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Home My WebLink About040-1294-40-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: � ATTACH TO PERMIT) ( 479329 0 GENERAL INFORMATION State Plan ID No: Personal Oformation 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: Hawksford, Thomas Troy, Town of 040 - 1294 -40 -000 CST BM Elev: Insp. BM Elev: BM Description ,yam Section/Town /Range/Map No: ('t� /00 0 / ~ �� fp -e f-T t 16.28.19.1689 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Septic Benchmark Y.� •S� IO /0";). of 0 Alt. BM :5F, Aeration B ldg. S ewer Holding r Ht In let Lc/ 3p _ 3. TANK SETBACK INFORMATION St/Ht Outlet? y l,' /OU TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic > f Dt Bottom Ppkv G H - Q&der /Man ? �S r7 /D Z'� 1 AeratioH Dist. Pipe Holding _ Bot. System , 4g C 3 •S Final Grade PUMP /SIPHON INFORMATION f��.vlwt-ct Manufacturer Demand St Cover r GPM r x o 4 19 2 Model Number TDH Lift Friction Loss ead T Ft Forcemain Length 1)i; ,_ Dist. to Well SOIL ABSORPTION SYSTEM t BEDITRENCH Width , Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ( / ( i / , SETBACK SYSTEM TO P/L 1 5 W LAKE /STREAM ACHING Manufact INFORMATION / t� HAMBER 013, O N V' Ty Of Sy i�� Lit() 1 > lot 1w Model Number. ST S DISTRIBUTION SYSTEM Dry 7' Heade /Manifold Distribution x Hole Size x Hole Spacing lVent to Air Intake Pipe(s) / Cj r / �— F U i Lengt Dia Length U/ L Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of T7eeded /Sodded xx Mulched Bed/Trench C nter �! Bed/Trench Edges Topsoil F: Yes No ]Yes [ j No COMM S: (Include co discrepencies, persons present, etc.) Inspection #1:� /t�' Inspection #2: Location: 515 East Cove Road Hudson, WI 54016 (SW 1/4 NW 1/4 16 T28N R19W) Piney Woods Lot 14 Parcel No: 16.28.19.16 §9 1.) Alt BM Description = O F VI�G>M -�C� C��Q/1�J� - 3 2.) Bldg sewer length amount of cover vc = vw I I x" fir. �n Plan revision Required? ] Yes No Use other side for additional information. Date Insepctor's Signatu a Cert. No. ID -6710 (R.3/97) Safety and Buildings County 11F 201 W. Washington A 762 ® �seonsin Madison I Sanitary Permit Numb��f ent of Commerce by CoJ Departm 51 h� Sanitary Permit Appl atioq ,, N. �, t tate Plan I.D. Number In accord with Comm 83.2 1, Wis. Adm. Code, personal inkrmation you providetj �,` may be used for secondary purposes Privacy Law, s"i5.04(I)(m) r` {�� Project Address (if different than mailing address) I. Application Information - Please Print All Information Property Owner's Name Parcel # of # Block # e �w �s tzw 6> lzg - Property Owner's Mailing Address Property Location / &g / f APe- TV 2s CiX�� State / y Zip L Code Phone Number ) W Qi 7 / f �l / 7v� T —4 N . R co Firs II. Type of Building (check all that apply) / - ti �i 'l fir/ i I or 2 Family Dwelling - Number of Bedrooms (l/ Subdivision Name CSM Number ❑ Public /Commercial - Describe Use ❑ State Owned - Describe Use ❑City_ ❑Village Ig9 ownship of �j�(�L,/ III. Type of Permit: (Check only one ox on fine A. Complete line B if applicable) � A' New System ❑ Replacement System g p y g Y ❑ Treatment/Holdin Tank Replacement Onl Other Modification to Existin S 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 appl ❑ Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wctland ❑ Pressurized In-Ground- ❑ HoIdi g Tan�k t Filter El Aerobic Treatment Unit El Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter 2h Ahamb F W Drip Line A Gravel -less Pipe the (explain) Z� V. Dispersal/Treatment Area Iti ormation: Design Flow (gpd) Design Soil Application Rate Dispersal Arca Required (sf) Dispersal Arca p ed (sf) stem Elevatio VI. Tank Info Capacity in To Number Manufacturer Prefa Si Steel Fiber PIas tc Gallons Gallons of Units Concrete Constructed Glass New rod:11iad. Tanks Tanks Septic or Holding Tank Y a o� G VII. Respo nsibility Statement- I, the undersigned, assume responsi 'lity for installation of the POWTS shown on the attached plans. Plu 's Name (Print) PlumbV Signature MP tm Pi Number Business Phone Number e4 Plumber' Address (Street, City, State, Zip Code) c A0 (-kJ b ZZ VIII. unty /De artment Use Onl pproved El Disapproved Sanitary Permit Fce mcludcs Groundwater Date Issued suing A nt Signatur Stamps) Surcharge Fee) 61 El Owner Given Reason for Denial ✓ /° Q IX. Conditions of Approval/Reasons for Disapprova ,3 4 ,S YSTEM OWNER: J (�/ W . 200 ! tW Septic tank, effluent filter and V_� �lOf dispersal cell must all be serviced /maintained as per management plan provided by plumber. (,rat` sE C011?I.�J �' , l 2. All setback requirements must a main al @S p Pppl4nahip rridp/ord Attach complete plans (to the County only) for they stem on paper not less than 81/2 x 11 inches in si SBD -6398 (R. 01/03) C `%l�G� -a/ GUu.�iQin l/O f ��•l JO 4 B T7 Gy � 5 TIMM EXCAVATING Route 1 Box 192 S HEET NO. .77 OF WILSON, WISCONSIN 54027 CALCULATED BY W DATE � (715) 772.3214 (715) 386.5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE i ii . ; i i i L i e i i -t t [ i i t v i r ' j 'i- i� ............ ........... ....................... ....... ........ .. .... .... ..... i i j l i a � i I /a .... V i ] j Fi ./ i ... .......i...........i ..........: ....... ..i..........'......... ...........:.... .......:...........i..........: ..... .... ..... ..... ..... .... ..... > ... a .......... a ....... .........................:.'... ..t: f .i 1 �\ ......... .j ....................... >..... a ....... .. ... ....... .<............. .... ..: .. .... .... .. 1 ... t .... .... .. ..> ... ....... . .. ... 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OF WILSON, WISCONSIN 54027 CALCULATED BY DATE (715) 772-3214 (715) 386-5443 MPRS #3224 WI MMA #696 MN CHECKED BY DATE SCALE — .......... ........... .. i . ...... .... ..................... ........... .... ........... . .... ... .......... ........... ........... .......... ........... ........... .......... .... . .................................. .......... ............ ...... .......... ..................... ........... ............. ........... ........... ........ . ........... .... ......... ........... ........ ............. ...... ........... ........... .......... .......... ........... ........... ........... .......... ........... .......... ............ .......... ..................... ........... .......... .......... .......... . ........ .......... ........... ........... ........... .......... ....... ........... ......... ... — .................. ... .......... ........... .......... ...... ........... ........... ........... ........... ........... ww ....... . .... ...... ...... .......... ........... ........... .......... ........... ........... ........... .......... .......... ... .... .......... .......... .. ........... ......... ........... .... ........ ... . ... ........... ... .......... . .......... .................. ......... v ........ . ........... .. ...... ... ........... ........... ........... ....... ... ........... .......... ........... ........... ........... ........... .......... .......... ........... .......... ........... ......... ......... . . ...... ........... ........... ........... ........... ........... ........... .... .... ....... .... .... ........... ........... .......... ........... .......... ........... .......... .......... ......... ...... ....... ......... — ' ........... ............ ................. .......... ........... . ......... ........... ................... ........... ........... . ................ ....................... ........... ........... ........... .......... ........... ........... ........... .. ...... . .................................. ........... ........... ........... .: . .......... ................. ... .......... ........... .......... ........... ........... .......... ........... ...................... ...................... ............. ........... ........... ........... ........... .......... ........... ........ .. .......... .............. .... . ... ..................... ........... .......... ... .. .. . . ........ . ... ........... .......... ................. .......... ........... .................. ........... ............ ........... 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I ............ ......... ........... . . ............... ............................... ..................... .......... ----------- A - G. --------- ---------------- .................. ------------------ ............... .......... ............ .................. ................ ........... ....... .......... .......... PRODUCT 205 -1® Inc., Groton, Men 01471. To Order PHONE TOLL FREE 1-800-225-6380 JOB--76— m 7114,-Y�A.5 TIMM EXCAVATING Route 1 BOX 192 SHEET NO, r _ OF WILSON, WISCONSIN 54027 CALCULATED BY y` "`'DATE (715) 772 -3214 (715) 386 -5443 MPRS #3224 WI MPCA #696 MN CHECKED By DATE SCALE 4- ........... .......... * . , . , . , .� , . , . * :. * .l * :.� .. ..... ....... ........... ........... . ....... ........... .... ....... i (S V .. ;........ >.. ..... - .. .... .... .... l� ..... ... r5 .... .� - '�3,'� PRODUCT 205-1 Inc, Groton, Man. 01471 To Order PHONE TOLL FREE I- 800-225.6380 N *scow + 4oln ♦ MAL ORT #2271 Department of Commerce n o da s. Code Page 1 of 5 Division of Safety and Buildings ' Certified Soil Testing, LLC � t1 �00� County n , Attach complete site plan on paper not less than 8'/2 x 1 ?, inche W Size. 0 an must 5'f /G(7 j include, but not limited to: vertical and horizontal referen ' point (BM) I( � OF� Parcel LD. percent slope, scale or dimensions, north arrow, and lot ion b� t roa 0- 1294 -40 -0000 PI intall information ZNING Ple ase pr Rev' we ate Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). oZ I Property Owner Property Location Hawksford, Thomas & Mary Govt. Lot SW1 /4, NW1 /4, S16, T28N, R19W Property Owner's Mailing Address Lot # I Block # Subd. Name or CSMA _ /� 463 W. Omaha Rd. 14 Piney Woods �it d Sa t�( d City State Zip Code Phone Number City [] Village ❑ Town Nearest Road Hudson WI 1 54016 1 715 - 386 - 7403 East Cove Road New Construction Use: ® Residential / Number of bedrooms 6 Code derived design flow rate 900 GPD Replacement ❑ Public or commercial - Describe: Parent material loess over pitted till Flood plain elevation, if applicable NA ft. General comments install "conventional" in- ground trench syste w/ systsnx4ev 93.5 below 100.0 & 102.0 original contours; and recommendations: cut final grades to 99 @ original 100.0 99.5 @ on final 1012. fry (/S1' (��i Z(/� � or ng (/yw�"' ' ❑Boring # ' - - - - X Pit Ground surface elev. 100.0 ft. Depth to limiting factor > 124 in. Soil Application Rate Horizon Depth Dominart Color ' Redox Description Texture Structure "Consistence Boundary Roots GPD /ft' in. Mun ,ell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 1 0 -13 7.5YR 3/2 - sil 2 f -m sbk dsh cs if /m .6 .8 2 13 -23 7.5YR 3/4 - sl 1 m sbk dsh cs lm .4 .7 3 23 -36 - Is 1 m sbk mvfr gs im .7 1.6 4 36 -46 7.5YR 4/4,4/6 - sl 0 m mfr gs 1m .2 .6 5 46 -66 7.5YR 4/6 sl 0 m mfr cs - 2 .6 6 66 -124 10YR 6/4 - 0 sg dl - - .7 1.6 H5 has common str 5/4 & 6/4 s (0, sg, ml) bands 2 Boring # - Boring X Pit Ground surface elev. 102.3 ft. Depth to limiting factor > 144 in. ISoil 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 1 0 -6 7.5YR 3/2 - sil 2 f sbk ds gs if /m .6 .8 2 1 6 -10 7.5YR 3/2 - sil 2 m sbk dsh gs lm .6 .8 3 10 -26 10YR 4/4 - sil 1 m -c sbk mvfr gs 1m .4 .6 4 26 -64 7.5YR 3/4 - Is 0 sg ml cw - .7 1.6 5 64 -84 7.5YR 4/3 - fsl 0 m mfr cs - .2 .5 6 84 -144 10YR 5/4 1 - s 0 sg ml - 7 1.6 H4 has some inclusions 10YR 3/3 sl; H5 has stratified bands s w/ occasional sil inclusions ' Effluent #1 = BOD 30 < 220 mg /L and TSS >301< 150 mg /L * Effluent #2 = B D < 30 m and TSS < 30 mg /L CST Name (Please Print) Signatur CST Number Henry F. Grote 222774 Address Certified Soil Testing, LLC Date Evaluation Conducted Telephone Number E. 4366 353rd Ave. Menomonie, WI 54751 7/11/2005 715 - 233 -0398 SBD -8330 (R 07/00) Property Owner Hawksford, Thomas & Mary Parcel ID # 040 - 1294 -40 -0000 Page 2 of ___ , T ] Boring + Boring # t Ground surface elev. 98.1 ft. Depth to limiting > 14 in. Xi Pit factor 2 Soil Application Rat Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Etf#1 'Eff#2 1 0 -5 7.5YR 3/2 - sil 1 f -m sbk ds cs lm .4 .6 2 5 -10 7.5YR 3/3 - sil 1 m sbk dsh cs 1M .4 .6 3 10-16 7.5YR 3/4 - sl 1 m sbk dh cs 1M .4 .7 4 16 -58 7.5YR 3/4 fr cs - . 2 .6 - - -- 5 1 58 -124 10YR 5/4 - s 0 sg ml - - . 7 1.6 H4 Uas occasional stratified 10Yr 5/4 s bands ❑ 4 Boring Boring # Pit Ground surface elev. 99.2 ft. Depth to limiting factor > 130 in. Soil Application Rat Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Cola Gr. Sz. Sh. `Eff #1 -Eff#2 1 0 -9 7.5YR 3/2 - sil 1 f -m sbk ds gs if /m .4 .6 2 9 -14 7.5YR 3/3 - sil 1 m sbk mvfr gs lm % . 6 3 14 -20 7.5YR 3/4 - sil 1 m sbk mfr gs lm .4 .6 4 20 -32 10YR 4/4 - sil 1 m -c sbk mvfr cs 1M .4 .6 5 32 -67 7.5YR 4/4,4/6 - Is 1 m sbk mvfr cs .7 1.6 6 67 -130 10YR 4/4,5/4 - s 0 sg ml - - . 7 1.6 H5 has inclusions sl (O,m.mfr) on W pit wall +few on N pit wall; stratified, irregular, discontinuous 7.5YR 3/4 sl @ 76 -79; from 90 -130 on 5 pit wall is all 10YR 5/4 s but N pit wall is more sl than s below 74 "; best avoid this area ❑ 5 Boring Boring # X Pit Ground surface elev. 102.2 ft. Depth to limiting factor > 144 in. Soil Application Rat Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Cola Gr. Sz. Sh. `Eff#t 'Eff#2 1 0 -16 7.5YR 3/2 - sil 1 f -m sbk ds gs 1f /m .4 .6 2 16 -36 ! 75YR 3/3 - sil 1 m sbk mvfr cs 1M .4 .6 3 36 -44 7.5YR 416 - 0 mfr cw 1m .2 T .6 4 44-72 75YR 4/4,4/6 - / sg ml cs i . 7 1.6 5 72 -144 10YR 5/4 - s 0 sg ml - - . 7 1.6 large inclusion 10YR 4/4 sil @ 51 -60" in one place on north pit wall * Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 m /L ' Effluent #2 = BOD < 30 m /L T s 9 _ g and SS < 30 mg /L _ s 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 (R 07/00) Certified Soil Testing, LLC L Preperty Owner Hawksford, Thomas & Mary Parcel ID # 040- 1294 -40 -0000 Page 3 of 5 ' 1 Boring Boring # 7- Pit Ground surface elev. ft. Depth to limiting factor in. _ Soil Application Rat Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft' in. Munsell Qu. Sz. Cont. Colcr Gr. Sz. Sh. *Eff#,1 *Eff#2 i deep system recommended to avoid shallow multiple soil textures; 4 - 2.83' x 68' Infiltrator Quick 4 trenches will fit & give <0.7 gpd /sq ft; original grades should be cut to minimize bury depth & allow better aerobic transport * 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 or need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608 - 264 -8777. SBD -8330 (R 07/00) Certified Soil Testing, LLC lv-4 f �7 CzS,Z 0 YS 3 0 �loz,3� • y . ! � 1 s 3 J � _ 0 o Or Qr r C� r�l o � \ J u L,A \, I t M -- rn Wisconsin Department of Commerce SOIL EVALUATION REPORT. Page � of 3 Division of Safety and Buildings 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 S T 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. —OaD Please print all information. e ' wed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location ►mil R C) CE R.oDP� L 114 KW1/4 S � � T N R 1q E (o W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# S°) 02't�-1 MWO CA L)-" E 1. City State Zip Code Phone Number [D City (]Village ®Town Nearest Road Cz l� f -S Iti 5 o - ?- - L lS ) 4 ZS - L - )q Z •� � ZD . New Construction Use: ® Residential / Number of bedrooms �_ Code derived design flow rate GPD Replacement ❑ P ❑ Public or commercial Describe: Parent material 1`y � U V ts" iZ_ 1-t t �„ Flood Plain elevation if applicable ! ' ft General comments and recommendations: 'h1 buy- t'j / 0 1 L� ' 1S11Z1 BQ n 0j 0 �rL(� , W� 2002 1 )v IMU1.1 OF SitA� I=1 LL , 5T cP#Qx -�> COUNTY �V �TrX�2 �TL�U , 48 , Q .3 ZQM NGOFFiCE Boring# ❑Boring a '� 20D Pit Ground surface elev. Q �• S ft Depth to limiting factor Z 1 P 9 _ in. oil 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 sit zr�s k m u`(� -- ciki L U -1 iZ - 3/'6 3 3Z -q y _ •f� s��. s st � s bk Boring # ❑ Boring Pit Ground surface elev. ` 3 ft. Depth to limiting factor 39 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 � mvfi. dew — - fJ • S ° Z 1Z 3q 1p`1231 - si I Z�ns mv �Fr • ew — -s .$ .t- 3 Ply -- ),SLY ' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 _< 150 mg/L ' Effluent #2 = SOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Si azure CST Number Arthur L. Wegerer ;f. 0 1 . - 31 ` - , y 220254 Address W e g e r e r Soil Testing & Design S e r v i c e Date Evaluati on Conducted Telephone Number 421 N. I -fain St. River Falls, UI 54022 715 - 425 - 0165 1 Property Owner �Zd DP � L - Parcel ID # � , C> 1 fy G Page Z of F�] Boring # f❑G Boring pit Ground surface elev. 1 . 6 ft. Depth to limiting factor y C) in. Soil Application Rate Horizon : Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft' in. Munsell Qu. Sz. Cont. Color Gr. S z. Sh. 'Eff #1 •Eff#2 1 0 -Iq 1 1341Z 31 z - L Z m s bV� M\) Cjj _ • S - $ •(� Z iy -2 1pyR Sly — S� bk wt'F eW •S -� ,� 3 2 - 4 -y 0 Vn 'fir 0.S • Z - 3 , '/ U D 50 1011 lz Y 5 l e S !8 wl . 1n� •Fa , Z - . F] 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 F-1 Boring # Boring Ground surface elev ❑ ❑ Pit . 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 I '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 or need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608 -264 -8777. SBD -9330 (8.6100) I PLOT PLAIT Paae 3 of 3 " Scale 1' = SO ' 3Z0.1�' OF Fv 1-�3 E3►"►h�1- �t.1A00 ON _3�.y "_blA -_PVC _Pi.l?�''' tkiCLR'C'�F - - -- -- - - - - -- N� N 1 w`rovb2. �. g8 0' S v h ' )�J c� o \o �, a .2 • N \ 0 Cowl p i t (AL • $. �1S�L►Z.�, �•� \ qd \ 4 s , �Z -ts-o( 715- 425 -0165 220254 _ - CST Signature Date Telephone No. CST No. Job rio. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer I/ . bk K 2n6 j Mailing Address Property Address Jc- 5 ' (Verification required from Planning Department for new construction) City /State Parcel Identification Number LEGAL DESCRIPTION Property �^� 11 Pro P a Location J kJ %,, %,, Sec. �� , T Z N- , Town of r Subdivision P 1 li T &2�aL Lot #. Certified Survey Map # , Volume . . Page # Warranty Deed it 3!521 , Volume 2- 6 j z , Page # 3 Spec house ❑ yes 9 no Lot lines identifiable , �r yes ❑ no YSTEM 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, 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 et-ating 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. SIGNATURE OF APPLIQKNT 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 EXOFAPPLI7 cscribed above, by virtue of a warranty deed recorded in Register of Deeds Office. £ '7 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 System Management Management of this system is critical. As a condition of approval of these plans this system management section must be rev iewed with the owner, and the owner must be provided with a complete set of plans including this management section. If problems develop with the adsorption system or any other system components, the installing plumber, Timm Excavating, 715- 772 -3214, or the St. Croy County Zoning Office, 715- 386 -4680, should be contacted for assistance. General Proper functioning of an on -site disposal system, "septic system," is significantly dependent on the volume of water which flows into the system and the level of contaminants in that volume. The lower the volume of water and the lower the level of contaminants, the berter and longer the system will function. Typical system components include a septic tank or compartment to settle out solids and contain greases and oils, a filter on the outlet of the septic tank to retain small particles of the same density as water, a pump tank or compartment to allow a dose to be accumulated, a pump and controls, and finally some type of soil adsorption cell to recycle the water in a manner to protect ground water quality and public health. I If the septic tank is installed prior to sheet -rock and/or painting, pump the septic tank before normal use begins to ensure adherence to contaminant load design criteria. Install water- saving appliances whenever and wherever possible. Repair even small water leaks as soon as possible. Never pour grease or oil down any drain or stool. Garbage disposals are not recommended; if you must have one, use it sparingly. o No paper products other than tissue should go into the system. - �,o chemicals should go into the system. A\o,d surge Flows of water; try to spread laundry throughout the week. i Maintenance The septic tank must be inspected every three years by a properly licensed person. I f necessary, the septic tank must be pumped to remove solids and scum; pumping is required if the combined scum and solids volume equals one third of the tank volume. W the septic tank is pumped, any solids in the bottom of the pump tank must be pumped, and the filter must be back - washed into the septic tank to remove accumulated material. Periodic observation pipe inspections should be made by the homeowner to examine the state of the in -situ soil adsorption cell. Quarterly inspections are recommended; a licensed plumber should be notified if effluent is consistently ponded in the adsorption cell. If this system contains specific treatment components other than those mentioned here, maintenance requirements will accompany their specifications. o The pumping components for this system include an alarm which must be installed and remain on a separate circuit from the pump If the alarm is activated, minimize water use and notify a licensed plumber for service as soon as possible. The system allows reserve rapacity to accumulate some necessary flow until normal service can be restored; this volume is minimal, and no more than one or t u days should pass before any necessary repairs can be made. .A� o d compaction such as vehicle traffic within 15' down -slope of the adsorption system. 3 .Avoid disturbing the system itself such that might encourage erosion or disturb the required seeding of the system. 4 Particularly avoid winter traffic such as sliding or snowmobilin which might compact snow and lead to increased frost depth. g g P P 0 Surface drainage must be diverted around the system; avoid landscape changes which might send surface run -off into the system area. Contingency Plan Wastewater monitoring of volume and quality is not a normal requirement for low effluent strength systems; such monitoring ma} become necessary if problems develop. Any necessary monitoring shall be done in accord with the requirements of Comm 83.54 (2). Pumping and hauling of wastewater may be necessary while analysis and repairs are implemented. Additional testing, designing, and/or installation of additional treatment components or conversion to a holding tank may be necessary. Page 8 of 8 I _ _ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ' of FILE INFORMATION SYSTEM SPECIFICATIONS Owner sri Septic Tank Capacity 1�(V f f06 a l ❑ NA Permit # 2 Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer BC ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model 4— ❑ NA Number of Public Facility Units Pump Tank Capacity gal ❑ NA Estimated flow (average) gal /day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) gal /day Pump Manufacturer ❑ NA Soil Application Rate �, gal /day /ft2 Pump Model ❑ NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit .[VA Fats, Oil & Grease (FOG) :530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD <_220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispers I(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L - Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) <_30 mg /L NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cf Oml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size in dia. NA Other: ❑ NA er: ❑ NA Other: ❑ NA * Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: 2— 0 earl 1 (s) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell(s) At least once every: 2 3 0 ►�nth(s) (Maximum 3 years) ❑ NA yea (s) Clean effluent filter �� At least once every: f 3 ❑ yea�(s)(s) ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of <_12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. Page Z of 2 START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. I ' • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or.must be taken, to provide a code compliant replaceme system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evalua 'on to estab 'sh a suitable r9plac ps are q. Replacement systems must comply with the rules in effect at that time. �,{/y�� P7/I�` 2cjd /' ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. 1`r T alua ' a o ing ank be ' e ai a Ff2D{-II'B MZ+ ,, VV P A/6%k/ eofQSTR(Jg10" ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLkR POWTS MAINTAINER Name Name Phone 1-5 Y_ 32/ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name C 4 Name !St. G l au& 2wix Phone Phone "71S 3W40- !A This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. �l 796351 U 2 8 12 P 3 3? KATHLEEN H. WALSH ' STATE BAR OF WISCONSIN FORM I - 2000 REGISTER OF DEEDS WARRANTY DEED ST. CROIR CO., WI Document Number RECEIVED FOR RECORD This Deed, made between DONALD O. RODAHL and JOYCE J. 06/01/2005 10:00AK RODAHL, husband and wife, WARRANTY DEED EXOPT # Grantor, and THOMAS E. HAWKSFORD and MARY B. REC FEE: 11.00 HAWKSFORD, husband and wife, TRANS FEE: 749.70 COPY FEE: CC FEE: PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in ST. CROIX County, State of Wisconsin (the "Property") (if more space is needed, please attach addendum): LOT 14, PINEY WOODS SUBDIVISION IN THE TOWN OF TROY, ST. CROIX COUNTY, WISCONSIN. Recording Area N.O. ErJ X 359 HUDSON, IM 54016 040 - 1294 -40 -0000 Parcel Identification Number (PIN) This is not homestead property. Together with all appurtenant rights, title and interests. M (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions, leases and rights of way, if any. Dated this 27th day of May 2005 * * DONALD O. RODAHL + * JVYCE 1. RODA AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) S ( . C� Imo/° ) ss. County) authenticated this day of Personally came before me this 27th day of May ) 2005 . -Ah&a * bve named Donald O. Rodahl and Joyce J. Rodah 1" f ly TITLE: MEMBER STATE BAR OF WISCONSIN (If not to me Imown to be the person(31 TA executed$he fpreFwn authorized by § 706.06, Wis. Stats.) instrument and ac Jo Sallie. s +� ; r : THIS INSTRUMENT WAS DRAFTED BY ( L-t S' 7 ( IL LEO A. BESKAR Notary Public, State of '� F k M' RODLI, BESKAR, BOLES & KRUEGER, SC My Commission is permanent. (If not, sta3fiF#X@pWW n date: (Signatures may be authenticated or acknowledged. Both are not necessary.) ) ' Names of persons signing in any capacity must be typed or printed below their signature. WARRANTY DEED STATE BAR OF WISCONSIN INFO -PRO (800)855 -2021 www.infoproforms.com FORM No. I - 2000 Parcel #: 040 - 1294 -40 -000 07/21/2005 04:16 PM PAGE 1 OF 1 Aft. Parcel M 16.28.19.1689 040 - TOWN OF TROY Current X: CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * DONALD O & JOYCE J RODAHL RODAHL, DONALD 0 & JOYCE J 257 SADDLE RIDGE LA RIVER FALLS WI 54022 -8121 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 515 E COVE RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 5.120 Plat: 2331 -PINEY WOODS SUBDIVISION SEC 16 T28N R19W SW NW LOT 14 PINEY Block/Condo Bldg: LOT 14 WOODS SUBDIVISION Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) 16- 28N -19W SW NW Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 418/476 2005 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/23/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.120 80,000 0 80,000 NO Totals for 2005: General Property 5.120 80,000 0 80,000 Woodland 0.000 0 0 Totals for 2004: General Property 5.120 80,000 0 80,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Wo V I 00 � ................... 13! -V W r s I : M. 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