HomeMy WebLinkAbout040-1148-30-000 Wisconsin Departmeni! f co PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building DiJlsion
INSPECTION REPORT Sanitary Permit No: 499204 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:
MacDonell, Charles I Troy, Town of 040 - 1148 -30 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
/67- 13 M 1 13.28.20.578A
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
l,J; z ov` /ZSd 4•05 tob.-6 /oz. 46
Alt. BM I4 COJ4�4.. /b z • 37
Aeration Bldg. Sewer
5, is / , 3
Holding SUHtInlet
TANK SETBACK INFORMATION St/Ht Outlet 7-2 /
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD D Inlet _ �/ - '79 I DG
L; W 1
Septic /O i -7 Jr i 7 / Dt BoRorn
Dosing Header /Man.
Aeration Dist. Pipe
Holding Bot. System
PUMP /SIPHON INFORMATION Final Gr de
Manufacturer Demand St Colt
G M
Model Number
TDH Lift Friction Loss System Head TDH Ft
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
SETBACK SYSTEM TO �, BLDG WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION i CHAMBER OR
Type Of System: - 7 5 UNIT Model Number:
W
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size x Hole Spacing Vept tj Air In
Pipe(s) 1 \ 1 W
length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - G a Systems Only
I Depth Over IDepth Over jxx Depth of xx Seeded /Sodded xx Mulched
i Bed(rrench Center rench Edges Tops ' Yes H No Yes Q No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 308 N. Cove Rd. Hudson, WI 54016 (Gov't Lot 4 13 T28N R20W) metes & bounds Lot Parcel No: 13.28.20.578A
1.) Alt BM Description = �• ( �� -��
2.) Bldg sewer length =
- amount of cover
Plan revision Required? Q Yes �g(No
Use other side for additional information. �J
SBD -6710 (R.3197) -
Date Insepctor's nature Cart. No.
MA , .. Safety and Buildings Division County
as, m 201 W. Washington Ave., P.O. Box 7162 St. Croix
ts��O�,� Madison, WI 5370 162 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce (608)266 -31 aD
Sanitary Permit Application State Plan I.D. Number
In accord with Comm 83.21, Wis. Adm. Code, personal information c D Project Address (if different than mailing address)
may be used for secondary purposes Pt'iv G
I. Application Information - Please Print All Informati Same
Property Owner's Name oul t 1 Parcel #: Pending Lot # Block #
040 - 1148 -30-000 Na Na
Charles A. Macdonell OIX COUNTY
Property Owner's Mailing Address Property Location
308 North Cove Road Gov't lot 4 ; Section 13 ; T 28 _ N; R 20 W
City, State Zip Code Phone Number � pA
Hudson, WI 54016 715 386 -3424 a
II. Type of Building (check all that apply) � Subdivision Name CSM Number
X 1 or 2 Family Dwelling -Number of Bedrooms �2k/
❑ Public /Commercial - Describe Use
❑ State Owned - Describe Use []City ❑Village XTownship: T" Loy
III. Type of Permit: (Check only one bog on line A. Complete line B if applicable) ;
A. ❑ New System ❑ Replacement System Treatmen Tank Repla cement Only eF- Modification to Exisfn S stem
' _ 11Yr�YrC �P'6
Yl 7U r ! (
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
X Non - Pressurized In -Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑
Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic TZZntt ❑ Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter El Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe (expla in)
V. Dis ersaUTreatment Area Information: See inspection report for previously installed 2000 dispersal cell
Design Flow (gpd) Design Soil Application Rate (gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank 1,250 1 Wieser Concrete X
Aerobic Treatment Unit
l/ a of
Dosing Chamber
VII. Responsibility State ent- I, the ande gned, assume respon installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's Si ature MP/MPRS Number Business Phone Number
James K. Thompson �_ MPRS #30021 (715) 248 -7767
Plumber's Address (Street, City, State Zip Code)
340 Paulson Lake Lane, &ceola, WI 54020
VIII. Co /De artment Use Only
Sanitary Permit Fee (includes J Date Issued Issuing Agent ignature.(No ps) _
proved 11 Disapproved Groundw r Surcharge Fee) 2 , j
❑ Owner Given Reason for Denial / Gf 7 ( U / 0 l !.��
IX. Conditions of Approval/Reasons for Disapproval _� 4, /
�
YSTEM OWNER:
1 Septic tank, effluent filter and
dispersal cell must all be serviced / maintained
as per management plan prove e y p um er.
2. All setback requirements must be maintained
as eer a licable code /ordinances.
Attach complete plans (to unty /p ly) for the systemon paper less than gl/2 x 11 ess in size
SBD -6398 (R. 01/03)
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Govt. /oEs; Sec. /3 T. ofTroy,
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• ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Ownerfer
Mailing Address 3 &2f64 Ca - , e ke W
Property Address 1 5 1 �
// (Verification required from Planning & Zoning Department for new construction.)
City /State Lf A M , L,j Parcel Identification Number 00 - // `/8 -30 - C&O
LEGAL DESCRIPTION
coed . /07— 4
Property Location t/a , Sec. 13 , T Z 8 N R 20 W, Town of
Subdivision �� �� 111/>'1 Lot #
Certified Survey Map # , Volume , Page #
Wat� "ee – M � D , Volume 7 Page #
Spec house �e no Lot lines identifiable yes YO
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
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. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site
wastewater disposal 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 the St. Croix County Planning &
Zoning Department within 30 clays of the three year expiration date.
I/we certify that all statements on this form are true to the best of my /our knowledge. I/we am/are the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms
SIGNATURE OF APPLICANT(S) DATE
** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * **
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 08/05)
t
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner
0i / Septic Tank Capacity 125Z) gal ❑ NA
Permit # A
Septic Tank Manufacturer W ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer '�, ��� ❑ NA
Number of Bedrooms ��� ❑ NA Effluent Filter Model S ❑ NA
Number of Public Facility Units u ivH Pump Tank Capacity gal
Estimated flow (average) gal /day Pump Tank Manufacturer da-IGA
Design flow (peak), (Estimated x 1.5) gal /day Pump Manufacturer -0-11A
Soil Application Rate 0 g al/day/ft' Pump Model .0-4A
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit
Fats, Oil & Grease (FOG) <_30 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD <_220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) <_150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD 530 mg /L ❑ In- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) :530 mg /LNA ❑ At -Grade ;Zer. � Fecal Coliform (geometric mean) <_10 cfu /100m ❑ Drip -Line ''
Maximum Effluent Particle Size / nn dia. ❑ NA Other: ❑ NA
Other: ❑ 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 ever ❑ mo (s)
P y: (Maximum 3 years) 11 NA
ar(s)
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
Inspect sal cells) At least once every: G "
ear(s) s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: ❑ mo th(s) ❑ NA
ar(s)
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: ❑ month(s)
At least once every: ❑ 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.
s Page , 2 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 concpntrations 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.
0 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 fails and cannot be repaired the following measures have been, or•must be taken, to provide a code compliant
replacement 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 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
A / echnology a holding tank may be installed as a last resort to replace the failed POWTS.
T he
alua ' a o ing lank
be ' e ai ?f ¢Ci2 A16v✓ NS`79(XgX0^/
�+�If
❑ 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 /! 7 f� , fQ E e
Phone 7e
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name s- CKo dU 2 0�j�tl
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.
t► 2006
Wisconsin Department of Commerce SOIL EVALUATION REPO P age 1 of 2
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations
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 (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D.
-1 8 -30 -000
Please print all information. Reviews By Date
Personal information you provide may i u 1 Privacy l aw, s. 15.04 (1) (m)). Z o 6
Property Owner Property Location
Charles A. MacDonell Govt. Lot 1/4 1/4 S 13 T 28 N R 20 W
Property Owner's Mailing Address 2006 Lot # Block # Subd. Name or CSM#
308 Norht Cove Road
City Site Zip 8 m(0NW J City J Village 16 Town Nearest Road
Hudson I WI 386 -342 Troy 308 North Cove Road
J New Construction Use: 601 Residential / Number of bedrooms 2 Code derived design flow rate 300 GPD
✓� Replacement J Public or commercial - Describe:
Parent material Glacial Outwash Flood plain elevation, if applicable 687.0 USGS
General comments
and recommendations: Soil evaluation completed to verify suitability of existing drywell to allow replacement of existing collapsed
septic tank. Elev. at bottom of drywell = 92.37'.
Boring # -1 Boring
Pit Ground Surface elev. 100.82 ft. Depth to limiting factor >1 54 in. Sal Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Q P
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-5 10yr3/3 none I 2fsbk mvfr as 21',1mc 0.6 0.8
2 5-23 1 Oyr4 /4 none Is Osg ml cw 2f,1 me 0.7 1.6
3 23 -78 10yr4/6 none s Osg dl gw 1vf,f 0.7 1.6
4 78 -154 10yr5/6 none strat s&ls 0 sg dl - - 0.7 1.6
- T - - i L
Loading rate of horizon H#4 reduce Lk reduced permeability associated with irregular, discontinuous bands of 10yr4/4 Ifs.
* Effluent #1 = BOD 30 < 220 mg /L d TSS >30 < 50 mg/L ffluent #2 = BOD <30 mg /L and TSS S30 mg /L
CST Name (Please Print) Signat . CST Number
James K. Thompson S. 3602
Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number
340 Paulson Lake Lane, Osce a, Wl 54020 9/14/2006 715 -248 -7767
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759467
II. 2 5 4 7 P 4 2 KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIX CO.. WI
STATE BAR OF WISCONSIN FORM 3 —2000 RECEIVED FOR RECORD
QUIT CLAIM DEED
Document Number 04/13/2004 03:90PH
This Deed, made between Sandra Hatch Macdonell, as Grantor, and QUIT CLAIM DEED
Charles A. Macdonell, as Grantee. EXEMPT # ON
Grantor quit claims to Grantee the following described real estate in St. REC FEE: it.@@
Croix County, State of Wisconsin (if more space is needed, please attach TRANS FEE:
addendum): COPY FEE:
CC FEE:
Commencing at a point three hundred forty -one and one -half feet PAGES: t
north (341.5 ft.) of Northwest corner of the Northeast quarter of
section twenty -four (24) in Township number twenty -eight (28)
north of Range twenty (20) west, thence north two hundred ten
(210) feet thence west to shore of Lake St. Croix, thence
southwesterly along the shore of Lake St. Croix to a point due west
of the place of beginning, thence East to the place of beginning. Recording Area
Name and Return Address
Together with all appurtenant rights title and interests. Charles A. Macdonell
308 North Cove Road
Hudson, Wisconsin 54016 -8034
040 - 1148 - 30 - 000
Parcel Identification Number (PIN)
This (click to select) homestead property.
Dated this day of March, 2004
* SANDRA HATCH MACDONELL
*
AUTHENTICATION ACKNOWLEDGMENT
STATE OF W4'$ N OHIO )
Signature(s) authenticated this day of ) ss.
County �CLV'I:t f}d1 )
Personally cam Ap(ip a this , day of March, 2004
% * the above named Gradton NE k t � - Iro ' ' " to be the person Sandra Hatch
TITLE: MEMBER STATE BAR OF WISCONSIN Macdonell who executed the f strument and acknowledged
(if not, authorized by § 706.06, Wis. Stats.) the same. .- ERIN NEAL E Notcry Public
€'
THIS INSTRUMENT WAS DRAFTED BY Erin Neale In and for tho Sioto of Ohio
-
JODY T. KLEKAMP, ESQ. * £ i omm on xpieson o 16th 2
Cincinnati, Ohio Notary Public, Stag of xxll�a�,:. hid
(Signatures may be authenticated or acknowledged. Both are not necessary.) a �'
My Commission is tliit�ie state expiration date:
,) Z + , '. , t 4 � Ia11 i O0
'Names of persons signing in any capacity must be typed or printed below their signature.
QUIT CLAIM DEED STATE BAR OF WISCONSIN FORM No. 3 — 2000
1234685.1