HomeMy WebLinkAbout040-1287-30-000 lepartment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
wilding Division
i ' INSPECTION REPORT Sanitary Permit No: 420545 0
.cKAL 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:
Miller, Sam I Troy Township 040 - 1287 - 30-000
CST BM Elev: Insp. BM Elev: BM Description:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark I /
��`J62_ 1 Z SD l � ab•(o X017.0
Dosing Alt. BM
Aeration Bldg. Sewer
M
Holding St/Ht Inlet f • 57t
TANK SE BACK INFORMATION St/Ht outlet l q.8b� 96 . ZS —
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic ' ' > }5 , , 3 t �� Dt Bottom
Dosing Header /Man. I 0 • �S -�
Aeration Dist. Pipe $ems
Holding Bot. System
Final Grade
PUMP /SIPHON INFORMATION w • o f
Manufacturer Pernand St Cover
G
Model Num
TDH Lift on Loss System Head TDH Ft
Force In Length Dia.
OIL ABSORPTION SYSTEM a C v , L
R OI Width t Length I l No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 (02 SU J 3
SETBACK SYSTEM TO P/L LDG WELL LAKE /STREAM LEACHING Manufacturer: .
INFORMATION Type Of System: CHAMBER OR 02 �' S�fIS
� z '� _ Model Number: I D /
DISTRIBUTION SYSTEM
4eader /Manifold Distribution x Hole Size Ix Hole Spacing Vent to Air Intake
S Pipets o f
ngth "— > 4 Dia Length Dia Spacing
IL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
nch Center Bed/Trench Edges Topsoil g p Yes [] No [] Yes L No
?NTS: (Include code discrepencies, persons present, etc.) Inspection #1: Of / 13 CC 3 Inspection #2:
315 Glover Road Hudson, WI 54016 (NW 1/4 SW 1/415 T28N R19W) Glover Pr ' ' arc el No: 1 .19.1629
.ription = rJOT1r9`^^ 6t'2__ CL I `n Z3 ` `�1i 11.4 - cry. mss I
1? Yes XNo A-Y IS --
onal information. Q�
Date Insepctor's Signature Cart. No.
RECEIVED
;. 1 0 2002
LROIX COUNTY '�Z LO V-F- ''� --- -- coo C
ZONING OFFICE
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Safety and BuildintYs 1)ivisaa CO
201 W. Waington Ave., P.O. Box 7162 O JT - C RA f fC
�S a cousin Mattson. � 53707 - 7162 � Address 2 �
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De artment of Commerce Sanitary Permit Number
Sanitary permit Application 'qZC "S
in Dowd With Comm 93.21, Wit. Alm. Code, personal information you provide 0 Check if Revision
ma be used for Pri Law 05-040)(m) State Plan I.D. Number
L 0cm Intoavttion _ p{saaa PrLtt Au Int R -
pareel Number
property Owaar's Name o ( — -,xz
S rp I LL + - N P Location
property Owmr't Mailing Addnes ST.
CROIX, COUNTY �� 5� u• S f TZ N R
I � - / Code r Lot Number Bock Number
City. Star � ..`
CSM Number
II. Type d Building ccbeck all that apply) ocit
/� — P L T L U J �'t. ( ❑Village
i a 2 Family DWelliq - Number o/ Bed:oama
ownshi TeZ
PublWCo WNMW - Describe use , - lI1 �. /� Neatest Road
0 State owned vo -- Te!r r 0- L 4;�' /-,o V E 2 F D
one boot on line A (numbering scheme for Internal use) - Comps line B if applicable)
III, Type of Fmmit: (( only or C
A. I X 3 ❑ Re
anty rase
NeW 2 ❑ System plaoemeat o[ 6 ❑Addition m
Tads Onl Exist= System
:mein Date Issued
�� Patmk Number
B. C) Check d Sanitary )'mums PrevatsdY
N. of Permit: (Cheek all that aPPIP(nntn�Og �e Is for latetval use)
�� 47 ❑Sand Filter 50 ❑Constructed Wetiard
44� Nan _ Io-Grgmrl 21 0 Mound
L 510 Drip Line
410 Holding Tank 48 0 Single Pass
22 ❑ Pretturinod 30 ❑ Other
43 0 At-Grade 46 0 Aerobic Treatment Unit 49 0 Rec irculating
V, t Area n: Percolation Rau Sysum Elevation Final Grade
Dispersal /tea Soil Application Elevation
Dedtn (iPd) �� Area Propoaod Rsoe(dals./Days/Sq -PL) (Min./inch) Low
.� �r
4� rr Y
' t � � Gr � Si Steel Fiber Plastic
t��n g5
Msmtrfictunr� Glass
VL Tank Info Capacity in Total Number Concrete Constructed
Gallons Galloot of Talcs
New Esbtlos
Tanks I Taab
Septic or holding Tact
VII. R bill Statement 1, the tmderdgraed, assume respoadba`h for installation of the POWTS shown on the a ess P plain.
MP/MPRS Number Bu Ph Number
plumber's Name (Print) Plebe I S +� /r Z • V
I ri E I
ptivatbcr't Address (strat. City. StaOe, L) pr,O N L 'J �� r
VIII. Coon /De ent Use Od D Issued Issuing Agent Signature (No StamPs)
Sanitary Permit Fes (includes Grourdwaar
Approved ❑ Disapproved Surcharge Fee)
0 Owner Given Initial Adverse ` 22�� II /r3lo'Z
Dearmination
UL of APPcovaUi;easona fns; Disappr Ao� -
oa�a p1a�a (to the Corp edY) for rte me— M pra ulna Ilri :11 larLes Ya stae
I l SBn -6398 (R. 05/01)
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3
Qivision of Safety and Buildings
e
in accordance with Comm 85, Wis. Adm. Code
'
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County ST. 0.1!.0 X
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road}
Please print all information. R viewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner ROB�t ' ���OT Property Location
N W 114 SW 1/4 S 15 T $ N R l E (or W
Rr -A d� Blo
Maiffng Address Lot # ck # Subd. Name or CSM#
11 p b 3 -, F LE
City State Zip Code Phone Number ❑City ❑Village Town Nearest Road
Hv DSOtiI I.W1 s� of b ( LS) 38b- 3oS1 TTY`-( Gl - uv�Z lzos'rp
® New Construction Use: ® Residential / Number of bedrooms �_ Code derived design flow rate O U GPD
Replacement ❑ Public or commercial - Describe:
Parent n terial G VPN' pr (3vTw 1�& N Flood Plain elevation if applicable N- A
General comments
and recommendations: Rio MM 0 3 CL L •sft E Li 3 r yc V Z S' w ln� 10 U N t�S U H 1}! G b}
C w�I�C t`ry S t DEw yw > QnZ Lef-v� ert t" sL�RS P L-vz ckML .
S�S'Cj Pte{
Boring # ❑ Boring
® Pit Ground surface elev. 9 q • Z ft, Depth to limiting factor ? L S in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2
.�._ �--L3 JD�l231� __ sl I Z`�s h k wL� �� 1'� •`� -$
3{, -�l � — 1 S o Sg Y►�,1 CW . ' �-1 L_ -
Fl- Boring # Boring
® Pit Ground surface elev. O L b '-� ft. Depth to limiting factor
Sdt ication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary I -Root_ - GPD/ft
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Ef f#2
� 13 3$ Lo K cz 3l6 � st 1 Zht S b►z Vn.`F►- Cw — �S ��
2.3LY �S
ss_Lto !v
1-t I?- V& 0 Sg { _ 1, Z
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' Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) I CST Number
Arthur L • Wegerer 1-0 3 -' 220254
Ad dress Wegerer Soil T e s t i n¢& Design Service Date Evacuation Conducted Telephone Number
421 N. Main St. River Falls, wI 54022 1 - DL4 - cal 715 -425 -0165
Property Owner RSZ'L�DT Parcel 19 # N G Page �' of 3
Boring # ❑ Boring
�] Pit Ground surface elev. - 4 - 8 ft. Depth to limiting factor ? f O (z in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots I GPD/ft
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
Z`P m'F�-
ti -31 J 1b v I Z31 6 Z - Yn sbk Yh CAJ - , S •�
3 3) 1
L -sL �.S + = 1 o s� ►,11
S 6 -1 1 [ ►C._ k7 �1 fn
E
F-1 Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in;
Soil Application Rate.
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
i,
• Effluent #1 = SOD, > 30 220.mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L.
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The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777.
SBD -8330 trt.6100i
P Page 3 of
LOT PLAN
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165 220254
CST Signature Date Telephone Ito. CST No. Job PTO.
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Chamber 11" Stan- 'i 4" High 16" High
• • Si zes Dimensi��ns dard Capacity Capacity
Qe� �2 •,. �- RAY ++ ` 71 •.�
; � yr, K ��y+: 4 9' I ;; , l� � °� . �! � � , • ry
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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. C de, dn Ground
Soil Absorption Component Manual for Private Onsite Wastewate Systems
10567 -P (R.6/99).
Table 1: System Design Specifications
j Sanitary Permit Number
Number of Bedrooms
Design Flow -Peak (gpd)
E Flow - Average (gpd) v�
Septic Tank Capacity (gal) f z So
Absorption Component Size (ft') Z SS 1
Type of Wastewater Domestic
Table 2: Soil Absorption Component - Limits of Reliable Operatio Component
Septic Tank Component boil
Design Flow - Peak (gpd) f�c --P' )�-S� R33 1/8
Maximum Influent Particle Size (in) 220
Maximum BOD (mg /L) 150
Maximum TSS (mg /L)
Table 3: Maintenance Schedule
Septic Tank Inspect and /or service once every 3 years
Outlet Filter Inspect once a year nd a 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
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 se and outlet filter shall be assessed at least
once every 3 years by inspection. T e outlet fitted shal be c leaned as _ necessary to_ens�e``
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
more intense, and earlier, organic clogging of the soil.
2
l
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.
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address 3 0 X Yf I S/ t -4 — A S o N Lot s yo / G
Property Address 4 ° 15 /0 V E - k jc o A - U
(Verification required from Planning Department for new construction)
City/State 1-�v fl s N tom, t Parcel Identification Number o yo _ 12 — 30 - oeo
LEGAL DESCRIPTION
Property Location ' / +, ` W ' /,, Sec. . T , N - R / , Town of j 2 0
.Subdivision Co L D V li (L f' �' A 1 41 , Lot # 3
Certified Survey Map # to bd V ; Volume $ , Page # 57
Warranty Deed # &69 9 V L1 Volume L� Page # 7 Z 7
Spec house f yes ❑ no Lot lines identifiable$ 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
masterplumber, journeyman plumber, restrictedplumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal 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
days the three year expiration date.
U (0/3 0 / 02 --
CSTT NAT'LJRE ' OF AP LICANT DATE
WNER CERTIFICATION
i; t' tify (we) cer that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
ro � virtue of a warranty deed recorded in Register of Deeds Office.
(O 13 D l
GNATME OF 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
I Qc7
V01. I Q(4PA61 447 (�
WARRANTY DEED 069584
STATE OF WISCONSIN — FORM 2 K FYI'HLEEN H. WALSH
I<EG1'STER OF DEEDS
DOCUMENTNO. Sf. CkOix, CO., WI
RECEIVED FOR RECORD
This indenture, Made this 25th day of January A.D /14 20Q2' 01 -29 -2002 8:30 AM
between McDonald Homes Tnc a Minnesota yARRAHTY DEED
(Corpora ion /a duly EXEMPT M
organized and existing under and by virtue of the laws of the State of 1'�i�cw�II ed at CERT COPY FEE:
Inver Grove Heights, MN , aiis party TRANSFER FEE: 1102.50
of the first part, and CdPY FEE:
Sam E. Miller, a single person, RECOkDING FEE: 11.00
RAGES: 1
par of the second part.
Witnesseth, That the said party of the first part, for and in consideration of the sum of
$367, 500. 00 --------------------- -----------
to it paid by the said pan y_— of the second part, the receipt w hereof 6 hereby confessed THIS SPACE RESERVED FOR RECORDING DATA
and acknowledged, has given, granted, bargained, sold, remised, released, aliened, convey NAME AND RETURN ADDRESS
and confirmed, and by these presents does give, grant, bargain, sell, remise, alien, convey and First Federal Savings Bank
:onfirm unto the said par of the second part, his heirs LaCrosse— Madison
anc: assigns forever, Cite following described real estate, situated in the Count) of 201 Second Street
St _ Croix _ _ State of Wisconsin, to -wn:
Hudson, Wisconsin 54016
040 - 1061 -60 and 040- 1061 -50
PARCEL IDENTIFICATION NUMBER
Lots 1 through 7, inclusive, Plat of
Glover Prairie in the Tow of Troy,
y,
St. Croix County, Wisconsin.
(IF NFCFSSARY, CONTINUE DESCRIPTION ON REVERSE SIDE)
Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; and all the estate,
right, title, interest, claim or demand whatsoever, of the said party of the first part, either in law or equity, either in possession or expectancy of,
In and to the above bargained premtxs, and their hereditaments and appurtenances.
To have and to hold the said premises as above described with the hereditaments and appurtenances, unto the said par of the
second part, and to his heirs and assigns FOREVER.
And the said McDonald Homes Inc. , a Minnesota Corporation,
party of the first part, for itself and its successors, does covenant, grant, bargain and agree to and with the said parr_ of the second part,
his heirs and assigns, that at the time of the ensealing and delivery of these presents it is well seized of the premises
above described, as of a good, sure, perfect, absolute and indefeasible estate of inheritance in the law, in fee simple, and that the same are free and
cic arfro,n all lncumbronceswhatever,_ except easements, reservations and restrictions
of record,
and that the above bargained premises in the quiet and peaceahle possession of the said parr_ of the second part, his
nc;rs, and assigns, against all and every person or persons lawfully claiming the whine or any part thereof, it will forever WARRANT and DEFEND.
In Witness Whcreof, the said McDonald Homes, Inc., a Minnesota Corporation,
pal o: (h, ilrSl part. hn$ :aux•d these presents to be signed by Todd A, B1erstedt its Vice President,
- -H1ld s _ \Visconsm, and its corporme seal to be hereunto affixed (his
day „f January AD., / 20 02.
SIGNED AND SFAI.F.D IN PRESENCE OF
Mc " sota
C poste
�i ce P n dem
COUNTERSIGNED.
_ S ecretory ,
State of Wisconsin, -
St. Croix Counts s
Personally came before Inc, this 25th day of January AD 0 02
Todd A. Bjerstedt, ► PresidenVI r4/ / / / /J( / / // / 11LZ[[ IZZW -Z /// / / // i5(q(q(Igj
of the above named Corporation, to in e ms who executed the ng insn'umcni, and Io me known to he such President
and Seereiar� of said Corporation, an wle dy�! dt, e xecuteJ the fur oirn hs umenl is such ofhcers a r decd of said Corporation,
by ns authority
THIS INSTRUMENT WAS DRAFTED
No 0.Y r�pfA K ��
a J� Notary Public., St. Croix County, Wis.
STEPHEN J . DUNLAP__ WN1N� � My COInmiSSion (exp es) (is) _ la-. �) Z-003
Hudson, Wisconsin
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STATE OF \VISt.0N11N W Legal Blank Co., InC.
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