HomeMy WebLinkAbout020-1016-20-000
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No: 552329 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:
Barstad, Alan R. Hudson, Town of 020-1016-20-000
CST BM Elev: Insp. BMElev: IBM Description: Section/Town/Range/Map No:
-l s. ~Q C Lj " ' /110 12.29.19.726
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
3.0 ~5,&
Dosing / 4ri, / Alt. BM
Aeration Bldg. Sewer
d2 0 . , &
Holding S" Inl
~9• sy
TANK SETBACK INFORMATION st/ outi t 15(-'W 2~
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet at(f~~ t7 rA k
Septic jbb~ Dt Bottom t4
( Pi / l j?
Dosing Header/Marl'-
Aeration Dist. Pipe O b C 1 ,
Holding I
+ B. S Cbp b p.
PUMP/SIPHON INFORMATIO&YAVt Final Grade
Manufacturer Demand St Cover
GPM / q b_11~ k,11 Model Number ~f>Ts 0~
TDH Lift Friction Loss Sys Head TDH Ft ~y W Ste`
Forcemain Length ia. Dist. to Well ti S l ~1 A 1
SOIL ABSORPTI N SYSTEM qlQV PL) ,Q4,d
BEDITRENCH Width Length { No. Of T e ches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS SQ
-1; 1
SETBACK SYSTEM TO vv P/L BLDG WELL LAKE/STREAM EACHING nufi r: 7 - /7G
INFORMATION 1 CHAMBER O -
Ty Of System: f ^ > 3 O Model Number:
DISTRIBUTION SYSTEM ^ q0 OF A,0-44,
Head anifold Distribution I x Hole Size Ix Hole Spacing Vent t it I ke
Pipe(s) fi / / 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 ~1 ~f r 113 (Trench Edges Topsoil
c Q, G/ 0 Yes FE-] No ®Yes ffNo
COMMENTS: (Include de iscrepencies, persons present, etc.) Inspection #1:/ f d Inspection #2:
Location: 886 100th Ave. Roberts, WI 54023 (SE 1/4 SE 1/4 12 T29N R19W) NA Lot 6 Parcel No: 12.29.19.72B
1.) Alt BM Description = C~~l d ~
2.) Bldg sewer length= Av ~0
- amount of cover ug", A+ 6L~sg 0g 51 e v Ci5
Plan revision Required? Yes ININo 10~ v S
Use other side for additional information. l r-'4'ak SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No.
,{Jan QarSc~jOi~~.
/00 5-6
k~o6er~s, Ss~0~3
Sf . eIT)i}( Cod tJ A
Ga4,A) C/• 02C' -iG/6'ZC-till:
qua✓c~ dr~,~V~e.
EXi's-E.'nc~ Sr~ic
~ b[abcndcned G5
~ ~ Co cle..
'o /COQ ~✓e. ~ucll EXis~nq ~ j
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~ decd
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i• ~.,~T ~ KLf4 ini2:.
s ~ LyO 1`fcfr~'
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6G.~3' 33.37 33. 3'
~a S'~~ ~ J~%.°~ ~ /=Z ~ 4 ,~1 ~'GJ ~vEd ✓ o ~ ~a c1S'c~/
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/fit} c~ ti~ h~~
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V Wf~ d
30•
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9d
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df. IM A.
.g0V Safety and Buildings Division un
201 W. Washington Ave., P.O. Box 7 G Yd
' Cs9t X12 Madison, WI 53707-7162 mit Number (toobbe filled in by Co.)
Drce
Z /
/
Sap it Application State Transaction Number
In accordance with Com Adm. Code, submission of this form to the appropriate governmental AM:
unit is required pri a sanitary permit. Note: Application forms for state-owned POWTS are Project Address (if different than mailing address)
submitted to the De t of Commerce. Personal information you provide may be used for secondary
ur oses in accordance with the Privacy Law, s. 15.04 1 m), Stats.~~~ /oO
1. Application Information -'Please Pr' ll Information Aw~
Property Owner's Name Parcel #
a .J t- 7a o~ a -;7 O - O lG - 20- d a 0
Property Owner's Mailing Address Property Location
72- G~)
8 OV'a l,JFd XU G Govt. Lot ~
City, state Zip Code Phone Number -6
Y, Section 1?
U ?S r r ~7 ~az lJ`^ ~~G - ,$-d ? yy AA(circle one"
W
H. Type of Building (check all that apply) Lot #
91 or 2 Family Dwelling -Number of Bedrooms Subdivision Name E ot(_ J
41 QC40 ~ Block #
❑ Public/Commercial - Describe Use
❑ City of
CSM Number El Village
El State Owned - Describe Use 5~y?9 of
3112
~l ~ / ~ J / ❑ Town of /y10(.rd,N
III. Type of Permit: (Check my one box on line A. Complete line B if applicable)
A.
❑ New System Replacement System ❑ Treatmentmolding Tank Replacement Only ❑ Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner if AI)( )W AI N~ 1?EZ0,2 b
IV. Type of POWTS System/Component/Device: Check all that apply)
KNon-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) ef= ❑ Pretreatment Device (explain)
V. Dispersal/Treat nt Area Information: G + G
Design Flow (gpd) Design Soil Application Rat pdsf) Dis equired (s Dispersal Aye ropo (s System Elevation
G 4/ a S i t ' o zl,s
VI. Tank Info Capacity in Total # of Manufactu r
Gallons Gallons Units o $
New Tanks Existing Tanks c
° y
/_l Q a U n v) wC7 a
10,E 5z °
Septic or Holding Tank y /ed d W ,y
Dosing Chamber / N
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS s wn on the attached plans.
Plumber's Name (Print) Plumber's Signature P PRS Number Business Phone Number
;X 2
Plumber's Address (Street, City, State, Zip Code) J
070 S G 77- Ad //<r~G~ ~ f
VIII. County/Department Use Only
Approved ❑ pprove Permit Fee Date I ued Issui gent Signat e
$
O 'en Reason for I 7 h~
IX. Condit' easons for Disapproval
1. Septic tank, eftluettEfiher and 3 ~ 6(.U c7y5Tt 4 C~
dispersal cell must all be services I mainta ted. ~J
as per management plan provided by plumber. G~ C4_
2. AR.ss(b0ick fequVements must be maintained
Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x 11 inches in size
SBD-6398 (R. 02/09) Valid thru 02/11
f7 a..✓ ~'J a Y' S~a~ ~ $'~%s~ S S I a2 ' 4 /QZ~GJ j~d`J-✓ a ~ cUa e~~5'ayr/
41
~~U 60 ~ :tip
v
ol- n L ~1 Zd~a
•
9~~ i/4 ~
Soil Absorption System Cross Section
I
ft
ft
4" Schedule 40 Final Grade
PVC Vent Pipe
With Vent Cap ft
Leaching ♦ ~o d
Chambery 31
ft
System Elevation
3
ft f t ft
Soil Absorption System Plan View
D P
Si'- ft
{
ft Leaching Trench 1
Chambers
IIIIIIIIIIIIIIINW 4" Dia.
Vent Or Observation Pipe Trench 2 Header
Trench 3
Leaching Chamber Specificatlons
Manufacturer And Model :L T,~ « re .r (f~ a "C
EISA Rating ji'~ sq ft per chamber Soil Application Rate v gpolsq ft
gpd Design Flow ~Z_ Soil Application Rate 1;25' EISA = ,~G Chambers
3 rows of chambers each.
Page of
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Q~ aV ~ Septic Tank Capacity Q® 69 al ❑ NA
Permit # Septic Tank Manufacturer f'ese ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer 104 ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model S-95- ❑ NA
3
Number of Public Facility Units ❑ NA Pump Tank Capacity Q al ❑ NA
Estimated flow (average) ~f SO gal/day Pump Tank Manufacturer ~Sey ❑ NA
Design flow (peak), (Estimated x 1.5) x'40 gal/day Pump Manufacturer ❑ NA
Soil Application Rate gal/day/ftz Pump Model ❑ NA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ❑ NA
Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD5) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BODS) _<30 mg/L ❑ In-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound
Fecal Coliform (geometric mean) 510° cfu/100ml ❑ Drip-Line ❑ Other:
Maximum Effluent Particle Size YB in dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other: ❑ NA
*Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect' condition of tank(s) At least once every: meoanthl(s) (Maximum 3 years) ❑ NA
I? Wy
Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑0 month(s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: month(s) ❑ NA
• year(s)
Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA
❑ year(s)
Flush laterals and pressure test At least once every: p Yea 1)(s) ❑ NA
❑ month(s)
Other: At least once every: ❑ year(s) ❑ NA
Other: ❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one-third (Y3) or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of 512 months, shall be performed by certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill aoove normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at-grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or: must be taken, to provide a code compliant
replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
AIIA ❑ The site has not been P^~~~ata^ * __a° the PnWTR a soil and site
„ hnamant araa If nn ranlftn .1 hla hnidmtl tank
,0
❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
< <WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DU NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name l✓r`ll.'~c ~h G ys.o`jo'GY' Name
b
Phone Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name . GC r CG
Phone Phone 1 _ _p
This document was drafted in compliance with chapter Comm 83.22(2)(b)l1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are.detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at-grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or. must be taken, to provide a code compliant
replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
r_2- of the POWTS a soil and site
❑ The site has not b n Plai~~a*P!1 _ _ ,
e « ti .E tit nninromPnt araa if nn ranl_ hIP a -holding tank
❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
< <WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name ",'rCrIe4 .Y' Name
Phone Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name G~ CrDV
'5:~-
Phone Phone 1 _ 7{p
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.540), (2) & (3), Wisconsin Administrative Code.
5,14796 'r CERTIFIED SURVEY MAP .
LOCATED IN THE SE 1/4 OF THE SE 1/4 AND SW 1/4 OF THE SE 1/4 OF
SECTION 12, T29N, R 1 9W, TOWN OF HUDSON, ST. CROIX COUNTY, WISCONSIN.
S 1/4 CORNER
SECTION 72 / s
6-
w (CORNER FALLS-IIV -MOONBEAM LEGEND
a POND, USED ST. CROIX
t 1 o REFERENCE MONUMENTS) ROAD, / SW1/4 SE1/4 COUNTY SECTION CORNER,
1 _ - / -
- i MONUMENT, BERNTSEN CAP,
NORTH 264.00'-
FOUND. (UNLESS OTHERWISE
1
254.17' NOTED)
253.55
WES~T% LINE OF THE SE 1/4 F THE SE 1/4 0 1"X24" IRON PIPE, WEIGHING
9.83'
1 ' 1 (R 9.37) 1.68#/LINEAL FOOT, SET.
V
1 a • 111 IRON PIPE, FOUND. +
, ~ 1 I
1 ! 100 ~"~y 3/4" IRON BAR, FOUND.
` 33
1 33' 4 (R) SLANT DATA INDICATES
LOT 1 PREVIOUSLY RECORDED
1 1
INFORMATION
1 l ` Z`.~M-
1 LOT 5 15-AGE 5
O-1417
1 w DOC. X3931 1 1 OWNER & SUBDIVIDER
1 0~4 0 LESLIE L. FLAHERTY
i 4144 CORONADO LANE
1 1 1 OSHKOSH, WI 54091
l N~ 1
N
J
W 1
1
Z
Z ASSUMED BEARINGS REFERENCED
IT tO TO THE SOUTH LINE OF THE
' o SE 1 /4 - SE 1 /4 SE 1 /4 OF SECTION 12 WHICH
i D m = y m BEARS WEST.
3.37 192.50'1
m co CD SOUTH 225 7' co I--
Ip 0 1 5 p z
o ~ 1 - a? ~ o I INCLUDING EXCLUDING
f- 1 U 1 iq o EXISTING EXISTING
D Q 1-~ D TOWN ROAD TOWN ROAD
RIGHT-OF-WAY 1 N RIGHT-OF-WAY
" I - I
.11 A
~ 2 388 AC. 2 5 C.
m o m
1 1_,_ 100' ~q LOT 5 104 038 S.F. 92,126 S.F.
c rn I p
_ 1 1 y~ LOT 6 1.847 AC. 1.531 AC.
r 4 80,452 S' F. 66,687 S.F.
rn r Ir
m ~1 l
12: D OUTLOT 1 0.755 AC. 0.339 Ac.
- 33,310 S.F. 14,759 S.F.
o~
Ito h; .-ROVED
1 0 0l LOT 61 N
m _ QQ f~'
00 co 1
- a
j 1,1.4
A1~ + c 1 iSEPTIC TANK
O
11- rn FILEL
1 VENT I] y
C I y ,,iOtX COUNTY
J UN Q 5 1996 r -;,k:,ar pensive Plannie
-l I l y
t- - - KATHLEEN R WAiSFi Zoning and
(D 1 -e CENTERLINE' IQ Registerof Parks Committee
Deeds
DRIVEWAY
-l 1 y Z 1 , SL Croix Co., wt
1 t t t ti _ not recorded
v-n
POINT OF `J SCALE 11~"t `~Yg °E
BEGINNIN 66.43' 3.3 3.3 1
SOUTH t>0
264.00' 0' S 100'
0 1 33. j 33' 1
1 6.6, 1 UNPLATTED LANDS
% l
DATE. APRIL 1 1 1996
SE CORNER
SECTION 12
T29N, R19W
THIS INSTRUMENT DRAFTED BY DARIN FLATER PAGE 1 OF 2
Vol. 11 Page 3112
_ ~ v o ''C-sic
:'r ATI° II AR 0r WI GC_ (IN I.IN rt"IRAI _ 1087
WARRANTY DEFD
DOCUMENT NO. VOL
REG1%ER'S OFFICE
White Pine, Inc- a Wisconsin Corporation, ST. GI)t' Crp., W I y
- OEC U 3 1997
coneys and warrants to Alan R. Barstad. j 10:10 AM i
d single person
Re star of Deeds
TH;S SPACE RESERVED GGR RECGRt^,1NG O-ATA
NAMF. AND RETURN AODRES~
the following described real estate in _ S t . Croix County. 3 3-7 l -
State of %Vuconstn: !
Outlot 1 and T.o of Certified Survey Map,
filed June 5, 2995 in. Vol. 1111'[, page 3112,
as Document No. 544796, located in the T
Southeast Quarter of the Southeast- Quarter
and the Southwest Quarter of the
Southeast Quarter of Section 12, Township FARCE~IOENT[FICAT[GN NUM3 R
29 North, Range 19 West, Town of Hudson,
St. Croix County, Wisconsin-
TRANSFER
ESE
~ t This is not homestead property.
I4Gkx (L not)
Exceptiontozvarranties: easements, restrictions and rights-of-way of record,
if any.
Dated this tar day of `t =_9M4= t penemhgr A.D., 19 97
White Pine, Inc._
(SEAL) By n.~:224 (SEAL)
Hank FogelberV, President
I
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
t
State of Wisconsin,
ss.
St. Croix
_ County
authenticated [Ills _ day of i9 Personally came 1:,-fore tnc 0,ts _ 15~------ clay of
}Q$MJXX{S.'EQ€X December . the above named
- - -WEh i t, e P i n e- I. r c- a W i ~C.OSl.c i n
_-C- 1.L].L' ,--8~--H.3cl~r~)1GTg2-bE Fb
Ti i-i.i] NlCNlBFR STATE i'i-\t< OF iSC ONSIN r OU lie Pres ent
NOtarv
j'ur.lic
`--'---}1314' tlj WiSC
authunxd h.• §70t .OC, \\'IS Siats i 07]Sap] to n, mean to be th Isoll %cho esectned Elie ft Teg"tng
nt.tr ncnl and acknpc[edK( th._ sank
'TI[IS INSTRONIENr VJA DRAFTFD Be l
Brenda oulin
Fturlson~._:.I 54016,
(<,en.uure: n,av he .uahrntu'alit'. .,r a, kno%,Iedged nosh arv nca -rrnancn: (If not, statt• exnlr.ul,m elate
STArT DAh OF IS( 0 IN
\~a12 R.1~IY OF t.D Fnnu N,, 2 - i-d_, ~:•'~!;-t a.~•c-e
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
p
Owner/Buyer _,M-L- ,00,j 4`~A4t5T
Mailing Address _ 98(P o oy", Xe l j _
Property Address 9&& (d oqk-~ Ve_k-L'.J`e.
(Verification required from Planning & Zoning Department for new construction.)
City/State e' y'i 5 Parcel Identification Number _
LEGAL DESCRIPTION
Property Location 5= 1/4 , Z= 1/4 , Sec. T 2,9 N R /Q W, Town of _ ae4ro'V
Subdivision- - Lot #
Certified Survey Map # Volume , Page #
Warranty Deed # Volume ZD , Page # _-;?O'l
Spec house yes Lot titles identifiable ye 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 SComm. 83.52(l) 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.
[/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.
l/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 w anty deed recorded in Register of Deeds Office.
X Number of bedrooms 3
SIGNATURE OF APPLICANT(S) DATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey trap if
reference is made in the warranty deed.
(REV. 08/05)
2284
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code ~ A.C.E. Soil & Site Evaluations
my
Attach complete site plan on paper not less than 8%2 x 11 i hoc m
. Pla roix
include, but not limited to: vertical and horizontal referen oint Parcel I.D.
percent slope, scale or dimemsions, north arrow, and loca n and
0 16-2 000
Please print all informa n. Revie d By Date
Personal information you provide may be used for secondary p (Prij1PYW3. t5A~1A14 / /
Property Owner f ~1 t ocati
Alan R. Barstad CRUI 8 SE 1/ SE 1 S 12 T 29 N R 19 W
NNIN 14
Property Owner's Mailing AddressIz - T= _10-K # Subd. Nam or CSM#
886 100th Ave. 6 na CSM Vol. 11, Pg. 3112
City State Zip Code Phone Number City _I Village l/ Town Nearest Road
Roberts WI 54023 (715) 381-6568 Hudson 100Th Ave.
New Construction Use: y_f Residential / Number of bedrooms 2 Code derived design flow rate 300 GPD
601 Replacement J 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 0.4 gpd/sq.ft./day loading rate. Recommended
installing 4 trenches at 90.0', 89.0', 88.0'& 87.0'.
Boring # -I Boring
Pit Ground Surface elev. 92.37 ft. Depth to limiting factor > 108° in. Sal 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 0-12 1Oyr3/2 none sil fill 2mpl mvfr as 2fm 0.0 0.0
2 12-23 1Oyr4/6 none sicl 2fsbk mfr gs 1fm 0.4 0.6
3 23-30 1Oyr4/4 none sl 2msbk mvfr cs 1fm 0.6 1.0
4 30-38 1Oyr4/6 none Ifs Osg dl cw 1f 0.5 1.0
5 38-49 7.5yr4/6 none Is Osg dl aw lvf 0.7 1.6
6 46-108 1 Oyr4/6 none gr s Osg dl - - 0.7 1.6
Boring # -_I Boring
16 Pit Ground Surface elev. 93.02 ft. Depth to limiting factor >119" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/W
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-5 1Oyr3/2 none sil fill 2mpl mvfr as 2fm 0.0 0.0
2 5-17 7.5yr4/6 none Is Osg ml gw lvf,f 0.7 1.6
3 17-54 1Oyr5/6 none s Osg ml aw - 0.7 1.6
4 54-80 1Oyr5/4 none fs Osg dl aw - 0.5 1.0
5 80-89 5yr4/4 none scl 2csbk mfi aw - 0.4 0.7
6 89-119 10yr514 none fs Osg dl - - 0.5 1.0
* Effluent #1 = BOD > 30 < 220 m /L nd TSS >30 < 50 mg/L
D,:5.30 <
g Effluent #2 _ BO m /Land TSS 30 m /L
s 9 9
CST Name (Please Print) Signatu CST Number
James K. Thompson / L- 3602
Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number
340 Paulson Lake Lane, Osceola, WI 54020 4/3/2012 715-248-7767
Property Owner Alan R. Barstad Parcel ID # 020-1016-20-000 Page 2 of 3
F31 Boring # I Boring
J Pit Ground Surface elev. 92.31 ft. Depth to limiting factor >123" 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 0-24 10yr4/4 none sl fill 2msbk mfr as 2fm,1c 0.0 0.0
2 24-32 10yr3/3 none fsl 1 msbk ds cw 2fmc 0.2 0.6
3 32-48 7.5yr4/6 none Ifs Osg ml cw 1fm 0.5 1.0
4 48-56 7.5yr4/6 none Is Osg ml gw 1f 0.7 1.6
5 56-123 10yr4/6 none s Osg dl - - 0.7 1.6
4] Boring # Boring
✓J Pit Ground Surface elev. 92.65 ft. Depth to limiting factor 0" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-48 na na fill na na na na na na
Area consists of fill and construction rubble. Location unsuitable for POWTS installation.
F-1 Boring # I J Boring
Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS <-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 a Site Evaluations
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