HomeMy WebLinkAbout161-1093-90-000
Vtlisconsin Department of Commerce County:
PRIVATE SEWAGE SYSTEM St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
538861 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal inform?tion you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City X Village Township Parcel Tax No:
McNally, John & Debra Village of North Hudson 161-1093-90-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
t OP 1_0 QQ ; - r 64, 13.29.20.742
TANK INFORMATION ELEVATION DATA
~
TYPE MANUFACTURER CAPACITY S ATIION / • SZ HI FS ELEV.
1
Septic Benchmark
12 0 117 ~S v is 00 ; v
D g l n Alt. BM
f Y~ r) S6
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet S q7• (o 1
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD T(/ l S v (o 95 -7 - Z 53
Septic G(` lS ' 6 (l Dt~ttom t O/ q-7• q G
g ~1 Z,L / r Heade
an. 7s
M tJ4 -T- -3
T Io. S
Aeration Dist. Pipe
Tor B - 164
Holding BotJ`Syste r 1 Sa
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer Demand StR Cover yy~
GPM l~ 110 ' /JD
Model Number , • Y
Ia 2 ~l.
TDH Lift Friction Loss System ead TDH Ft
COG~l.2 ~Q ZO°b ~
Forcemain Length Dia. is. to wen S 25 S-7~ f
SOIL ABSORPTION SYSTEM KL-
BED/TRENCH Width Length No. Of Tr nches PIT DIMENSIONS No. Of Pits Inside Dia Liquid Depth vs~ 1\ DIMENSIONS 11 1
dy
SETBACK SYSTEM TO P/L BI p~- WEL LAKE/STREAM ACHING Mgp}afactu LLLh
INFORMATION HAMBER O . {-Y~ a
17 61'
Ty Of System: A4i^ / 29 i F - roUNI Model Num
ber:
DIS RIBUTION SYSTEM D ai"►veaQ~cL~¢_ a~,o SG~f V0o~s_
anipld Distribution x Hole Size x Hole Sp" Vent o Air Intake
Pipe(s) / r/
Length I Dia_ Length Dia Spacing ( / l
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 c/5
Bed/Trench Center Bed/Trench Edges Topsoil
Yes Efl No ~ Yes ® No
COMMENTS: (in1clude code discrepencies, persons present, etc.) Inspection #1: 1 / ZIF 2 6 ll Inspection #2:
Location: 207 Sommers Landing Rd. N Hudson, WI 54016 (NW 1/4 SW 1/4 13 T29N R19W) St. Croix Station Lot 18 Parcel No: 13.29.20.742
1.) Alt BM Description = *Yyyol 2.) Bldg sewer length 3 ~ar 4oAAVLJ2-
- amount of cover ~
Plan revision Required? Yes VNo ' 1
Use other side for additional information. F~--
Date Insepctor's S gnature Cert. No.
SBD-671 0 (R.3/97)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 538861 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 X Village Township Parcel Tax No:
McNally, John & Debra Village of North Hudson 161-1093-90-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
13.29.20.742
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
BED/TRENCH 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: 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 xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
Yes ® No [_M~ Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 207 Sommers Landing Rd. N Hudson, WI 54016 (NW 1/4 SW 1/4 13 T29N R19W) St. Croix Station Lot 18 Parcel No: 13.29.20.742
1.) Alt BM Description &0
2.) Bldg sewer length 3u LQQ~4f/J~
- amount of cover = U
Plan revision Required? Efl Yes FE
No
Use other side for additional information.
SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No.
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A" COPY
P5.2a-rC!
ifibmb commerce.wi.gov Safety and Buildings Division County
1111. Washington Ave., P.O. Box 162 St. Croix
'Wisconsin Madison, WI 707 62 Sanitary Permit Number (to be filled in by Co.)
epartment of Commerce
Sanitary Permit Applicati State Transaction Np b
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental Project Address (if different than mailing address)
unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are
submitted to the Department of Commerce. Personal information you provide~Secondary Same
purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. c
1. Application Information - Please Print All Information
Property Owner's Name Parcel #
John & Debra McNally 161-1093-90-000 , 7 Z
Property Owner's Mailing Address ST CROIX COUNTY Property Location
207 Somers Landing Road N 'LANNING & ZONING OFFICE
Govt. Lot
City, State Zip Code Phone Number NW SW '/e, section 13
Hudso, WI. 54016 715 -386-7159 (circle one)
VI ype of Building (check all that apply) Lot T 29 N; R 19 r W
r 2 Family Dwelling - Number of Bedrooms 4 18 Subdivision Name
IF X 1 S 17 6r Block # Plat of St. Croix Station
❑ Public/Commercial - Describe Use Na ❑ City of
❑ State Owned - Describe Use CSM Number Md'Village of North Hudson
Na ❑ Town of
III. Type of Permit: (Check only,one box on line A. Complete line B if applicable)
A. ❑ New System lacement System El Treatment/Holding Tank Replacement Only El Other Modification to Existing System stem eP Y g Y (explain)
❑ Permit Transfer to New List Previous Permit Number and Date Issued
B• ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber
Before Expiration Owner
C/ v
IV. We of POWTS System/Component/Device: Check all that apply)
Non-Pressurized In-Ground ❑ Pressurized In-Ground At-Grade ❑ 'MJ nd >,244 nin~ojf suitabl (s it M /d < 24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component (explain) (/YC~%YyK~/`CTPretretrr(ent v ce expia n
V. Dispersal/Treatment Area Information: 44 nfiltrator "Q4" Standard Plus chambers & 8 endca s, Pol Lok PL-525 effluent filter
Design Flow (gpd) Design Soil Application Ra gpdst) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
600 gpd 0.70 gpd/sq. ft. 857.15 sq. ft. 920.80 sq. ft. 95.50'
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units o d
U q y
New Tanks Existing Tanks c w D
Septic or Bolding Tank 00 1,200 1 Weiser Concrete X
Dosing Chamber Na Na Na Na I add --h C'~iYUS
VII. Responsibility Statement- I, the u dersigned, ass a responsibility for i on of the POWTS shown on the attach plans.
Plumber's Name (Print) Plumbe s Signatu MP/MPRS Number Business Phone Number
James K. Thompson MPRS 30021 (715 248-7767
Plumber's Address (Street, City, State, Zip Code
340 Pa son Lake Lane, Osceola, 54020
VIII oun /De artment Use Only
Approved El Disapproved Per/mit Fee Date Issued uing Ag t Si re ~
11 Owner Given Reason for Denial $
IX. Conditions of Approval/Reasons for Disapproval
SYSTEM OWNER: l~ yt nv/ru~ R~~l `
1 Septic tank, effluent filter and Sys lcLdh (~C~Gt~ n
dispersal cell must all be serviced /maintained ~ ~
as per management plan provided by plumber. y v ,
2. All setback requirements must be maintained
as per applicable codp/ordinnnrps
Attach to complete plans for the system and submit to the Con only on paper not less than 81/2 x 11 inches in size
SBD-6398 (R. 02/09) Valid thru 02/11
2265
3
Page I of
UATION REPORT A.C.E. Soil & site Evaluations
SOIL EVAL
Commerce 85, Wis. Adm. Code County St. Croix
Wisconsin Department of in accordance with C
and Buildings in size. a nd t parcel I.D.
Division of Safety di 161-1093-90'000
plan on paper not less than 8'/: x11 inches d. Date
Attach complete site 1 and horizontal rand location land d) ce to n ~U 10
include, but not limited fo: vertlca Reviewe BY
Percent slope, scale or dimemsions, north arrow,
Please print all informs nvac~y La,, S. t5. m))' 19 W
29 N R
rovide MY be used for secondary Location SW 13 -r
Nil Property NW 1 A 114 S
Personal information You P ® Z ~
f'1 Govt. Lot
l~.rr 1 # Subd. Name or CSM#
Property pwner Lot # Block St. Croix Station
John E. & Debra A. McNally I. ct<Jlx (,AUNTY OFFICE 18 Nearest Road
Village _1 Town Road North
Property pwnees Mailing Roadss NrINING ?ZONING J City Somers Landing
Somers Landing Code Phone Number North Hudson GPD
207 State ZIP 7158 600
City V11I 54016 715-386' n flow rate
Code derived desig
Hudson of bedrooms _ Na
p!
Use ~ Residential I Number
scribe: if applicable
_ New Construction J public or commercial - De Flood plain elevation,
✓J Replacement ft.lday loading rate. Proposed
Glacial Outwash dispersal cell with 0.7 gpolsq.
Parent material S _ 95.50'.
General comments conv Existing dispersal cell elev. -
and recommendations: S► stem a elv. 9for conventional PO soil Application Rate
sY >104 in
factor - Rod 'I DIfe E
99.71 ft. Depth to limiting Boundary *Eff#
J Boring Ground elev. Consistence
Boring # 16 Pit Surface Texture Structure 0.6 0.8
Redox Description Gr. Sz. Sh• cs 3fm2c
Dominant Color Qu. Sz. Cont. Color ds O g
Horizon Depth Munsell I 2fgr cw 3fm2c 0.6
in. none ds
10yr312 2fsbk 2fm 0.7 1.6
1 O-7 I
none dl gw
10yr414 Osg 0.7 1.6
2 7-30 none Is & gr_ _
7.5yr416 s&gr Osg dl
3 30-42
` 10yr416 none ' 30
4 42-104 If i
p 3 ravel & co s. ~~~•r
/I t S3, ain approx. 40% 9
Horiz
Soil Application Rate
>104" in.
factor GPDIft*Eff#2
99.65 ft. Depth to limiting Boundary Roots *Eff#1
J Boring elev. Consistence
1~3 Boring # f6 Pit Ground Surface Texture Structure 0.6 0.8
Redox Description Gr. Sz. Sh- cs 3fm2c
Dominant Color Sz. Cont. Color 2fgr ds 0.8
Horizon Depth Murrsel► Qu. I 3fm2c 0.6
in. none 1.E
1 0-8 10yr312 none I 2fsbk dl gw 2fm1c 0.7
10yr414 Osg j.1
2 8-15 none is & gr dl cw 20mc 0.7
3 15-27 7.5yr416 Osg p.7 1.
none s & 9r dl
27-48 7.5yr416 j & gr Osg
4 none
10yr416
48-10 01, ` pbd
5 it /-0 rox. 40% gravel & cobbles.
& 5 contain app < 30 m91L
J H 3,4 TSS _
* Effluent #2 = f30D5 <-30 mglL and
CST Number
IL an TSS >30 `-1 m91L 3602
> 30 < 220 mg Telephone Number
* Effluent #1 =BCD 5 Signatu
ate Evaluation Conducted 715
James K. -248-7767
/ CST Name (Please Th mpson D912912011
Address A. E. Soil & Site Evaluations la WI 54020
3 40 Paulson Lake Lane,
Conventional POWTS Index & Tilte Sheet
Project Name: McNally 4 bedroom Replacement Conventional POWTS
Owners Name: John & Debra McNally
Owner's adress: 207 Somers Landing Road N, Hudson, WI 54016
Site address: Same
Project Location:
Subdivision: Lot 18, Plat of St. Croix Station
Legal Description: NWv4 SWi/4, Sec. 13 T.29N., R. 19W., Village of North Hudson, St. Croix Co., WI.
Parcel ID 161-1093-90-000
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 P ber Restn ted 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)
McNally 4 Bedroom Dispersal Cell Sizing Calculations
1. (4 bedrooms)(100 gallons estimated flow)(1.5 design factor) = 600.00 Gpd design flow
2. Infiltrative capacity of native soil = 0.7 gpd/N. ft.
3. Absorption area required: 857.15 sq. ft.
4. Absorption area as proposed: 920.80 sq. ft. (44 chambers total)
Infiltrator "Quick 4" = 20.00 sq.ft. EISA per chamber, Infiltrator "Quick 4" end caps = 5.10 sq.ft, EISA
857.15 sq. ft. - (8 endcaps)(5.10) = 816.35 sq. ft.
816.35 sq. 1/20.00 = 40.82 chambers required
Number of trenches: 4 _ 11 chambers per trench (44chambers total)
Trench width: 2.83'
Trench length: 47.00'
Trench spacing: 9.00' on center
Total system area w/ 6' trench spacing: 21.00'x 47.00'
Pg. 3 of 11
Soil Absorption Svstem Cross Section
99 0'
O` ft
4" Schedule 40 Final Grade
PVC Vent Pipe
With Vent Cap ft
Leaching
Chamber
System Elevation
z.B3 ft Co ft
Soil Absorption System Plan View
ft
93 ft {
6'. CD ft Leaching Trench 1
Vent Or Observation Pipe ~ Chambers
4" Dia.
Trench 2 Header
Leaching Chamber Specifications
Manufacturer And Model Lrtra.~r✓Y `~Q-S!~ 5 .,C/.P.-C/
EISA Rating 24.0 sq ft per chamber Soil Application Rate O.70Jgpd/sq ft
(P CO gpd Design Flow + Soil Application Rate Z.O.O EISA = 73 Chambers
rows of 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 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.
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) 3864680.
r
• Filters
PL-525 EFFL UENT FILTER ( )
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
extension handle
the largest commercial filters in its
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:`
The PL-525 Effluent Filter should '
operate efficiently for several years
under normal conditions before
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
installed filter contains an optional
alarm, the owner will be notified
by an alarm when the filter needs
servicing. Servicing should be Gas deflector
On"HOM
done by a certified septic tank' ! Automatic shut-off
pumper or installer. ban when filter
is removed
1. Locate the outlet of the U.S. Patent Noll 6,015,488
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 MIESER COIICAETE SCALE:3/4" = t' REV NO. DATE:
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DRAWN BY:SWT
Z SEPTIC MANUAL W3716 US HWY10. MAIDEN ROCK, N4 54750 DATE: JANUARY 2008
V REV. JAN. 2008 800-325-8456 FILE: SHEET 13
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owne ~ iol.e e'k'
Mailing Address ~„~7 ~0/lIQ/S `C~►e~i q,ol~'(.
Property Address 54,ene
(Verification required from Planning & Zoning Department for new construction.)
City/State I-Acjs Parcel Identification Number A 1-1093 - 9d
LEGAL DESCRIPTION 4e-e4 C ,
Property Location 144) t/4 , 3 4)t/4 Sec. f 3 T ~N R~W, J~ lie 0
Subdivision Plat: 5t. C e. \c n , Lot # .
Certified Survey Map Volume Page #
Warranty Deed # _ (o (o 0(f 3 9 (before 2007)Volume , Page # ~~09
Spec house u yes 0 no Lot lines identifiable 0 yes 0 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.
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.
Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Num r bedrooms
SIGNATURE 0 APP C NT(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)
P 9~ri
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) 07 ~S mil, poa-0(d, located
at: X50'/4, Section To ! ___~N, Range W, #ccqc , , St. Croix County iscon
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 recFmt date of inspection or service
Did fluty back occur fi-om absorption system? Yes t,~ No
(if no, skip next line.)
Approximate volume or length of time: ,,,,r-gallons minutes
Tank Capacity: zU~
Construction: Prefab Concrete v--__7St_ eel Other _
Manufacturer (if known):.
._,e o Tank (if ki-iown): 30 Qzgrs
Permit number (if know 15(7
icensed Plumber Signature) (Print Name)
(Title) (License Nunlbcr.MPRS
le
(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
P5. /oo'~l
VOL .1 f 5'0PA:,E 69
STATE BAR OF WISCONSIN FORM I - 2000
IF3, 6 0 6:Z38
Document Number WARRANTY DEED KATHLEEN H. WALSH
REGISTER OF DEEDS
This Deed, made between David J. Allan and ST. CROIX CO. , WI
Janet S. Allan husband and wife RECEIVED FOR RECORD
Grantor, 10-31-2001 8:25 AM
and John E McNally and Debra A. McNally, WARRANTY DEED
husband and wife as survivorship marital property EXEMPTN
CEP.T COPY FEE:
COPY FEE:
Grantee. TRANSFER FEE: 1140.00
Grantor, for a valuable consideration, conveys to Grantee the following RECORDING FEE: 11.00
described real estate in St. Croix County, State of PAGES: 1
Wisconsin (the "Property") (ifmore space is needed, please attach addendum):
Lot 1B, St. Croix in the Village of North Hudson,
St. Croix County, Wisconsin
Recording Area
Name and Return Address
161-1093-90
Parcel Identification Number (PIN)
Together with all appurtenant rights, title and interests. This is homestead property.
(is) (is not)
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except
Roadways, Easements, and Restrictions of Record.
Dated this 30th day of October 2001 .
s *David J. All
Q21n7- J, d hpa,;..j
s *J et S. Allan
AUTHENTICATION: ACKNOWLEDGMENT
;iO~~.PrY pUe~i STATE OF WISCONSIN ) ss.
Signature(s)
St. Croix County. )
authenticated this day of K1kTV. i Personally carne before me this 30th day of
PALM ' t October the above named
David J Allan and
Janet S. Allan
TITLE: MEMBER STATE BAR OF WISC liSG,=
(If not, to me known to be the person s who executed
authorized by §706.06, Wis. Stats.) the fo ing i t me d cknowledged the same.
THIS INSTRUMENT WAS DRAFTED BY 4 dry V P lm
Michael H. Forecki Attorney N ry blic, State of Wisconsin
Eau Claire Wisconsin My Commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.) Deeembe 12 2004
*Names of persons signing in any capacity must be typed or printed below their signature.
WARRANTY DEED STATE BAR OF WISCONSIN FORM No. I-2000
ttorney Michael H Forecki 1830 Brackett Ave, Eau Claire WI 54701-1627
Phone: (715) 835-3029 Fax: (715) 835-4112 Michael H. Forecki T6807275.ZFX
Produced with Zipforrr ' by RE FormsNet LLC 18025 Fifteen Mile Road Clinton Tawnship. Michigan 48035, (BOO) 383-8805
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FEET COUNTY SECTION CORNER MONUMENT F
0 1.1/4"IRON PIPE WEIGHING 2.27*/LINEAL
IOO' 200' ! 1" IRON PIPE WEIGHING L68** /LINEAL
4 2"X 30" IRON PIPE WEIGHING 3.650 /I
ALL OTHER LOT CORNERS STAKED A
BEEN MADE TO THE WEIGHING 1'.68*/LINEAL FTt EXCEPT I
r ALL ANGULAR WHICH ARE I* X 3d IRON PIPE WEIGHIN
a THE NEAREST TWENTY CX 24" IRON PIPE WEIGHING 1.61
SAL UES SHOWN, SET ON LINE .
#ORE OR LESS. # UTILITY EASEMENT, WIDTH SF
■ STONE MONUMENT, FOUND
pg. 8 o~lr'
Parcel 161-1093-90-000 01/09/2006 10:45 AM
PAGE 1 OF 1
Alt. Parcel M 13.29.20.742 161 - VILLAGE OF NORTH HUDSON
Current X 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
O - MCNALLY, JOHN E & DEBRA A
JOHN E & DEBRA A MCNALLY
207 SOMMERS LANDING RD N
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 207 SOMMERS LAND'G RD N
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: 04/38-ST CROIX STATION 1977
ST CROIX STATION LOT 18 VIL NH Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
13-29N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
10/31/2001 660638 1751/469 WD
2005 SUMMARY Bill Fair Market Value: Assessed with:
108575 429,500
Valuations: Last Changed: 05/20/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 112,000 308,300 420,300 NO
Totals for 2005:
General Property 0.000 112,000 308,300 420,300
Woodland 0.000 0 0
Totals for 2004:
General Property 0.000 70,000 202,600 272,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 112
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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AS BUILT SANITARY SYSTEM REPORT
OWNER u 10*9997 u 0-s,0rs SEC . L~, T fN-R-
ADDRESS ST. CROIX COUNTY, WISCONSIN.
lpv)
1
SUBDIVISION T 77,0,) LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
LVEUTHING WITHIN 100 FEET OF SYSTEM
Al F. i
U V
JL
NrJllb,.. Wyl. 1, is/iq.blts. rt/1r MYlli -i•N: Wr.ll.: . . i ,ia . a.ll',.r
.i
r +
I di ate o th Arrow.;
R I.SckLi: -+`--;r
/s 7~P tr
BENCHMARK: (Permanent reference Point) Describe: ~4
,Elevation of vertical reference point: Slope at site:
cif! ~
SEPTIC TANK: Manufacturer: (mot) C (,,S QZ-15 Liquid Capacity: ~ 2-00
Number of rings on cover Tank manhole cover elevation:
Tank Inlet Elevation: Tank. Outlet Elevation:
PUMP CHAMBER''
Manufacturer: Number of gallons
yc a gallons; total capacity o
Nwiiber of gal. pump set or a cycle-
distribution lines gallon: size oT pump head;
gallon per.minute horsepower ran name of pump
and model number r-
Type of warning device
HOLDING TANK: Manufacturer Number of gallons
9-/;7 0i
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM
~6
Sanitary Permit
State Septic
NAME TOWNSHIP-A/ St. Croix C o u n t y
1,0CAT10N _ Section/WwL.ot Subdivision -,57, (YOIX 32-
E PT TANK
_
Size gallons Number of compartments_
U istance from: We11-JAL- Building---- - 12% slope-
Highwater!
PUMPING CHAMBER
Size gallons Pump Manufacturer -Model Number
110LD ING TANK
Size gallons Number of Compartments
Pumper Alarm System___
Iistance from: Well Building 12% slope
Highwater
ABSORPTION SITE
Bed Trench
Iistance from: Wellq 91)'6 Building _ 12% slope
Highwater_---1~/
ABSORPTION SITE DIMENSIONS
Width of trench 7 ft Required area ft.
Aq- Length of each line ft Depth of rock below tile in.
H Number of lines Depth of rock over tile in.
Total length of lines l~%11 ft Depth of tile below grade in.
Distance between lines ~ ft Slope of trench per 100 ft.
Total absortption area 0 1D ft Type of Cover:
PIT DIMENSIONS
Number of pits Gravel around pits yes no
Outside diameter ft Depth below inlet ft
Total absorption area J ft
Area required ft
A, X
867 State and County State Permit #
PL
o 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. #
A. OWNER OF PROPERTY Mailing Address:
//19A) IYOS 150AAA r ~X 5/1 40 guhsUA)j ~v~ Sao
B. LOCATION: A1/V'/4 :j(jJ.Y4, Section , T4Y N, ReZO E (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village .%CTtS/ fi~uQSo~
0~ Township
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) Variance
Single family X Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY /ZOO Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured-in-Place Steel Fiberglass Other (specify)
New Installation 7'` Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area Ff, sq. ft.
New Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trent es
Seepage Bed: _Length S~ Width Depth Tile depth (top) No. of Lines 7
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land ~.S %6 Sg Distance from critical slope
WATER SUPPLY: Private M 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, I
NAME 90 15 CA-7- /C 117- C.S.T. # ~ S-O Z d?Zancl other information
obtained from
r) A ,41(/ (owner builder).
Plumber's Signature MP/MPRSW# Z6 / Z Phone #go% - Z f,50
Plumber's Address 22
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, h
r
r
F
/C
Apo (._1 AIAL pQ5g60 SC.oP~
. a ..a .....i ..~}e. . e RW
P
A z
DEPARTMENT OF REPORT ON SOIL BORINGS AN ` Y & BUILDINGS
IN
LABOR DUSTRY, CC > O. BODIVISION
X 7969
~10 KW
HUMAN RELATIONS PERCOLATION TESTS (11J) N, W153707
o G
LOCATION:W SECTION: IP/ UNICIPALITY LOT NO.:B O.: I~yO
NW 1/ 1/ /2--- A21 N/R Z° E (or) W Pv® 6O*6 ~P s ;o,,✓
COUuNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS:
St.ciPo/X Jfgv~ f1//~P~✓ x'0.5' S'oM,~ER sT. ~o~~
USE DATES OBSERV .v
NO. BEDRMS.: COMMER~lAL DESCRIPTION: DESCRIPTIONS: PERCOLATION PTESTS:
Residence C! New ❑Replace 7,2-- /?,P/ / Z 2-
RATING: S= Site suitable for system U= Site unsuitable for system #-h iqv 1,0.9141 S,4AJP
r ONVENTIONAL: MOUND: IN-GROUND-PRESSURE YSTEM-IN-FILL HOLDING RECO MENDED SYSTEM: (optional)
NS ❑ U ®S ❑ U ❑ U : lo~UvE,uT,ov,~G ~,~~tr~vF~EOD i3~v
If Percolation Tests are NOT required DESIGN RATE: S T M If any portion of the lot is in the
under s.H63.09(5) (b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
%e.
B- r .7 z 9y " > 7Z 3y"oe, c s ~ IV/C .6 L'~s~~`' .~o.1
o CS to--
" /Co "~f.~, c.s ~ „G~,~~ • G S ~ "f'uro o~P. S. y.P.
04 e sr
"'i3N.GS 5'"a/-13w,L5S L2'•~-.,ut o 9,P.
1 ~j` o ~ 0,V. c d
B- J/ / ✓ 9~ ,r A& "AW, Ls j? S 2 L " 40A &,e S
"D
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD1 PERIOD2 PERIOD PER INCH
P- 3 1 > > J'
P-
P- 2- v 3
3
P_ I
P-
P-
PLAN VIEW: 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 the surface elevation at aU borings a7n_the direction and percent
of land slop. 80r7_OH OJ= .BE/~ 7D L%t A7_ ~/t dJ9T/ON a%` 3 ~~EU• ~~r
SYSTEM ELEVATION Rte /.IF /3drro» e3/3so w,?/ c:e EX~ct~y 1~,- 314•
l / io
~o
nr, i s ' _ of /u a• g3 '
62.
evv ef-l-, 16A loo"
NVE Al AAJ
17 11
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