Holding (�/ Ht Inlet S S
TANK SETBACK INFORMATION Ht Outlet S l �- 3 Z
TANK TO P/ L WELL BLDG. Air i to ntake ROAD t Inlet
Air
Septic 4- } i NA
D NA Header / Man. q 5 0 /00 -'Z
Aeration N Dist. Pipe u +• Z io
a, an
Holdng Bot. System K . YL
PUMP/ SIPHON INFORMATION Final Grade U %0 3. Z
rer errand St cover 2 / /6 2
Model Number G
TDH Li Friction TDH F ea
rcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED kTRENC Width Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIM 3 12. 3 DIMENSION
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Ma ufacturer:
SETBACK BER
INFORMATION Type O �/ , Mod Num r
System: G 7o 3 r
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. q / Length V-�_� AJ& Spacing S(!
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over FBed h Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Tren ch Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS (Include code discrepancies, persons present, etc.)
Inspection #1: y1 Inspection #2:
Location: 537 Tulgren Street, Hudson, WI 54016 (NE 1/4 SW 1/4 5 T28N R19W) - 0528191417 Frontier -Lot 9
1.) Alt BM Description 3�
2.) Bldg sewer length = > S�' rHS u�- v e 4.5 ''k 4A-/ �.
-amount of cover = >/� ; >yz �� 6 %,f s�w�� a•r5 Zo' 11�s�•r- sf %H / f
1 / L ( I , ` 1
f r , r� S c� GQr w e� �.
Plan revision requl d? ❑ Yes C�7 No
Use other side for additional informwion.
SBD -6710 (R.3197) Da a Inspector's Si ature Cert. No.
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ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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53 Twl Gn1 "� Sanitary Permit Application Safety & Buildings Division
201 W. Washington Ave.
In accord with Comm 83.21, Wis. Adm. Code PO Box 7302
`�. �JC��sfi�i See reverse side for instructions for completing this application Madison, WI 53707 -7302
Department of Commerce Personal information you provide may be used for secondary purposes (Submit completed form to county if not
[Privacy Law, s. 15.04(l)(m)] state owned.
Attach complete plans to the county copy onl stem, on paper not less than 8 -1/2 x 11 inches in size.
County State Sanitary Permit Num Q ifte)tision to previous application State Plan 1. D. Number
�1f : c�ee t 3�• � ` � ,
I. Application Information - Please Print all In r n o Location:
Pro Owner Name Y Property Location
/ [y r
Ply t jig t` T2VN 1 //E o
I/4 I/4 S ,
property ownces Mailing Address -1 Lot Number Block Number
Zi Code khntme Number Subdivision Name or CSM Number
City, State P"
❑ City
X I. Type of Building: (check one) ` — - t ❑ Village
1 or 2 Family Dwelling - No. o> Bedrooms : - t k ' ; Town of T c y
Public/Commercial (describe use :_ 1 1
❑ State -Owned �•s Nearest Road
3�.TAE N s x? �/'3 Nprnf/Ls �N �T AIC 7 - KEN qz;'"ot
? 9_ J p
� �L- � /i "�T' r --� � / [� � Parcel Tax Numbers) D y0. 1 � ? ►'Q„ O D
III. T e of Permit: Check only one box on line A. Check box on line B if a licable 19 • ( L 4 I 1
A) PD ew 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑Addition to
System System Tan Onl
Existing System
Permit Number Date Issued
B)
ity Perm it was reviousl issued
W. Type of POWT System: (Check all that ap ty ❑ Sand Filter ❑ Constructed Wetland
� on- pressurized In- ground Lf 4c 14 ❑ . ound
❑ Pressurized 1 - ground t olding Tank ❑ 1l ❑Single Pass ❑Drip Line
❑ At- de 3 3 81•zs .. n Aerobic Treatment Unit ❑ Recirculating ❑Other:
V. Dispersal/ Area Info rmation:
t.. Design Flow (gl;d) 2. Dispersal Areas. Dispersal Area 4. Soil Application 5. Percolatior. Rate 6. System Elevation Elevation Grade
Required Proposed Rate (C61s gs Tvlinlinch) oQ / O tdQ
v
VII. Tank Capacity in Total #t of Manufacturer .Frefab Site Steel Fiber- ass Plastic
Information New Gallons Tanks Con- Con- g
New Existing cretc structed
Tanks Tanks ❑ ❑ ❑ ❑
_.. X 1260 _ SF ❑ ❑ ❑ ❑ ❑
VIII. Responsibility Statement
I, the undersiEEed, assume res onsibilit for installation of the POWTS sho on the attached plans . Business Phone Number
Plumber's Name (print) Plumber's Signature (no tamps): MP/MI RS No.
Plumber's Address (Street, City, State, Zip rode)
a 1 ( 5v W �l
IX. County/Department Use Only
❑ Disapproved Sanitary Permit Fee, (Includes Grommdwater Date Issued Issuing Agent Signature (No stamps)
CH Approved rm❑ Owner Given Initial Adverse charge Fee)
Deteination a ]b _ zMD
X. Conditions of Approval /Reasons for Disapproval: '
I
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Wisconsin Departmentof Commerce SOIL AND SITE EVALUATION Page I of 3
Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
A.C.E. Soil 8c She Evaluations
Attach complete site plan on paper not less than 8'/: x 11 incase in size. Plan must County
tnctude, but not limited to: vertical and horizontal reference pant (Blur, direction and St. Croix
percent slope, scale or dimensions, north arrow,
Pisa
, and I ` F. iorr ani�ttist�nce to nearest road. Parcel I.D.#
Prt of 040-1021-90
APPLICANT INFORMATION - al/iii'forniatio11, g Date
Personal intonnation You provide maybe used for purpos(Privacy Law, s. 15.04 (1) (m)). mewpd
Property Owner L' P r Location
Miller, Sam Lot NE 1/4 SW 1/4 S 5 T 28 N,R 19 W
Property Owners Mailing Address I Pt "` [ A .Lot Block # Subd. Name or CSM#
P.O. Box 151 u 37 Ck x 9 Plat Of Frontier
City State ,Code Phon City ❑ Village ®Town Nearest Road
Hudson W1 5 Q 16' 'ft -Z'f6 , Troy Tower Road
® New Construction Use: ❑ Resi at ftmti it s 4 ❑Addition to existing building
❑ Replacement ❑ Public or con esaibe
Code Derived daily flow 600 gpd Recommended design loading rate .5 bed, gpd/ft .6 trench, gpd/fi
Absorption area required 1200 bed, f1 1000 trench, ftz Maximum design loading rate .5 bed, gpdr .6 trench, WNW
Recommended infiltration surface elevation(s) 100.00. ft (as referred to site plan benchmark)
Additional design / site consideration Install tren ches using high capacity infiltrators. Maintain system location as far east as possible.
Parent material Glacial outwash y °t `� Flood lain elevation, if a licable NA it
S= Suitable for system Conventional Mound In - Ground Pressure AT - Grade System in Fill Holding Tank
U= Unsuitable for system ❑ S® u ❑ S® u ❑ S ®u ❑ S® u MS 0 u ® S❑ u
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPDIft2
n9# Horizon in. Munseli Qu. Sz. Cont. Color Texture Gr . Sz Consistence Boundary Roots ged ;Trench
1 1 0 - 10yr3/2 None A 2fsbk mvfr as 2fin,lc 0.5 0.6
2 12 -26 1Oyr4 /4 None sl 2msbk mfr gw 2fin,lc 0.5 0.6
Ground 3 26 -55 10yr4/6 None sl 2msbk dsh aw if &m 0.5 0.6
elev
106.04 ft 4 55 -97 10yr5/4 None s &gr Osg dl gs - 0.7 0.8
Depth to 5 97 -117 10yr6 /4 None s Osg dl - - 0.7 0.8
limiting
factor ao 0
>117'
Remarks:
1 0 -22 1Oyr2 /1 None sl 2fsbk mvfr as 2ftn,lc 0.5 0.6
2 22 -31 1Oyr3/3 None sl 2msbk mfr gw 2f,1mc 0.5 0.6
Ground 3 31 -54 10yr5/4 None sl 2msbk dsh aw if &m 0.5 0.6
elev
107.17 ft 4 54 -62 10yr6/4 None is Osg dl gs - 0.7 0.8
Depth to 5 62 -124 1Oyr6/4 None s &gr Osg dl - - 0.7 0.8
limiting
factor
>124'
�'•� ZZ.D� --
R 12" diameter silt pocket observed in horizon #5 m2d7 5yr5/8 reder4. features observed at outer edges of silt inclusion result from greater
matric potenW of silt to 2=ding sand. Redox. features are not indicative of groundwater,
CST Name (Please Print) Signature: �_ Telephone No.
IC Thompson / 5- -- -- 715- 248 -7767
James
;�
Address A.C.E. Soil & Site Evaluations Date CST Number Ref#
340 Paulson Lake Lane, Osceola, WI 54020 12/31/99 3602 1157
PROPERTYOWNBL' Miller, Sam SOIL DESCRIPTION REPORT l + + s7 Page 2 of 3
RCEL
PA I,D.# Pn of 040- 1021 -90 A.C.E. Soil & Site Evaluations
Depth Dominant Color Mottles Structure GPW
Horizon in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. siste<toe t3oundary Roofs
Bed Trench
3 1 0 -17 10yr2 /1 None sl 2fsbk mvfr as 2%m 0.5 0.6
2 17 -33 1Oyr4/2 None sl lmsbk mfr gw 2f,lm 0.4 0.5
Ground
elev 3 33 -70 10yr5 /4 None ifs lmsbk dsh gw if &m 0.5 0.6
103.74 ft 4 70 -87 l Oyr5 /4 None is eosg dl gs - 0.7 0.8
Depth to 5 87 -123 10yr5 /4 None Ifs & s Om & Osg dl - - 0.4 0.5
limiting
factor
>123
Remarks: H #5 consists of a mixture of Om ifs & Osg s. Horizon loading rate adjusted to reflect most restrictive soil condition.
4 1 0 -28 10yr2 /1 None sl 2fsbk mvfr as 2fin,lc 0.5 0.6
2 28 -43 10yr4 /2 None sl Om. mfr gw 2f,lm 0.3 0.4
Ground
elev 3 43 -56 10yr5 /4 None Ifs Om dsh gw 2f,lm 0.4 0.5
100.29 ft 4 56 -66 10yr5 /4 f2d7.5yr5/8 Ifs (Lm dsh cw -'
Depth to 5 66 -120 10yr5 /4 None is & s Osg dl - - 0.5 0.6
limiting
factor
>120
Remarks! consists of a mixture of stratified Is & s. Loading rate adjusted to reflect penMvability restriction assocaited with stratification. One
foot rue avolied to dwegam redox. features found in
5 1 0 -26 1Oyr3/2 None sl 2fsbk mvfr as 2fin,lc 0.5 0.6
- 2 2638 1Oyr4/2 None sl 2msbk mfr gw 2fm,lc 0.5 0.6
Ground
elev 3 38 -50 10yr5 /4 None sl 2msbk dsh aw if &m 0.5 0.6
100.21 ft 4 50 -65 7.5yr4/6 None is Osg dl gs - 0.7 0.8
Depth to
limiting 5 65 -118 10yr5 /4 I None s Osg dl - - 0.7 0.8
factor
>118
Remarks:
Ground
elev
Depth to
limiting
factor
Remarks:
r
3 or3
Pro. P&C Orfl- n4 ✓ ,�tC¢: / = s!o
0. /S/ /1 EyYSwrq See., 5 A /9u7
s�lol� ✓ P, -E
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PrrMao y 5ysfe 61
Af cq
43
■ Q�,oCace•r,�..,f A rea z is ct�'
By ■
0 0{'
re bear: 4 s su -+l,
¢ /fLA
�►fr`d /off S•Ea�('?
E/eO-
X58, 29 �
Fu
u.re
`\\� _ down
road
Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In- Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWTS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
10567-P (R.6/99).
Table 1: System Design Specifications
Sanitary Permit Number 3 3�'3
Number of Bedrooms
Design Flow - Peak (gpd)
Estimated Flow - Average (gpd)
Septic Tank Capacity (gal) k
Soil Absorption Component Size (ft) SAWV&l
Type of Wastewater Domestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component _
Design Flow - Peak (gpd) Zbo o -V
Maximum Influent Particle Size (in) U 1/8
Maximum BOD (mg /L) 220
Maximum TSS (mg /L) 150
Table 3: Maintenance Schedule
Septic Tank Inspect and /or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
t .The contents of the septic tank shall be disposed under s. 281.48 Sta s p
P osed of in accordance with
11 Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping NR 3, ( g p g P 9 Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
P
Restrooms).
The operating condition of the septic tank and outlet filter shall be assessed at least
once every 3 years by inspection. 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
Management Plan for a Septic Tank and Soil Absorption Component '
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole 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
be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
organic clogging more intense, and earlier, g g of the soil.
9 9
2
Management Plan for a Septic Tank and Soil Absorption Component
Plantings of deep- rooted trees and shrubs directly over or within ten feet of the
component should be avoided since root intrusion into the component may obstruct wastewater
flow.
3
pp
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer !29& 094 L ��
Mailing Address 8 )e /
Property Address S 3 7 , V 4.. Ce (Z E
(Verification required from Planning Department for new construction)
City /State H V 1) SO 1V Parcel Identification Number O 9/0 - Z �O 2 g 4 d
LEGAL DESCRIPTION -7-
Property Location N %4, S W '/,,Sec. �� T N -R `� own of 1 " Y
Subdivision Lot # /
Certified Survey Map # to i 5 5 , Volume Page # 1 W `/
Warranty Deed # X 4 S q 1 , Volume 1 y y Z , Page # L
Spec house yes ❑ no Lot lines identifiable 'o yes ❑ no
SYSTEM MAINTENANCE
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.
The property owner agrees to submit to St. Croix 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 1/3 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 Commerce 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 Zoning Office within 30
P p-jD f the three year exp' tion date.
I 3 r � 0� /o�/
ATURE F APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
f perty described abov b virtue of a warranty deed recorded in Register of Deeds Office.
= ''SIGNATURE PLICANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * **
** Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
J
Vill1442ME 42
STATE BAR OF WISCONSIN FORM 2 • 1999 460684 1
KATHLEEN H. WALSH
REGISTER OF DEEDS
Thk Deed, made between Kathryn B. Tuleren, and Ferris — ST. CROIX CO., WI
_R_ T1jgren vi fe apd l&ui9�d
RECEIVED FOR RECORD
�z
Grantor, conveys and warrants to 07- 14-1499 11:00 11
Sate E. Miller, a single person. WNARNTT 00
El01PT 1
` Grantee. CERT Copy FEE&
Grantor, for a valuable consideration, conveys and warrants to Grantee COpr FEE:
TRIWSFER FEE: 2221.10
the following described real estate in St. Croix County, State of RECORDING FEE: 12.00
Wisconsin Ole "Property *): ms: a
Recordim Area
Name and Return Address l
001022-10:001022-30; 040• IMI.90:
040-1029-20:040-10211-70
Parcel Idensifkation Number (KM
This is not h mealmad property.
j
(See Attached Exhibit `A')
Exceptions to warranties: Easements, restrictiorus and rights -of -way of record, if any
Dated this 13th day of July, 1999.
• • Kathryn B. ulgrc�
Ferris R. Tulgren
AUTHENTICATION ACKNOWLEDGMENT
Signaturc(s) STATE OF WISCONSIN )
) ss.
authenticated this _ day of St. Croix Couny )
Personally came before me this 13 day
• of July, 1999, the above named Kathryn 9. Tularm.
and Ferris R. gren; xtfe arty --
TITLE: MEMBER STATE BAR OP WISCONSIN to
(If not, _ me mwn to the per s) Wllo executed the foregoing
authorized by 4 706.06, Wis. Slats) instru and ackl I ' ye the same.
THIS INSTRUMENT WA5 URARTED BY
Attorney Kr6thm Ogland
Hudson, WI 540i6 mulUf1public, State of Wisconsin
(Slgruarel Very be suthenlicated or ackrowiedged. Berth are rot My Commisslo u ne m (i t tot, suite otpiradon date:
C1 '
neGry ) $reada Poulin 7 f f r �
Notary Public
State of Wiscunsin
•Name& of person signing In any apsciry should be typed or printed below their signaaues
WAAAAMy DUD VATS "A Or WricoHm
rOaM W.I•Im
avF0aaeArl0M ►110F ea4011k a COWANY FOWDIrtAC,M 80"a42021
r 1442 43
EXHI
BIT "A"
in the NE of SE of Section 8 and in the NW 'A
That certain parcel of land located Township
ALL in
28 North, Range 19
of Wisconsin more y described as follows:
Of SW '/+ and t Tr full
St. Croix County , '08 "
Section 5� 5 thence N87 °51
Beginning a West, Town of Y
t
the West quarter comer of said line of said Section 5) a distance of
on the East -West quarter line
(recorded bearing
Of Se 2342.24 feet; the
nce S00 °13'24 "E. 854.00 feet; theecalo 87 sa d East I ne, 00 feet o a
thenc
point on the East Ilse of said NE '/• of corner /�� o said NW '/• of SW '/•
08 feet to the SE corner of said NE' /, of SW ' /•; thence along the
S00 °13'24'F 46 f;7 °54'54 "W,
South line of said NE' /4 of SW' /+ and the South l� X70.48 teet; thence S said
S87 °54'54 "W, 2372.41 feet; thence N00 °3 said
thence along
91 feet to the monumented West line of said NW I A of SW '
273 ° � " 9416 feat; thence
West line, N00 °30'28'E (fecorded as N01 32 36 E). .2
° '13 "E (recorded as
" ed as N63 °54' "W) . 458.40 feet to the North line of said NE '/•
N64 "W (r ecord said North line, N88 20 to the Po
of SE' int of
/+ ction E }, 478.69 feet (recorde
6; thence along
.88-4019T and N89 °24'42 "d as 25 Y• rods
Beginning•
i
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