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HomeMy WebLinkAbout040-1287-60-000 i L7 L-QT S ,4 c.. 7 F ni N .4 'r �—r tA 3 r � � _L 3 ! G2 i C ��_� brit r�� ►��FS (�j - T��.� -� T��,cc�! i fo AAA � Y ov . � M to i m I' i � .L 7 -r13 I 2$ C� e f ti Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix t Safety and Building Division INSPECTION REPORT Sanitary Permit No: y 408258 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 I Troy Township 040 - 1287 -60 -000 CST BM Elev: Insp. BM Elev: 7BMDescription: TANK INFORMATION Fl- EVAtION Fl- DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic L ,Z Benchmark �. 'os• --0 Dosing 7`' Alt. BM 7i /ly • j �•SZ. q�.18' Aeration Bldg. Sewer 6 •�� 9t r Holding St/Ht Inlet x•28 �.�' St/Ht Outlet TANK SETBACK INFORMATION• �,9} TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic /V ,( 2Q' Dt Bottom Dosing kvt tff Header /Man. �ID. 1 n s,` 0 ' Aeration Dist. Pipe t '[ lu Holding Bot. System r PUMP /SIPHON INFORMATION Final Grade C / 5 ' $' C r+ , 0 ' Manufacturer De St Cover 2 •�� fO � ,' �/ Model Nu m 7 TDH Lift 'on Loss System Head T Ft For cema' Length Dia. Dist. to Well SOIL RPTION SYSTEM REN Width Length t No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMEN IONS 2 SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Ma facture INFORMATION CHAMBER OR t G GL's Type Of System: UNIT NN . ti� Model Num �' M DISTRIBUTION SYSTEM Header /Manifold 4 Distribution x Hole Size x Hole Spacing Vent to Air Intake 4 --�' 11> M' Lengt Dia Length Di Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of eded /Sodded xx Mulched r Bed/Trench Center Bed/Trench Edges Topsoil A Yes F] No [ Yes L No COMMENTS (Include code djgcrepencies, persons present, etc.) Inspection #1/17 -- 4nspection #2: J J A P - lao ev G 1- << - Location: 629 Glover Road Hudson, WI 54016 (NE 1/4 SW 1/415 T28N R19W) Glover Prairie Lot 6 Parcel No: 15.28.19.1632 1.) Alt BM Description = AW / s t 2.) Bldg sewer length = 20 - amount of cover = a Plan revision - -- r additional inf ormation. Yes No Use other s de fo Re -- SBD -6710 (R.3/97) Date Insepctor's Signature Ce 44 ` Camay Safety and Bullduhgs 17ivision �A 20l W. Washington Ave., P.O. Box 7162 isconsin Madison, Wt 53707 - 7162 S� Address 6 3'S'J 5~ fo 29 LnvCa? RD Depart ment of Commerce O 0 • N r Saa`tiry Sanitary permit Application 0 5 0 in accord with Comm 83.21, Whs. Adm. Code, Peraoosl information you provide ❑ Check if Revision ma be used for Irivacy Law a15. 1 m State Plan I.D. Number L Ap - Pkaas Paint All nuormatlon parcel Number propom Owner's Nam° — �p0 -' Ot)D 40 129 S � ' . I property Location q Propetq Ownar'a matting Address E4! wu S S T Z� N R' l E 26,X Lot Number Block Number zip Code Phone Number � Cky• Stan CSM Number Subdivision Name 1 t-� 0 S a W1 ► LOV EIt— 2i4 E n. Type of Building (cbock an that apply) ; L'� SPj / T f L A N Ocky 1 or 2 Fturrty Dwellft - Number or Bedrooms C] PubliclCWMMr W- Desor� Use o est R 2 O Nearest Road t/a c,H of RL t41) owned f - �� `P3.7�" IS - -� lets Une B if aPP _ T� scheme f internal use). Come livable) III. Type of Permit: (Check on umbering or Camty ore or A. 1 New 2 ❑ Sy� 3 0 Replacement of 6 0 Additim to Tank Od stem Dare Issued soem Permit Number B. 0 Check if Satsitary Pezmk Pm * Isnhed Check l b an that sppy)(numering scheme b for internal use) ; o D: Ft u5 ><� ,C l`/4cf� /K G Ch tsllGsr 5 IV. Type of Permit: ( g/s A /? �1'1b0 ►. / Non - Pressuri>7od hrGcotmd 210 Mound 47 ❑Sod Filar 50 ❑ Conswct SO A - 44 '��w+ri[•*o'^S C.� f L� 41 410 Holding Tank 48 ❑Single Pass S1 ❑Drip Line 22 0 Presauinod 10-Gratod 3o 0 other K ✓'� V ; t 'C' 45 0 At -Glade 46 0 Aerobic Treatment Unit 49 0 Rec V t Area lntormatio0: Soil Application Percolation (Min./Inch) Rate System Elevation Fi (�) nal Grade Dispersal Area Dispe Rewi red rsal Area Elevation Dodp proposed Ra*Gals.Msys/Sq.Ft.) 1p� s p Site Steel Fiber Plastic in Total Number Macofscr Glass VI. Tank Info Capacity GAUM of Taub q L a , Concrete Con:rrucood tt Gallons W vA New Ezbdo{ Tanks Tanks Septic a HOKM Taot / 2 G 0 I W IF ( E Do" thanhber 8 I VII. R bill Statement L, the underdgned, assume respoosibihty for installation or the POWTS shown on the attached plans. lt�/1v1PRS Number Business Phone Numbe 's Name (Feint) r plumbers Shgnamm ( c phtmber YC �-e— plwabec's Address (Street. City. StaOe, Zip Code) s d f✓ VIII. Count Me 3n ent Use Od ssning Agent Signauue (No Stamps) Sanitary Permit Fee (includes Groundwater Date Issued L Approved 0 Disapproved Surcharge Fee) O ❑ Owner Given Initial Adverse �S !� Deocrmination IX. Coodldoos �0( A p f 5:0.11 ' e SO. 0 + Attars es�ptsts pima pas the Cor•q Only) for the gstea as paver net Isms am sl/1 a 11 U atae SBn -6398 (R. 05/01) L a % e A. /Z ©rA p � B� I LeT Co L i. S Y 14 LTEW2 K A T a 3' 3 I �a J � De �S' tij ` s.yX 3 y N M io n'1 I` Sn1 m<<L.EtZ Y O L o q i A. ! LJ i-oT S r l � ' Y 1l L t ►� I^k T a a i >> i W / SAE /141 vs�- a �AAA zyX 3Y N M Oo n'1 r .Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings ' in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must County ST• C)LZ l 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. C Please print all information Rev' wed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ? ( z J1 LAA, Property Owner Property Location J C �O ST�17 T fit- 1/4 SW 1/4 S 15 T Z-8 N R lq E (or w PrepeRy-AwmOe Mailing Address Lot # Block # Subd. Name or CSM# City State Zip Code Phone Number ❑ City ❑ Village 2 Town Nearest Road Hv DsON3 I wl sg0L 1b ( - t LS 38(_ 3osl - 773&{ 1 GLUVQTL RoA D New Construction Use: Residential / Number of bedrooms Code derived design flow rate b r3O GPD ❑ Replacement ❑ Public or commercial - Describe: Parent rViterial y e L PrL 0 Ui 7N f g2} Flood Plain elevation if applicable N is ft• General comments and recommendations: CZ�epy t y „ r , Er�1 3 rx c) . S' �\J LTH_ I UN LT'S OF Gtr CIPm C t S L D� N DL2 � V Ctt ►1 r3 Q P kEve CELL Ql0 . S ' C- 1-FL(,_ e -kELL_s F-11 Boring # . ❑ Boring ® pit Ground surface elev. 3 6 . b ft. Depth to limiting factor - > I LZ 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 o_ty 16ci,z.z ._ _ St) Z`�sb rn'f�- c I 'D 1� •s `� Z )L) 3q z y ti -. 31L - si Zln Yn 3 -2.3 yr2_ - l s D m ��? -S t o� 2S16 _ 0 s q Yl .,, oq ,z rA1 Boring # E] Boring Ground surface elev. �� ft. Depth to limiting factor ? ® Pit lisgtion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary' t5 GPD/ftz In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 O -tS lb`1 tz- 31 z S)) Z`fS6 m"fY 1S 3Z -1P- 3Lb S11 Zltz 56 m- cw 3 3Z- �LZ -SYR 3!y S a s m) CS O s� 5 SV -1)6 0Y /Z S4 os Z + 9 / ' Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 _< 150 mg/L • Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg& CST Name (Please Print) ature CST Number Arthur L 'Wegerer 2 =01 - 220254 Address g Date Evaluation Conducted Telephone Number . . ode erer Soil Testing & Design Service 421 N. Hain St. River Falls, WI 54022 1 - O L4 - 715 -425 -0165 Pro a Owner �TS�L�D T [> P rtY Parcel ID # �FIJ�I N G Page Z of 3 D Boring # ❑ Boring ® Pit Ground surface elev. 6 -S ft. Depth to limiting factor 7 l 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 •Eff#2 Z �3 3o to-tR 3 !6 — s I Z -4 s b ►-V 3 3n -III - SL/ lz� l pS9 Z; s SL is to Lriz u/6 F-1 Boring # ❑ Boring ❑ pit Ground surface eiev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Rools GPD 1ft 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 Ou. 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 i 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 -6330 (R.6100) PLOT PLAN Page 3 of Scale 1' = So ' J 2. . Sv L W '�ti2 I Sot �- I�v� CLI cl� S AL'c�'tiz.k S`2sl�wrs I R-c� S I s•3T — e•� ' q 2 40;1 —� �4o' U �- o- F 0 r J OVTL4T = ► 1 4•L. 10.0,0'_ RT O-EN rL &je OF 6wVETt- 'X40ftD_. eL 01 o 715 - 425 -0165 220254 Ol - O� - 6 CST Signature Date Telephone 1--To. CST No. Job NO. c r - - _ BiODjifusar Specift6titio C hambw r = Hoo End Oew Kn Universal 1 C ap Av c[ilable Si zes Chamher 11" Stan• 14" High 16" High Dimensions dard Capacity Capacity ,off. -�; �' ' a�� �' '.. e � .. ' •. _ . , _. 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 thin System (POWTS) shall include information and procedures for a by the department, agent, e conditions of the parameters of Comm 83 and d B e plans h and permits for system are on file at the county or governmental unit. The app zoning or health department. This management plan complies with Comm 83.54astems SBrpund Soil Absorption Component Manual for Private Onsite Wastewater Treatment S 10567 -P (R.6/99). Table 1: System Design Specifications Sanitary Permit Number Number of Bedrooms �o 0 Design Flow - Peak (gpd) Estimated Flow - Average (gpd) 5 Septic Tank Capacity (gai) i z. Soil Absorption Component Size (ft) �� pomestic Type of Wastewater operation Septic Table 2: Soil Absorption C ompo nent Tank Component Component S p � Design Flow -Peak (gpd) 1/8 Maximum Influent Particle Size (in) 220 Maximum BOD (mg /L) 150 Maximum TSS (mg /L) Table 3: Maintenance Schedule 3 ears Septic Tank Inspect and /or service once every y years ears Outlet Filter Inspect once a year and clean at least once every Soil Absorption Component Inspect once every 3 years Septic Tank The septic tank shall be maintained by an individual certified toed service n a septic an tanks wth under s. 281.48, Slats. The contents of the septic tank shall be disposed C Pits, hambers, Grease NR 113, Wis. Adm. Code (Servicing Septic Holding Trenches, Tanks, Pu Privies, ies, or Portable Interceptors, Seepage Beds, Seepage Seepage Restrooms). The operating con dition of the se and outlet filter shall be assessed at least ears b inspection. T e outlet filte shall be cleaned as necessary o once every 3 y y - me to ns are proper operation. The filter cartridge should not be removed unl ed f om is enclosu If the retain solids in the tank that may slough off the filte r '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 f A 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. Thy s s Q s sfiQ ►+-• �� - B /�e.� -r, f / vs -. ' A n Q�W\ �� a L 7ti l e z- /�2P /�'It �' 0./�Q W��� bQ uS � o �$ S�S fiKQ r!a- ZZSO 3 f his - 3 Yom g (,,,f Z ZO fl 3 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer , s A Mailing Address Z' &V Property Address �� �� 4 (Verification required from Planning Department for new construction) City/State 14 v O s o P-- W ► Parcel Identification Number It ? � LEGAL DESCRIPTION Property Location '/4, , '/•, Sec. T RI N -R�own of =Y �bdivision D X_ �' ! l I ,Lot # Certified Survey Map # 4SD 81 ; Volume Page # Warranty Deed # tr L '6K try Volume Z y Page # q c/-7 Spec house yes ❑ no Lot lines identifiable g 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, journeymanplumber, restricted plumber or a licensed pumperverifyirig 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 St. Croix County Zoning Office within 30 days of the three year expira ' te. ATURE APPLI DATE %: rOWNER CERTIFICATION b; V(we) certify that all statements od this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of c5t7� d a irtue of a warranty deed recorded in Register of Deeds Office. SI A PLTCANT 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 ' 1 p tc V111. 1 O ?4 447 WARRANTY DEED 669584 STATE OF WISCONSIN — FORM 2 - K ATHLEEN H. WALSH REGISTER OF DEEDF) DOCUMENT NO sr. noix co., WI RECEIVED FOR RECORD This indenture, Made this 25th day of January 2092, 01 -29 -2002 8:30 AM be veeen Mc Donald Homes, Tnc a Minnesota WARRANTY DEED Ccirprnrat i on Mr/cYlp� lord duly EXEMPT A organized and existing under and by virtue of the laws of the State of V "Y(SA Med at CERT COPY FEE: _Inve hts MN �i/IDd VW party of the first part, and CRAY FEE: T RANSFER FEE: 11 am E. Miller a single person T r RECORDING FEE: 11.00 D0 PAGES: I par of the second part. Witnesseth, That the said party of the first part, for and to consideration of the sum of $367, 500. 00 --------------------------------- to It paid by the said part x Of the second part, the receipt whereof is 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 umo the said par of the second part, his heirs LaCrosse— Madison aiw assigns forever, the following described real estate, situated in the County of 201 Second Street St. Croix _State of Wisconsin, to• wit. Hudson, Wisconsin 54016 040 - 1061 -60 and 040 - 1061 -50 PARCEL IDENTIFICATION NUMBER Lots 1 throu h , inclusive, P lat o Giove Prairie in the Town of Troy, St. Croix County, Wisconsin. (If NFCESS,ARY, CONTINUE DESCRIPTION ON RE \'F.R5[ )IDE) Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining, and all the estate, right. tit le, interest, claim or demand whatsoever, of the said party of the first part, either in law or equity, either In possession or expectancy of, m and to the above bargained premises, and their heredoaments 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 part rte— of the second part, his heirs and assigns, that at the time of the cnscahng and delivery of these presents it is well seized of the premises above described, as of a good, sure, perfect, ahsolule and indefeasible estate of inheritance in the law, in fee simple, and that the same are free and cicarfromallmcumhranaswhatcver,_ except easements, reservations and restrictions of record, and that the above bargained premises in the quiet and peaceable possession of the said par _ of the second part, his heirs, and assigns, against all and every person or persons lawfully claiming the whole or any pan thereof, it will forever WARRANT and DEFEND In Witness Whiereo f, the said MC Donald Homes, Inc. , a Minnesota Corporation, an. ni thr Lrsl pan,ha; caused ibex presentswbv signed by Todd A Bjerstedt its Vice President /Plaid ✓a��ll ✓�F✓ / / /// 11,! LL / / / / /! / / / /! / / / / / /; ¢E c Et,l Hudson _,_, Wisconsin, and its corporate $eal to be hereunto affixed this day of January A /u 20 02. �1GNI:D AND >F.ALF.D IN PRESENCE OF Mc NALD HO S sota Co poratc n\ ice President O DD A. JER T COUNTERSIGNED. Secretary State of Wisconsin, St. Croix County „ Personallycametxdoreme,this 25th clay of January AD ,f 20 02 Todd A. Bjerstedt. Presider j,l r2Q! /!!/ !!/!/!!!. /!!!!!/ / / / / / /!!///// Ili, l9 of the above named Corporation, to mG Q e ns who executed the ng m,n'umem. and to me known to he such president and Secmat - of said Corporation, an wle th, e , xcuted the fun . uim its tunent as such officers a e decd of said Corporation, by its authonty. t : THIS INSTRUMENT WAS DRAFTED NO t�� OIY kQrOy_ R �.. Q,kLS'T Notary Public', St - Croix County, Wis. STEP HEN J DUNLAP 14H1M , My commission (cxpires) (is) Hudson, Wisconsin- l,.. .r. ,.I .T Dili. Jralr.J u.h , :;III Irr�n.J yP,wr I.� s ii �,J cr..r I,n h ,n, i�lrp hl., a .r) S TA T L Or NV I SOON m N W nc o� o Lariat Blank Co.. Inc. \\ARNANT\' [)I FO - By k ,,tpur oo 1'o rm No' 2 Mihveukee, WIS. J y , r s' m • �pp , I � i 9 Po1 j TCN UN! �� uln I _ au swerve ICI I ® O oil — J � I � r• � O 09q�OR —p Cod i