HomeMy WebLinkAbout040-1035-10-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety aPrJ Building Division r
INSPECTION REPORT Sanitary Permit No: 430071 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:
Fe ereisen, Tom I Troy Township 040 - 1035 -10 -000
CST BM Elev: Insp. BM Elev: BM Description: ' Section/Town /Range /Map No:
ao.o' CV -0 I Csi 6w• 1 P0c 08.28.19. �I
TANK INFORMATION ELEVATI N DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
� • s (0�0 10.5fl Uo•5
po
Dosing Alt. BM
Aeration Bldg. Sewer •.�O ��Z•o"1
Holding St/Ht Inlet p /
/
TANK SETBACK INFORMATIO yrt S bjA St/Ht Outlet G 1 -o �l•`�3
TANK TO P/L WELL B - Lb G. Vent to Air Intake ROAD Dt Inlet
Septic ,� �• `L ` , I -+ t Dt Bottom
Dosing �-� Hea a Man. 1
Aeration Dist. Pipe wq
Holding Bot. System 12. Z, (>
p. 8A
Final Grade 1 • Q� lo;• :16
PUMP /SIPHON INFORMATION 6 -_ ease
Manufactur r Demand St Cover �•� 3 • • �r
GPM •Zo
Model Number
TDH Lift Frictio ss System Head TD Ft
Force in Length Dia.
SOIL ABSORPTION SYSTE Z(
BED /TRENCH Width Length No. Of Trenches PIT DIMEN ONS No. Of its Inside Dia. Liquid Depth
DIMENSIONS 3
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING M of �t4Tr:
INFORMATION Type Of System: CHAMBER T OR ( T
Model Number: t1
DISTRIBUTIO TEM 'e tc -
Head Mgpif � Distribution x Hole Size x Hole Spacing Vent to Air Intake
y Pip s)
Len Dia Leng Dia Spacing
SOk COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded /Sodded 1 xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
L] Yes U No F No
(Poca tion E NTS I c[Od�,co�gl' crep�ncies, persons present, etc.) Inspection #1: 3L ?'�3 Inspection #2:
. // 449 Townsva lley Rd [[ Hudson,, WI 54016 (SW 1/4 SE 1/4 8 T28N R19W) NA Lot 1 Parcel No: 08.28.19.
1.) Alt BM Description = u k S T. y,NV� t+K►�•.
2.) Bldg sewer length =
- amount of cover = 4Z { e3w COVAr
Plan revision Required? Yes No �"' -�+
Use other side for additional information. _ ± -Q_ �_ ^^�. _ ___ __J
SBD- 571 7) Date Cert.
Insepctor's Signature
Kok—
MA
*\
Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162 ao (}
*is eonsin Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce (608) 266 -3151
Sanitary Permit Applie io i _ State Plan LD. Number
1
In accord with Comm 83.2 1, Wis. Adm. Code, personal info - nation you provide
may be used for secondary purposes Privacy Law, s .04(1)9 t �D 2003 ''' Project Addres (if c ifferent than mai'.ing address)
I. Application Information - Please Print All Information C! l( Y G , ( � ��VMiLC�
r -4) Owner's Na me ! -- - Parcel a Lot it Block fl
(10t Gr^� Gil S �'� A a 0 0 7o d 4 _
perry Owner's M ailing Address 2 1)))1 Property Location
1V J `" 0 ' /a, Sa,Section
City, State Zip Code Phone Number --
l'l W � (circle o tc)
II. Type of Building (check all that apply) T Z3N: R� __E ort
* 9 1 or 2 Family Dwelling - Number of Bedrooms
Sibl;diuiu" Name CSM. Number
❑ Public /Commercial - Describe Use 7 7t -Q V l `7 R q
❑ State Owned - Describe Use 6� TQ ( (�tJ j (Q 9" l t ❑City — ❑Village owuship of
III. Type of Permit: (Check only one box on line A. Comp lete line B if applicable)
A. New System �--- - - - - --
y ❑ Replacement System ❑ Treatment/ Holding Tank Replacement Only ❑ Other Modification to E;;isting System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. Type of POWTS System: (Check all that apply) —
Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade j Single Pass Sand Filter
❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter
❑ Recirculating Synthetic Media Filter Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other explain)
V. Dispersal/Treatment Area Infor ation: 3 /,
Design Fjow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) I Dis e LVAre a Pro ed (sf) System Elevation®
VI. Tank Info Capacity in Total Number Manufacturer Prefab Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanis
-- - -- - -- —
S eptic or Holding Tank /„�) ._ -
U
Aerobic Treatment Unit ! 00 - - - -,
Dosing Chamber W --- —
VII Responsibility Statement I , the undersigned, assumeiresponsibility for installation of the POWTS shown on the a ttac he d pan s.
Plu tier's Na me (Print) Plumb s Si gna re MP /MNumber Business Phone Number
/AJ Plumber's Addre ss (Street, City, State, Zip C e)
VIII ount /De artment Use Only` - - - - -- —
Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Is mg Ag^ t Sig atur Stamps)
g )
Surcharge Fee �` (A
El Owner Given Reason for Denial �ZJ �� �/ (� 3
Co dd off Approval /Reasons for Diis�a�pprj val
Co
���?d [fit- K.+�.- V�- / ���� / •I CJ
Attach complete plans (to the County only) for the sys em on paper not lets than 81/2 x 11 inchef in size
SBD -6398 (R. 01/03)
a:
__. . .
mz
itt
iK
J
V \A
D
� a►
LN
. Af
� f D
BZ
I
t�
1 coip --77
1
l
Z z46��
l000r
k
A
tA
7
,. C.tz.2u5 v
M_
Y
' a
/ �, �.
0
a
0
?� c
ad
co
l�I
Lr
i
� r
W
o
� c
Q
LL O X ^ o
z
i �
GL ,
h
W
t �o
ull 1 Q
0
0
r
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page _ of 3
Division of Safety and Buildings
In accordance with Comm IS US Arim c'`nQJn _
ntyY
Attach complete site plan on paper not teas than d 112 x 11 inches I size. 11IE i =" 5T CR°VX
f point 1
Include but not limited to: vertical and horizontal reference rence po ( B ). dlrectlon and Parcel I
percent slope, scale or dimensions, north arrow, and location and d lance to nearesil road.
JAN 1 4 ? 0 eview y Date I�
_. _
Please print all Information. /„
Porsonat Information you provide may be used for secondary purposes (Priv cy L�w�q 1 ; g1 (� (m)), _ ( t� (G G
Property Owner �vYF -f�` ="T01r _(
��yTm1�1 SES1rJ 114 X1/4 S$ T 28 N R 19 W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# �� f
4M TDWA J ,5NL Pe�vD/NG
City State ADs Zip Code Phone Number 0 City ❑ Village Town Nearest Road
K\w vJT Sy 01b 0 15) Sgt - 36g qo C\-6 TowmsUAtLF-Y �-
New Construction User Residential / Number of bedrooms _ Code derived design flow rata _ —. y�_ _.. - -- - - -• GPO
❑ Replacement ❑ Public or commercial - DescAbe:
Parent material _O ITIN"H _ _..___ -- Flood Plain elevation if appticabie _ —._. N��___ -• -- n '
General comments
and recommendations: ::ty��puA}p Co fJv7,;& T101�1fxL- "t R>E,JJCt��S
' Ot7 LphDlNG �,RT
Boring El F—/ Boring #
Pit Ground surface also. j�,� H. Depth to limiting factor _� � — in. Soil Ilcaticn Bete
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots —1j PD/il'
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 Eff#2
3 m 0 r l ! r Z
10 J Va� (r2—
3 45 K — s Os rn 1�� Ord I , Z
4
13- a v2/
;t3 44- k0� : 57- l
b 47- f YR 5 '
7 to . S � y S S dl --- � D,7 Ir Z
J Boring
Boring # Q
J Pi; Ground surface elev. _q 7! ft. Depth to limiting factor 7 � �� in. S dicaffon Kate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundaryl Roots GPD /ff
in. Munsell Qu. Sz. Cont. C olor Gr. Sz. Sh. i 'Efi#1 'Eff#2
10 I �msbK 3r -Kl 0.7 f - Z
md �r . 5 2 � - 7 Z
;4 m\
' Effluent #1 = BOO , > 30 < 720 rrg1L and TSS >30< 150 mg& Effluent M= BOD c 30 mgll. and TSS < 30 mg/L
CST Name (Please Print) Ignalure CST Number
A Q0 HO�t G"r&- �► ZZ g3?
Address Date Evaluation Conducted Telephone Number
t
WIS b90 Aver IZI E 'FAu -s WT 5402z Or -o8 -o 5 _
IL
I
f
,
$� S' ��yF1C81�ErJ� - Tow k e A 1 A
�A Parcel IDp NI L Page
Property Owner F11�E15�_►a 2�`^ _ice ---
(�
U Boring # Boring G �b g 7 J �a In. Sill Ilcation Rate
Ground surface elev. __ r�D�_ _ ft. Depth to Iimitln factor
Texture Structure Consistence Boundary Roots G 0
Horizon Depth Dominant Color Redox Description •EIVI *E"2 - f
In Munsell Du. 5z. Cont. Colcr { Or. Sz, Sh.
1 C7 -q Me z. / I — ' ( 3f -Ls6K M r c� 34-
m 02 1,2-
Z- 4- 5 ) o YK -~ 5 rn -l- vy , V C s - m 0, 7 1. Z
d
Boring # Boring
❑ pit Ground surface elev. R. Depth to Ikniting tailor ,.�_._ In. Soli Ikstion Rate
Horizon Depth Domnt Color Redox Description Texture Stnrdure Consistence Boundary Roots GPI
in. M Ou. Sz. Cont, Color Gr. Sz. Sh.
'E", Ef(g2
1
I�
1
Boring
Boring tt Ground surlace elev. _ —� _,___ it. Depth to limiting factor
❑ Pit Solt pljcRuon Rate
Horizan Depth Dominant Color Redox �De crlp tion Texture Structure Consistence Boundary Roots GPOlff in. Munsell Qu. Sz. nt. Color Gr. Sz.
Sh. 'ENi11 'EtNt2
'Effluent fil = SOD, > 30 � 220 mglL and TSS >30 5 150 mgll- ' Effluent #2 = BOD < 30 mglL and TSS 130 rng/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•t U0 IR.WWr
�I
000 ��o pA��3
1 Ptz 0MM OWNED; Ev EI2� LE ENO. 4 10
uYEl2 ;FEYE��iSE M
E '
T 29 J Tow OV S 4W Z " G -22"
S 1 C7Zf unD - 115.
� -50fL "INGW/ f3KKFa
NO COMM 63 SMACK PPOPLEM5
3>qc��
rp- Rof oSAD
P�
3 � T
� ► - /Olo.Ct7 �
W o
3 /o ao U
102 ,00
100.00 LE B2
�
O (� gg.00 u
I , n g�
i
CT. F
5'
' Rk W& g j 5lGNEO C5t
ZZLI 3 Z
OA1E: 01- 0V- 03
f r
1
Standard Erosion Control Plan
for 1 & 2 Family Dwelling onstruction Sites
g r
According to Chapters ILHR 20 & 21 of the Wisconsin Uniform. Dwelling Code, a soil erosion control plan needs
to be submitted and approved prior to the issuance of building permits for 1 & 2 family dwelling units in those
jurisdictions where the soil erosion control provisions of the Uniform Dwelling Code are enforced. This Stan-
dard Erosion Control Plan is provided to assist in meeting.this requirement.
Instructions:
1. Complete this plan by filling in requested information, completing the site diagram and marking (✓) appropriate boxes
on the inside of this form.
2. In completing the site diagram, give consideration to potential erosion�that may occur before, during, and after grading.
Water runoff patterns can change significantly as a site is reshaped.
3 Submit this 'plan'at the time of building permit application.
Site Diagram Scale: 1 inch = feet
EROSION
CONTROLPLAN
LEGEND
PROPERTY
LINE
EXISTING
DRAINAGE
TD TEMPORARY
DIVERSION
FINISHED
-' DRAINAGE
LIMITS OF
GRADING
SILT
FENCE
STRAW
BALES
¢5 ?, GRAVEL
VEGETATION
SPECIFICATION
TREE
PRESERVATIO
STOCKPILEr
SOIL
i
indicate r
Please ate
by completing tr
arrow below.
i'
I O c
_
I
PROJECT LOCATION `�"c �►s�1�yAll��r r i4u6:S6o I _ a
—r —r
BUILDER I.. umb 1�sV i't>GR.S LNG, OWNER 1 00 t A ►m fi_4 � iS� Q
EROSION CONTROL PLAN CHECKLIST
1°ia:. Check ( ✓) appro
Q priate boxes below, and complete the site diagram wil'i necessary information.
`
'F
Site Characteristics
Bil North arrow, scale, and site boundary. Indicate and name adjacent streets or roadways.
6 , Location of existing drainageways, streams, rivers, lakes, wetlands or wells.
O lLocation of storm sewer inlets.
Location of existing and proposed buildings and paved areas.
W The disturbed area on the lot.
Approximate gradient and direction of slopes before grading operations.'
Approximate gradient and direction of slopes after final grading operations.
r &J O Overland runoff (sheet flow) coming onto the site from adjacent areas.
1 Erosion Control, Practices
O ,� Lo'cation of temporary soil storage piles. ,
"Note' Soil storage piles should be placed behind a sediment fence, a 10 foot wide vegetative strip, or should be
covered with a tarp or more than 25 feet from any downslope road or drainageway.
Ifi Location of gravel access drive(s).
Note: Gravel drive should have 2 to 3 inch aggregate stone laid at least 7 feet wade and 6 inches thick.
Drives should extend from the roadway 50 feet or to the house foundation (whichever is less).
Location of sediment controls (filter fabric fence, straw bale fence or 10 -foot wide vegetative strips) that will pre -
s.Nent eroded soil from leaving the site.
❑ l Location of sediment barriers around on -site storm sewer inlets.
O !i Location of diversions.
Note: Although not specifically required by code, it is recommended that concentr•?ted flow ( drainageways) be
diverted (re- directed) around disturbed areas. Overland runoff (sheet flow) from adjacent areas greater than
10,000 sq. ft. should also be diverted around disturbed areas.
O CY�Location of practices that will be applied to control erosion on steep slopes. (greater than 12% grade).
Note: Such practices include maintaining existing vegetation, placement of addit:.)nal sediment fences, diversions,
and re- vegetation by sodding or by seeding with use of erosion control mats.
O CV Location of practices that will control erosion in areas of concentrated runoff flow.
Note: Unstabilized drainageways, ditches, diversions, and inlets should be protected from erosion through use of
such practices as in- channel fabric or straw bale barriers, erosion control mats, staked sod, and rock rip -rap.
When used, a given in- channel barrier should not receive drainage from more than two acres of unpaved
area, or one acre of paved area. !n- channel practices should not be installed in perennial streams (streams
with year -round flow.)
O , CB ;Location of other planned practices not already noted.
.....�f.,M• —� —� .,.....� °mow,
_•.
.. . ..... .... . ..
8e �r9
D
L
I LI
.If • -ol'
r
a
Indicate management strategy by checking ( ✓) the appropriate box:
a -
Q = / Management Strategies
❑ C�3' Temporary stabilization of disturbed areas.
Note: It is recommended that disturbed areas and soil piles left inactive for extended periods of time be stabilized
by seeding (between April 1st and September 15th), or by other cover, such as tarping or mulching.
Permanent stabilization of site by re- vegetation or other means as soon as possible (lawn establishment).
Indicate re- vegetation method: Seed 10 ❑ Other ❑
Expected date of permanent re- vegetation: SPA ZvC
Re- vegetation responsibility of: Builder ❑ Owner /Buyer (�
Is temporary seeding )r mulching planned if site is not seeded by Sept. 15 or sodded by Nov. 15? Yes ❑ No ❑
❑ Ce; Use of downspout and /or sump pump outlet extensions.
Note: It is recommended that flow from downspouts and sump pump outlets be routed through plastic drainage
pipe to stable areas such as established sod or pavement.
❑ GYTrapping sediment during dewatering operations.
Note: Sediment -laden discharge water from pumping operations should be ponded behind a sediment barrier until
most of the sediment settles out.
Proper disposal of building material waste so that pollutants and debris are not carried off -site by wind or water.
LET Maintenance of erosion control practices.
• Sediment will be removed from behind sediment fences and barriers before it reaches a depth that is equal to
k half the barrier's height.
• Breaks and gaps in sediment fences and barriers will be repaired immediately. Decomposing straw bales will be
replaced (typical bale life is three months).
• All sediment that moves off -site due to construction activity will be cleaned up before the end of the same workday.
All sediment that moves off -site due to storm events will be cleaned up before the end of the next workday.
Gravel access drives will be maintained throughout construction.
All installed erosion control practices will be maintained until the disturbed areas they protect are stabilized.
For more assistance on plan preparation, refer to Chapters ILHR 20 & 21 of the Wisconsin Uniform Dwelling Code,
the DNR Wisconsin Construction Site Best Management Handbook, and UW— Extension publication Erosion Control for
Home, Builders.
The Wisconsin Uniform Dwelling Code and the Wisconsin Construction Site Best Management Handbook are available
through State of Wisconsin Document Sales, 608/266 -3558.
Erosion Control for Home Builders (GWQ001) can be ordered through Cooperative Extension Publications, 608/262 -3346
or the Department of Industry, Labor and Human Relations, 608/267 -9360.
EROSION CONTROL REGULATIONS
UNIFORM DWELLING CODE (DILHR)
PROJECTS AFFECTED MAINTENANCE AN WASTE DISPOSAL
• All new 1 and 2 family dwellings in Wisconsin started • Sediment controls must be maintained until the site is
on or after December 1, 1992, stabilized by mulching and seeding, sodding or
• Additions to dwellings built after June 1, 1980. landscaping
APPLICATION PROCESS • All building waste must be properly disposed to pre-
vent pollutants and debris from being carried off -site
• Erosion control plan must be submitted with building
permit application to the local building inspector in ENFORCEMENT
communities where the dwelling code is enforced • Erosion control inspections will be made during other
• Erosion control plan must show: regular inspections (footing and foundation, rough con -
- Location of the dwelling, other buildings, wells, sur- struction, final, etc.)
face waters and disposal systems on the site with • Violations must be corrected within 72 hours
respect to property lines • Stop work orders m ,.y be issued for noncompliance
— Direction of all slopes on the site FOR MORE INFORMATION, CONTACT
— Location and type of erosion control measures • Local building inspector
CONTROLS REQUIRED • Department of Industry, Labor and Human Relations
• Silt fences or straw bales along downslope sides and side (DILHR), Safety and Buildings Division, P.O. Box
slopes 7969, Madison, Wisconsin 53707, (608) 267 -5113.
i •
ut 'FftM Gravel access drive
n ! Straw bales, filter fabric fences or other barriers to
protect on -site sewer inlets
,. '• „ • "'Additional controls if needed for steep slopes or other
special conditions
STORMWATER PERMIT (DNR)
PROJECTS AF F iCT'ED — Proposed erosion and storm water pollution control
• Any construction project that disturbs 5 acres or more practices during and after construction
• Smaller sites that are part of a planned development — Documentation that an erosion control and storm
involving 5 acres or more of land disturbance water management plan which meets DNR standards
• Effective October 1, 1992 for any new or continuing has been prepared (plan does not need to be submit-
project ted with the application)
• Exceptions: Indian tribal lands and work done by local —Other information related to site location and per -
: -government staff mit holder
APPLICATION PROCESS CONTROLS REQUIRED
• File a "notice of intent' application (Form #3400 - 161) • Erosion control mea:;ures specified in the Wisconsin
with the Department of Natural Resources (DNR) 30 Construction Site Best. Management Practice Handbook
days before construction begins • Measures to control storm water after construction
• Application must include: FOR MORE INFORIVIATION, CONTACT
— Timetable for land disturbing activities and installa- • Department of Natural Resources, Storm Water Per -
tion of erosion control measures including project mits, P.O. 7921, 1�;adison, WI 53707 -7921, (608)
start and completion dates 266 -7078
LOCAL' ORDINANCES
Check with your county, and city, village or town for any local erosion control ordin .ces including shoreland zoning
r::quirements. Except for new 1 & 2 family dwellings, local ordinances may be more s rict than state regulations. They
inay also require erosion control on construction projects not affected by state or federal regulations.
A publication of the University of Wisconsin - Extension, in cooperation with the Wisconsin Departmont of Natural Resources and Depart-
ment of Industry, Labor & Human Relations, Ron Struss, UWEX Water Quality Specialist, Western Area, and Carolyn D. Johnson, UWEX
Water Quality_ Specialist, Southeast Area.
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer ''"
Y �- Ann L L IZe 1
r
Mailing Address
Property Address
(Verification required from Planning Department for new construction)
f- dKn /0 33' /o D o
City /State gyb,%ow Parcel Identification Number 1?4 DKp 0 37 30 0 0 C)
LEGAL DESCRIPTION
Property Location &W '/4, ' /a, Sec. , T_1i�_N -RJj_W, Town of - T'Ra!j
Subdivision V- S &\
Certified Survey Map # 7 �3� '� p , Volume ��`� Page # !is 3L6
Warranty Deed # 7 13 -5 , Volume `Z Z Sd , Page # _ �_s 0 .
Spec house O yes l no Lot lines identifiable yes O 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.
I/we, the undersigned have Lead the above requirements and agree to maintain the q h private sewage disposal system with the standar
g P g p Y
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
days of the three year expiration date.
Z\ /10 /a>,
SIGNATURE OF 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
the Rroperty described above, by virtue of a warranty deed recorded in Register of Deeds Office.
'5L Z/ 03
SIGNATURE OF APPLICANT DATE
****** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * **
** Inefaide 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
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 (8.6/99).
Table 1: System Design Specifications
Sanitary Permit Number �U
Number of Bedrooms
Design Flow - Peak (gpd)
Estimated Flow - Average (gpd)
Septic Tank Capacity (gal)
Soil Absorption Component Size (ft')
Type of Wastewater Domestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow - Peak (gpd)
Maximum Influent Particle Size (in) 1/8
Maximum BOD (mg /L) 220
Maximum TSS (mg /L) 150
Table 3: Maintenance Schedule
Septic Tank Inspe and /or service once every 3 year
Outlet Filter Inspect once a year and clean at least once 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
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
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
r -
Management Plan for a Septic Tank and Soil Absorption Component
filter is equipped with an alarm t serviced i the alarm is activated continuous)
qu pped w he filter shall be se c d f . y
Intermittent filter alarms may indicate sure flows or an impending continuous alarm. The
Y g P 9
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 i es, and a visual inspection for an evidence of surface seepage or discharge
I
PP
P Y
g
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
more intense, and earlier, organic clogging of the soil.
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.
o Pi 6, X73
715 6117 23�/
CO
2 ptjr/% ,1 6 "�r�
- 71,5 - - to - 6 KS
3
1 2256P 150 t
723353
STATE BAR OF WISCONSIN FORM 3 - 1998 KATHLEEN H. VALSH
QUIT CLAIM DEED REGISTER OF DEEDS
ST. CROIX CO., VI
Document Number
RECEIVED FOR RECORD
S L Tpis l Deed, made between V t/ or m a r, a r7,4 05/29/2003 08 s 35Ad
t r C'�/ `C F E QUIT CLAIM DEED
EXEMPT t B
Grantor, REC FEE: 11.00
and TJL s E TRANS FEEL
COPY Ffifi
/ /S CC FEE:
Q S St.1 r U i V0 lr Mq r. +4 I D'r, in i7P Grantee. PAGfiS: 1
Grantor quit claims to Grantee the following describ� estate in
s
, Grantor
lP I O X ) r County, State of Wisconsin:
0 c Q 'r e c7- 1 �'1 Record ng Area -
f / n / E f / 4/ an � T /t �., Name and Return Address e y t� � e l \ se • t
l 1q o 5� (�� of SPA. V�`1 Tow►�s Valley
N W H see n , �� 5t/o) 16
Af
7 O 6-F Tie
Parcel Identification on Nu (PIN
This homestead property.
o /+
s u t
Vey
3 J 7
p ��a p oc, c.c m e o f li
ecor cct fhe ��5; StPr
on
Together with all appurtenant rights. title and interests.
+� M _P�•
Dated this day of ano
I! C co t (SEAL) i'.07 he yC % y 1Sen (SEAL)
eu�re Z &0
(SEAL) — (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) ,
State of Wisconsin,
es.
County.
authenticated this day of Personally came trefore me this a 4 day of
'OD 1 the above named
rr sew
TITLE: MEMBER STATE BAR OF WISCONSIN to
(If not, me known to be the person who executed the foregoing
authorized by 5706.06, Wis. Stats.) instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY QD Ili ./!� *
Notary Public, St of Wisconsin 4 07'
My commission is permanent. (If not, state on date:
(Signatures may be authenticated or acknowledged. Both are not
necessary.)
Names or persons signing In any capacity moat be typed or printed below their signature.
STATE BAR OF WISCONSIN Wisconsin Lagal Blank Co.. Inc.
QUIT CLAIM DEED FORM No. 3 - 1998 Milwaukee, Wis.
a - 2 3 1 7 0
VOL 17 PAGE 4526
KATHLEEN H. WIL
REGISTER OF DEEDS
ST. CROIX CO. MI
RECEIVED FOR kECOR
CERTIFIED SURVEY MAP 05/28/2003 03:00
RTIFIED SURVE HAP
LOCATED IN THE SW 1/4 OF THE NE 1/4 AND THE NW 1/4 co FEE:
OF THE SE 1/4 OF SECTION 8, T28N, R19W, TOWN OF TROY PAGE • 2
ST. CROIX COUNTY, WISCONSIN.
N 1/4 CORNER
SECTION 8 b
T28N, R 19W OWNERS AND SUBDIVIDERS 3
M NORMAN AND SHIRLEE FEYEREISEN W
O — 6 N- 429 TOVINSVALLEY ROAD
I HUDSON, WISCONSIN 54016
_ o 1— o c
I I I UNPLA TIED 8QIx z
B R /CK SW 114 -NE1 14 LAND
N 89 °23' 35" E 333.21' w x at; m
— — — — — —� 50.42' 282.79' IWO
I S£ 1 /4 -NW 114
W�
LOT 1 WOta.
m� mzo(n
I Q� 3.525 ACRES
° 153,540 S.F.
I OI 3I N INCLUDING .-
TOWN ROAD
'\ N I RIGHT -OF -WAY
PROVED zo ST. C,ROIX C h ° (
.. i r r j 1 I o 3.000 ACRES
U I N h 13os84 s. F. UNPL A_ T_ TED
_
EXCLUDING 50' W
'� AY 2 Z�Q� 3 2 °' TOWN ROAD
8 I o LAND
x_ 3
RIGHT-OF-WAY I ►� — — —
II
I
IF (1Q1 1t>4t ' 'w yVt.Tlf, JU YS W r' , tD O
�pt�F.�val data a i shalt be g I io W 150 I B 1 S
PROPOSED 82 .(n
I DRIVEWAY - EAST -WEST 1/4
150'
------- - - -�Iz -- -- 83 I - -- --
I ZI i
�{ - ' - SECTION LINE
UNPL A T TED I 0� II 0
I I - - 5 0'
LAND I a Iul
DRAINAGE
I z. o WAY LO
47.89' 1 278.38'
I S 89 W 326.27'
x
NW 1 14 -SE 114
o POINT OF
NE 114-SW N BEGINNING
/ w '/4 =o 1 33'' .33� i UNPLA T TED LAND
�W I I I
E I LEGEND
COUNTY SECTION CORNER MONUMENT,
N
ALUMINUM CAP, FOUND.
0 1 1/4" x 24" IRON PIPE WEIGHING
1.68# /LINEAR FOOT, SET.
- — EXISTING FENCE.
S 1/4 CORNER B1 SOIL BORING PERFORMED BY MARY JO
SECTION 8 HOLLISTER ON JANUARY 8, 2003.
T28N, R 19W
- BUILDING SETBACK LINE.
SCALE IN FEET (R-) PREVIOUSLY RECORDED INFORMATION.
*NOTE: ALL IRON PIPE SET ARE DIMENSIONED
AS OUTSIDE DIAMETER.*
0 50 100 200 300
THIS INSTRUMENT DRAFTED BY JEROD A. FINK FARCE r CF F
Vol.17 Page 4526
r
t I
CERTIFIED SURVEY MAP
LOCATED IN THE SW 1/4 OF THE NE 1/4 AND THE NW 1/4
OF THE SE 1/4 OF SECTION 8, T28N, R19W, TOWN OF TROY,
ST. CROIX COUNTY, WISCONSIN.
SURVEYOR' S CERTIFICATE
I, JAMES D. FILKINS, REGISTERED LAND SURVEYOR, HEREBY CERTIFY THAT
I HAVE SURVEYED, DIVIDED AND MAPPED THIS CERTIFIED SURVEY MAP LOCATED IN THE
SW 1/4 OF THE NE 1/4 AND THE NW 1/4 OF THE SE 1/4 OF SECTION 8, T28N, R19W,
TOWN OF TROY, ST. CROIX COUNTY, WISCONSIN, DESCRIBED AS FOLLOWS: COMMENCING
AT THE S 1/4 CORNER OF SAID SECTION 8; THENCE N 00 °56'46" W (BEARINGS
REFERENCED TO THE NORTH —SOUTH 1/4 SECTION LINE OF SAID SECTION 8, ASSUMED TO
BEAR N 00 0 56'46" W) 2476.57' ALONG SAID NORTH —SOUTH 1/4 SECTION LINE TO
THE POINT OF BEGINNING; THENCE N 00 °56'46" W 465.64' ALONG SAID NORTH —SOUTH
1/4 SECTION LINE; THENCE N 89 °23'35" E 333.21'; THENCE S 00 °05'30" E
465.65'; THENCE S 89 °23'35" W 326.27' TO THE POINT OF BEGINNING.
THIS PARCEL CONTAINS 3.525 ACRES, MORE OR LESS, BEING 153,540 SQUARE FEET,
MORE OR LESS, INCLUDING EXISTING TOWN ROAD RIGHT —OF —WAY, AND 3.000 ACRES,
MORE OR LESS, BEING 130,684 SQUARE FEET, MORE OR LESS, EXCLUDING EXISTING
TOWN ROAD RIGHT —OF -MAY. SUBJECT TO ALL EASEMENTS, RESTRICTIONS, AND
COVENANTS OF RECORD.
I CERTIFY THAT I HAVE MADE SUCH SURVEY, LAND DIVISION AND CERTIFIED SURVEY
MAP BY THE DIRECTION OF THE OWNERS OF SAID LAND, THAT SUCH MAP IS A CORRECT
REPRESENTATION OF ALL THE EXTERIOR BOUNDARIES OF THE LAND SURVEYED AND
THE SUBDIVISION THEREOF MADE, AND THAT I HAVE FULLY COMPLIED WITH THE
PROVISIONS OF CHAPTER 236 OF THE WISCONSIN STATUTES AND THE SUBDIVISION
RULES AND REGULATIONS OF THE TOWN OF TROY AND ST. CROIX COUNTY IN
SURVEYING, DIVIDING, AND MAPPING THE SAME.
DATE: FEBRUARY 5, 2003 97Z
REVISED: MARCH 4, 2003 AAES D. FILKINS S -2246 JOB #02 -2660
LII EGISTERED LAND SURVEYOR
OGDEN ENGINEERING COMPANY
ipn 1234 SOUTH WASSON LANE
coov RIVER FALLS, WISCONSIN 54022
JAMES D.
FILKINS a
5.2248 OWNERS AND SUBDIVIDERS
RIVER FALLS, Q 429 TOWNSVALLEY ROAD E I SEN
� HUDSON, WISCONSIN 54016
qr� U R��
� mm�u��unua�a
NOTE: EACH PARCEL SHOWN ON THIS MAP IS SUBJECT TO STATE, COUNTY, AND
TOWNSHIP LAWS, RULES, AND REGULATIONS (,I.E., WETLAND, MINIMUM LOT SIZE,
ACCESS TO PARCEL, ETC.). BEFORE PURCHASING OR DEVELOPING ANY LOT,
� CONTACT THE ST. CROIX COUNTY ZONING OFFICE AND THE TOWN OF TROY.
THIS MAP HAS BEEN APPROVED BY THE TOWN OF TROY.
I
DATE MARGARET ANN DESLAURIERS, CLERK
PAGE 2 OF 2