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020-1163-50-000
Wisconsin Department of Commerte PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 552352 0 GENERAL INFORMATION 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: Davis, Kevin W. ers Hudson, Town of 020-1163-50-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: c3~ ~g Z 12.29.20.948 950 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER t 5 CAPACITY STATION BS HI FS ELEV. Septic ` / Benchmark 414.7 C/y a d4 A Dosing ,r,J $ / Alt. B,• t --!F. /(V q~ Aeration Bldg. Sewer ~ t~".' 1 b a G X~ Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet 9• ~S $~7• TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Q IL Septic N . a ~ ~ • O 5C Dosing ` ~L He,er/ a 15 Aeration Sr Dist. Pipe ~ r L,/ Holding Bot. System 70• (o Final Grade PUMP/SIPHON INFORMATION Manufacturer De and St Cover • f 9/ 5~` GPM rr' ~-k (p Model Numb Valve, . vT TDH Lift Friction Loss System H TDH t VoA~~ /62 N.` T Forcemain a. Dist. to Well SOIL ABSORPTION YSTEM BED/TRENCH Width Length - _ No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 44,51 SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR ~o~..~~ Type Of System: UNIT Model Number: moo„ DISTRIBUTION SYSTEM f r~ .J'' . Jr' f' , S • S =-/3. S He der/Manif° IDistribution x Hole Size x Hole Spacing Vent to Air In ke C I-~~~i.~ Pipe(s) Length Dia Length Dia Spacing ` SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Dept f jxx Seeded/ oddedYes xx Mulched Bed/Trench Center 2• G~ Bed/Trench Edges ` Topsoil No Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: / Location: 296 Edgewood,Drrive Hudson, WI 54016 (SE 1/4 NE 1/4 12 T29N R20W) Edgewood Estates L t 18,19,20 Parcel No: 12.29.20.948 950 1.) Alt BM Description= Co~~~... G i `6 O Y\ 2.) Bldg sewer length = - amount of cover = X~ ✓V I n D(`o a 1 / 1 I J ~-r ,~"'rL►,.ti- •1-a l~ fiC d~ l 10 Oz1 Plan revision Required? Fta~ Yes No 5 a~ Use other side for additional informati n. SBO-6710 (R.3/97) Date Insepctor's Si ature Cert. No. County ' !Safety and Buildings Division .J % . CMG/X 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co-) ~I Madison, WI 537 71 XZ1 State Transaction} Number s it Application A In accordance with P~ is. Adm. Code, submission of this form to the appropriate governmental unit is required prior to a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Addres (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary r ✓ purposes in accordance with the Privacy Law, s. 15.0 1 m , Slats. I .S I 1 N ( f 1. A lication Information - Please Print All Information Property Owner's Name Parcel # KEVIN Nr l5 ozo-(03- 5-o -coo Property Owner's Mailing Address Property Location 1A T V Z Ld&6WO© Dm). Govt. Lot 91~1 City, State Zip Code Phone Number e_ y,, tJ Section 7- . ,(circle one 0 50AJ W T 7 T Z _N; R V EAV IL Type of Building (check all that apply) Lot # f 0 Subdivision Name 1 or 2 Family Dwelling -Number of Bedrooms A Block# ,4111 ❑ Public/Commercial - Describe Use ❑ City of CSM Number ❑ Village of ❑ State Owned -Describe Use HDsON Town of 11N 111. Type of Permit: (Chet one box online A. Complete line B if applicable) A. ❑ New system 19 Replacement System Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) - - List Previous Permit Number end Date Issued B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New Before Expiration Owner y IV. Type of POWTS S stem/Com nent/Device: Check all that apply) 19 Non-Pressurized In-Ground ❑ Pressurized In-Ground .Q At-Grade p Mound ? 24 tit. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain)Li ❑ Pretreatment Device (explain) V. Dis ersal/Treatment Area Information: 7(sfO)Dispersal Design Flow (gpd) Soil Application Rate(gpdsf) Dispersal Area equireArea Proposed (sf) System Elevation gn0. 6L13 075 ©100'$!•!06 8f, y50 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units 5Z~ t j y New Tanks Existing Tanks _wt 10 c- e c y ~ r _e Septic or Holding Tank O `O~ 2 66,6 s W t F S Efe Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber' Si re MP/MPRS Number Business Phone Number ©r+N 5c~Fyki(~r ~~c -rr 77 7~ O 71S 76,0 -o'Y86 Plumber's Address (Street, City, State, Zip Code) 7-11 ,4 VII oun epartment Use Only Permit Fee Date [sued Issuing A gn a _ Approved ❑ Disapproved $ r l l ❑ Owner Given Reason for Denial 11,5- 2V 1 IX. Conditions of ApprovaUReasons for Disapproval- ` 1 v SYSTEM OWNER: " /y rJJ 1 Septic tank, effluent filter and dispersal cell must all be serviced / maintained Yt~ as per management plan provided by plumber. Gar Z ~G,f gL 22. All setbackieq r~IAlfQtalhgSltem submit to the County only on r not less a S y7 x 11 niches in size l~ r r ,f Y ~,r,~, SyS as per applicable code/ordinances. wire Cy '3 ' k~!-1 c~~- • i;1.~ l ~ ' ~,E~ _ c' J SBD-6398 (R. 11/ I1) PLOT PLAN N Project Name: Davis Repacement Septic System Legal Description: SE 1/4,NE1/4 S12 T29N R20W P.I.D: 020-1163-50-000 Subdivision Name: EDGEWOOD ESTATES Lot 18, 19 & 20 Township: HUDSON Parcel Size: 1.002 Acres SCALE: 1" = 40' County: ST. CROIX System Elevation: T1=90.66' 4 inch Sch 40 -ASTM D2665 Slope: 10% T2=89.66' 4 inch 3034 - ASTM D3034 A BM1 Elevation: 93.08 To of Transformer T3=88.66 0 BM2 Elevation: ■ Backhoe Pits: ~RoPi: LrnJrS Lo 7" !~,ly,tZO GAP Aco ~0u~e /©00 ~14L wiop® G VAU1E /SZSCCi: ~ 8 j 3c3Y i ~ ~ AX`S r~ a• ~ 9 ~ ~ .'aN~ _ ~ ~ ate 7 r ' Sc i f3.3 ~ ~ i •~~NCFf~ CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Davis Replacement Septic System Owners Name: Kevin Davis Owner's Address 296 Edgewood Drive Hudson, WI 54016 Legal Description: SE1/4, NE1/4, S12, T29N, R20W Township Hudson County: St. Croix Subdivision Name: Edgewood Estates Lot Number: 18, 19, & 20 Block Number Parcel I.D. Number 020-1163-50-000 Plan Transaction No. Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross Section Page 4 Septic Tank Specifications Page 5 Effluent Filter Information Page 6 & 7 Management and contingency plan Page 8 Septic Tank Maintenance Agreement Page 9 Existing Septic Tank Certification Page 10 Bull Run Valve Information Page 11 &12 EZ Flow Information Page 13 Map Page 14 Warranty Deed Page 15-17 Soil Evaluation Report Designer: John Schmitt Licnese Number: MPRS 223760 Date: 5/11/2012 Phone Number: 715-760-0486 Zit Signature: (-44 i In-Ground Soil Absorption Component Manual Version 2.0 SBD-10705-P (N. 01/01) Page 1 of 17 PLOT PLAN N Project Name: Davis Repacement Septic System Legal Description: SE 1/4 NE1/4 S12,T29N R20W P.I.D: 020-1163-50-000 Subdivision Name: EDGEWOOD ESTATES Lot 18, 19 & 20 Township: HUDSON Parcel Size: 1.002 Acres SCALE: V„=4W County: ST. CROIX System Elevation: T1=90.66' 4 inch Sch 40 -ASTM D2665 Slope: 10% T2=89.66' 4 inch 3034 - ASTM D3034 A BM1 Elevation: 93.08 To of Transformer T3=88.66 BM2 Elevation: ■ Backhoe Pits: t DROPEP-7-Y LIA1ES 1-07" 16 f Z0 G~P_A,(o N614 st b /dpC&.4L . tau ~CW /060 dRIVE rJ scr. ,05.T LGAL V~LOt s7z3- ~ X131 3e3y iCX~s ~E SCE µ rt 7-3 y d. R3 i _ t L ~C t~~~ ,'en SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT Page Of Project Name: Davis Replacement Septic System 3 No. of Cells 4.5 Per Cell 3 ft Cell Width 13.5 Total No of EZ1230H 45 ft Cell Length 225 sq ft EISA Per Cell 4 ft Cell Spacing 675 sq ft Total EISA Manufacturer Model Laying Length EISA Rating Infiltrator EZ1203H-5ft 5.0' 25.0 EZ1203H-10ft 10.0' 50.0 Gravelless Leaching Unit Manufacturer: Infiltrator EZ Flow Gravelless Leaching Unit Model: EZ1230H Typical Cross Section Finished Grade 93 ft Observation Pipe with approved cap or vent Soil Backfill 36 in • Geotextile Fabric 88.7 ft Infiltrative Surface 12 in I 84 ft Limiting Factor a >36 in Slotted and Anchored Vent/ Observation Pipe with Cap W 7~ Plumber/Designer Signature: License 223760 Date: 5/11/2012 Page 3 61" 42" z 86" r m N -1 D 45j" I 0 I ~r'~z= `I 4" I co o < I < n m -u c m I rr-o0 I o m Ell r D n~ mr 3 t 0 -4 0 D O mZ C U) m <0 I m o m X K D 0 z c c cn > o D ~r- n zm D r = r 2 2 v_ X m (n ~0 z z O O 0 r r K D 0 nD n D Z Z o rOD~r =fin WAN z O z m Z Zr-A 0 oc ) n O~z C) ~Omoz m>O OD- C 3 Wso u OrN O ~r-I > 1100 Q) 0 =-0 c) OzA olF. N Z ~ C m m ~ W = m DmD D MO M>O i ~O~ O. m 0 m D N r~z n xzcc MU) c r- r N (n r C C r r+, A i Z 0S•• -I NN-I O~mrO~i~ mOm~ O cn = cn DO < (n?r r- c~Dm m -o r0 =mom .ZI -Ip r O D< O 0o y m N D N S X 1 74 O r~ O p -Di KW -P r- -0 m O D f~1 m -u v -q (n x z O n cnmD I m r 4 0 nc~- Z0 00 0 m O in c w (n0-Ti Dr No~N v0Oo o -n 0 0 0 \ o z O m o m cn CO O ~ m -o n D 0 c <-1 N 00 0DD DS o wa,m D Z 3 m O N \ =rZ r win -I Z M c z D:k 0 Co =D 0 0 O D 0 ~O-n 0X ~O~ 0 O n 20 m ~ O m 0 1 Z N C) 0 O M O'co O z o 07 K) V) m m o O m o N N m ° o J z F co AID ;u F-4 D o r00 X C z x C) N m w ~ m m r z Z r ~ m \ O m WLP1000-MR SCALE:1 4" 1' REV NO. DATE: 0 m OBER millETE DRAWN BY.SWT -n I Z SEPTIC MANUAL W3716 US HWY10. MAIDEN Roar, wi 54750 DATE: JANUARY 2008 0 REV. JAN. 2008 800-325-8456 FILE: WLP1000-MR PSWO P1~LY Inc. gK.INSTALLATION INSTRUCTIONS Innovations in Precast, Drainage PL-525/PL-625 FILTER & Wastewater Products INSTALLATION INSTRUCTIONS Center filter Livhw with opening .y W N T Jn M0 a ~ e Additional pipe or Polylok Extend & Lok° Glue for centering. Step 1: Step 2: Step 3: (A) Locate the outlet of the septic tank. (A) Before installation, place the (A) Glue the filter housing on the (B) Remove tank cover and pump tank filter housing on to the outlet pipe. outlet pipe. if necessary. (B) Make sure that the housing (B) Insert the filter cartridge in the is positioned so the filter can be housing, making sure the filter removed from the tank for cartridge is properly aligned and maintenance and service. completely inserted in the housing. MAINTENANCE INSTRUCTIONS 1 1 w Step 1: Step 2: Step 3: Locate the outlet of the septic tank. (A) Remove tank cover and pump (A) Insert the filter cartridge back if necessary. into the the housing making sure • NOT USE PLUMBING (B) Pull the filter out of the housing. the filter is properly alighed • ' and completely inserted. : L WHEN FILTER IS (C) Hose off the filter over the septic tank. USE RUBBER S Make sure all solids fall back into the (B) Replace septic tank cover WHEN CLEANING FLIER septic tank. Page 5 1 j Installation Instructions for VAEZJ9EZflow Systems in Wisconsin y INFILTRATOR Wisconsin Department of Commerce, Safety and Buildings 5. The Absorption area (SF) necessary for a given site shall Division, has reviewed the specifications and/or plans for this be sized based on maximum daily sewage flow (GPD) and product and determined it to be in compliance with chapters : the Permeability for the site. If certain criteria is met, the Comm 82 through 84, Wisconsin Admin. Code, and Chapters EISA sizing can be used in Wisconsin, resulting in a 40% 145 and 160, Wisconsin Statutes. All sites must meet the Site smaller drainfield. & Soil Conditions & Locations & Isolation distances as noted in : local regulations. : 6. Place EZflow bundle(s) in the EZflow configuration ap- proved by system design permit specified for the particu- The approved products are 1203H (3-12" bundles with pipe in lar site. The top or center-most bundles containing pipe center bundle in 5' or 10' lengths) and 1203HP (3-12" bundles are joined end to end with an internal pipe coupler. Any with pipe in each bundle in 5' or 10' lengths. : additional aggregate only bundles that may be required, should be butted against the other aggregate-only bun- A single pipe bundle contains a four inch perforated pipe sur- dles and do not require any type of connection. rounded by EPS aggregate and is held together with poly- ehtylene netting. A single aggregate bundle contains aggregate 7. The top of each GEO cylinder contains a finer fabric pre- only and is held together with polyethylene netting. : manufactured in between the netting and aggregate. The fabric is inserted to prevent soil intrusion. The installer Materials and Equipment Needed shall make sure the the GEO is positiioned upward and is • EZflow Bundles : in contact with the fabric contained in the adjacent cylin- • EZflow Geotextile Fabric : der before backfilling. • EZflow Internal Pipe Couplers : • Pipe for Header and Inlet 8. The EZflow Drainfield Systems should be installed in a • Backhoe/Excavator level trench in all directions (both across and along the trench bottom) and should follow the contour of the ground Installation Instructions surface elevation (uniform depth), with all continuous The instructions for installation of EZflow products are given adjoining 10-foot cylindrical bundles placed end to end, below. This product must be installed in accordance with state with central bundle distribution pipe interconnected, rules defined in chapters Comm 82 through 84, Wisconsin Ad- without any dams, stepdowns or other water stops. ministrative Code, and Chapters 145 and 160, Wisconsin Stat- utes, as well as the local health department's current design 9. The trench top shall be graded such that water will not manual. pond. Backfill should be seeded or sodded immediately after completion to reduce erosion. 1. After the local health department has determined sizing, configuration, and layout for the EZflow systems, stake 10. EZflow EPS bundles are flexible and can fit in curved or mark with paint the location of trenches and lines. Be trenches as may be necessary to avoid trees, boulders, or careful to set correct tank, invert pipe, header line or dis- other obstacles. tribution box and trench bottom elevations before instal- lation of pipe bundles. 11. EPS aggregate is lighter than water, therefore, it might be expected that natural buoyancy forces would tend to 2. Remove plastic EZflow shipping bags prior to placing cause EZflow assemblies to float out of ground when bundles in the trench(es). Remove any plastic bags in the ponding occurs. Field experience has shown, however, trench before system is covered. that this is not a problem when systems have a minimum of 6" of soil cover as recommended by manufacturer. 3. This product must have geotextile fabric that meets re- quirements of s. Comm 84.30 (6) (g), Wis. Adm. Code, installed directly on top of the product and extending 1203H-GEO down along the sides of the product to a point at least six : inches from the bottom of product. Geotextile Barrier Material 4. When installed in a trench, the trench should be dug to a width of 36 inches. This not only saves labor in excava- tion, but also provides better load-bearing capacity after back-filling is complete. Pal e.14...... .1 _ Vol' Y 7 f~ 1 4 I POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page-Lof FILE INFORMATION SYSTEM SPECIFICATIONS Owner: Kevin Davis Tank Manufacturer: Week's Concrete Prodl r NA Permit # E Septic Dose Holding Volume: 1000 gal DESIGN PARAMETERS Tank Manufacturer: Wieser Concrete r NA Number of Bedrooms: 3 r NA E Septic E Dose Holding Volume: 1000 al Number of Public Facility Units: r NA Vertical Distance Tank Bottom (s) to Service Pad:_NA ft Estimated (average) Flow: 300 gal/day Horizontal Distance Tank(s) to Serivce Pad: ft Design (peak) Flow = estimated x 1.5: 450 gal/day Specific servicing mechanics must be provide if vertical is>15 feet or if In Situ Soil Application Rate: 0.7 gal/day/ft2 horizontal is > 150 feet. Specific instructions to be provided on back. Standard Domestic Influent/Effluent Monthly average Effluent Filter Manufacturer: Polylok r NA Fats, Oils & Grease (FOG) 530 mg/L Effluent Filter Model: 525 Biochemical Oxygen Demand (BOD5) 5220mg/L r NA Pump Manufacturer: NA Total Suspended Solids (TSS) 5150mg/L Pump Model: High Strength Influent/Effluent Monthly average Petreatment Unit Fats, Oils & Grease (FOG) 530 mg/L Manufacturer: Biochemical Oxygen Demand (BOD5) 5220mg/L r NA r Mechanical aeration r Peat Filter rk NA Total Suspended Solids (TSS) 5150mg/L r Disinfection r wetland Petreated Effluent Monthly average r Sand/Gravel Filter r other. Biochemical Oxygen Demand (BOD5) 530mg/L Soil Absorption System Total Suspended Solids (TSS) 530mg/L r NA bt In-Ground (gravity) r in-Ground (pressure) r NA Fecal Coliform (geometric mean) 5104cru/100m1 r At-Grade r Mound Maximum Effluent Particle Size: % in dia. r N r Drip-Line r other. Other: r Other: F NA MAINTENANCE SCHEDULE Service Event Service Frequency When combined with sludge and scum equals one-third of tank volume Pump out contents of tank(s) When the high water alarm is activated mon"s) Inspect condition of tank(s) At least once eve : 3 r Y-(s) (Maximum 3 ears) r NA g Inspect dispersal cell(s) At least once eve : 3 r y-(s) (Maximum 3 ears) r NA r month(s) Clean effluent filter At least once eve : 1.5 r year(s) r NA month(s) Inspect pump, pump controls & alarm At least once eve : r rear(s) r NA g Flush laterals and pressure test At least once eve : r year(s) NA month(s) Other: At least once eve : r yew(:) r NA Other: Rest old dranfield for 3 years, then alternate drainfields annually. 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 Insepector; POWTS Maintainer; Septage Servicing Operator (pumper). Tank inspections must include a visual inspeciton 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 a check for any back up or ponding of effluent on 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 indicated a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumualtion of sludge and scum in any treatment tank equals one-third 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 Admininistrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, petreatment 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 30 days of completion of any service event. (Rev.2/05) Page 6 ~ START UP AND OPERATION Page of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil 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 extended 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 and may overload them resulting 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) discharge; 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, pits and other soil absorption systems 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 fails and cannot be repaired the following measures have been, or must be taken, to provide the opportunity to obtain a sanitary permit for 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 the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort. The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ 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: TREATMENT TANKS AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES AND LACK SUFFICIENT OXYGEN TO SUPPORT LIFE. NEVER ENTER A TREATMENT TANK OR HOLDING TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK IS VERY DIFFICULT. ADDITIONAL INFORMATION: POWTS INSTALLER POWTS MAINTAINER Name: John Schmitt Name: John Schmitt Phone: 715-760-0486 Phone: 715-760-0486 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name: Name: St Croix County Zoning Phone: Phone: 715-386.4680 This document is intended to meet minimum requirements of Ch. Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Use of this document does not guarantee the performance of the POWTS. Page 7 (Rev. 2105) ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer v r , t''/ s Mailing Address Z 9 E p6 U_)0c 0 Ode. r{U 050 A) W Z- Property Address Z91(0 E d (SEW O o yj did, (Verification required from Planning & Zoning Department for new construction.) City/State HLJAJ50 A).# ICU ' Parcel Identification Number DZ 0'~~ /~3 S© 0~ LEGAL DESCRIPTION Property Location .5 W 1/4,.5 0) '/4 , Sec. / Z , T Z9 N R Z © W, Town of U o5 411 Subdivision Plat: EDC' t Wf>O 0 5 7-i47'L=S Lot # Certified Survey Map # , Volume , Page # ( before 2007) Volume Warranty Deed # ( # Page Spec house ❑ yes Kno Lot lines identifiable 'yes ❑ no 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 days of the three year expiration date. Uwe 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. 09/07) Page 8 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) q (a Cd &6 i~ 0 CIO .ark y located at: t i/a, 1/4, Section ! Z , Town_2!Z_N, Range_2 0_W, Town of u 5 o /J , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service ~ Did flow back occur from absorption sYstem? Yes No X (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: / 00o Construction: Prefab Concrete Steel Other Manufacturer (if known): c f- K S C. Age of Tank (if known): Z 11,5 o4!2 S Permit number (if known) / T© N IV SC H.*In t ~T (Li sed Plumber Signature) (Print Name) mots ZZ3 7( t~ (Title) (License Number) MP/MPRS - /-2011 (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 Page 9 American Manufacturing Company Bull Run Valve Page 1 of 3 T Order Info Training Videos Contact Data Center Home About Site Map 11 :771 E I Drip Systems Watm/Wastewalm Controls Products Downloads Design Guidance THE BULL RUN TM VALVE / i 'WATER-TIGHT ACCESS CAP RISER CAP ADAPTER RISER TUBE VALVE DIRECTION HANDLE The Bull Run Valve TM is designed to split flows to septic ~ oUTPORT fields or systems. In addition to the advantages of longer life and easier installation it is the most public 4' OUT PORT health safe alternating device available for wastewater disposal applications. The use has absolutely no contact with wastewater due to the valve's leak-proof and 7t external operating characteristics. The change over from 4" IN PORT one drainage field to another can be accomplished in less than a minute by simply turning the valve without The Bull Run Valve is available in 4" sch 40 pvc digging or contact with wastewater. and is suitable wherever septic disposal systems are used - in commercial, industrial, and residential applications. OPERATING THE VALVE The direction control handle should be rotated Field Field Field Field periodically to direct effluent to one or the other No. I No. 2 No. I No.2 of two septic fields. After removing the screw cap at the top of the riser tube, the valve handle j = can be turned with the valve key furnished. Valve Valve Positioned Positioned BULL RUN VALVE on No. 1 on No- 2 Complete Valve Kit dunng Contains Odd Years Septic Septic Even Years Tank Tanis 1. Bull Run Valve body 2. 28" Valve Key 3. Riser Cap Adapter ITEM DESCRIPTION 4. Watertight Access Cap BRV4 BULL RUN VALVE 4" BRVBULK BULL RUN VALVE & KEY ONLY BRVCIRISER BULL RUN VALVE RISER W/ CAST COVER BRVCIRISER - 4" BRVKEY28 BULL RUN VALVE KEY 28" ADJUSTABLE TO 28" BRVKEY36 BULL RUN VALVE KEY 36" HIGH POLY RISER Page 10 http://www.americanonsite.com/american/catalog/brv.html 5/11/2012 EZflow by INFILTRATOR 1K IC r - I„,FJ ~ as.r.:d,,,{ AX W00-1 "i_3. C:;; 1.+ s .~A a ~ z :~}q ! ,.a • Always clean and free of fines • Bundles are quick to install, saving costs on heavy machinery and labor • Modular construction allows configurations to match trench dimensions for most system shapes and sizes • Engineered for optimal storage and absorption efficiencies • Ability to contour along sloped sites and around trees or landscaping • Lightweight system is perfect for repairs and tight job sites • Easily hand-carried into position reducing time and labor • 5' or 10' lengths with simple snap, internal couplers • Easier cleanup at the job site with the elimination of stone • Manufactured from recycled materials rather than a mined natural resource • A wide variety of diameters and configurations to meet any installation professional's needs • Approved in many jurisdictions with an increased efficiency rating, reducing drain field size • Also useful for foundation and other drainage applications • Backed by the leader in the onsite wastewater industry 4- 1 19 Vt. EZ1101,1U, *Wr by INFILTRATOR For technical assistance, installation instructions or customer service, call Infiltrator SPAWhAl6t 800.689.7759. STATE BAR OF WISCONSIN FORM 2 - 1999 6 Z9 1 4E%4 S EEDS WARRANTY DEED REGISTER H. DWALSH Document Number ST. CROIOh' DEEDS ST. CROIX CO., WI This Deed, made between Patrick L. Kelly and Michelle L. Kelly RECEIVED FOR RECORD husband and wife 10-16-2000 10:30 RM WARRANTY DEED Grantor, and Kevin W. Davis, a single person EXEMPT 11 CERT COPY FEE: COPY FEE: TRANSFER FEE: 520.50 RECORDING FEE: 10.00 Grantee. PAGES: 1 Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area Lots 18, 19 and 20, Edgewood Estates Subdivision in the Town of Hudson, Name and Return Addn s T 1 St. Croix County, Wisconsin, tylr3o XY34 c ~/S T 5V • ~t° 20-1163-50-000 Parcel Identification Number (PIN) This is homestead property. (is) C*X00 Exceptions to warranties: Easements, restrictions and rights-of-way of record, if any. Dated this day of September 2000 » » Patrick L. Kelly itte.h.c I t kP eCEI » Michelle L. Kelly AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ) ss. ■ Cam' l~"t ~C County ) authenticated this aylaE13FI-CA , r'jr=rhRTQE(f~ Personally came before me this day of NOTARY pU8LJC September 2000 the above named ■ CONSIN Patrick L. Kelly and Michelle L. Kelly, husband and wife » TITLE: MEMBER STATE BAR OF WISCONSIN ([f not, to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY » Attorney Kristine Ogland Notary Public, State of W consin Hudson, 134016 My Commission is perm ent. f not, 7- Names to expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) ~ I , --1'd ) » ofpersons signing in any capacity must be typed or printed below thew signature. di/amatlon Pr f a.bn.l. comp. Y. F«,d du LWa WI STATE BAR OF WISCONSIN 800455-21021 WARRANTY DEED FORM No.2-1999 ST. CROIX COUNTY ZONING DEPARTMENT • AS BUILT SANITARY REPORT I r t` Owner ~ct r,1r),e i Property Address .4 , a e- J oc,4 o2L ~ ` 4 4 ST Cq0iX ' City/State /✓u se,4 Zd Z 5 5-D~c ~ CC>uN g 't7t~INt~ 0FFCe a Legal Description: Lot /d'/9av Block Subdivision/CSM # IC, -k -od '/a '/a, Sec. Z, T2N-R/9• W, Town of 11 Ai s®.,-, PIN # 02 0 -/14'3 -•So -000 SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION: Tank manufacturer AL' C,Sek- Size ST/PC 10~ l Setback from: House Well PAL, Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: A7 LAY. Type of system: oepro~ Width I Length 3e;- Number of Trenches Setback from: House Well P/L Vent to fresh air intake ELEVATIONS: Description of benchmark Elevation Description of alternate benchmark ----7d d1`:-- Elevation Building Sewer ST/HT Inlet ST Outlet 9 PC Inlet PC Bottom Header/Manifold 3. 7 9 Top of ST/PC Manhole Cover Distribution Lines ~2 3 ;2 1 ( ) Bottom of System ( ) • ( ) Final Grade ( ) Date of installation 1-2 //,~'//JVPermit number State plan number Plumber's signature CJ~GI`~~` License number a ~ D Date12! Inspector 4-lve Complete plot plan NOTICE: Please provide the following: . • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW i i" Q~ ~ ,bG ':gyp f1b.~,vdo,r/ l FX3~ ,Bed V a s> INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division Countv INSPECTION REPORT ST. CROIX .GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary PermitNo.: Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)]. 324669 Ei' jo deppiftnne: Ifibi6IonIlage Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: iUl7b`U1V Parcel Tax No.: ~ 020-1163-50-000 Iri ~ TANK INFORMATION ELEVATION DATA A9800560 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic j~ Benchmart bZ 0 Dosing Aeration Bldg. Sewer [Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Vent P/L WELL BLDG. AirIto ntake ROAD Dt Inlet Septic NA Dt Bottom 4'•j 3 Dosing NA Header/ Man. Aeration NA Dist. Pipe ';F5,77 Holding Bot. System to 12, W PUMP / SIPHON INFORMATION Final Grade . 90 16 •IZ Manufacturer mand , ,fob S 3 7 Model Number Y GPM TDH Lift Fri Ft oss Head Forcemain Length well SOIL ABSORPTION SYSTEM BED/TRENCH Width q / Length3 No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 1 a ~ DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufact SETBACK INFORMATION Type r r CHAMBER model Nu er: syst OR UNIT DISTRIBUTION SYSTEM Header / Manifpld Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length / b 1 Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 12.29.20.948-950,SE,NE 296 EDGEWOOD DRIVE S 4w~ vte 4;u~w U Plan revision required? ❑ Yes fX-No q Use other side for additional information. '7 Date inspector's Si ature Cert. No. SBD-6710 R.3/97 Safety and Buildings Division . Visconsin SANITARY PERMIT APPLICATION p201 W. OBoW shingtonAvenue Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707-7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit(NNu~mmber Personal information you provide may be used for seconds ~ y y ry purposes C] Check if revision t previous a plication (Privacy Law, s. 15.04 (1) (m)]. S' State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location 42 T VL't A We-1 i4, S 2 T , N, R E (or Pr perty Owner's ailing Address Lot Number Block Number a9& d e to Dr= ZZIU o City, State Zip Code Phone Number Subdivis n ame or CSM Number Nearest Road 11. TYPE F BUILDING : (check one) ❑ State Owned r~ it( age ❑ vil Public 1 or 2 Family Dwelling - No. of bedrooms J Town OF 100W0 1191 4,1410 :1U 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 4a p. 010. Q7~ n~ 1 ❑ Apartment/ Condo ea -!r-6r a 7 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2. 1Z Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5, ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 R1 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground Pressure / 42 E] Pit Privy 13 ❑ Seepage Pit L?X 5(0, 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) p Elevation lot d Feet QSJ~ Feet ~Sr~ Y G~ '-I'i Capacity VII. TANK in gallons Total # of Prefab. Site Fiber- Exper- INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete struCon- tted steel glass Plastic App Tanks Tanks ep=ic Tan QQQ C r C,$e ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (N Stamps) N PRSW No.: Business Phone Number: Plumber's Address (Street, City State; Zip Code): !d 9d cam IX. COUNTY / DEPARTMENT USE ONLY l ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps) oApproved E] Surcharge Pee) / Owner Given Initial / C De/ 'I Adverse Determination 6 /Od l/ X. CO DITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: V~1 Caves ~~n 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3151. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. 11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line 8 if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number- Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 81/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. ~h CS '`~r~1C -5 C, X20 ' oz`s 1006 V° A- A t`=r'y ioe- ' ~~•~-fie ap ~L,elr l60, t13/ ol, U 3i0~ ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the *cljK residence located at: S, section (2 , T a4 N, R d W, Town of 1714c(So-41 Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced: ;f4&, IXev Did flow back occur from absorption system? T Yes No (If no, skip next line) Approximate volume or length of time: ? gallons ? minutes Capacity: Construction: Prefab Concrete X Steel Other Manufacturer: (If known): ~J•cS Age of Tank (If known) : 1S'',rs (Signature) (Name) Please print (Title) (License Number) ll~~ z Date Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name $aaral~cv Signature PRS ~~?~YD I Wisconsin Department of Industry, S D SITE EVALUATION / .3 Labor and Human Relations Page of Division of Safety and Buildings b s. ILHR 83.09, Wis. Attach complete site plan on paper not less tha 1 x 111 Pla~i rr~ t County Include, but not limited to: vertical and horizon erence po rectio percent slope, scale or dimensions, north arro d lororj an distance to nee as road. Parcel I.D. # ct LL.. R, 1998 ~:7~ //6,3 -5'0 APPLICANT INFORMATION - Pleas t all i T~lon.~ Re ' wed by Date Personal information you provide may be used for se 0 s. _04 (m)). d o Property Owner roperty Location Govt. Lot .$-F 1/4 A~E114,S /Z T 21 N,R 24 E (o W Property Owners Mailing Address Lot # Block# Subd. Name or CSM# 2• f6 i!;''P~OOO :~w • f.20 d o~ T-f-TeS• City State Zip Code Phone Number / Nearest Road /f ( 3 q/.1 ~2(Q El City El Village I~ Town d' too oD A/lOrUi2 . ❑ New Construction Use: esidential / Number of bedrooms Addition to existing building replacement ❑ Public or commercial - Describe: IVIp Code derived daily flow gpd Recommended design loading rate IV/le bed, gpd/ft2 trench, gpd/ft2 Absorption area required LV bed . ft2 SG 3 trench, ft22 Maximum design loading rate bed, gpd/ft2 - trench, gpd/ft2 Recommended infiltration surface elevation(s) (as referred to site plan benchmark) ~~ST~~/Qtl Additional design/site considerations ~s~ ,S.A~ •L `G~! S Px d oy- / 7f Paregt material 5z-tVP UTw/~ Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system 9f El U ❑ s alf-I E~ U ❑ S ❑ s GJ-t ❑ S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 Texture Consistence Boundary Roots Bed , Trench in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. l C p. 3 /o Y.2 1/2- EGG SL /f s,0d~ 4►- f/2 4 S 2e y : • S 2 •t7 /0 Y1, C Yll~ i S l~ S Ground le'W 3/ /l~• S/L /f✓i elev. ~ N . Depth to ' limiting r ' (~O factor l 4__In. E LTl'N SYY?0" f/V *7 -j ell, Remarks: _~w /"iWT Soils Boling # .6 16Y4f 31 SL / 16 Yk 31Y 5~~ 17L Ground 491 /d Y S ~ Gf~ - • 7 'g elev. Depth to limiting factor _'`w in. Remarks: CST Name (Please Print) Signature 7 T No. 96 L` as Address v /C F Date 6 CST Number O ©G~_ 7 • 226375 Private Sewage Consultants 665 O'Neil Rd. Hudson, Wis. 54016 6 r- c > Y Pew s /.STEM •3 `l~ !,v y,~,~v~ pis a,~,~ . 3 3 /Uor Allow svS T;e~ci Pi5-r. / 1 ~~GG yI SOIL DESCRIPTION REPORT 3 PROPERTY OWNER / Page of PARCEL I.D.# d Z d ' ~~(Q 3 - S'O Borin # Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 3 o S /o Y/e 313 - SL /7rs- k 4w V f Cs' 3 • • S Ground •23 31 ~W/* elev. Depth to limiting factor G T- Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots PD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench Boring # , Ground elev. ft. Depth to limiting factor In. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) Ni- t3 ' O 22 32 ~ 1314 i ~x/Si . li> f li [3 1'5; 71Aj 6-- 5 y5-i Af 60 0, T &0 G t o 0 61o 5VfJ~574P- (0,J-T7AV-5 Q\ IPA -23 _ ~ •~J Tod a~ (3csx /6 LV 6 i'/.r 0 - 3, Q$ psaoe consultants t)Ibr}chtS wag p(w 8 Ad 56018 065 01001% Wls• Npdso^ O 2- 0 10/7-15 i ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owt ;r/Buy : t ?ft79-Q V- VCFLLY w "L c(o b _ _ Masi ng Ad r.6 a: ! s -1q6 ~LewsxrA, fy' f~ Q j50'--'. U Prol ,rty Ai 1c i;•,° ss 29 6 F j o~eu-ourl sc y-, ~,w 1 o (6 __i (Verifra,tion required from Planning Department for new construction) CitY State Parcel Identification Number 0 20 16 3 - 5~ LV AL D:`!'1 il,':'RIPTIOi T Prol zty Lc cc U:i on '/o, f/,, Sec. 7 Tlj LJ N-RAW, Town of IAVJS Subs ivisior, _ of sue` 1% ~A W ,Lot # 1?3 r~ " Cer tied S a cy Map h 3 q 6,D i 3 ' . Volume , Page # Wai rslnty Di! d o IR , Volume 11 -LV , Page # - Spe- house t'.1 yes ❑ no Lot lines identifiable ❑ yes ❑ no - S C1EM M 1!1; [NTENAI ICT+ Impi ),q c ' ii$e and man atenance of your septic system could result in its premature failure to handle wastes. Proper m, ::tenancc com ti`s of pwr pt kg out the so ptic tank every three years or sooner, if needed by a licensed pumper, What you put into i t system can : feet the 6 eu, itiou of the ;eptic tank as a treatment stage in the waste disposal system. The ar :r:; :xty owner rcgrees to submit to St. Croix. Zoning Department a certification form, signed by the owner: End by a mast rplumb!x j urneymanp,umber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewaterdispo i, system is in "roper o "je rc r ing eonditic a and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/' S :full Audge. Uwe the undi,:r i ; aced have re; ,d the above requirements and agree to maintain the private sewage disposal system with the andards set f. th, here it, :13 set by the Department Qf Commerce and the Department of Natural Resources, Stato of Wisconsin. G; is tfication statii that yc is . ; optic system has been maintained must be completed and returned to the St. Croix County Zoning; Otficc; N ithin 30 ys f the rt re , exp' ti oa date. ~ vv- Ii-( 18 ATUR.1; t 114 AT t T DATE OV1 aR Cl is TIFICA't'ION I (w+) ; rtify that all statements on this form arc true to the best of my (our) knowledge. I' (we) am (ar,>) the'c; ; r ier(s) of ope ,"tie ; c ; ibed above, by virtue of a warranty deed recorded in Register of Deeds Office. L2 i S iA 7'`c A ICAI IT DATE * Any u rmation that is mis-represented may result in the sanitary permit being revoked by the Zoning Departme; -,t **1 elude v it ~n ibis 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 530819 State Bar of Wisconsin Form 2" 1982 WARRANTY DEED " DOCUMENT NO. VQ(.1128PAGE 549 fc 'U iv! r _ _ Dennis M. B'ornstad and Tracey E. Bjornstad, , husband ad~wire, - S U L 33,995 M 'd j 12:40 PAM C ~ conveys and warrants to - Patrick L. Kelly and Michelle L. fit, t, ? Kelly, husband and wife, ' ~U F- X THIS SPACE RESERVED FOR RECORDING DATk1 NAME AND RETURN ADDRESS IFI EQUITY TITLE SERVICES ~r o ` the following described real estate in St. Croix 400 SOUTH SECOND FilE i-IUDSON W154016 c7 County, State of Wisconsin: 0 N Ix~.- 0" - llj~p3 -,~o [ (Parcel Identification Number) Lots 18, 19 and 20, Edgewood Estates Subdivision in the Town of Hudson, St. Croix County, Wisconsin. V2 31 This is homestead property. (is) Exception to warranties: Easements, restrictions and rights-of-way of record, if any. Dated this day of June 19 95 . (SEAL) (SEAL) D parf is M. B' rnstad I of (SEAL) Ir (SEAL) r AUTHENTICATION ACKNOWLEDGMENT Signature(s) Dennis M. Bjornstad, STATE OF WISCONSIN Tracey E. Bjornstad SS. ~ County. authenticated this: ~ day of Tti nP '19-95- Personally came before me this day of 19 the above named KristinaFOgland TITLE: MEMBER STATE BAR OF WISCONSIN (If not, . authorized by §706.06, Wis. Stats.) to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Kristina Ogland u ~ s p C z 30 m $ s rr r nZi I • ~a~ STA TE JIVIC 30 am , q Cc All 46 t 0 m 1~3• r + < .4 mu lot I -C 31, . °a. £ sent. i64. 4'r. 04 ~ o ey.~►af .„fir==--- -~0~1 ~ ~~A~ N o N P ° ~ O 4~~ 1 1 O ~ 1 N m m 'M~ ► ~I Z n rv w ar I: AT F 4E 1/* COANER _ 1 IT* . -owl NI 0 1. RI -LO s .P 147. I ° + ~ I 0 -i N PI Sim ~ w - M 1 M.00' w E ~q ,,°a 0! aI :4 N z Q o ; m W Z 0 _ N I iaa_oo_ a-fi.. 4_ as.oo *gqI ~Ni o 8 102 514 1 -P PUBLIC _ ~ - - - ~ s C) ST. CROIX COUNTY WISCONSIN ~I N 0 1 ZONING OFFICE N ■ ■ / ■rrei ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 May 9, 1995 Pat Kelly 12011 Juniper Street, NW Coon Rapids, MN 55448 RE. Edqewood Estates, Lots 18, 19 & 20, Located in the SE 1/4 of the NE 1/4, Section 12, T29N-R20W, Town of Hudson Dear Pat: Per your request please find enclosed copies of the As Built Sanitary System Report, soil test report and the site plan for the above referenced property. If you have any questions regarding the enclosed, please do not hesitate to contact our office. Sincerely, Denise Boron Secretary St. Croix County Zoning Office, Wisconsin db Enclosure Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. T ,f N-R-.24- ADDRESS -7Q~ j2J,`4 46Liet/ ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT l,?` _-2 c' LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM r ~ INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used v~ Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: / L,C-1O Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: eft Number of feet from nearest Road: Front ,,&Side10 Rear, O Q feet From nearest property line Front, /////''"'''"'''0 Side,O Rear, O feet Number of feet from: well :>building: .5 (Include this information of the above plot plan)( 2 reference dimensions to-septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: / Length: 3 4;~; Number of Lines:~_ Area Built: /I 5 Fill depth to top of pipe: (,t Number of feet from nearest property line: Front, Side, O Rear,0 Ft. Number of feet from well: -5-/ Number of feet from building:( (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector Dated : K Plumber on job: License Number : cE' j G Z 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOh' 7969 BUREAU OF PLUMBING vADISON, WI 53707 ikCONVENTIONAL ❑ALTE R NATI VE State Plan l.D. Number Ilf assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE: Dennis B•ornstad 706 Michaelson St., N. Hudson, WI 10 '~y Jl BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: SE NE Section 12, T28N-R20W, Town of Hudson,Lots 18,19,20,Edgewood )-z12 7(~ Name of Plumber MP/MPRSW No.. County: Estates Sanitary Permit Number: William Schumaker 6382 St. Croix 54989 SEPTIC TANK/HOLDING TANK: MANUFACTURER: - LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER p~ PROVIDED: PROVIDED. _ /©d o YES ❑NO ❑YES ❑NO BEDDING: VENT O'IA.. VENT MATL: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH y~ A ALARM. / LINE I / AIR INLET: YES ❑NO IIL FEET FROM 4' / I ~ ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. P /SIPHON MANUFACTURER. WARNING LABEL JLOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL r BUILDING. VENTTOFRESH (DIFFERENCE BETWEEN FEET FROM LINE/ AIR I LET PUMP ON AND OFF) ❑YES ❑NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LErJ',TH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BED/TRENCH WIDTH LENGTH INO. OF DISTR. PIPE SPACING: COVER JI NSIUE DIA #PITS LIQUID TRENCHES. / i RIAL PIT DEPTH: DIMENSIONS If ~1 GRAVEL DEPTH FILL DEPTH DIS PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO ISTR. NUMBER OF PROPERTY WELL: BUILDING: AVI NT TO FRESH BELOW PIPES- ABOVE COVER. ELEV. INLET. ELEV. END. PIPES? FEET FROM LINE/ ~f r R INLET: 7/7 NEAREST- MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- ❑ YES NO meets the criteria for medium sand. TIONS MEASURED. ❑ SOIL COVER TEXTURE PERMANENT MARKERS: OBSERVATION WELLS ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED. CENTER. EDGES: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: TRENCHES: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV.. DI A.-.ELEV. PIPES: DIA.: ELEVATION AND : DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: ❑YES ❑NO ❑YES ❑NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNAT RE. S TITLE. DI LHR SBD 6710 (R. 01 /82) m wlsconsln APPLICATION FOR SANITARY PERMIT COUNTY ,1(~~ DILHR :OA &t-t;e ~ OEPFIRTRIEnT OF (PLB 67) UNIFORM SANITARY PERMIT # InDUSTRV, LABOR 6 MUTRn RELRTIOnS rg 9? 51 -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS 19.0 AC4 PROPERTY L ?EATI N CITY: I 11/4 %1/4, S T' ?N, R E (or) V Lj_ O LOT NUMBER{ BLOCK NUMBER SUBDIVISION NAME AREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED K 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): THIS PERMIT IS FOR A: IX-New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank L~ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature: MP/MPR(SW~ No.: Phone Number: Plumber's Address: Name of Designer: COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved 6&yUU a 9 ~ ~ „~~r~ X ❑ Owner Given Initial Q Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR-SSD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber 1 INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town; 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. c,. t r tb 6 ti c w~ u ► Pf- 1061 cx~ r I uawv:~.hne,-o-w. ase,vsc. a. ....,.:rs'6xttti. ar►x«ee.,ww:....o...... _ __._..~.-..~~.....~...w. r n ~ m my c"n'w~? w?cc,c3O y O (D Q O A n ~D M O~ 3 `cr O C C C N W 7C `OG z ? o? p' •p a M CD O =O n *0ccpcn ; 6go° ~x~ o wO CD v " r. ~ w 'O ~p ~ cp v N 3m OA. 0 (D ir 0 CD C O A) O > > ? co 0 = O W -s =r O O O C- C a« CO) o CL co) C :r co O ~y O'-(Op Qo A A NNE oDcC) C.)o g w aOD0w O to (A 0) Z ~ d 0 OD w ? N_ Z nCD `D~~m?a 1 N N Nam o?~o?v RI viwa CL CD Ca =r OL cC~CD C 300 .0 CD - (D C ? 0 cl CD C~ O cn N tq cn _ 4\.. ,v o m m acc CD CD co CD B'o'a moo`-'~a« G t Ooh ccnccawo m w~ aaa0 N a - CL O % Q 3E (-A* cr ~G) !A ID so I 3c cD"3 ~(A0 A C ~ cp C O N n O O 7 m O m p, .t Ul .a a caw -,cp-4CID co c scM= O v =r 0) r-O 0 a 3 0 0 : • O - a o m o ~O `:i{4`y.;:'•..",,•'!: %•i".~.{'.<••::f'{;i•' • ter. O 2 pit>. r t"r O •t•4• r3.... r .t i • 71` DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS I ~'ti'S"f G3Y, , B" 7 LABOR HUMAN AND RELATIONS PERCOLATION TESTS (115) MADISON, HUMAN WI 539 (1-(63.09(1) & Chapter 145.045) LOCATION: SECTION: ?OINNSFI /MUNICIPALITY: LOT NO.: BLK. NO.: SUBDI VISIO-*,i NAME: 5F- 1w0/ IZ/T29N/RzcE► .vt>sorJ Ig-~v - Eti&Ewooa r.'fcAres COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: 6'1' , ~i •O I?C C 0 t4 Jt' r / I f ~ - b Jt)2f.IST1•rt7 706M IGNA~~~•-5010 ST. I~tD. l~yD_.:.yN S40 / USE DATES OBSERVATIONS MADE NO. REDRMS,: COMMERCIAL OESCF3IPTION: V New UESf:RIPTIONS: ~rT~CULr:, IUN TES iS: Ii [Residence l N A. US1New ❑Replace PROFILE c~ 3U/`t1~ fa~ Ca 41 So I I_ rt, coo Ic- P. 49 S6 l Lc, o NA M t,4 RATING: S- Site suitable for sy_s_tem_ U= Site unsuitable for system CONVEN`f IONAI.i f+AOUND:70S ~STEM•IN-FILL hIOLDING TANK: O SYSTEM:(oplicn~,1) . - LLJS U EJU]C)SM CIS❑U © E-Is®U~~'x~ If Percolation Tests are NOT required -DESIGN RATE: ~ I if an I( y portion of the tested area is in the under s.H63.09(5)(b), indicate: N,t Irl , Floodplain, indicate Floodplain elevation: N. A. DF-c'MAL- PROFILE DESCRIPTIONS t- f_ a 'r BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH rts>r ELEVATION OBSERVED EST. HIGHE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) _ r /•30' C-- y ; L1 21 1) U' Zt. r,- B, $L w C~A• („L Mao 5 W flo>`(z olis a 0.0s Dr-.7b men S B• Z °l,vU /v~,oS h1o~JE y Gj,vv r O,6o' 3N L; o.ao' P-c aN SL, w/GR.; M E~ 5 CS W G, 0,70' !5,,,;L; 0,10"P-0 g,J GL •r•r rC. j o,zo' 2.o 5^J B-3 ~-Sv 99.45 M oi.tt~ > 5~ 5 V M~oS 0-10' BNCSw 6,P 7,5 8x, -P S Mt=nS w I~okt_lzonrS 0,03' Dr.. f3"j ►vNet, S. , o.z o' d L L • oc~' ~ L w 7.55 ' L3r1 ►✓1 I~ .S~ B- 7 . C::'9'/5 Nc.> t1 8, 75 GS W/607 Imo, .%,j M 5 B- I~Iar'j > ~.1.r0 a. go' Gc c; bo' Lr. D 'A ; .9a 8rv lvler> S W C-a P_ C C,B Le; IM.it_ NoTI= : NVMac-_1L ~-0► •P-ESPorr c?, trF PERCOLATION TESTS A G?JAC~t~N~+r- $a R.a rvG TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTE'S . r=. NUMBER tNek1ES- AFTERSWELLING INTERVAL-MIN. P RI D t PERIOD 2 P R f PER INCH P. 4.95 Nome 3 Z' 8 -11 61G 2 ~i rd l . 4 5r 0).9: P. 4-52. -3 z P- 3 .245 Ior lc 3 z;//(. S 00.4 P- P. LP 9 PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale n distances Describe what are the lori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at atf borings and the direction and ne cent of land slope. SYSTEM. ELEVATION oil, 00 ~-Ur z D 1 ~ I I 'ZO f O SOIL SOP-15 Wbl,-.M T' IEST i .._.i p ~.g-INCH. Imo,.. i_ ..t _.i .._l_ _ _ P•Z. _ f 71 t by o-10 0 - ~ 1 q s ' i I! E TL 1-i { I i - I Al ._1..._ L...._ - v i i ! I I - - - - I J- ?-,e I ~ ~ t _1 r ' t I I a PI-A T C-~ M t .I, = $E,NGH M~1•C.k• i i A V- t ' ~ ~ I L.d L I s , r f To N ~L)pGo~~ PIPE, Et _.r a~ i , 160 r 0 t-OT ~ I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and me ods pacified in the: Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. RA:57 L.IAI C _ of L.oT z o (NAM E (print): 1 TESTS WERE COMPLETED ON: ADDRESS: CERTIFICATION NUMBER PHO~tE NUMBER (optional): 4-07 No -1 u o s N u) I S v/( /Sj l -405a CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER - J H a ST C- 105 r 9 H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z t7 a ti OWNER/BUYER ROUTE/BOX NUMBER Fire Number i CITY/STATE Cam' ZIP PROPERTY LOCATION: 3 L AJE 4, Section, 'rZl__N, R201 W, Town of St. Croix County, , ,L Lot number= Subdivision I-Aee I Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into I the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. y 0 E I/WE, the undersigned, have read the above requirements and agree vii to maintain the private sewage disposal system in accordance with z the standards set forth, herein, as set by the Wisconsin Depart- b ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SICNED DATE St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. APPLICATION FOR SANITARY PERMIT S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor',("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - C . Owner of Property C C- ` e, M Location of Property _'Section T N - RW Township L) f\ Mailing Address A) co k-, Subdivision Name l.v G U - Lot Number f - Previous Owner of Property i Lkf L Total Size of Parcel 1.~~'rr~S Date Parcel was Created At 1-j Are all corners and lot lines identifiable? ' Yes No Is this property being developed for resale (spec house) ? Yes_ No Volume ~ S^ and Page Number 7 q6 - as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed C2. Land Contract 3. Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. PROPFRTy OWNER CERTIFICATION I (We) ceAtt 6y that att statements on this Gahm ane tAue to the best o6 my (aura) hnaw.2edge; that 1 (we) am (ahe) the owneA (b) aA the pnopenty descn i.bed in .th iz .tn6an.mati.an Bohm, by v.cA.-tue o~ a wcvvcanty deed necanded in the 046ice a6 the County Regi-6teA o6 Deeds cus Document No. ; and that 1 (we) phe6 entty awn the pnopa6 ed site soh the sewage poa system (oA I (we) have obtained an easement, to hun with the above debcAi.bed phapehty, 6o& the constAucti.on a6 said 6ystem, and the same has been duty hecohded in the 066i,ce ab the County RegiA teh o~ Dee6 , a6 Document No. ) J~l c lc / C U-i~o"SIGNATURE OF CO-OWNER (IF APPLICABLE) SIGNATURE OF OWNER DATE SIGNED DATE SIGNED i 'RW + a - P~'C~`n is 3d hr '4~ ~ ~ •'~a s yR{• ~ r ar+~ xS r` ;'~iw Y i'sld~ k,➢ xA.t q "^r ! z. _ygn#pr~y ,Yr 7tgyyc: uj t!~4 } • 3a !M 5_ w too*, ~ e e~+eUtt' yr na arrrwar r , xrw~+J-i w~..~ , , Eby ~}q•$~ .y, Mg}w+yiT a 841,1 J . zi• .a~ ~ ~.t~.:a b'+F "3 . 'tlFy11 ~ ~.yAr,~~~~j~~T~t* :v'•. bAk, t^•i ♦ Ff - '..:tfai'bikrrti4 !;,i,M,.~'• ~ r.il~t-9F w~' '+w ~s.•tM" E~~e:. a...r, i,::~~y. X+f~ uwxs-p . .491 . ,.si. c r 3:. tl'w f -+F'SCP`'• ~°iRA x. •a~'v ~ 4 3 ilk 4i "I ate: u~.ri wia➢,~^ ;r`a... t~,• w: t aw+1i • } t J W" "Was: I r4it µ i • ~ ~ 't i' t 4• i ' 414 TT. j cs, :2,3 Ir 1ti:~ a T77 7i VOL. 695PASE5.9 t REGISTSRa ~ ) FICF_ Rec'd. ,-,r Cc...,,.,' 5th A F F I D A V I T day of Sept,A. 1 J 84 3:45 P P.A. STATE OF WISCONSIN) James O'Connell j SS 1"%1K of 1 ST. CR OIX COUNTY Li GA4).,,_ Deputy I, James E. Rusch, Registered Wisconsin Land Surveyor, hereby depose and say: That I have surveyed and platted Edgewood Estates, located, in the SE: 1 /4 of the NE 1/4 of Section 12, TZ9N, R20W, and in the SW 1 /4 of the NW 1/4 of Section 7, T29N, R19W, Town of Hudson, St. Croix County, Wisconsin; That there is a proposed on-site liquid waste disposal system intended for, and a percolation test completed on Lot 20 of said plat; That said system is intended to serve a home intended to be built on Lot< !9 s" 2'p of said plat; And that 1 make this affidavit to inform all future purchasers of said Lots j and of the possible existence of said system. /Subsc,y,j,~,~dand sworn to bef ore me thine "S day of Mary,... Rus(; ~ Not 'y Public 4 State of Wisconsin My?mrni~ expires June 14, 1987 This instrument drafted by: James E. Rusch ')LJIMP-N47hC-1 DEPARTMENT OF RINGS D & BUILDINGS INDWSF RY, REPORT ON SOIL BO AA r.. F►►jr f1A O. BOX DIVISI 69 LABOR AND PERCOLATION TESTS (11 _s Nov 1o ' MIADi ON, wl 53707 R,UM*R§L*TIONS (H63.09(1) & Chapter 145.045) (D' ZommG LOCATI ~ SECTIO%~~ ~(or TOWNSHIP/ LO ,NO.: ISION faf;A COUNTY: OW ER`S BUYER'S NAME: MAILING ADDRESS: " 5J, Cta-Ax A14J"t)(4 _44c, 1 £ dL DATES OBSERVATIONS MADE USE NO. BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS. P ATIO TESTS: Residence New ❑Replace I P-01 O RATING: S= Site suitable for system U= Site unsuitable for system _ ROUND-PRESSIJ r O®ENTIO~NAL: M®S.❑U JIUTAN TTTttt If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the A under s.H63.09(5)(b), indicate: Floodplain indicate Floodplain elevation: /f PROFILE DESCRIPTIONS ABBRV. ON BACKTEXTURE, AND DEPTH BORING L NUMBER DEPTH IN, ELEVATION DEPTH OSERVED OUND EST.EHIGHESTSTCHARACTER OF O BEDROCK IF OBSERVED SOIL (SEE THICKNESS, B- NO _Af ",91SI V. a Aft -57 B- •Z Q a - ~_S'~ 4,i_.t, 7 ~D / 7 S/ st :S/ " ~i7 s B- 3 /oz's 0~-3`' 7 " ~o " ~s / s'/ B S 13- PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P- 40 t~ `3 q P- A10 P-6 q11 3. , P-_ P- P- _ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show t e surface elevation at all borings nd "the~ erection and percent of land slope. n.--. -,s !dT is SYSTEM ELEVATION /o o F O,g~rd flos c. /~e_ A / S. i ; \ S T N 3 d _it E, 3 I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. TESTS WERE COMPLETED ON: NAME (p ;ft). ADDRESSl: CERTIFICATION NUMBER: PHONE NUMBER (optional): Z4./ 09ke, 4wtk" 'U'cc- S.-r- Ar CST 51rokATU: DISTRIBUTION: Original and one copy to Local Authority, Prop(3Ly Onnei and Soil Tester. Di LHrs` 8D-5395 (.-.82/82) - 0'1 F INSTRUCTIONS I -.a, --)MPLET.. FORM 116 - SRC? - 6396 4$ r{ •I, To b' a end accurate soil test, your report must irr<aude; I, Co IT,: ription; 2. The use - clearly indica this is a resit =r commercial project; 3, MAXI' f bedrooms 'eial use plane( 4, Is this a nent syst- 5. Complete r iY rating boat A `W=ITE IS SUITABLE FOR A H ~Ntu TAN IF ALL OTHER SYSTE'1" ARE RULED OUT BASED ON SOIL CONDIT[ 6. PL-ASE use tht s arcs shoe here for writing profile descrip, ~.d com _ the plot plan; 7- r%r~. tF A LEGI _L " agr4im accui ~ ''-)cating your test locations. 19 . eferred. A ah-, sheet w rv `.e us4d if desi li sure y( it rr ark and ver,,, 'ion i point are t a(-rrnanent; 0, C --plete all c, boxes as nanTes ` flood to ~ est exernp- It a as floc 71.7x; your ct. `ro A distribu AL TF 31; - TH THE VITHIN 30 E IF COMPL ..._..1/IATIONS FOR ` IFIED SOIL , ,V&-_RS 17extures Ctfri BR cal. . _ 1 SS - 9r 3") LS I H!, - [ ,ar t ri ;t t TO Ti low PL l `A (ol ~a~~ LoT L~~t PLOT cared CR O55 SaTION 'MANS r~ f3 y N a e 3 -et 3& 6%L TESTS 5 ~b yr 03 -111f r/0,0 ccle • S PROUD I-: f ! . F, v ot^ 7~ v ~~G ' CSAf 4161 3 f 76 b Pt . S ti0 L _ ,16NED r L/cE~s 3367 1%0,o ~ Ti4 7-- - Fresh Air Inlets And Observation Pipe Approved Vent Cap Minimum 12"~ Above Final Grade - 1 Y 4 , Above Pipe 4~~ cost iron si, Vent Pipe -'to Final Grade Marsh. Hay Or Synthetic Covering Min. 21' Aggregate fjf~,L'4U~l~ ~/v Over Pipe . yG s Distribution y pv~ T Tee Pipe o o o .o o _ ~UC L~ Aggregate x r rY o > Perforated Pipe Below 0 " "L" 1171 _ Beneath Pipe r: At CouPlire 9 .Terminatin 9 o' Bottom Of System ti