HomeMy WebLinkAbout020-1144-70-000 County: St. Croix
Wisconsin Department of Commerce , PRIVATE SEWAGE SYSTEM No:
Safety and Building Division INSPECTION REPORT 538759 0
(ATTACH TO PERMIT) o:
GENERAL INFORMATION
Pinformation you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)J.
me: City Village X Township Hudson, Town of 020- 44 - -000
& Jamie Range /Map No:
CST BM Elev: Insp. BM Elev: BM Descr' tion: 17.29.19.756
/UO (� Oa 'v ( ELEV ION DATA
TANK INFORMATION STATION BS HI FS ELEV
TYPE MANUFACTURER CAPACITY
Benchmark 161
/00.0
Septic _ I Oo SI VL
Iv Alt. BM r r �. V
Dosing , f, b � as 10 Oj
►�
Aeration Bldg. Sewer
St/H% Inlet - !_ 3 q
Holding V
S Outlet
TANK SETB INFORMATION G
TANK TO P/ WELL BLDG. Vent to Air Intake ROAD Dt Inlet a
w ^�,-' �y p
Dt Bottom ( /Ili' d� qc(- 06
Septic
ader /Ma
ng S t
Dist. Pipe
Aeration
Bot �System 0 15- g 1
Holding Lx(/naa.
Final Grade Li 2 's S i OS
PUMP /SIPHON INFORMATION Demand St Cover 2 .35 11- z
Manufacturer GPM
Model N mber
TDH Lift Fric' oss em Head TDH Ft S
Forcemain Length Dia•
SOIL ABSORPTION SYSTEM
Length No. Of Trenches PIT DIMENSIONS No, Of Pits Inside Dia. Liquid Depth
BEDITRENCH Width 9 /
HU
DIMENSIONS '7 + v
LAK S REAM LEACHING Man r
SETBACK SYSTEM TO P L r tBLD W CHAMBER OR
INFORMATION Ty Of System: 0 I UNIT Model Numb
IBUTION SYSTEM 5�1 S
x Hole Size x Hole Spacing ; Vent to it Intake
Header / anifold Distributio Dia f I f[ // 1
/ rl Pipe(s) / l!/
Length Dia Length Spac n
i L /
x Pressure Systems Only xx Mound Or At -Grade Systems Only xx Mulched 7
xx Depth of xx Seeded /Sodded g7�= Topsoil 0 Yes [ No J Yes No ch Edges
Inspect `` I
COMMENTS (Include code discrepencies, persons present, etc.) ion #1: /�l 1 f Inspection No
Parcel No: 17.29.19.756
Location: 966 Wert Rd. Hu son WI 5 1 1 I QSW 1��1/_4 17 T29N R19W) Park V Est es II Lot 6 � �
1.) Alt BM Description - �' fl
2.) Bldg sewer length
- amount of cover
Plan revision Required? Yes [ No Cert. i No
�� ~ W
�_ _
_ — - - -- --
Use other side for additional information. Date Insepctor Signature
SBD -6710 (R.3/97)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
538759 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:
Smith, Jason & Jamie Hudson, Town of 020 - 1144 -70 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
17.29.19.756
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer
Holding SUHt Inlet
St /Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe
Holding Bot. System
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
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. Tid u Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System:
UNIT Model Number:
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
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 Depth of xx Seeded /Sodded Mulched
Bed/Trench Center Bed /Trench Edges Topsoil xx
0 Yes D No D'", Yes
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 966 Wert Rd. Hudson, WI 54016 (SW 1/4 NE 1/4 17 T29N R1 9W) Park View Estates II Lot 63 Parcel No: 17.29.19.756
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? q gE Yes Ed No
Use other side for additional information.
SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No
commerce.Wi.gov Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162 St. Croix
� Z i sconsin Madison, WI 53707 -7162 Sanitary Permit Number (to be filled in by Co.)
epartment of Commerce 7 � 1
Sanitary Permit Applic _ State Transaction Number /AJA'
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this rn7nsfor propriate government Project Address (if different than mailing address)
unit is required prior to obtaining a sanitary permit. Note: Application te -owned POWTS are
submitted to the Department of Commerce. Personal information you ex� f /,, I / +e(� . � u oses in accordance with the Privac Law, s. 15.04(1 )(m ), Stats.
i_ `' Same 7&, GTl .
I. Application Information - Please Print All Information y -=F PRC419 Property Owner's Name i 4: �' a'f Parcel #
PLANNING t'+ 020- 1144 -70 -000 �C /
Jason &Jamie Smith
Property Owner's Mailing Address Property Location
966 Wert Road Govt. Lot
City, State Zip Code Phone Number SW ' /4, NW '/4, Section 17
(circle one)
Hudson, WI. 54016 651- 261 -6595 T 29 N; R 19 E or W
II. Type of Building (check all that apply) Lot #
❑ 1 or 2 Family Dwelling -Number of Bedrooms 3 63 Subdivision Name
Block # Park View Estates II
❑Public /Commercial - Describe Use Na El city of
❑ State Owned - Describe Use CSM Number ❑ Village of
Na ❑ Town of Hudson
III. Type of Permit: (Check 0 one box on line A. Complete line B if applicable)
A, ❑ New System a lacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
Y P Y g P Y g Y ( P )
9/Z v
B• ❑ Permit Renewal El Permit Revision 11 Change of Plumber ❑ Permit Transfer to New
List Previous Permit Number and Date Issued L 5
Before Expiration Owner
IV. a of POWTS S stem /Com onent/Device: Check all that appi `
X Non-Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank Other ispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dispersal/Treatment Area Information:38 Infiltrator "Q4" standard chambers & r. endca s, Wieser Concrete filte anister w/ Pol Lok PL -525 effluent filter
Design Flow (gpd) Design Soil Application (gpdsfj Dispersal Area Required fj Dispersal Area Propo (sf) System Elevatjan
450 gpd 0.60 gpd/sq. ft. 750.00 sq. ft, 771.60 sq. ft. 92.75'
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units
New Tanks Existing Tanks 'n Y a
U v�
Septic or Holding Tank Na 00 1,000 1 Wieser Conc ete X
Dosing chamber Na Na Na I Na
VII. Responsibility Statement- I, the u ersigncd, ass. c responsibility f nst ation of the POWTS shown on the attached plans.
Plumber's Name (Print) ber' Sign 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, Osceola, WI 54020
VII oun /De artment Use Onl
Approved isapproved Permit Fee Date Issued Issuin gent Sign
Y zj�
$yob yz�,i
11 e n Reason for De ' 1
IX. Conditions of A ppr�oval/Reasons for Disapproval
SYSTEM OW NER:
I . Septic tank, effluent filter and
dispersal cell must all be servkes / maintained
as per management plan provided by plumber.
2. Al setback tegil ferhents must.be maintained
Attach to complete plans or the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size
SBD -6398 (R 02/09) Valid thru 02/11
Conventional POWTS Index & Tilte Sheet
Project Name: Smith 3 bedroom Replacement Conventional POWTS
Owners Name: Jason & Jamie Smith
Owner's adress: 966 Wert Road, Hudson, WI 54016
Site address: Same
Project Location:
Subdivision: Lot 63, Plat of Park View Estates 1
Legal Description: SWv4NEi /4, Sec. 17, T.29N., R. 19W., Town of Hudson, St. Croix Co., WI.
Parcel ID #: 020 - 1144 -70 -000
Page 1 Index and Title Sheet
Page 2 Site Plan
Page 3 Dispersal Cell Sizing Calcualtions
Page 4 System Cross Section
Page 5 System Management Plan
Page 6 Filter Specifications
Page 7 Filter Tank Cross Section
Page 8 Parcel map
Page 9 Septic Tank Maintenance Agreement
Page 10 Certification for Utilization of existing septic tank
Page 11 Waranty Deed
Attachments: Soil Evaluaiton Report
Mater PI ber Restric d Service: James K. Thompson, Dept. of Comm. Credential #30021
Signature: Date:
Page 1 Of 11
Design pursuant to In- Ground Soil Absorption Component Manual for POWTS, version 2.0 SBD- 10705 -P (N.01 /01)
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DISPERSAL CELL SIZING CALCULATIONS
1. (3 bedrooms)(100 gallons estimated flow)(1.5 design factor) = 450.00 Gpd design flow
2. Infiltrative capacity of native soil = 0.6gpd/sq. ft.
3. Absorption area required: 750.00 sq. ft.
4. Absorption area as proposed: 917.40 sq. ft. (45 chambers total)
Infiltrator "Quick 4" = 20.00 sq.ft. EISA per chamber, Infiltrator "Quick 4" end cap (pair) = 5.80 sq.ft, EISA
750.00 sq. ft. — (2 pair endcaps)(5.80) = 738.40 sq. ft.
738.40 sq. ft. /20.00 = 36.92 chambers required
Number of trenches: 2 @ 19 chambers per trench
Trench width: 2.83'
Trench length: 78.00'
Trench spacing: 9.00' on center
Total system area w/ 5' trench spacing: 12.00'x 78.00'
Pg. 3 of 11
Soil Absorption SYStietn dross Section
99.00
ft
Final Grade
4° Schedule 40
PVC vent Pipe 6.00
With Vent Cap �_ ft
Leaching — 92.75
Chamber ft
`8 6.0 System Elevation
ft
Soil Absomtion Sim-ten Plan View
ft
2.83
ft
i 6.00
ft Leaching Trench 1
7Ventbservation Pipe Chambers
4' Dia.
Trench 2 Header
Leaching Chamber Snecificatiions
Manufacturer And Model Infiltrator Q -4 standard
EISA Rating 20.00 sq ft per chamber Soil Application Rate 0. 60 gpd/sq ft
450.00 gpd Design Flow + 0.60 Soil Application Rate + 20.00 EISA = 37 .50 Chambers
2 rows of 19.00 chambers each.
Page of
Conventional Septic System Management Plan
Pursuant to Comm 83.54, Wis. Adm, Code
General
The conventional septic system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall be maintained
in accordance with component manual SBD- 10705 -P (N.01 /01). All local and /or state rules pertaining to system
maintenance and maintenance reporting shall be complied with.
Septic Tank
Septic tank servicing mechanics comply with Comm. 83.54(1)(e). Septic tank to be located within 150' of service pad, with
bottom of tank to be <_ 15' below service pad elevation. The operating condition of the septic tank and outlet filter shall be
assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in
the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR
113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are
not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be
needed to maintain less than 1/3 scum and sludge accumulation in the tank. The outlet filter shall be cleaned as necessary to
ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank
that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be
serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water
tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of
service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater
than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank.
No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank
abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS
component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If
such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings
Division,
Soil Absorption Cell
Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should
be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for
vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface
within and above the system and will promote frost penetration during cold weather months. Cold weather installations
(October- March) dictate that the system be heavily mulched for frost protection.
Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not
exceed maximum design flow specified in the permit for the installation.
Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the
owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring.
Effluent flow shall be alternated between dispersal cells on a two- year /1 -year schedule by use of diversion valve.
Effluent to be diverted from new dispersal cell to old cell at 4 year anniversary of new system installation. Old cell to be
utilized for a 1 year period. Afterwards, effluent dispersal to be alternated between cells on schedule to allow use of new cell
for two years and old cell for 1 year.
Contingency Plan
If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the
system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil
absorption cell to bring the system into proper operating condition.
Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Thompson at (715)
248 -7767 or the St Croix County Zoning Department at (715) 386 -4680.
x M1+.
• ® °_ Filters
yy� fey �i
PL -525 EFFLUENT FILTER (COM MERCIAL)
Polylok, Inc is pleased to add its
new commercial filter to its existing
line of quality effluent filters. The
PL -525 is rated for over 10,000 GPD Alarm ,
(gallons per day) making it one of accessibility Accepts PVC
the largest commercial filters in its extension handle
class. It has 525 linear feet of 1/16"
filtration slots. Like the Polylok
PL -122, the new Polylok PL -525 has
an automatic shut off ball installed 525 linear feet
with every filter. When the filter is of 1/16
removed for cleaning, the ball will filtration slots Rated for over
float up and temporarily shut off 10 ,000 GPD
the system so the effluent won't
leave the tank. No other filter on
the market can make that claim! Accepts 4" & 6°
SCHD. 40 Pipe�� -
�•. M r
PL -525 Maintenance:
The PL -525 Effluent Filter should k
operate efficiently for several years M kY
DA
under normal conditions before $. MI—
requiring cleaning. It is recom-
mended that the filter be cleaned
every time the tank is pumped or
at least every three years. If they
installed filter contains an optional
alarm, the owner will be notified
by an alarm when the filter needs'
servicing. Servicing should be o Gas deflector
done by a certified septic tank Automatic shut-off
pumper or installer. ball when filter
1. Locate the outlet of the U.S. Patent No# 6,015,488
is removed
septic tank. 5,871,640
2. Remove tank cover and pump
tank if necessary. PL -525 Installation 1. Locate the outlet of the
3. Do not use plumbing when septic tank.
filter is removed. Ideal for residential and com- 2. Remove the tank cover and
4. Pull PL -525 out of the housing. mercial waste flows up to pump tank if necessary.
5. Hose off filter over the septic 10,000 Gallons Per Day (GPD). 3. Glue the filter housing to the
tank. Make sure all solids fall 4 or 6 outlet pipe. If the
filter is not centered under the
back into septic tank. access opening use a Polylok
6. Insert the filter cartridge back Extend & Lok or piece of pipe
into the housing making sure to center filter.
the filter is properly aligned and 4. Insert the PL -525 filter into
completely inserted. its housing.
7. Replace septic tank cover. 5. Replace the septic tank cover.
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FILTER CANISTER DETAIL SCALE: 3/4" 1' REV NO. DATE:
MIESER cuOURETE DRAWN BY:SWT
Z SEPTIC MANUAL W3716 US HWYI0. MAIDEN ROCK, WI 54750 DATE: JANUARY 2008
J �° REV. JAN. 2008 800 - 325 -8456 FILE: SHEET 13
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REGISTERED LAN T�SDAY OF0 A� 978 NO.
DATED THIS �- N�� I5- 16
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��� I ��R
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerMuyer - T4 S 041 5 .�J ,� . �1 �/ . � .. SM :T-�
Mailing Address
Property Address �' ''�'` U T a i"
(Verification required from Planning & Zoning Department for new construction.)
City/State N L yS C AI I/li Parcel Identification Number f* µ ` 7� U O 0
LEGAL DESCRIPTION q
Property Location 5 0 ' /a , �� t /a ,Sec. ��, T ' N R / W, Town of � r/ � G�
Subdivision
J.4 (f- t�z v� LV f 14 WS IT- , Lot # .
Certified Survey Map # 4 2 , Volume , Page # f k
Warranty Deed # 8 1 E , Volume , Page #
Spec housei Lot lines identifiable
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.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin.
Certification 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.
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 -3
q 1231 Zell
SIGNATURE OF APPLICANTS) 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. 08105)
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
Tliis is to certify that I have inspected the existing septic
presently serving the following residence:
(Street address) !,c>p,,�� owl located
at: ,ScJ /4, 6- /4, Section /_ , Town ,Z-2 N, Range XF W,
Town of a aY. , 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 QZ /, �//
Did flow back occur from absorption system? Yes v' - - No
(if no, skip next line.)
Approximate volume or length of time: Z4. avn gallons �2, �p minutes
Tank Capacity: a,2p W
Construction: Prefab Concrete 1-- --- Steel Other
Nlanufacwrer (if known):
Ac f Tank (if known):
Permit number (if kno �29s
Licensed Plumber ignature) (Print Name)
(Title) (License Number)=/MPRS
(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
.= �,dniinistrative Code)
Rev. 9/2008
0 of 11
l 111111 IIII(11111 flli(Illl(llfll I((I I(Ilil (ll(illl
* 8 7 6 4 4 5 1
876445
STATE BAR OF WISCONSIN FORM 2- 2000 KATHLEEN H. WALSH
REGISTER OF DEEDS
Document Number WARRANTY DEED ST CROIX CO., WI
RECEIVED FOR RECORD
THIS DEED, made between Steven J. Shaw and Helen A. Shaw, fWa 06/09/2008 03:15PH
Helen A. Reis, husband and wife, Grantor, and Jason Adam Smith and WARRANTY DEED
Jamie Lynn Smith, husband and wife, as Survivorship Marital Proper , EXEMPT I
rante -e --- "—"' REC FEE: 11.00
Grantor, for a valuable consideration, conveys and warrants to Grantee TRANS FEE: 846.00
the following described real estate in St. Croix County, State of Wisconsin: PAGES: 1
Lot 63, Park View Estates Second Addition in the Town of Hudson, St.
C roix County, Wisconsin.
Metro Legal Services
EDIRET 866329 A
996310 WD 476840
Recording Area
ft
Na a and Return Address:
Edin Realty Title, Inc. 1�ETROIEON��$INIEI�
400 S. a St. —Suite 115 3011l1
Exceptions to warranties: Hudson, 4016 IlN1il'�'
Easements, restrictions and rights -of -way of record, if any. 866328
020- 1144 -70 -000
Parcel Identification Number (PIN)
This is homestead property.
Dated this 16th day of May, 2008.
* teven J. Sha Helen A. Shaw, f/k/a Helen A. Reis
* *
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
c;o eri ST. CROIX COUNTY. ) ss.
authenticated this 16th day of May, 20motar! Publ
of 1N Personally came before me this May 16, 2008 the above
�t�te named Steven J. Shaw and Helen A. Shaw, f/k/a Helen A.
* Reis, husband and wife to me known to be the person(s) who
TITLE: MEMBER STATE BAR OF WISCONSIN executed regoing i strument and acknowledged the same.
(If not, 0
authorized by § 706.06, Wis. Stats.)
THIS INSTRUMENT WAS DRAFTED BY * Cheri or tZ
Notary Pu lic, State of Wisconsin
Peterson, Fram &Bergman — Steven H. Bruns My commission is permanent. (If not, state expiration date:
50 East Fifth Street, St. Paul, MN 55101 2/27/2011 )
(Signatures may be authenticated or acknowledged. Both are not necessary.)
*Names of persons signing in any capacity must be typed or printed below their signature
WARRANTY DEED STATE BAR OF WISCONSIN FORM Not -2000
2242
Wisconsin Department of Commerce ;int(BM), PORT Page 1 of 3
Division of Safety and Buildings in accordamm 85, Wis. Adm. Cod A.C.E. Soil & Site Evaluations
complete site Ian
Attach con on + County
p p paper not less than 8/: x 11 has �lau�t 9 St. Croix
include, but not limited to: vertical and horizontal referencdirectr'bn A d 1 percent slope, scale or dimensions, north arrow, and loc ad. Parcel I.D.
� 020- 44- -000
Please print all informa NE & ZONING OFFICE Revi d By Date
Personal information you provide may be used fors es dvacy Law, s. 15.04 (1) (m)). 7,7
Property Owner v fil Property Location
Jason & Jamie Smith Govt. Lot SW 1 NE /4 S 17 T 29 N R 19 W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
966 Wert Road 63 Park View Estates II
City State Zip Code Phone Number City J Village r/ Town Nearest Road
Hudson I WI 1 54016 1 651 - 261 - 6595 Hudson I Wert Road
New Construction Use: v/ Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD
1/f Replacement _f Public or commercial - Describe:
Parent material Glacial Outwash Flood plain elevation, if applicable Na
General comments
and recommendations: Site suitable for conventional POWTS dispersal cell with 2.6 pd /sq.ft. /day loading rate. Proposed
system elevation to be 9 Existing system elev. = 93.50 .
FT] Boring # J Boring
Pit Ground Surfaceelev. 97.60 ft. >1 12" in. Soil Depth to limiting factor Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2
1 0 -20 1Oyr3/2 none I 2fgr mvfr cs 2fmc 0.6 0.8
2 20-46 1Oyr4/4 none Is Osg ml cw 3fmc 0.7 1.6
3 46 -56 7.5yr4/4 none sl 2fsbk mfr cw 11fm 0.6 1.0
4 56 -112 1Oyr5/6 none s Osg ml - 1vf 0.7 1.6
All horizons contain approx 20% cobble and stone.
F yj Boring # I Boring
Pit Ground Surface elev. 97.90 ft. Depth to limiting factor >119" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fV
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 "Eff#2
1 0 - 34 1 Oyr3 /2 & 4/4 none I & Is frl Na Na gi 2fmc Na Na
2 34-44 1 Oyr4 /4 none Is Osg ml cw 2fm,1 c 0.7 1.6
3 44 -60 7.5yr4/6 none s Osg ml cw 1vf,f 0.7 1.6
4 60 -70 7.5yr4/4 none sl 2msbk mfr cw 1v1f 0.6 1.0
5 70 -119 1Oyr5/4 none s Osg ml - - 0.7 1.6
rr
All ho ' ons contain appi OKOT cobble and stone.
Effluent #1 = BOD 30 < 220 mg /L a d TSS >30 < 0 mg/L 'Effluent #2 = BOD < 30 mg /Land TSS < 30 mg /L
CST Name (Please Print) Signat . CST Number
James K. Thompson _ -- 3602
Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number
340 Paulson Lake Lane Osceola, WI 54020 4/15/2011 715 - 248 -7767
Property Owner Jason & Jamie Smith Parcel ID # 020 - 1144 -70 -000 Page 2 of 3
3] Boring # J Boring
/f Pit Ground Surface elev. 98.78 ft. Depth to limiting factor >122" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-9 10yr3/2 none I 2fgr mvfr cs 2fmc 0.6 0.8
2 9 -29 10yr4/4 none Is Osg ml cw 2fm,1c 0.7 1.6
3 29 -44 7.5yr4/6 none Is Osg ml cw 1fmc 0.7 1.6
4 44 -58 7.5yr4/4 none sl 2fsbk mfr cw 1vf 0.6 1.0
5 58 -122 10yr5/4 none s Osg ml - - 0.7 1.6
All horizons contain approx 20 % cobble and stone.
F-1 Boring # I Boring
J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots PD
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
F-1 Boring # - Boring
J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD 5 > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS <30 mg /L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608- 264 -8777.
SBD -8330 (R.07/00) A.C.E. Soil & Site Evaluations
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Parcel #: 020- 1144 -70 -000 10/12/2005 1 1 5 O F I
A
Alt. Parcel #: 17.29.19.756 020 - TOWN OF HUDSON
Current j_X i ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
STEVEN J SHAW O - SHAW, STEVEN J
C - REIS, HELEN A
HELEN A REIS
966 WERT RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 966 WERT RD
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 2.910 Plat: 2276 -PARK VIEW ESTATES 2ND ADD
SEC 17 T29N R1 9W PARK VIEW ESTATES 2ND Block/Condo Bldg: LOT 63
ADD LOT 63
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
17- 29N -19W
Notes: Parcel History:
Date Doc # Vol /Page Type
07/01/2004 767603 2608/161 WD
07/23/1997 1151/472 WD
07/23/1997 1117/405 TI
2005 SUMMARY Bill #: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/26/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.910 40,900 169,100 210,000 NO
Totals for 2005:
General Property 2.910 40,900 169,100 210,000
Woodland 0.000 0 0
Totals for 2004:
General Property 2.910 40,900 169,100 210,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch #: 221
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
i
AS BUILT SANITARY SYSTEM REPORT
NSIN.
'ER ! G r r f 4 u 4 , TOWNSHIP !7 a J B A SEC. T2- N. R�W
.0
3DIVISION . ADDRESS U t�,n , ST. CROIX COUNTY, WISCO
u� n
bill
w , LOT LOT SIZE
PLAN VIEW
-Distances b dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
v u56 i
--
I
M
j
k '
Ir�dipate Noi A ' r 7 j
_ _i
v� j "�
PTIC TANK(S) I GGJ ✓ IiFGR. 1/� f ^ ? ^ CONCRETE STEEL
N0. of rings on cover Depth 5 DRY WELL
rt,NCHES NO. of width length area
D no. of lines 2 width 1 Z length are
6U.-GATE _
depth to top of pipe '
(W, RATE , AREA REQUIRED AREA AS BUILT 2
iSCiaimer: The inspection of this stem by St. Croix Coun y does not imply complete
P Y P
o;-pliance with State Administrative Codes. There are other areas that it is not possible
0 inspect at this point of construction ?' St. Croix County assumes no liability for
Stem operation. However, if failure is noted the County will make every effort to
termine cause of failure.
ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. '
I `INSPECTOR
DATED PLUMBER ON JOB
LICENSE NUMBE '
AS BUILT SANITARY SYSTEM REPORT
T41 TOWNSHIP SEC; ./7r,?j N R /
ADDRESS
ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION_ C - ASj A17 1, LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
0W— EVERYTHING WITHIN 100 FEET OF SYSTEM
I LJ&
A
r
lrdi,cnte 140 th Arrow
SC L
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: Slope at site:
SEPTIC TANK: Manufacturer: e- is e Liquid Capacity:
Number of rings on cover : 1--2 Tank manhole cover elevation.
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set or a cycle _ gallons; tc I a - capac i 1 y
distribution lines gallon: size o pump__ hejd,
gallon per minute horsepower___ branU of punip
and model number
Type of warning device
HOLDINC TANK: Manufacturer Number of gallons______________
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM
Sanita &y PE.nmit
State Sept.'.
NAME St. C &oix County
location S ME Section_Z_? Lot # � e 3_ Subdivi.6i0n � u
S1' TANK
Stize. 4, ".urnoe4 ub eumpa&-tmen-tb _
D- 6ta ,6 &om: Wett Building 1.20 6tope
Highwate&
PUMPIN CHA
Size gatton6 .Pump Manu6aetu &e4 Model Numbe&
IIJLOI TANK
Size gattonb ;.Numbers ob Compa4.tment,6
Pumpe& AZa &m Sy.6tem
Di6tanee 64om: W ett Building 12% 6t ope_
Highwate &
ABSOR PTION SITE
Bed T &ench
Vi 6nom: WeU Building t2% .6tope
Highwate&
ABSO RPTION SITE DIMENSIONS
Width o6 t &eneh 6t Requited area 6t
Length o6 .each tine 6t Depth o6 nock below tite in
Numbers. o6 ti -tees Depth o6 &oeh oven tit'e n
Totat Length o6 Zinea 6t Depth o6 tite below g &ade in
D.Letanee between tine.6 6t Seope ob t&ench Ln. pen 100 6t
r
Totak absonption. a &ea 6t Type o6 Coven: Pape& on st&aw
PI DIMENSIONS
Numb e& o6 pit,6 G&avet a&ound piths ye6 no
Outside. diamete& 6t Depth below inlet 6t
' M I
Totat ab6o&ption anea 6t ?
Anea &equilLed 6t
1J485
REPORT ON INSPECTION OF SANITARY PERMIT # a ��
(1 ) Name and Address of Permit Holder Person /Persons at Site (2 )Date of Inspection
'i
ame, ress, License o. o ns a ing Plumber
Time of Inspection
3 INST LATION CONSISTS OF: ❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber
❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank []Fill System
ermanen reference Point) Describe:
Elevation of vertical reference point: Slope at site:
(5)MATERIAL AND DEPTH OF SEWER:
W SEPTIC TANK: Manufacturer: Liquid Capacity:
Tank Inlet Elevation: Tank Outlet Elev:
# ft to lot or property line: # ft to well:
(7)DOSING TANK: Manufacturer: # of gallons:
# of gallon pump set for a cycle gallons; total capactiy of distribution
lines gallon; size of pump head; gallon per minute ;
horsepower ; brand name of pump and model number
Is the warning device installed? []YES ❑ NO Wired? []YES ❑ NO
8 HOLDING TANK: Manufacturer of gallons ;
construction ; depth to the cover ft; If septic tank is
being used are baffles removed? YES ❑ N0; ft from residence;
ft from well; ft from property line. Type of warning device
Is the warning device installed? ❑ YES ❑ NO; Wired? []YES ❑ NO;
Locking device on cover? []YES ❑ NO; Diameter of vent and material
Distance from building to vent
(9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth;
ft to residence; ft to well; ft to property line;
ft to ordinary high water mark of lake or stream; ft to edge of slopes
greater than seepage pit inlet pipe - elevation ft; bottom of
seepage pit elevation ft.
(10) SEEPAGE BED SIZE: ft width; ft length; tile depth;
lineal feet tile; ft to residence; ft to well; ft to lot or
property line; ft to ordinary high water mark of lake or stream; ft to edge
of slopes greater than 20% falling away toward lakes, water courses or drainage ditches
Elevation of tank discharge line entering bed ft.
11 SEEPAGE - Total length of seepage trench ft; width ft;
tile depth ft; ft to well; ft to ordinary high water mark of
lake or stream; ft to edge of slopes greater than 20% falling away toward lakes,
water courses or drainage ditches; elevation of tank discharge line entering seepage
trench ft.
(12) Has system been installed in area indicated on EH 115? ❑ YES [:]NO
(13) Has system been installed in floodway? []YES ❑ NO Floodplain? ❑ YES ❑ NO
DILHR -SBD -6095 N.0 /80
<
State and County State Permit # 4
PLB 6 7 Permit Application County Permit #
for Private Domestic Sewage Systems County,
*DENOTES STATE APPROVAL REQUIRED
Date Approval . Received from State if Required State Plan I.D. # r
A. OWNER OF PROPERTY Mailing Address: A4 % nil JS
�ah W� Nt ® 7 C •4ve, r6ve %fly
B. LOCATION: % ' /a, Section L2, T N, R E (or) W Lot# _ City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township io
C. TYPE OF OCCUPAf�aY: Commercial * Industrial *Other (specify) *Variance
Single family _ Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY 000 Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured -in -Place Steel Fiberglass Other (specify)
New Installation Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured -in -Place Other (Specify)
E. EFFLUENT ISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft.
New —Replacement Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Width Depth Tile depth� (to p, // — No. of Trenches
Seepage Bed: Len gth Width k Depth O� Tile depth (top) No. of Line 21
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land t a Distance from critical slope 0
WATER SUPPLY: Private VJoint ❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner:
1, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared
by the Certified Soil T ster
yy,, �L `
NAME t` hl e- /` 6 � 1 C.S.T. # 7 ( and other information
obtained from ^ l Ifil h (owner /buil , 2 Q 2
Plumber's Signature P /MPRS # A/I 5 'f 2 , Phone # 7—T I 2 � J
Plumber's Address w e G W I
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
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.EH •1.15 Rev. 9178`
REPORT ON SOIL BORINGS AND PERCOLATION TESTS��
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53707
LOCATION ' /a, /a, SectionT N,R&
��(or V�1 Township or Municipality
Lot No. , Block No. a County JT. Cra
ti ubdivision Name
Owner's/Buyers Name: O "-t .t/
Mailing Address: �il�
TYPE OF OCCUPANCY: Residence_kNo. of Bedrooms — COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS
SOIL MAP SHEET �� NAME OF SOIL MAP UN IT �.B r��lr -d7� -��•� Y�o�+�•�
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN /IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P Ike- o e ,4 3A '
P-.2 e e a ,-e J 6 4A 9 ov 3 3'
P -3 - Se Xcra & 14 Ali) 3 3 3 —3
P—
P—
P—
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
TEXTURE, MOTTLING AND DEPTH TO BEDROCK
NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B— / a+�e, 7 '7s / .2 11 S1 4olo " s1, „S
B— 3 x h, a e- 7 " v "7 d "S 'sI s *6 eV l ,2 , •S
B— y 6ii 7 6 �� ,. re -7r Jk64f1-S*6r•t oh o Z "—s
B- 6 a 6'� s" sc .,� co 3 "
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy ' 4v'ai Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope RVA A" r' *"
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