HomeMy WebLinkAbout040-1270-10-000 Wisconsin Depailmentoif Commerce Count
PRIVATE SEWAGE SYSTEM St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
463321 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:
Li'ewski, Joseph & Kerith Troy, Town of 040 - 1270 -10 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
1 CST 17.28.19.1488
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ^5 VZ f C) Benchmark 3q Q/, 3 1
L
Dcsiag Alt. BM
o �S god t 9
Aeration Bldg. Sewer
Holding St/Ht Inlet
............... .
5
TANK SETBACK INFORMATION St/Ht Outlet C/5
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic J . /A . I Dt Bottom
—.--
Dosing '`^ Header /Man.
ct
Aeration Dist. Pipe <31 g14
23t Z y4
Holding 1- .._ Bot. System
6
PUMP /SIPHON INFORMATION Final Grade 1 j . (,•,� l'� �I
Manufacturer Demand St Cover
GPM /C(� 4,
Model_Nurrlb'ef -� t ' 35 /
TDH Lft" Friction Loss System•Head t3k1" Ft 1 J
_- 7Z C 7, (C,5
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia Liquid Depth
DIMENSIONS Q O ' �yf� 1 --
SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of ( System UNIT Model Number `—
C.� ,c,.tc. _ q4 &/i �JrT
�yv.cr�
DISTRIBUTION SYSTEM z1 C43N
Header /Manifold � Distribution x Hole Size x Hole Spacing Vont to Ai Intake
/ Pipe(s)
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over I Depth Over 1 xx Depth of xx Seeded/Sodded xx Mulched
Bed /Trench Center Bed/Trench Edges Topsoil Yes No Yes No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: /_ /_
Location: 439 Crocus Hill Road Hudson, WI 54016 (NW 1/4 SW 1/4 17 T28N R1 9W) Troywood Lot 12 Parcel No: 17.28.19.1488
1.) Alt BM Description = ��iz-� S Cc,1L� ;&
2.) Bldg sewer length
amount of cover = ,
Plan revision Required? ] Yes o�I
Use other side for additional information.
Date 471nsepctoi` Signal Cert. No.
SBD -6710 (R.3/97)
' Safety and Buildings Division County C ()�
r 201 W. Washington Ave., P.O. Box 7162
VisconSIrl Madison, WI 53707 - 7162 Sanitary Permit be Ito be fill;d in by Co.)
(608)266 -315 3 d-
Department of Commerce State Plan I.D. Number
Sanitary Permit Application
In accord with Comm 83,21, Wis. Adm, Code, personal information you provide\ Project Address (if different than mailing address)
may be used for secondary purposes Privacy Law, s15.04(1)(m)
I. Application Information - lease Print All Information EIV ED �fj C C �� L1 U
Property Owner's Na me
arcel N Lot N Z Block a
a 0.5 J, Ei2
Property ovati
Property Owner's M ailing Address on I Lay
5 T C;i <UfX �:(iLlf�•;1�'
/ q ZONING OFFICE: C /7
, 6 /- 3 N Inl E �iT /a, 7 '/a ,Section
City, State Zip Code Phone Number
/ / /�/ C (circle one)
%� ✓V t/`i ( ✓ `[. L T $ N; RILE or 6
II. Type of Building (check all that apply) Q
Subdivision Name CSM Number
1 or. 2 Family Dwelling - Number of Bedrooms T�
❑ Public /Commercial - Describe Use
11 r State Owned - Describe Use 3 r ul Ri Z ❑City_ ❑Village WTownship of 41zo_
III. Type of Permit: (Check only one box on line A, ComIkete line B if applicable)
A' New S stem ❑ Replacement System ❑ Treatment /Holding Tank Replacement Only ❑ Other Modification to Existing System
❑ List Previous Permit Number and Date Issued
B. ❑ Permit Renewal ❑ Permit Revision Change of ❑ Permit Transfer to New
Before Expiration Plumber Owner
IV. T e of POWTS System; (Check all that apply)
No - Pressurized In- Gro und ❑ Mound > 24 in. of suitable soil ❑ Mound c 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter
❑ Constructed Wetland ❑ Pressurize In-Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter
❑ Recirculating Synthetic Media Filter Leaching ChaT ❑ Drip Line Gravel-less P'p ❑ Oilier explain) 3 Y:
V. Dispersal/Treat ent Area Information: ` �/7 �'CG {� l�,L 3 a 3.3 1
Design Flow (gpd) Design Soil Applicn Rate(gpds Dispersal Area Required (sf) tspersal Are 4ro5sie� mf) stem Elevation o
e-o � A ,Nl� a. v
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plas
Gallons Gallons of Units oncrete Consoucted Glass
New Existing
Tarots Tanks
Septic or Holding Tank ✓ 0 ZJb I 5
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumb 's Na me (Print) Plumber's Si gna e MP /M*;RNumber Business Phone Number
, /V 6u .4
Plumber's Addre ss (Street, City, State, Zip e)
6(,c f wtr2 LV �Fv
VIII, ount /De artment Use Onl
Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued uing Age t Sig tore tamps)
Surcharge Fee)
❑ Owner Given Reason for Denial +
LX. Conditions of Approval /Reasons for Disapproval �r
SYSTEM EFL: l'2,'y�'4 Cam. 0 3• Sa�S�'� -
1 ° eptic tank, effluent filter d
dispersal cell must all be serviced / maintaine
as er management plan provided by plumber.
2. All setback requtremen s ttrezrnaitriaine�— `3 s ✓ f,n GAG. G��� t
as per applicable code /ordinan Qc�ZOYi
Attach co plans j(o the un only) for he s stet n paper not ss ize p
SBD -6398 (R. 01/03)
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Gustum Septic Service
Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County St. Croix
include, but not limited to: vertical and horizontal reference pant IBM), direction and Parcel I.D.
�1.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. v JJ Ib C��
Please print all info "ipon. Date
Personal information you provide maybe used fo nddrypdFp ises (Privacy L -w KZ04 (1) (m)).
`-
Property Owner }� r - Pr Location
Humbird Land Corporation I, - i = {� ' ; Govt., of 1/4 SW 1/4 S 17 T 28 NR 19 W
Property Owner's Mailing Address i .., Lot # I Block # Subd. Name or CSM#
332 Minnesota Street, East 1404 ,7 O T21 n/a Troy Wood Subdivision
City State ;p -bode Phong Nx l City _j Village r Town Nearest Road
Saint Paul I MN I 0`1 z b - 5 Troy E Cove Rd / Crocus Hill Road
0 New Construction Use: ,y� Residential /,A 3 Code derived design flaw rate 450 GPD
Replacement _� Public or corma�ercfal Desc
Parent material outwash plains Flood plain elevation, if a2'48' n/a
General comments
and recommendations: Part of 2 acres. BM #1= 100.0'. BM #2= 92.85. Recom nd system elevati 9 from
preliminary boring work done 5 -5 -00. �
[ F4�8Boring # -1 Boring /
_f✓ Pit Ground Surface elev. 95.15 ft. Depth to limiting factor 5 in. Sal Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
*Eff#1 *Eff#2
1 0 -9 10yr3/2 none sil 2msbk mvfr as 2f,1m 0.5 0.8
2 9 -15 10yr3/4 none sil 2msbk mvfr cw 1 f 0.5 0.8
15 -29 10yr4/4 none sil 2msbk mvfr cw 1 f 0.5 0.8
-I 4 29 -38 10yr4/6 none gr. is 1msbk mvfr cw - 01 1.2
�2. 5 - 10yr5/6 none gr. s 0 sg ml cw - 0.7 1.2
6 f 51 -75 10yr6/6 none gr. s 0 sg ml - - 0.7 1.2
Boring # j Boring A b
1/ Pit Ground Surface elm. 95.15 ft. Depth to limiting factor >72 in• Sal Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
*Eff#1 *Eff#2
1 0 -5 10yr2/2 none sil 2mcr mvfr as 20m 0.5 0.8
2 5 -18 10yr2/2 none sil 2msbk mvfr cw 1f,1m 0.5 0.8
3 18 -23 10yr5/3 none sil 2msbk mvfr cw 1 f 0.5 0.8
4 23 -30 10yr4/4 none sil 2msbk mvfr cw - 0.5 0.8
5 30 -38 10yr4/6 none sil 3msbk mfr Cw - 0.5 0.8
6 38-60 10yr4/6 none sl 2msbk mfr cw - 0.5 0.9
7 60 -72 10yr4/6 none Is 1 msbk mvfr - - 0.7 1.2
* Effluent #1 = BOD ? 30 < 220 mg/L and TSS >30 < 50 mg/L * Effluent #2 = BOD -S mg/L and TSS <30 mg/L
CST Name (Please Print) Signature: CST Number
Tom Gustum 227618
Address Gustum Septic Service Date Evaluation Conducted Telephone Number
N13450 937th St., New Auburn, WI 54757 11/16/00 715 -658 -1344
property owner Humbird Land Corporation Parcel ID # _ en ding Page . 2 of
2] Boring F # J Boring - -- -- 16 Pit Ground Surface elev. 94.75 ft. Depth to limiting factor >75 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots __ _0P_D/$' _
*Eff#1 *Eff#2 -
1 0-4 1 none sil 2mcr mvfr as 2f,1m 0.5 0.8
2 4 -14 10yr2/2 none sil 2msbk mvfr cw 1 f,1 m 0.5 0.8
u r 3 14 -23 10yr3/4 none sil 2msbk mvfr cw - 0.5 0.8
y 4 t23-35 ) 10yr4 /4 none sil 2 sbk mvfr cw - 0.5 0.8
ta
5 35-48 10yr4/6 none r. sl 2msbk fr cw - 0.9
6 48-62 10yr5/6 none gr.Is lmsbk mfr cw - 0.7 1.2
7 62 -75 10yr5/6 none gr. s 0 sg ml - - 0.7 1.2
Boring
F-1 # _j Boring
,,J Pit Ground Surface elev. ft. Depth to limiting factor in. Sal Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots SPD1fP -__
*Eff#1 *Eff#2
Boring # JBoring
-- --
Pit Ground Surface elev. ft. Depth to limiting factor in. Sal Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIR:
*Eff#1 *Eff#2
i
< > < - < <
Effluent #1 - BOD 5 > 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.
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner L Ie/Z' Septic Tank Capacity /25 gal ❑ NA
Permit # .3 ? Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer ���— ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model 14 ❑ NA
Number of Public Facility Units --- 3-NA Pump Tank Capacity a ❑
Estimated flow (average) a0 al /da Pump Tank Manufacturer A
Design flow (peak), (Estimated x 1.5) l 00 g al/day Pump Manufacturer ❑ NA
Soil Application Rate 0. 5- al /da /fts Pump Model ❑ NA
Standard Influent /Effluent Quality Monthly average" Pretreatment Unit NA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average I JMsoersal Cells) ❑ NA
Biochemical Oxygen Demand (BOD 530 mg/L K103 - Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L NA t -Grade ❑ Mound
Fecal Coliform (geometric mean) 510` cfu /100 ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA
Other: 13 NA Other: [3 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— ❑ onth(s) (Maximum 3 years) ❑ NA
earls►
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 - ❑ monthls► (Maximum 3 years) 13 NA
earls)
filter At least once every: m ar(s) l ❑ NA
Clean effluent
S � 3 ❑ yearlsl
❑ month(s)
Inspect pump, pump controls & alarm At least once every: ❑ year(s)
❑ month(s) A
Flush laterals and pressure test At least once every: ❑ year(s)
❑ month(s)
Other: At least once every: 13 year(s)
❑ NA
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 512 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.
• 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 f ils and cannot be repaired the following measures have been, or.must be taken, to provide a code compliant
replacemen stem:
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 evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
❑ 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.
T ted to
alua ' o m9 0 nk
e ai e TIC �Df� !�/ CoNS77zc/c
b f10}d 18
❑ 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 INSTALLER POWTS MAINTAINER
Name a Name
Phone /,5 -�� 3 — Lf q� Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name !J Name 15t. C ( b ZOtill�cl
Phone Phone
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.
U. 27 07 P 319�i�`�
KATHLEEN H. WALSH
REGISTER OF DEEDS
STATE BAR OF WISCONSIN FORM 2- 2000 ST. CROIX CO• • 1iI
Document Number
WARRANTY DEED RECEIVED FOR RECORD
12/02/214 02: 45P1!
THIS DEED, made between Mengkou Hurshuajer and Nuchami WARRANTY DEED
Hurshuajer, husband and wife, Grantor, and Joseph C. Lijewski and Kerith EXW #
W. Lijewski, husband and wife, as Survivorship Marital Property, Grantee. REC FEE s 11.
Grantor, for a valuable consideration, conveys and warrants to Grantee ?Rl►11S FEE; 315.00
the following described real estate in si. Croix Cotmty, State of Wisconsin: ur
C
Lot 12, Tray Wood, Town of Troy, St. Croix County, Wisconsin. PAGES: 1:
I
Recording Area
Name and Return Address:
Edina Reahy Title, Inc.
400 S. 2` St. - Suite I15 1 1
Exceptions to warranties: Hudson, Wi 54016 V
Easements, restrictions and rights -of -way of record, if arty. 1 448820
040 - 1270 -10 -000
Parcel Idcntification Number (PIN)
This is not homestead property.
Dated this 11 th day of November, 20
* Men ou Hurshua er * uchami Hurs a'er
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
ST. CROIX COUNTY. ) ss.
authenticated this 19th day of Novembe Y,
Personally came before me this November !'j, 2004 the
above named Mengkou Hurshuajer and Nuchami Hurshuajer,
* Nib husband and wife to me known to be the person(s) who
TITLE: MEMBER STATE BAR SIN ex d the f ing instrument and acknowledged the same.
(If not _- -___ --
authorized by § 706.06, Wis. Stats.) \hMtO-t�-
: 1S fNSTRUMENT WAS DRAFTED BY �J une Vanl40111en —
Peterson, Fram & Bergman — Steven H. Bruns N Public, State of Wisconsin
54 East Fifth Street 5t Paul, MN 3510] My commission is permanent. (If not, state expiration date:
7/27/2008 )
(Signatures may be authenticated or acknowledged. Both are not necessary.)
*Names of persons signing in any rapacity must be typed or printed below their signature
NLARRANTX DEED STATE BAR OF W iSCONSIN FORM Ne.2 -2000
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