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Home My WebLink About020-1143-50-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 538812 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 Dolan, Mark I Hudson, Town of 020- 1143 -50 -000 CST BM Elev: Insp. BM Elev: BM Description: ^ Section /Town/Range /Map No L /� •S 1 C.5 ( 17.29.19.744 TANK INFORMATION A ELEVATION DATA TYPE MANUFACTURER •.� CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM C 1 03 �$• 3Z r' te" �e-�. Aeration Bldg. Sewer �alz SZ •��' �� Holding St/Ht Inlet 1 TANK SETBACK INFORMATION St /Ht Outlet 7- Z( 9 , 2 TANK TO P/L WELL j BLDG. Vent to Air Intake ROAD Dt.la" yy Z Septic �, r � �+,• � � J � 7• `f� 9� � / Dosing Header /Man. Aeration Dist. Pipe . 15 9� •� Holding Bot. System � • l5 yz. � _ PUMP /SIPHON INFORMATION Final Grade �. 5?• Manufacturer Demand St Cover IV. 3Z GPM Model er Vn.iJ'c" L..` 7. 0 1 3 .7 TDH Friction Loss System Hea TDH Ft g�. V L bo 7.10 Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 Z SETBACK SYSTEM TO P/L JBLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type Of Syste CHAMBER OR m: , �� /� UNIT Model Number 310 /'j"' J DISTRIBUTION SYSTEM 5 A -, . - r42 P 11) 5 Header /Manifold N Distribution x Hole Si x Hole Sp cing Vent to Air Intl J. Pipe(s) a ! I 1 1-engt h—/6— 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 Mulrned —` - -� Bed/Trench Center / r !S Bed /Trench Edges Topsoil \ \\ 1 Yes No Y a No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2 Location: 464 McCutcheon Hudson, WI 54016 (NW 1/4 NE 1/4 17 T29N R19W) Park View Estates 2nd Add. Lot 51 Parcel No: 17.29 19.744 1.) Alt BM Description = 1� Goje". 2.) Bldg sewer length - amount of cover = i � Plan revision Required? ❑ Yes No � I Use other side for additional information. i_ L `_�__ Date Insepctor' Signature Cert No SBD -6710 (R.3/97) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 538812 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 Dolan, Mark I Hudson, Town of 020 - 1143 -50 -000 CST BM Elev: 7�7 BM Description: Section /Town /Range /Map No CST BM Elev: 17.29.19.744 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing 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 BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: I 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 T Over xx Depth of xx Seeded /Sodded xx Mulched Be O er Center rench Edges Topsoil Yes No j Yes No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2 _ Location: 464 McCutcheon Hudson, WI 54016 (NW 1/4 NE 1/4 17 T29N R1 9W) Park View Estates 2nd Add. Lot 51 Parcel No: 17.29.19.744 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? ❑ Yes ❑ No Use other side for additional information. Date Insepctor's Signature Cerf No SBD -6710 (R.3/97) frgmmerce.wi.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 St. Croix i as I�son, WI 53707 -7162 Sanitary Permit Number (to be filled in by Co.) I)rlt or come . ° _. NE® Fl8' /Z Sanitary Permit Applicat on r late Transaction Number / 1 ^ In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this fo to the n �ovy�g gntal roject Address (if different than mailing address) unit is required prior to obtaining a sanitary permit. Note: Application fo s for l�d�'P((r W f9 are submitted to the Department of Commerce. Personal information you provi a may be u e �dd pp fflyary /_ p urposes in accordance with the Privacy Law, s. 15.04 1 m , Slats. ST. C OIX�OT1 ame 7W I. Application Informat' — Please Print All Information d /L- Property Owner's Name Parcel # 020 - 1143 -50 -000 Mark &Adele Dolan Property Owner's Mailing Address Property Location 464 McCutcheon Road Govt. Lot City, State Zip Code Phone Number NW ' /., NE '� <, Section 17 (circle one) Hudson, WL 54016 715 386 - 8732 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 51 Subdivision Name Block # Park View Estates 2 Addition El Public /Commercial — Describe Use tctt� +Mt°_� Na ❑ City of ❑ State Owned — Describe Use CSM Number ❑ Village of Z a, Na El Town of Hudson III. Type of Permit: (Check otAne box on line A. Complete line B if applicable) A* ❑ New System eplacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal 11 Permit Revision 11 Change of Plumber El Permit Transfer to New List Previous Permit Number d Date ssued Before Expiration Owner / D 7 IV. of POWTS S stem/Com onent/Device: Check all that appl Non - Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component explain) ❑ Pretreatment Device (explain) V. Dispersal/Tr tment Area Informatio :32 filtrator "Q-4 Plus" standard chambers & 4 endc s, Wieser Concrete filter canister w Pol Lok PL - 525 effluent filte Design Flow (gp Design Soil Application e(gpdsf) Dispersal Area Requijfed (st) Dispersal Area Proposed (sf) System ev 10 450 gpd 0.70 gpd/sq. ft. 642.86 sq. ft. 651.60 sq. ft. �/ 92.00' VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units New Tanks Existing Tanks o. U iii ti w C7 G, Septic or Holding Tank Na 1,000 1,000 1 Wieser Concrete X Dosing Chamber I Na Na Na VII. Responsibility Statement- I, the unde igned, a ume responsibility for' allation of the POWTS shown on the attached plans. Plumber's Name (Print) Plum is Sign r MP/MPRS Number Business Phone Number James K. Thompson �_ I MPRS 30021 (715) 248 -7767 Plumber's Address (Street, City, State, Zip Code) 340 Paulson Lake Lane, Osceola, WI 54020 VIII. Coun /De artment Use Onl Approved lsapproved Permit Fee Date Issued Issuing nt Signature Iven Reason for Denial $ q °O $ 1 11 IX. Conditions of Approval/Reasons for Disapproval 3) 1 .Septic tank, af>ltlap0 MW 00 dispersail cell myst all - as per management plait V �u sew rfet c 1WjfiPTe7FFWM the system and submit to the County only on paper not less than S 1/2 x 11 inches in size SBD -6398 (R- 02/09) Valid thru 02/11 I ■ So // 2 da & e'7 / " • Prop�r� �� , c�l =sue rJ,'04 cam. o fl , P�opose.d d,'uz�s;o� �a��e t,.y /hol LoK pe S?SQ{f /uen ��i %Ee /a E oc/L�. i 91.7 - be 975 4cti�t�L /C o�id r{ �� •�� y1S5/ M c.y`� o o A51, 0 Qes,'� copy Conventional POWTS Index & Tilte Sheet Project Name: Dolan 3 bedroom Replacement Conventional POWTS Owners Name: Mark & Adele Dolan Owner's adress: 464 McCutcheon Rd., Hudson, WI 54016 Site address: Same Project Location: Subdivision: Lot 51, Park View Estates 2nd Add ition Legal Description: NW1 /4 NE1 /4, Sec. 17, T.29N., R. 19W., Town of Hudson, St. Croix Co., W I. Parcel ID #: 020 - 1143 -50 -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 her Res 'cted Service: James K. Thompson, De 't. of Comm. Credential #30021 Signature: 5 ---- Date: Page 1 Of 11 Design pursuant to hi-Ground Soil Absorption Component Manual for POWTS, version 2.0 SBD- 10705 -P (N.01/01) • Pro�06r�i S�� / f � �Cu fclte0� /wl ,(� � S l /�la -� off' /�.�,C'�/, "tk✓ sec /J 11,4O( +7 5 Z-- craiX 60 mil. Pcl ,1 0- / /,/3 -so - COO e; nq /. 39 a cre.s P�opos�- dd,'uci5�on ✓a�.F ✓C �� cr S ✓ G >��u EX�J vi� /� X S 2 cl.25/a�6a/ Ce // 6e /GCpnlJGC �cEJ. /Zt/Q{� 5u - 4ce ��LU,` I W,, SO de-tncked J ,1 - EXiS�%n �e s;dncc M J Tr e e l 82 m / ft3SGCMfd t14F_1' _ /�.�� G i 7tnC o GO O lQ2 Si �11CC', 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 = 0.7 gl2d/sq. ft. 3. Absorption area required: 642.86 sq. ft. 4. Absorption area as proposed: 660.40 sq. ft. (32 chambers total) Infiltrator "Quick 4 Plus" = 20.00 sq.ft. EISA per chamber, Infiltrator "Quick 4 Plus" end cap = 5.10 sq.ft. EISA 642.86 sq. ft. — (4 endcaps)(5.10) = 622.46 sq. ft. 622.46 sq. ft. /20.00 = 31.13 chambers required Number of trenches: 2@ 16 chambers per trench Trench width: 2.83' Trench length: 66.00' Trench spacing: 9.00' on center Total system area w/ 6' trench spacing: 12.00'x 66.00' Pg. 3 of 11 Soil Absomtlon System Cross Section 99.25 ft 4' Sd*dule 40 Final Grade PVC Vent Cap Pipe +� 9,. (J O ft With Vent _. ft Chamber �--- 92.00 System Elevation Leachin ft ft Soil Absoml lon System Plan V1 . ft 2.83 ft 6.00 L W eaching Trench Trench 1 Vent Or Observation Pipe Chambers P9 4' Dia. Trench 2 Header Leaching Chamber SR20cafJons Manufacturer And Model Infiltrator "Q -4 Plus" Standard EISA Rating 20.00 sq ft per chamber Soil Application Rate 0 gpd /sq ft 450.00 gpd Design Flow + 0 '70 Soil Application Rate + 20.0 EISA = 3 2.00 Chambers 2 rows of chambers each. j Page 4 of 11 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 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 to allow use of each cell for a two year period. Contin¢ency 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. q. Sad /l 7 I ■ Filters µ Mks A 4 PL -525 EFFLUENT FILTER (COMMERCIAL) 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 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 PL -525 Maintenance: y The PL -525 Effluent Filter should operate efficiently for several years a� under normal conditions before v. requiring cleaning. It is recom- mended that the filter be cleaned every time the tank is pumped or at least every three years. If the y installed filter contains an optionalk alarm, the owner will be notified by an alarm when the filter needs servicing. Servicing should be Gas deflector done by a certified septic tank pumper or installer. Automatic shut -off 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. 1. Locate the outlet of the 3. Do not use plumbing when PL -525 Installation 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 back into septic tank. filter is not centered under the 6. Insert the filter cartridge back access opening use a Polylok 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. i 431" D U M Ll I 1-1 po m Z D D D D D N N m Z rm0 C) 2 rnAr O � n I D r 371„ NN N 4m 2 2„ z m 6 o m �t 7m D Zr mr a r n 2 m m D (� O Z Q a 0 m 18" MIN. r (Tl m C G A A C D p O r 37" I o z 2� e a 2 m D : O m O z O U7 m D D (A r —� D N Z Ln A j ry r m m D �J r n ^O C D m m O z _D ri o O � -� r ,1 C m m D D - C/ � 0 m D D D z � C O� z -< FILTER CANISTER DETAIL SCALE:3 /4° _ , REV NO. ° m MIESER COPCAETE m DRAWN BY:SWT J ' \zz SEPTIC MANUAL W3716 US HWYIO. MAIDEN ROCK, N1 54750 DATE: JANUARY 2008 REV. JAN. 2008 800- 325 -8456 FILE: SHEET 13 p . IW // 113.97' N 45 05" W 90 50'50" 1 1 112.30 S 44 "W 89 62.41' S 22 E 45 °55'00' l j 61.32 S 23° 1 5 ' 35 " E 4 5 04' 10" S 0 ° 43' 3d'E 20 1 19 1 18 280.60 N 45 0 19 '45.5 • . 9 '49 N 0`46 -- 61.32'' N 68 "W 45 N 45 41 "'W I I 113.00' S 0 46' 51" E 2'10 N 44 "E 28.46' N 55 0 ' 7'32'W 20 2942" ----_--------J-- 98.31' S 75 "W 75 49' 34" PARK LANE 82.09' S 7 05' 56 "W 61 44' 14 " cfl - - S 89 °13'09' W 132.71' 579 35'E 12 °04'50" -_- -- 66.00 ------ -_.- -- 61.32' N 66 04 "E 45 04'10" N 89 09 "E 9 �O 24.59 S 52.51 04 E 75 °51 34 S 14 °5517 E 65.48 S 7.51 4 E 14° 08' 26" S 14 0 55'17 "E 6 fi 373.20 S45 6 1945.5' E 89 °05'49' S 8905240'E ESTATES 323.70 S52 2358.5 "E 74 °57'23 S 89 "E I (.0 125.93 S28 °3 46 85 E 27 ° 23'03' N - -r -_ - � 160.00 S59 0 48'30 "E 35 °00'2 I 36 58.22' S 83 °35'40" E 12° 34' V A D T) C).00 b` 1 1 35 0 ;oZ I 34 I 'a - .- 3 3 I 1 tO 1.29 ACRES m i I o o0 ° t4 03 i 1 18 {.7 p� O 7 l73.{t t7g.72' 48' '� 0� W 30 0.04' - - -- 358. 0 S 8 *13'09 "W C° .G o' n _ U N 89 °52'40" W 300 00 O G F - �: s 54 1 .�. c - z 22 0 1.23 ACRES�._� w , o V s3\ \ 53 6 6' 0 51 -. - 135 ACRES 0 1.38 ACRES 55 2cc o' o J , o 0 2.27 ACRES I, ,81 h S89 °13.09 "N'� .J 83 "VV - -- R ° 80. � �i�. McCUTCHEOK � I � 'ss °.,cs �( V`+ 'd LANE IT / J N 89 *1309E cj h C8 6i' \ r 1 36 ACRES c� 56 \\ 1 03.17' I 2.11 ACRES MCCUTC o 57 � h.1 S89'5. 2 62 ACRES a .9:'2' i i �O� ES C . - 'S' 63 ^T 165 B AR � � - o I � 59 o cli 1.60 AC, Fl ,� N6e° Z� JTCHEON ROAD 26963 2 K 1 325.00 _ 275 -- - - -- -- 3C0.0 0 N 89 ',5 240" W 300 00 62 i o 61 I'�I E0 z ., i ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner eta Mailing Address Property Address (Verification required from Planning & Zoning Department for new construction.) City /State Parcel Identification Number L& - 0 — � �— LEGAL DESCRIPTION Property Location / �/, , Sec. /7, T _W, Town of //Cco6;�7ri Subdivision Plat: ?Q-T)e jJ e,_j z Z S ,Lot # 57 . Certified Survey Map # Ili; , Volume , Page # Warranty Deed # (before 2007)Volume , Page # Spec house ❑� o Lot lines identifiable �[] C+Y 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 ST SIG ATURE OF APPLICANT(S) 8 /,0 E 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) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to cert ify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) 4#" � r� located at: Wa-) 1 /4 �'/ Section 17 , Town :2-2 N, Range �q W, Town of sue-, , 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 C/ Did flow back occur from absorption system? Yes_�No (if no, skip next line.) Approximate volume or length of time: gallons 1_ minutes Tank Capacity: G� Construction: Prefab Concrete _ k"" - Steel Other _ Manufacturer (if known): !o,"e5e - Age of Tank (if known): 3 1 ; ceens 2 ed tuber (if know Plumber Signature) (Print Name) � 0, (Title) (License Number),M11tMPRS (D at 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 f �A13421"FS )t - ti AM ZF - -a - - _ _ _ .ia_ - '[s!�_ sTwZ�,JerstT+rCZT'°aWt xFZOAOIr¢ nr3w MP ~� 17.i a 4L7'L'Gi7. ��f B3L>g� cum rrt� o F;c:- - rd! this — a_L►f - zdcry, 7 . _ aat t� I$Z1 S5e0l, Thal the saad Gran to inr sslt)able eonsulerataou - ateYx'ao thn.tal3os�int€ 2359[tbld -?ea1 25'aalEt in --- St— I.X €gat 5 £ , parker^ ew Es.t~Ates -5 1Zni , t di t on -t(3: the: TQ►vns p _3n� z� y ao = o 1 On Croix County, c 5 t .. � •4 T � s K 4 TIYia ...... ..... homgstesd property. -` 4 J. 3 443•d (ia not) Together with all, and singular the beredltaments and ,appurtenances thereunto helonV - 4 z _ Utl warrants that the title is good, eadefeanible in fee simple and Jree and clear of encumbrances except } r easemgents, covenants and restrictions, if an}�, of record. - and will warrant and defend the a, -Ire. _ Dated this :•. ' ...... 2_.8, 1......................... day of _ ........... `�'°_ -•--- -- - _ ---------------- - ._ -. -• --•- (SEAL) y SAME M T. T.F.R _ •--- ......................... -•- --• - ----(SEAL) ------ ' ........... ... - f A,UTH.1lYTICA,T.I01V - P CHI+tU94LEDL;MEN =T Signatures authenticated this __ ..;__._ day of STATE OF -WISCONSI - �lx - County:' ' ` ! ---- -- - ------ --------------------- Personally came before me, this _2-8th _da IS$yy. , the above named T ��+ , ---- --- 4� - --- -- TITLE. biEbIBE,II STATE BAR OF WISCONSIN E �'v � '� " e -man �_ ti ! _ (2f not, _. -._ _ ._..._ -_ a Cr -•-� author zed by § 706.06, Wis. StaLs.) {((( :. _ -- -_-_. - T"ts .45TituMENT_yy'AS DijiAFTED +o me known to be the person t ito�ecup the c I rEYN100D. C4Ri MURRE\Y ' RrAJFL R GARI foregoing i n strument and acknowledge ti'S, s!Ae ! _ MICIQ.ESEN BUILDING, F O. BOAC 229 ff � or HUDSMI --- ISIitt 5 15 ------------ �— (Signatures may be authentic�.teil or acknowledged. Both Notary Public _.St..._�TD�i......... County Wis. are not necessary_) i My Commission pe (I _ is pe nent; f not, state expiration �.�..__ ._5 _••---- ---- - - - - - date: _...-----•.-- +{ "tiames of persons signing in any eapar_ity should be type:) or printed b-loor thor signatures, P . �� O�,•/ WARRAk.'T° .T)Yd'ED_ STATE BAR. OF WISCONS NV wiseorsin Legal BjVk Co. I—. _ FORM No.1 -- 1977 Mi)waukee, Wis.- aobg44$2 ). . 2255 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings in accordance with C n MFA(ft1•f-9N1NN C A.C.E. Soil & Site Evaluations Attach complete site plan on paper not less than 8%: x 11 inches in siz . Plan anOO Y10HO . .LS Coi m include, but not limited to: vertical and horizontal reference point (BM), irection St. Croix percent slope, scale or dimensions, north arrow, and location and dis nce to J I 1 V onv Pa I I. D. Please print all information. 020 1143 50 Re ewe y Personal information you provide may be used for secondary purposes (Priv Law, s e V!� 10'1, Date Property Owner rope oca ion O Mark P. &Adele A. Dolan Govt. Lot NW 1/4 E 1/4 17 T 29 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 464 McCutcheon Rd. 51 Na Park View Estates 2Nd Addition City State Zip Code Phone Number J City Village 0 Town Nearest Road Hudson WI 54016 715 - 386 - 8732 Hudson McCutcheon Road New Construction Use: V1 Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD sol Replacement I Public or commercial - Describe: Parent material Glacial Outwash Flood plain elevation, if applicable Na General comments and recommendations: Site suitable for conventional POWTS dispe� ell with 0.7 gpd /s .ft. /day loading ;rate. Proposed system elev.= 92.00'. .r v M 0 Boring # J Boring s Pit Ground Surface elev. 98.46 ft. Depth to limiting factor >126" in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -7 1 Oyr4 /4 none sl fill na dsh aw 2vf,f na na 2 7 -23 1Oyr3/2 none sit 2fsbk mfr cs 2vf,f 0.6 0.8 3 23-32 1Ory4/4 none sk 1msbk mfr cw 1vf 0.4 0.7 4 32 -58 1Oyr5/4 none s 0 sg ml gw - 0.7 1.6 5 58 -126 10yr5/6 none / s 0 sg ml - - 0.7 1.6 it observati n 10 "- 126" completed by use of hand auger. Boring # J Boring 16 Pit Ground Surface elev. 99.39 ft. Depth to limiting actor >136" in, 9 Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -7 1Oyr3/3 none sil 2fcr mvfr as 2vf,fm 0.6 0.8 2 7 -12 1Oyr3/6 none sit 2fsbk mfr cw 1vf,fm 0.6 0.8 3 12 -18 1Oyr4/6 none Is 0 sg ml cw 1vf 0.7 1.6 4 18 -44 1Oyr4/6 none s 0 sg ml gw - 0.7 1.6 5 44 -136 1Oyr5/6 none s 0 sg E - - 0.7 1.6 q2- f1 Soil observation 106 - 136 "" completed by use of hand auger. * Effluent #1 = BOD? 30 < 220 mg /L and S >30 < 150 g/L * uent #2 = BOD < 30 mg /L and TSS < 30 mg /L CST Name (Please Print) nature: CST Number James K. Thompson 5 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 7/26/2011 715- 248 -7767 i • Proper� �5�..(' e :pit 4�6f,4 1 / G `r( eCu Estes- ft.5.2= �''.fdd.� nw�4'�7E�s'; /�,�dso�, S� Crd � �/. PC/ o ono - acres cam. ofd' co'l cr: S� U G Z�-., efv 6e - , ecc ,, me-c'tco% /L`�'a�K Sar eC eltu = 9Z.7S" EW0 Is EX :shin al bedrec>.. - 7 - - - - - - - - QesideneC h .99c, 1. m - 455kmeof elegy = /60.0. a ,c'c Ce Astifrres /�, 3 ~ I w � I 0 o I N O i O d q I i U Z C LL C I I Cl) O 'S w z •' rn z c a €0 z m n N a c O C O z v Z� � C w V Q O O d Z C fn l- O O Z c E v (D d g c m CD I •1V � (D `mac o o O o N Q z m z o N = � Z V E o N o �i > H m a ) g o c a L @ d O r NN al O 3 3 Z •ti aaa CD 0 y 00 Obi } O N . O N O p = N E d r O m N O �t O 'e C 'C N E f0 to N C l) � C � n O m C 7 N N M d N p C y O • O C,4 0 N N m !0 U T it O 2 ° Z 2 cn € a �# a L: a 4-, rr`Nw E 3 o _1 A ci(L 2 ';0 U)0 Parcel #: 020 - 1143 -50 -000 12/06/2005 09:00 AM PAGE 1 OF 1 Alt. Parcel M 17.29.19.744 020 - TOWN OF HUDSON Current A 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 MARK P & ADELE A DOLAN O - DOLAN, MARK P & ADELE A 464 MCCUTCHEON RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description * 464 MCCUTCHEON RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.380 Plat: 2276 -PARK VIEW ESTATES 2ND ADD SEC 17 T29N R1 9W PARK VIEW ESTATES LOT Block/Condo Bldg: LOT 51 51 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 17- 29N -19W Notes: Parcel History: Date Doc # Vol /Page Type 2005 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.380 55,900 187,100 243,000 NO 05 Totals for 2005: General Property 1.380 55,900 187,100 243,000 Woodland 0.000 0 0 Totals for 2004: General Property 1.380 28,700 173,100 201,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 135 Specials: User Special Code Category Amount 018 - RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 • AS BUILT SANITARY SYSTEM REPORT R ' " ► ^ , TOWNSHIP _SEC. T 2qN, R ! q W .0. ADDRESS LAW. v , ST. CROIX COUNTY, WISCONSIN. "3DIVISION C LOT LOT SIZE PLAN VIEW Distances b dimensions to meet requirements of H62.20 - SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 1 / U V • , 1* voI i ! d i ! I di atte o th A ro 5C L EPTIC TANKS) j 17 O MFGR. P r- CONCRETE STEEL NO. of rings on cover � Depth DRY WELL ttNCHES NO. of width length area J no. of lines *,-, width 7 length r 2 - area l depth to top of pipe '- aG?.EGATE RATE AREA REQUIRED / j� AREA AS BUILT �iwlaimer: The inspection of this system by St. Croix County does not imply complete *Vliance.with State Administrative Codes. There are other areas that it is not possible , 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 itermine cause of failure. TEASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM ' a�r DATED — j — UL - -,Z f PLUMBER ON JOB _ LICENSE NUMBER t P O R I O F ON I N ") 1 k/ I f) i A 1 S1 WA t S yS i C M ((o f t Ii if if kit 0 "A) J'j A 4 C itt, i x Cutavt L c at 4'- 0 n-lf f lilt SEPTIC TANK S i z C o j N (4 o 6 Ii o c o in 4 if. of e P,7 0-t Atarlcv, W If iq h w a c it VUMPING CHAM6H� S i" j (I (j ex e tt (I I'l Mio dc,1' Na mb,! It FOLDING TANK S 4 7- a o kt h N (4 at b Q it o Co aq i ii,?( t it k , i tlh u m c it A e a- c In V t (t V1 c v I( o m W i e j"I I i c Fl I (A A 6-S 0 K'PT I O N S f H. 0 f a yl c ol it k i rn v-f f 6 1 1 ,t e, l'i it I t i, (I It (A) (t C A(`).SOKP7 [ON SITE "DI Wa "dth (.j(, Otqyic6t (t a i It v (I a it a L (, yt �j t. Pt o /, o a. c 4'. ill (P t dcph"l of Iloct", bo(mat o It o oo" It- ; (6t T t ak Pc vt g .(1 o it ' u tai .t t(X kl C 0 o rl a It c �t i T o t a i� a b A (I It 'I if C o o c t (iip PCT V[MCNSIONS Numb (,it, o( -,t f c 0 a to (" (I a rit t o" I( Totae absolip)l:�'ovj A I(. o a it (i ( it it x+397 REPORT ON INSPECTION OF SANITARY PERMIT # (1 ) Name and Address of Permit Holder Person /Persons at Site (2 )Date of Inspection ame, Adaress, License NO. OT instaning Plumber Time of Inspection 3 INS, LATIO 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: (6)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? [DYES ❑ 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 []NO; 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.; li.neal 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 TRENCH: 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% failing away toward lakes, water courses or drainage ditches; elevation of tank discharge line entering seepage trench ft. (12) Has system been installed in area i on EH 115? [] YES ❑ NO (13) Has system been installed in floodway? ❑ YES ❑ NO Floodplain? ❑ YES 0 NO DILHR -SBD -609 N.0 /8 { �� { I! _: 1, Ti : U 01 F aye !!d a 7 d tS N; e a A,�. ON p ' mI v yp, tR'yytlg{�.i 1 {Y� .ti. I t 1 K ifi I T T . i s m tai it list q } { a � t' t. �` ) y� J i IT ii-911w, ru w oft W - vk: P } , :z �a xt 3•'* 1s , r '*` : ,�" ir rya, az. n ,'x'u s 1 ifff NT NA k }. r t 1Sn gg s IN .., 3 �v4i %' ' .sx'C ' "hR fAR "A i # -, X 4","'I t: .iAi r .�o-x t 3'b �: so. 3�.`:a `::, .5 t. .�a.,f.. a.:.•.K .. ...c. rurr :it' State and County State Permit # - A--i'6 7 67 Permit Application County Permit # /,V 2 for Private Domestic Sewage Systems County df2eeziaL * DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY ' ' Mailing Address: B. LOCATION: IV /4 ',, Section T R (or) Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village A P H/ ¢ 7 f Towns C. TYPE OF OCCUPANCY: * Commercial * Industrial *Other (specify) * Variance Single family Duplex No. of Bedrooms No. of Persons D. SEPTIC TANK CAPACITY Total gallons No. of tanks HOLDING TANK CAPgITY Total gallons No. of tanks I 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�DISP0SAL SYSTEM: Percolation Rate Total Absorb Area -- New (/ Replacement Alternate (Specify) sq. ft. Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top No. of Trenches Seepage Bed: Length Width Depth Tile depth (top 3 ° � No. of Line �— Seepage Pit: Insid meter Liquid Depth No. of Seepage Pits Percent slope of land ` 6 Distance from critical slope WATER SUPPLY: Private Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, 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 Tester n f S C`j �, r s 1 �h NAME / C.S.T. # ~ 7 ^'/ J�� and other information obtained from 4 / (owner/builderL— _ Plumber's Signature MP /MP - 5 g Z Phone # � 'f 3 Plumber's Address n w G 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. a F : i 3 � M cry nA e m ; _ e 10 o I Z E E e .f V� w .e.... : 115 Rev'9 B $ 9 / REPORT ON SOIL BORINGS AND PERCOLATION TESTS �► ,, WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES RECEIVED �> P.O. BOX 309, MADISON, WISCONSIN 53701 ,y 1, VC � JUL 25 1580 ZONING LOCATION: �� '�'/4, 17 ®(or Township or Municipality /Y� /4, Section T N,R � Y _ Lot No. Block No. , l County Subdivision ame Owner's /Buyers Name: S Q t ub Mailing Address: 4,J 15 d TYPE OF OCCUPANCY: Residence A: of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW - REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS c.- ps OLV - ! � PERCOLATIO TESTS SOIL MAP SHEET S F NAME OF SOIL MAP UNIT 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 AFTE INTERVAL MIN /IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P / " See, e Ir D 3 w ..5� P- '' -se-'a- / L p -3 • P- 3 - See_ 06 - w 6 . Jr 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- 3 6 " so B_ .r /./Ou 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 ` 0 , 0�" ndicate scale or distances. Give horizontal and vertical reference points. Indicate s 1 Su.` or -Alp 14 E �... __ �.. __ .. _ , .. ; _ ,. •x Tr"c9�u �JN TI t esE c�cw -ce. a 3 � E 0 � s Ava, ._ S Y4 7 �?'^n. ,/r M,4 _ a��'' °;' . 's