HomeMy WebLinkAbout040-1287-50-000 Wisconsin Department of Commerce PRIVATE S EWA GE SYSTEM County: St. Croix
Safety and Building Division , � s A S A
INSPECTION REPORT Sanitary Permit No: 405143 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:
Miller, Sam Trov Township 040 - 1287 -50 -000
CST BM Elev: Insp. BM Elev: IBM Descri
TANK INFORMATION ELIEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark 1
10 1 �. o
Dosing Alt. BIM
Aeration Bldg. Sewer
Holding St/Ht Inlet 2
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic 1 { 3 / Dt Bottom
Dosing Header /Man. S- 32(
Aeration Dist. Pipe 1
L 20
Holding Bot. System
PUMP /SIPHON INFORMATION Final Grade 1 zo
Manufacturer Demand St Cover
Model Number
TDH Lift Fric' ss System Head TDH
Forcemain ngth Dia. ell
SOIL-ABSORPTION SYSTEM
BED/TRENCH Width t Length ( No. Of Trenches PIT DIMENSIONS No. CIT P s Inside Dia. Liquid Depth
DIMENSIONS 3 1 -15.
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer.
INFORMATION CHAMBER OR 13 `04c
Type Of Syst m: UNIT Model Num : u
v. b� / e-
5 3 ---
DISTRIBUTION SYSTEM
Header /M 'old IDistribution Ix Hole Spacing Vent to Air Intake
Pipe( s Vo l
Length e- Lengt Dia pacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
Yes [] No 0 Yes E] No
C tt�s
��OMMTNT$: ()nclude ode i p persons present, etc.) Inspection #1 Z.u� Inspection #2:
�� eC' /`t- -f — J
Location: 623 Glover Road Hudson, WI 54016 (NE 1/4 SW 1/4 15 T28N R19W) Pr in? L ' 5 Pa�el�9.1R1
1.) Alt BM Description= IASe' S�: vrvs.. Cs.x� • 3 ) (, °S�tI�M
-2$
2.) Bldg sewer length - :34t :34t I
- amount of cover = ct2 4 . 4
Plan revision Required? o
Yes �
9N
Use other side for additional informati n. ` 3 7.t30Z
Date Insepctor's Signature Cart. No.
SBD -6710 (R.3/97)
Safety acid Buildirtgs Division CO10L
201 W. Wa tingwn Ave., P.O. Box 7162 c
iscon Madison, � 33707 - 7162
Conn Sim AddressAddress artment of Commerce � Permit Number
�� w Sanitary
Sanitary permit Application X051 � 3
In vXMd wilb Co 93.11, Wis. Aft. Code, per"W information You provide ❑Chi if Revision
ma used ftu Pri Law 515. 1
,`' State Plan I.D. Number n
L Applicatim 1��on ' Pkass Prior All Informatoa CE V / r
parcel Number
ptoporgi owoer•5 Name sf h - /,--15 7 - SV -00 v
L L 6Z ooAl Property Locatio
Md
prop" Owar's Usallittf0� S� GR �FF1G S I S ? Sr N I Code a Number Lot Number Block Numbe city. Stan Subdivision Name CSM f k 4 f t
EL d BuRding (dna�k an that apply) ✓ �'PhJ��� Doty illttge
1 or 2 Family Dwelling - Numbec of Bodrooms ❑V
owruhi T D
❑ pubbUCommMr W - Un
Nearest Road )
/a te/
❑ Swe a 3
_ 3 � , ,' a �R l ! a ✓ fete
(Checx on line B it aapplicable) III, Type of Perratt: only one box on line A (numbering scheme for internal use). Comp
1�y or Corm►? uu
A. 1 0• New 2 ❑ �'� 3 ❑ R of 6 ❑ Addition to
Tank On'- stem
Date Issued
Stem
Permit Number
B. ❑ Cbeck if Sanitary permit Pr'oviM*
Lsued
aD that apply)(numbering scheme is !or internal tree)
IV. I'm of Peemlt: (Cbedt 47 ❑ Sand Filter 506 Coa�cructed Wedand,_S1 ✓✓ >
44 Non - In- Ground 21❑ Mound 51 ❑ DriP line *
22 ❑ & 41 ❑ Holding Tank 48 ❑ Single Pass
45 At-Grade
46 C] Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑Other
C1 /!
V. t Ana Information: Percolation Rate System Elevation Final Grade
Dispersal Area D�� Area Soil Application Elevation
>p (gp) Rate(Gals.(DaYdS9.Ft) (Min. /Inch)
. ltequirod i, Prnposod 4,Z C174 /
T g 1_� 0 9 33 0.17
p� Site Steel Fiber Plastic
VL Task info ; in t f rr ia� Concrete
oncr Conatructod Glass
Galloas
New Eawd"
Tanks Taob
Sepac or HoWmg Tank Q
D-4 tom-".
VU. R bill Statement 1, the tmderdgmed, assume raponstbilitY for installation of the POWTS shown on the Business plans.
Piamber's Name (PtM0 Plumber' ;Signaaue ^�
Mp/MPRS Number Business Phone Number
Plttmber's Address (Street• City, State, Cade)
VM. t /De eat Use Onl Date Issued m9 ent Signaa+rs o Stamps)
Sanitary Permit Fee (includes Grourdwater
Approved ❑ Disapproved Surc6ugs,Pee)
❑ Owner Given initial Adverse ,- l+ � 5-
DeSetminstwn �
I1C. Copoltlo5sa o! ApprovaUReosom !or Disapproval � —
:r4?dWy� 0_A_ v
q� 7A Azw'_-W� - �4�
tie Ceoaty say) for on Paper 5 ttl/l
SAD -6398 (R. 05 /01)
j - `� >� /t�oz gletlj5k �e7
y 5w l enA o
ell
00
!S7 7 7 er
a.11
7
Wisconsin Dep artment of Commerce SOIL EVALUATION REPORT 3
Diviwop of Safety and Buildings , I Page of
in accordance with Comm 85, Wis. Adm. Code
County
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must ST. cep )0 x
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel 7"-
percent slope, scale or dimensions north arrow,
o ,and location and distance to nearest road.
Please print all information. evie ed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (rr C' '�•,
Property Owner Property Location
C to GAVE V v� E 1/4 SW 1/4 S 15 T Z 8 N R l E (or W
FFeperIY Q wAedsMailfng Address Lot # Block # Subd. Name or CSM#
t o b etZSry t �tZi Ut S -- GLOV P���t2LE
City State Zip Code Phone Number ❑ City E] Village a Town Nearest Road
}}UDSpIv LAJI I sgOL1 ( LS 38 6 - 3osl TT�� GLUUt;SZ PoPrD
New Construction Use: ® Residential / Number of bedrooms L 4 Code derived design flow rate b 0 o GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent naiterial G /'rC_l t� O u S-ti, t5` H Flood Plain elevation if applicable t-3, A
General comments
,an recommendations: M L N' Z COLS tr(N 3 X c� -1 S r kJ LrL-� � S U I J t
�� 1�1G1�4 e�ACt. 1'S o1=
s�. s��wl _ �tz.s PL`2 e�.r_
` .
�S iilrLrd � `to 12 w► l ki . Ll Fj" . A h.0vo µ'!IQ sc Z Z ,
' Boring # ❑ Boring
® pit Ground surface elev. C 1 -1 - ft. Depth to limiting factor 7 L ly in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - Eff#1 'Eff#2
r p - 3 ) p '-1 }z. 31
Z 13 -3� l0`�ti3tb — Si
S3 -uo !p `1tZ4/l6 O S9 w► 2
Z
T
F q Boring # ❑ Boring
Ground ? L !
surface el q. 'Z
pit e lev. c '1 ft. Depth to limiting factor l7 in.
Soil Application Rate
Horizon
Depth Dominant P Color Redox Description cnp6on Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - Eff#1 - Eff#2
Z'b ►z
3 ►S - -5 231 — 1 c� s9 M1 Lw — .--, L_ Z
lo yrZY1 — - s o gc� I _ ,.�. 1, Z
Effluent #1 = BOD >
30 < _220 mg/L and TSS >30 < 150 m Effluent #2 = <
_ 9/L - BOD 30 m and TSS < 30 m
9n- _
s _ g/L
CST Name (Please Print) Sign ure CST Number
Arthur L: Wegerer CJ =O(- 5 220254
Address Wegerer Soil T e s t i n a & Design Service Date Evaluation Conducted Telephone Number
421 N. Bain St. River Falls, WI 54022 1 - OLj -01 715 -425 -0165
Property Owner �S �2ST'L�T Parcel ID # N G Page Z of 3
Boring # E] Boring ,
Pit Ground surface elev. �) S - ft. Depth to limiting factor 1 S in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots -9 GPD /ft
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2
ZL — sib Z'Fs.�l r�'A- .s . g
Z ZI -y l lO�tz316 — Si1 Zw SbVc )'n
3 � 1 -S �/ � S `9lZ31 — 1S a s9 ► � �yQ — 1 , Z ,
4 Is[ 1D `/0 y/6
v.,
Wd
Boring #
Boring /�) !z C - 1) , j
❑ 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
• Effluent #1 = BOD > 30 < 220. mg /L and TSS >30 _< 150 mg/L • Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L .
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services of
need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608-264-8777.
08 264 -8
777.
sBD•9330 (R•6=)
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PLOT PLAN Page 3 of
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CST Signature Date Telephone ITo. CST N
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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
Y ( ) p
i
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or 9 overnmental 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
Number of Bedrooms
Design Flow - Peak (gpd) Cao 0
Estimated Flow - Average d
9 (gpd)
Septic Tank Capacity (gal) - Z-
Soil Absorption Component Size (ft') - z g S
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)
Maximum TSS (mg /L) 150
4 V42�—�� Table 3: Maintenance Schedule
Septic Tank Inspect and /or service once ev ears
Outlet Filter Inspect once a year an cean 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 shal be c leaned a nec essa toe re
pro per o rn� ation The filter cartridge should not be remove un ess provisions are made to
retain solids in the ank that may sloug o e filter w en 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
now cover over
the component may removal of s Y lead
during winter months. The compaction ore P
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
i
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.
Q clS el r S ✓S S
< a C / �, � �. �, G c• � y Z- 0
3
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer SA f" i /) t L L f__ I-C_
Mailing Address an
S
Property Address 4 1 3 C_ I r y L
(Verification required from Planning Department for new construction)
City/State �/ U Q S tD Parcel Identification Number 4 /0 - 1 7- 526 -COZY
LEGAL DESCRIPTION
Property Location PF ' /., (A) '/•, Sec. t S . T F N - R_Zj � Town of
o �t7 � Lot #
�bdivision '
Volume Page # S�
Certified Survey Map # (0 .
.r,
Warranty Deed # �o `7 S y . Volume / Z Page #
Spec hous �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
master plumber, journeymanplumber, restricted plumber 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.
I/we, 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 of the three year expini ' n date.
GNATURE ICANT DATE
'. : rOWNER 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 : de 'bed a b virtue of a warranty deed recorded in Register of Deeds Office.
`� • . , DSO /0 /02
A P CANT 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
r p
N or 1 8(4PA61 t�
WARRANTY DEED 669584
STATE OF WISCONSIN — FORM 2 i41 FHLEEN H. WALSH
REGISTER OF DEEDS
DOCUMENT NO. S7. CROIX CO., WI
RECEIVED FOR RECORD
This indenture, Made this 25th day of January A.D,/l 092! 01 -29 -2002 8:30 AM
between Mcnnna 1 d Homes . Inc a Mi nnesL)ta WARRANTY DEED
C C)rporati on __ AIVWp(,✓d i duly EXEMPT A
organized and existing underact' by virtue of the laws of the State of 1�Ji�r Alll, famed at CERT COPY FEE:
Inver Grove Heights, MN ,(�LU19{41 party of the first part, and COPY FEE:
Sam E. Miller, a single person, TRANSFER FEE: 1102.50
_ G FEE: 11.00
PAGES: 1
par of the second part,
Witnesseth, That the said party of the first part, for and In consideration of the sum of
5367, 500. 00----- ---- ------------------ - - - - --
to It paid by the Said part V of the second part, the receipt whereof is hereby confessed - _ THIS SPACE RESERVED FOR RECOROING DATA
and acknowledged, has given, granted, bargained, sold, remised, re le l scd, aliened, conveyed NAME AND RETURN ADDRESS
and confirmed, and by these presents does give, grant, bargain, sell, remise, alien, convey and First Federal Savings Bank
:onkrm unto the said par of the second part, his heirs
LaCrosse - Madison
anc assigns forever, tike following described real estate, situated in the County of 201 Second Street
St , Croix _ State of Wisconsin, to - wit: Hudson, Wisconsin 54016
040 - 1 -60 and 040 - 1061 -50
PARCEL IDENTIFICATION NUMBER
Lots 1 through 7, inclusive, Plat of
Glover Prairie in the Town of Troy,
St. Croix County, Wisconsin.
(IF NFCFSSARY, CONNNUE DESCRIPTION ON RE%'FR$ 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 of 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 premises, 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 pan, 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 par 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 n good, sure, perfect, absolute and indefeasible estate of inhertnnce in the law, in fee simple, and that the same are free and
dear from all mcumbranceswhateaer,_ except easements, reservat and restrictions
of record,
and that the above hargamed premises in the quiet and penceahle possession of the said part__ of the second par t, his
nclrs, and assigns, against all and every person or persons lawfully claiming the whole or any part thereof, it will forever WARRANT and DEFEND
In Witness Whcreof, the said McDonald Homes, Inc., a Minnesota Corporation,
party of III, Lrst part, has caused these presentstobe signed by Todd A. Bjerstedt its Vice President
. l/ P/ �id�✓ �f �lnGtl�f�( g�t1d, ���LLU1L1 ////////// L11L11111!_LLL1_
at HudSOri ___, \Visconsin, :tad its corporate seal to be hereunto affixed this
25th day of January AD „ / 20 02.
SIGNI:D AND SEAI FD IN PRESENCE OF
Mc NALD HO S sota
Co borate e
j .. C
Vice Presldem
ODD A. JER T
-” COUNTERSIGNED.
Secretary
State of Wisconsin, —
St. Croix County.
Personallycametx•foreme,tlais 2 5th day of January __ AD �� 20 02
Todd A. Bjerstedt, President l o4l //////////// 11LLU1 /_1L//_LLIZI-
Of the above named Corporation, to in c ins who executcJ the umg instrument, and to me known to fx such President
and Secretary of said Qvporation, an wledy�l th executed the fot oin< its tunern as such officers a ae decd of said Corporation.
by Its authority
THIS INSTRUMENT WAS DRAFTED ~� /f
NO ebSr-
Notary Public, S . Croix County, Wis
____STE
J . DUNLAP µ>Nt►a Nl Commission (expires) (is) Ya- Z) X003
Hudson, Wisconsin
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y STATE OF WISCONSIN WiSC Ons�n La9at Blank Co., In
t�'ARRA,�'TI' WTI)- By L.nrpar�r�on Iurm No. 2 Milwaukee, was
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