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HomeMy WebLinkAbout040-1293-20-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 430590 0 GENERAL INFORMATION (ATTACH TO PERMIT) 6" State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 3 1 Permit Holder's Name: City Village X Township Parcel Tax No: Palm, Bill & Carol I Troy Township 040 - 1293 -20 -000 CST BM Elev: Insp. BM Elev: BM Description: ,, Section/Town /Range /Map No: /o f3 '-k 17.28.19.1677 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ' l % Oc� %C L Benchmark Dosing Alt. BM Aeration Bft Sewer 17A / C Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic , Dt Bottom Dosing 1 Header /Man. Aeration DPst -Ripe Holding Bot. System Final Grade S e& s - ► PUMP /SIPHON INFORMATION S. Q-t T_ 'A Manufacturer Demand St Cover GPM Model Number ��Lr (j ,z y �. w�• y TDH Lift Friction Loss System Head TDH Ft T. � � � -r-( � -� l u 1 .5 - i Forcemain Length Dia. Dist. to well ` — </,, c> SOIL ABSORPTION SYSTEM BED/TRENCH Width Length _ No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. ILiquid Depth DIMENSIONS SETBACK SYSTEM TO C' P/L BLDG IWE LL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR s,,C '• ��y. �! Type Of System: UNIT Model Number; ZaC1 . `�O < - k - 5= DISTRIBUTION SYSTEM ICY n-s ' Z"-- Header /Manifold IP�ptribution x Hole Size x Hole Spacing Vent to Air Intake ' e(s) -- Length Z� Dia Length Dia SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over , t Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Ed soil 3 U Edges Topsoil - F -1 Yes [� No L] Yes I „] No COMMENTS' (Include code discrepencies, persons prbsent, etc.) Inspection #1: tv 1 6 1 1 Inspection #2: / / Location: 472 East Cove Road Hudson, WI 54016 (SE 1/4 NE 1/4 17 T28N R1 9W) Piney Woods Lot 2 Parcel No: 17.281,1677 1.) Alt BM Description = S. T Cr, U-e.. 2.) Bldg sewer length = r 4 - amount of cover = i 5 Plan revision Required? RE Yes No Use other side for additional information. 0 (8.3197) Date Insepctor's Signature Cert. No. fety Aid Buildings Division County � RE E 1 2�Wasl1 �gton Ave., P.O, Box 7162 S-� C�Z O i scon (�' Madis i, WI 53707 - 7162 Sanitary Permit Number (to be tilled in by Co.) De partment of Com $lW m ce DEC 0 4 2003 (50 8) 26 6- 3 15 1 315 -30 5 O Sanil.a y CM CAPPUC tion State Plan I.D. Nuniber In accord with Comm B_ .21, Wiz- 0NJN(l QkF onal inf rmation you provide may be used for seconci purposes Privacy Law, s15.04(1)(m) Project Address (if different than mailing address) I. Application Information - Please Print All Information Property Owner's Na me Parcel /{ Lot N '�- Block # LL C4 �6L L _ Property Owner s M ailing Address Property Location -- City, 'fate q, A Zip Code Phone Number circle one) 1�. Type of Buildhi T N; R yp g (check all that apply) 1 or 2 Family Dwelling - Number of Bed'som. Subdivision Name ❑ Public /Conurtercial - Describe Use ❑ State Owned - Describe Use ❑City_ ❑Village V ownship of -�v e 0Y I11. Type of Permit: (Check only one box on line A. Complete line B if applicable) - M93 � A. ,New S stem Y ❑ Replacement System ❑ Treatment /Holding Tank Replacement Only ❑ Other Modification to Existing Systeut B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. T pe of POW'TS System; (C}rec]< all that apply) � — -- - -�- - -- --- --- Non - Pressurized hr Ground ❑Mound > 24 in. of suitable soil ❑Mound < 2�4 in. of suitable soil ❑ At -Grade ❑Single Pass Sand Filter ❑ Constucted Wetland ❑Pressurized In Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑ 12ecirculatiug Simd Filter u _Unep a" a f ❑Recirculating Synthetic Media hitter ❑Leaching Chamber ❑Drip Line ❑Grave -less Pipe � Other (explain) V. Dispersal/Treats lit Ar Informati Desi�n Plow (glxl) Design Soil Application Rate(gptso Dispersal Area Required (st) Dispersal o oy� i) Celli Elevation 0 7et , I, S J�� G+ Z io t VI. Tank Info Capacity in Total Nwnber Manu file tner Prefab Site Steel "bt e�'l�Cic Gal Gallons of Units Concrete Constructed la h New Existing Tanks Tanks_ Septic or Flulding'fatil: Aerobic — Dosing Chamber —1 X VII. o ilea nsibilit Statement - I MP /AVumber -- — _p Y t he usrdersigired asstwre responsibilit f or installation of the Pla POW`1'S shown oil the attached plans. n per's Na me (Print) Ptun�tber's Si gnatura ines -- I }3uss Phone Number Plumber's Addre ss (Sweet, City, State, Zip C 2--2 =____ G 61111 n - i r vf 5 �1/ VIII. Cou /De partment Use Only pproved ❑ Disapproved Sanitary Permit Pee (in lodes Groundwater Date Issued Issuit Agent Siguattre (No Statues) 111!!! Surcharge Pee) El Owner Owner Given Reason for Denial 2 ,7 �- O , 7.CD3 IX. Conditions of Approval /Reasotrs for Disapproval -- - - -- SYSTEM OWNER. 3) A v, a dQrtr, � 1 Septic tank, effluent filter and ��. I dispersal cell must all be serviced / maintained as per management plan provided by plumber. S�i�t�„� 10,r. S 2. All setback requirements must be maintained as per applicable code /ordinances. Gam~ tl CZ A R J Y �C cam. Attach complete plans ito the County only) for the systeus ou I er u, 1 than 8 /2 11 inches in siz n SBD -6398 (R. 01/03) PL-t4- Pc-,4A.J Lu, j o V 09 � 6 � PCa-,.l �m I p 4- i y ( vv,. 1 � V wsconsin Department ofCommerce SOIL EVALUATION REPORT Page of 6iv`ision of Safety and Buildings z 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 Include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information Re • wed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). DEC Property Owner p � Property Location U O N f�I•�D J O CE RODS}}{ L be t, -Lot S E 1/4N /4 S T $ N R E (or CVq Property Owner's Mailing Address Lot # Block # bq. N4 qr # IQ wpOD City State Zip Code Phone Number []City c - illagq �U earest Road jZtU - F[TUU bv1 S�oZZ (�lS) �IZS 6��Z � ® New Construction Use: E. Residential / Number of bedrooms L— Co pved 0 fat v b 01J; GOD E] Replacement E] Ot Public or commercial - Describe: ST CPX Parent material Tt LL Flood Plain i General comments and recommendations: ZFCO O� � �s �e. � s 3 � � . - �..,S�, SLpEwtwpNZR L�eg CH,AW�B� Q °cwt U� �tLS 3E M PcX tmum 3v" kZeP. a Boring # ❑Boring Pit Ground surface elev. L4- S ft. Depth to limiting factor 8 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. I 'Eff #1 'Eff#2 0 1 -q 10`1 R- 313 Z Cl - Z O -� S LI P- 3 L3 - L 3 z_t c_q7 z •$K1 -31y L '4 Ln In , 4 R s1b Boring # ❑ Boring ® pit Ground surface elev. O 3 • Z ft. Depth to limiting factor 6 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 0 -9 l0`i(Z - s I l cSbl2 �nV ew - -� Z R -Z Z 7S VV_ 313 _ L 1 c5�12 rn . Lt . 6 12- yl - s lc-sbk m v i� -� Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signa re CST Number Arthur L. Wegerer O --: ` ' 220254 Address W e g e r e r Soil Testing & Design Service Date Evaluation Conducted Telephone Number 421 N. Main St. River Falls, UI 54022 �Z.L`� -Ofj 715 -425 -0165 Property Owner `� d )�>/a H 1_ - Parcel ID # lO 1 Y J G Page Z of F:�] 3 Boring # ❑ Boring n ® pit Ground surface elev. 0 1 ` • ft. Depth to limiting factor ? O 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 o - IbKR -313 — \C-5b )M cw - .y Z R - 70 - ) .S 4IL3 1 Y U s , Zk k- 2 JIt )o`22Vic F-1- Boring # ❑ Boring ❑ Pit Ground surface eiev. ft. Depth to limiting factor 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 ❑ ❑ 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 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. SB"330 (R.6/00) it PLOT PLAIT Page 3 of 3 ✓Scale 1' «l�.oZ ' sw►ttz �'Rmt I B.3 / Ta- a 0 7 r � rvi N Lol' t t~oT Z Lur 3 f i v_�� t - -0 _- Ou J A" PIPE sPrWL- a- I _ GRc�! p--- �V VL -1g - 715- 425 -0165 220254 CST Signature Date Telephone Ijo. CST No. Job "10. Combination Septic Tank and PLIMP CHAMOER CROSS SECTIOtJ AtiD SPECIFIC VEQT CAP WEATHEK PKOOF JUUCTIOQ 5OX . ti'C.I. VElJT PIPC APPROVED LOCK IQC. FROM DOOK, MA IJHOLE COYER r-vfTt't wAftNl>JG L1�6EL. ,jtUDOW OR FRESH ppy�DQIT' AR wTAKE .d � � t'�'t(Z -Tl G dam' C+'t"'� v _ . i � � • j �lQOT �., PROVIDE. I - -'— IM LET 'AIRTIGHT SEAL SAFr-�� A I (� I APPROYED JONTS i w C. T. PIPE�PJC APPROVE[) JOIUT Emil- .�� I I ( r w l c. IPEaR 0 ALAR _P Tank constr n _ I i M shall comply with I II ILHR 133.15 and 33.20 I I OW c I I I PUM OFf P -� D CONCRETE �' QLOCK 3 APP, - RISER EXIT PER `ITfED 01JLy IF TAUK MAQUFACTLJRER HA5 SUCH APPROVAL. 6EDOIr:G SCPTlC F SPECIFICATICtJS DOSE V)l � 03kJ0- ZZ� ►JuMbCF, OF QOSES: PER DAB TAI -J K5 MAQUFACTU9.CR.: TA)-JK 51ZC; GALLOfJS DOSE VOLUME ALARM MAIJUFACTLIRCR: SS - L� ZQ SLIV� " IKJCLUDIfJG OACKFLOW: � ' GAILOUS MODEL QUMBER' IQL H CXPACITIES: A= — 3 UCHESOR GALLOU5 5W1TCH T.�PL: 8 = Z IWCHES'OR / � G� LLOUS PUMP MAQUFACTURER: S C= IUCHE5 OR( �Z LLOIJS MODEL ►JUM6EK: f �Ti� D = OR Z ��" GAILO►J5 5WI7CH TYPE: u`��'l MOTE: PUMP AUD ALARM ARE TO 0l. tAlWMU DISCK RArE _ lhSTAILED OtJ SEPARATE C4RCUITS VERTICAL DIFFEKEWCE DETWEEU PUMP OFF AUD- DISTRIBUTIOU PIPE- __1_1_�F EET -{- MiS JIMUM 1JETW SUPPLY PRESSURE , . , , , , , , , . . _ Q_ FEET f SL_ FEET OF FORCE MA X '�W pfLF RICTIQW FACTOR -. FEET TOTAL CO MAMIG HEAD FEET As per ilanu£acturer Lam_ gal /in. s M E4Q Series 4/10 HP Effluent and Drain Water Pumps Performance Curve MODEL ME40 EFFLUENT PUMP CAPACITY LITERS PER MINUTE 0 50 100 150 200 250 300 350 40 12 35 10 U) 30 L W H 25 8 Z t 20 6 Q V F - 15 J O 4 ~o 10 5 2 0 0 0 10 20 30 40 50 60 70 80 90 100 CAPACITY GALLONS PER MINUTE F.E. Myers, A Pentair Company • 1101 Myers Parkway, Ashland, Ohio 44605 -1923 419/289 -1144 FAX 419/289 -6658 Telex 98 -7443 K3326 7/91 Printed in U.,$.A. T � � ► fl � N ` • G Q x7 D � V 8 j CA 3 0 CD Z m" Q D CL a 5 D ti w =" z Z o O V X 1 � i y (D r \ � — ••INVERT c r a 6 J T 1 D 3 =� J a J w 4) co 1 D 0 r D W t Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In- Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWTS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. 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 ,30 Number of Bedrooms Desi n Flow - Peak (gpd) Estimated Flow - Average (gpd) Y aD Septic Tank Capacity (gal) l Soil Absorption Component Size (ft2) 15PP ft Type of Wastewater Do stic Table 2: Soil Absorption Component - Limits of Reliable Operation Septi Tank Compon Soil Absorption Component Design Flow - Peak (gpd) GD Z3, 9 96 Maximum Influent Particle Size (in) 1/ Maximum BOD (mg /L) 220 Maximum TSS (mg /L) 150 Table 3: Maintenance Schedule Septic Tank Inspect and /or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the sep ' nk and outlet filter shall be assessed at least once every 3 years by inspection. The utlet filt shall be cleaned as necessary to ens ure p opera tion. The filter cartridge shou not be removed unless provisions are made to retain solids in the tank that may slough ough off the filter when removed from its enclosure. If the 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. PL�P_ PI- 9 - '7Ks-- ►,I �-- C .� Go iU c 2 6+ r- 715 6 `4 7 C � r CO Q a �(/6 - 7 IS '? �'�_ Y °_ - X 6 79'7 3 ST CROIX COUNTY SEPTIC: 'TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM ' OwnerBuyer ° t El Mailing Address t� �y'7� ce>III�N LGp�_C f W, SYoat Property Address 7 - CCU vt_ �oc J - auisc'o (Verification required from Planning Department for new construction) City /State UVS(— !::::) Parcel Identification Number LE DESCRIPTION o Yo - 1 29 3 - zo - M-ToC. 1 67T) Property Location 'SC ''/4, NE '/,, Sec. / 7 , T d-,S -RAW, Town of TAN Subdivision 6dnr9 c S , Lot # Certified Survey Map # , Volume , Page # _ Warranty Deed # � 7 � , Volume 24643 , Page # (a Z') Spec house 0 yes O no Lot lines identifiable yes O 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 b. a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposaI 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. Ceruriicanon stating that your septic system has been maintumed must be completed and returned to the St. Croix County Zoning Office within 30 days of �he three ye r c p+ra date. GNATURE OF APP ANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are tnic to the best of my (our) knowledge,. I (we) am (are) the owners) of the roperry describe ove, virtue of a warranty deed recorded in Register of Deeds Office. / 03 GNATURE OF AP 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 staniped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed .U. 2463P 620 - 7,4 7 1 7 STATE BAR OF WISCONSIN FORM 2 - 2000 REGISTER OF DEEDS Document Number WARRANTY DEED ST. CROIX Co., WI This Deed, made between Donald O. Rodahl and Joyce J. Rodahl RECEIVED FOR RECORD , husband and wife Grantor, and William L. Palm and Carol J. Palm, 11/26/2003 04 :15P?l husband and wife as survivorship marital property Grantee. WARRANTY DEED Grantor, for a valuable consideration, conveys and wan-ants to Grantee EXEMPT # the following described real estate in St. Croix County, State of Wisconsin (if REC FEE: 11.00 mo eeded, please attach addendum): TRANS FEE: 224.70 OT TWO (:Z) ,)PI WOO DS SUBDIVISION IN THE TOWN OF COPY FEE: TROY. u Iect to easement in Volume 2119, page 312, as document CC FEE: number 706922. PAGES: 1 Recording Area Name and Return Address CAr D L J. Part of 40 -1068- 70-000 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Exceptions to warranties: easements, restrictions and rights of way of record, if any. Dated this I -( day of November 2003 * * Donald O. Rodahl * * oyce J. Ro 1 AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ) ss. tP- 0'04. County. ) authenticated this day of Personally came before me this � "1 '—� day of November , 2003 the above named Donald O. Rodahl and Joyce J. Rodahl TITLE: MEMBER STATE BAR OI;. GO1V IN . :V � (If not, _' l 0T Aig to me known to be the person(s) who executed the foregoing authorized by §706.06, Wis. .) * : * _ ins ent now g the same. THIS INSTRUMENT WAS WtAF�D BY G = an ack i-� Joseph D. Boles - Attorney at Laves B L� . River Falls WI 54022 ' • . . ��` Notary Public, State of (1) � l{�kll ���,` My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Bo( Necessary.) 3 ) * Names of persons signing in any capacity must be typed or printed below their signature. INFO -PRO (800 )655.2021 www.infoprofomns.com STATE BAR OF WISCONSIN WARRANTY DEED FORM No. 2 - 2000 L OCA TED .OUTLOT I J QUTL.0T ...... I I i NW -NE NE -NE 140.02 145.02' --- -___ 50.02' SW - N I N 8 O p _ z LOT 3 rn C ° m : L OT 2 °= 1.06 ACRES 1. OE w 1. 18 ACRES m 46, 334 S0. FT; 0 LoT r 46. 3. � 51, 422 S0. FT. w '� •� � N � V n _ 1.51 ACRES OD m aD 65,833 S0. FT. 0 4 4 - ,_ -- S7ge Nd 1% §mow - ?9; 44 0-5 - 339.jf— Z � • � �' r gt3' � p6 58. 3' © -r" - —�-�_ - /. /- V 4 1; - , 1 ,q9. DRAINAGE - e 50 26 , E j- EASEMENT HWE - 895. 00' .,�R•� N j LFE -897. 00' N39 4 42 E � --e , �G �. , t Z6•w� O 45.30 5 68 �s �. / 9•.. UNPLATTED LANDS '�� ME 8, PAGE �2 23 ..... s o �����. oh s �� VOL U