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020-1287-60-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 567275 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: Pederson, Dan & Gretchen Hudson, Town of 020-1287-60-000 CST BM Elev: Insp.BM Elev: BM Description: Section/Town/Range/Map No: /60.o /60 ' O _ "' //G oil. ,S',c ., 21.29.19.1402 , TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION ? S /02.35 HIFS ELEV. Septic Benchmark n� . // I.S/,T//Ak: ,^ /' �t�6 2,2L /o2.26 /00,6 T- M y v V L <LaJ , h f / -�j �j` Alt. BM 2 .91 g'/ y/ Fs 6 �•t•.. GOw�i 7 Aeration PolAi doL Bldg.Sewer eW∎,'S4-u(/-gol vIL Holding St/Ht Inlet , tie j St/Ht Outlet U �`� ��� �,/ 9'4•/Z. TANK SETBACK INFORMATION �''!///VVV ttt :�r �-, /� �.tC,a7 TANK TO P/L ® BLDG. a o Air Intake ROAD Dt Inlet, / �` ` ' ��'i,%c,�-F 7-35 9 y Septicf X3 F, . Do ' r. `74501 BB= Header/Man. Aeration _-_ Dist.Pipe 63 IMI_ Holding �—_' Bot.System 945 1-2' 5 4C � Final Grade PUMP/SIPHON INFORMATION / #.7 to cl 7. 5 Manufacturer Demand St v F.f(I-c,. Cgn••ii A. qp GPM j 1�1- ✓s �-l� 231 I.vi Model Number frliALJ I {-6✓(_' t�+4 TDH Friction Loss System Head TDH Ft 1Lift e e:a a GPuckz`u-C C,e!. /.I Forcemain Length Dia. Dist. • ell SOIL ABSOR- 'N SYSTEM BED/TRENCH Width / Length r No.Of Tre�hgs PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 1"2 Z it .Li � �.. SETBACK SYSTEM TO P/L J BLDG WELL LAKE/STREAM LEACHING Manufacturer INFORMATION Type Of System: / CHAMBER OR '�i�.F•� 6 >�ra�� f� / ..„...k_ �� ,�/ Model Number: 1 DISTRIBUTION SYSTEM taa.k.) el,.., Header/Manifold // Distribution x Hole Size x Hole Spacing Vent to Air Intake ‘'."-eve Length Dia "h Length Dia `�Pacing 5�v SOIL COVER /x Pressure Systems Only xx Mound Or At-Grade Systems Only 74.•-Z 0 4-Z.0=to a Depth Over Depth Over xx Depth of Seeded/So..ed xx Mulched Bed/Trench Center \ 5.d xx 1 Bed/Trench Edges ` Topsoil 1 �/ 1 es No I Yes No COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2: / / Location: 514 Prairie Lane Hudson,WI 54016(SE 1/4 NW 1/4 21 T29N R19W) Wells Fargo Station of 6 P2rce/ o: 21.29.19.1402 1.)Alt BM Description= 14'1' '.l Cid��i� I PJ g.'� 0"'��►'{' ,.r 3 t y N �` 2.)Bldg sewer length= 1 /- amount of cover= 't 6 �t Lo c.•kis Qt.._ Plan revision Required? g Yes RiNo I I. Z7 13 qTA side for Use other s de o additional information. _ i ,,/12111/1111K SBD-6710(R.3/97) Date / Insepctors •ignature/ Cert.No. 0 50,7 'holey i4' JaCns,,., ,%e%/ua6a,i Jo:rt Sri( I I. 0/ •fX/;Sel Peade else. ?,�M.i t�i,,"r.1353 L 1,nt Cre-€'4t-n 4.dse c n 6/4"4'airIe L&r Arson, �i 5co/� R i t,&e"Ls - o ita ie , U 6E4/MLA See 27 , /,- 5,1.//pea �. ar'/,44dsGn, sE.ervirC.�.,c.J/, /OG/, AI O,20-/2 7-60-a 6P�%.g X.dsacres l/ aSla h.e.le clei✓eu,Y�y eccaae kb0 0 Fool . ,i 7-511 E)034-n 9 u1e.tr--i II E7,3q it a• 451;(1 a /0c ` Plcti/j 101C101C7‘."/arc/ i o 1 :07,o Cow ' ' 1 Sid;nr�, As5uMed ,f(4:-/a1""` '' 0 r Pro °sad D P 47• Ja3,o, w67'/ 9zc tl(crr / M W:C U *el o 9%.°,•'' f i ! I ' ( 8)i i d,sp�s.lce/ / o� 1 ' ' I .s-- t!8 fazcoe:/cr 9_ 1Sa // LJ' muartw ica„/[c(// f / / / 0, , - 97 F d; ' & // Fallow / i / i \2-3,�SJvF X/13 .�202 � e G / / iii fl0.t/"/ohcc e-Awn41Is y3t1m �%. 46re97./7 Arrq • '` �uitace e/cc!Abe- 1 Sa; • • / / // , ; / spy . V - \ // ilt Spruce. •fire t s r r t ./' � r , ■ iek- 1 aiaiQ;la r/ 1'`--' t L ;^' . . 4vl , ? . C/oPy((-'-` / , /, 3 s 91' r County{e Safety and Buildings Division St.Croix a g 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) P= l Madison,WI 53707-7162 N. �� 5r, 7 27C Sanit. r - 4 • pplication State Transaction Number ° In accordance with SPS 383.21(2),Wis. . `�'"':C:. ,sub ,' ion of this form to the appropriate governmental unit Na is required prior to obtaining a sanit: ,,. ,. No-• • •plication forms for state-owned POWTS are submitted to Project Address(if different than mailing address) the Department of Safety and Profess . •- . Personal information ou rovide y p ay be used for secondary purposes in accordance with the Privac :w,s.15.04(1Xm),Stats. Satre L Application Information—Please Print All Information Property Owner's Name %, Parcel# Dan&Gretchen Pederson 74.t�> 020-1287-60-000 Property Owner's Mailing Address ° � , Property Location 514 Prairie Lane r?�x�oo4v Govt.Lot City,State I Zip Code Phone Number SE 'vs, NW ''v., section 21 (circle one) Hudso , WI 54016 (715)386-0122 T 29 N; R 19 E or W II. pe of Building(check all that apply) of# 1 or 2 Family Dwelling—Number of Bedrooms 4 X I Til 6 Subdivision Name VIP Block# Wells Fargo Station ❑Public/Commercial—Describe Use Na ❑City of ❑State Owned—Describe Use CSM Number ❑ Vil a of Na •own of Hudson III.Type ,f Permit: (C, =i ,i one ,o% , •I e A. Complete line B if applicable) A. 4 ew System i Replacement System ■ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber l ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration I Owner . 1 q 3 (/'J - 7/7//913 L) ( IV.Ty of POWTS System/Component/Device: (Check all that apply) on-Pressurized In-Ground ❑Pressurized In-Ground ■ '.� ❑Mound? in.of: ' le so' ❑Mound< in. ; suitab *it ❑Holding Tank ❑Other Dispersal Component a 1;' ) ..?....0. ': - :,, e t vice(explain / ,w / .., 7/ B 'rte V.Dispersal/Treatment Area Informatio:Ik �' orator"Q-4 Plus"Standard chambers&6 endcaps,PolyLok PL-525 effluent filter _ Design Flow(gpd) Design Soil Application '..._;,y,,-f) Dispersal Area Required(sf) Dispersal Area Proposed( sf) System Elevation 600 Gpd 0,50 Gpd/Sq.Ft. a 1200.00 sq.ft. 1,230.60 Sq.Ft. 92.50' ✓ VI.Tank Info Capacity i Total #of Manufacturer Gallons Gallons Units 4,441.5 i y N�Tan Tanks Existing T s `2 2 s 2 1 (ar�'1' fed -1'OaI 'do w5 a Septic or Holding Tank W320-MR 1,000 1,320 1 & 1 Wieser Conc/Wieser Conc. X Dosing Chamber VII.Responsibility Statement-1,the and rsigned,ass me responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plum, s Signatute MP/MPRS Number Business Phone Number James K.Thompson ' r 'z.._--- MPRS 30021 715 248-7767 Plumber's Address(Street,City,State,Zip Code ( ) 340 Paulson Lake Lane,Osceola,WI 54020 VIII ounty/Department Use Only Approved ❑Disapproved Permit Fee Date Issued Is ing Agent Si,+,store -�__nn� u , 4/ / S STEM G�/Iml er Given Reason for Denial $ 1 3 S. //5 i 3 /� u -- IX1c:IpOlOw ipf ns for Disapproval V t/Q t„[ P.�.,i ft U d e 4 .01 r /_— dispersal cell must be serviced/maintained v T�no as per management plan provided by plumber. �t,��(t ; /' f-e �� 14-: ,/i3 . 2.All setback requirements must be maintained D rv4 I1 l _ ,,4 1 �*. . �r S`t�W�t_OX. p.�L2 as per applicable code/ordinances. .D / ,�ct .�Ct atuel 10.Ket° Attach to tom,lets . ns for the system and submitdb the County only on n 86 not Ws tha 1!2 x 11 inches in size • sys " i i lie*5. 4,4i.___44AZ/Lee2 J W.'�/ f / SBD-6398(R. 11/11) " i tr % Se 644 Conventional POWTS Index & Tilte Sheet Project Name: Pederson 4 bedroom Replacement Conventional POWTS Owners Name: Dan&Gretchen Pederson Owner's adress: 514 Prairie Lane,Hudson,WI 54016 Site address: Same Project Location: Subdivision: Lot 6,Plat of Wells Fargo Station Legal Description: SE1/4 NW1/4,Sec.21,T.29N.,R. 19W.,Tn.of Hudson,St.Croix Co.,WI. Parcel ID#: 020-1287-60-000 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 Septic/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 Evaluation Report Mater P1 er Restric d Service: James K.Thompson,Dept.of Comm.Credential#30021 Signature: _ er"S---- Date: / , /3,.24/3 Page 1 Of 11 Design pursuant to In-Ground Soil Absorption Component Manual for POWTS,version 2.0 SBD-10705-P(N.01/01) • 5017 640.6y !I.76(45,„ //e//ua•E0II/2 e.jin1 1, p:, •ExiSli gr4de eltd• iininiVAI* 1 3 1t 6fL-Etltan f�'ds1 - 6/yP/•airi e Ls�re 14a/son, ,.J/. 54/o/G Nc i l ea, & f/LS ^a•yo tli. o- .3 .7 O',, 6E4/, uPs;Sec,2/-4Zsft./i9 2 U T. of 4/4d1oc, ..ervirc�.,c,)/. /O c-/. 01 e7,Zo-/287-6C-.06 4e17 z.B5 acres 6.514A4 a- olt■✓Cu.,c V queale Abort Zst1 d __7 U © //// 1°Cai/'i e /°wc, /ere/ t ,1 /oz ieg,_,Eei✓- i',. / ,' J 17crlG�nlrr�� >rJof' E,t73 ''' ' Srdrnc. Assu.hed /o 44: j 00 �T r Proposed 0,D Li �' a9�� 32-0 pllcrr / , ,.., 40 s„.. ,-- , 1,9 it or i 11)87 le' I �'y.SEt oliS�sclCe/ / 4-•1--�t/6!X1,/0:Tai '/ / /4 *(11 I ccr fa c e e lcd c 92Z.SV' ' / �e tea}- // /FJoposedd�sp'h'lCel(•I / allow / /-riieee(3)ererie%es at 2 t o/K�Q // ', ,_ a .4/E_IS6SC b'*sP� • �ystL„, . , 4 a e 9J./J' + Anil ., 5u/,dace elcd. be z.5-o. 1 • / , / Ny V / iltit t Spruce. ;•Tree �l, , -,,,„,.., I ! ,, Jt,. i. e' PEDERSON DISPERSAL CELL SIZING CALCULATIONS 1. (4 bedroomsx 100 gallons estimated flowx l.5 design factor)=600.00 Gpd design flow 2. Infiltrative capacity of native soil=0.5 god/sq.ft. 3. Absorption area required: 1,200.00 sq,ft. 4. Absorption area as proposed: 1,230,60 sq,ft.(60chambers total) Infiltrator"Quick 4 Plus"=20.00 sq.ft.EISA per chamber,Infiltrator"Quick 4 Plus"end cap=5.10 sq.ft.EISA 1,200.00 sq.ft.—(6 endcapsx5.10)= 1,169.40 sq.ft. 1,169.40 sq.ft./20.00=58.47 chambers required Number of trenches: 4 a,15 chambers per trench Trench width: 2.83' Trench length: ¢4' Trench spacing: 9'on center Total system area w/9'center spacing: 30'x 64' t:' Pg.3 of 11 Soil Absorption System Cross Section 97.sV' , IN .11— f95 � ft 1 fdso= I 4"Schedule 40 I Final Grade PVC Vent Pipe lIl With Vent Cap .12.5_10 ft Leaching --► Chamber 9,2 S6 ft System Elevation Z.$3 ft G ft (o ft Soil Absorption System Plan View 83 ft 2. ft [I 0 lII - �L 4 ft Leaching j Trench 1 Chambers --I _10 I Ill l loll l>T�Il111 l ll1I l l _ _ I 0 E \ 4"Dia Trench 2 Header Vent Or Observation Pipe or- I I I [ 0 Trench 3 Leaching Chamber Specifications Manufacturer And Model Tg/e/a- '¢-4/1'iO/ups jar dares/ EISA Rating X0.0 sq ft per chamber Soil Application Rate 0.5" gpd/sq ft 6,06 gpd Design Flow+ 0.5— Soil Application Rate + a-0.0 EISA= c'. 0 Chambers 3 rows of 20 chambers each. Page 47 of 1 I--I z W > 7, m K Z 58" REQD >> > O ,. c 4 C D I 50" co X 48" z m 0 rn I- - -1 o o m m UP 47" • W • --i 4" CAS r o 0 43" LL m 0 H ilk II n < 51" in < �� o m Nom II Cn UP 45" --1n■ • K 4" CAS I a C) w I T∎fir- N L 46" ' _1O -o c N r rn PO M 0 C 53 M C) P1 > m ( Z --i I Ui > 1 U m > r • 0 N Z< A r0 - Z Z 2 m 0 7C X > Dmi -mi m mm p O'v o > boo w o = O G)==m -irZ oz z( c zz -a Co v)-c+ -1_, wcro �,cn714 Cnl co Z = co < -1..z Fr", 0 Dm Co mm '000N f�l fV A'• a 0 m D -1 D 1 03771 0 ° A 0 0 Z o Co 0 o, - V) V) 0 . Z D p O Nm� I m r ? i'� �p_ TI _ co a v O N �� G) W°j Ir- co o. o n I- C o - X O c m \ Z r PI--1 1 m CO O 17 D 7� n� v vii < A -tm > Z =rZ r-- o c--) -i z o o O .. �� >4k0 000 N M m -�G r 0 VOr �M -1 m p o D /1 m <n my m o p ..< -0 m m 17 M C Z Vl =O O m r m O CO z Z r C m C) > 1 ! 1 D H m i7) r m 7) m I I 0 \ I W320-MR IIIIESE1I COnCAETE DRAWN BY: SME SCALE: REV. 1/NO 2 0" PRE POUR: rn 0 9 -+ SEPTIC MANUAL DATE: JANUARY 2012 DATE:. 3/6/12 POST-POUR: _` \ Z W3716 US HWY 10 MAIDEN ROCK, WI 54750 ° REVISED JAN. 2012 800-325-8456 FILE: W320-MR PS- 7 0- /1 Conventional Septic System Management Plan Pursuant to SPS 383.54,Wis.Adm.Code General The conventional septic system shall be operated in accordance with SPS 382-384 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. Questions on the operation or maintenance of the system should be directed to the installing plumber,Jim Thompson at(715) 248-7767 or the Polk County Zoning Department at(715)485-9279. Septic Tank Septic tank servicing mechanics comply with SPS 383.54(lxe). 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 cell to old Drainfleld at 4 year anniversary of new system installation. Old drainfield to be utilized for a 1 year period. Effluent dispersal to be alternated between systems on a two year rotating basis thereafter. Continaencv 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. Pg.5 of 11 03/4047:;;:k.4$7.f.:4-!.1, 6 ,'‘, ' X s4 /rip r Filters PL-525 EFFLUENT FILTER ( .{ ) i. 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 (gallons per day) making it one of accessibility lity iam— Accepts PVC the largest commercial filters in its extension handle class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok rr 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 , .` u, ` 3 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 t. servicing. Servicing should be emit, t Gas deflector i Nsltflkl'46 done by a certified septic tank =■"'' Automatic shut-off pumper or installer. " ��—" ball when filter is removed 1. Locate the outlet of the U.S.Patent No#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. 10 a. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Dan & Gretchen Pederson Mailing Address 514 Prairie Ln., Hudson, WI. 54016 Property Address Same (Verification required from Planning&Zoning Department for new construction.) City/State Parcel Identification Number 020-1287-60-000 LEGAL DESCRIPTION Property Location SE ' , NW y., Sec. 2 ,T 20 N R 19 W, Town of Hudson Subdivision Plat: Wells Fargo Station ,Lot# 6 Certified Survey Map# Na ,Volume Na ,Page# Na Warranty Deed# 915342 (before 2007)Volume Na ,Page# Na Spec house DyesOkto Lot lines identifiable o yesOno 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§SPS.3$3.52(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 Safety And Professional Services 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 4 / / SIGNATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning&Zoning Department.*** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. V.04 (REV.04/12) P�, 9ocil 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) 514 Prairie Lane,Hudson,WI 54016 located at: SE '/4, NW '/4, Section 6 , Town 29 N, Range 19 W, Town of Hudson , 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 SPS. 384.25, and it(they) appear(s)to be functioning properly. Most recent date of inspection or service October 18,2013 • Did flow back occur from absorption system? Yes No X (if no, skip next line.) Approximate volume or length of time: Na gallons Na minutes Tank Capacity: 1,000 gallon Construction: Prefab Concrete X Steel Other Manufacturer(if known): Wieser Concrete Age of Tank (if known): 20 years,installed 10/07/93 Permit number(if known) 193494 James K.Thompson (Licensed Plumber Signature) rint Name MPRS MPRS#30021 (Title) (License Number) MP/MPRS November 13,2013 (Date) Form to be completed by licensed plumber(Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 Pj to oil( 1 1111111II1I1NII11111111111111111111III11IIIIIIIII * 9 1 5 3 4 2 2 * 915342 DOCUMENT NO. SHERIFF' ED Q IECL ' BETH PABST r 9 REGISTER OF DEEDS ST. CROIX CO., WI 4 RECEIVED FOR RECORD WHEREAS, pursuant to a Judgment F6�re rent in the 04/29/2010 04:20P14 Circuit Court of St. Croix County, Wisco' n Marc �co i9, in an SHERIFFS DEED action between: EXEMPT 14 a l REC FEE: 13.00 FIRST BANK OF BALDWIN PAGES: 2 f/k/a THE BANK OF SPRING VALLEY Plaintiff, vs. CASE NO.08CV1133 CODE NO. 30404 JEFFREY J.FOLEY JULIA K.FOLEY a/k/a JULIA KAY FILAS-FOLEY U.S.BANK,NATIONAL ASSOCIATION,N.D. FIRST BANK RECORDING INFORMATION /3 Defendants. NAME AND RETURN ADDRESS Bakke Norman,S.C. P.O.Box 280 -- � Menomonie,WI 54751 J'• 020-1287-60-000 (Parcel Identification Numbers) and, after due advertisement, the subject premise hereinafter described was sold on April 6,2010, to Daniel L.Pederson and Gretchen L.Pederson,for the sum of$189,400.00. And, WHEREAS, Daniel L. Pederson and Gretchen L. Pederson are now entitled to a conveyance according to law, NOW, THEREFORE, the undersigned in consideration of the payment to him of $189,400.00, receipt of which is hereby acknowledged, conveys to Daniel L. Pederson and Gretchen L.Pederson,the following tract of land in St. Croix County,Wisconsin: 1of2 . , it D075 50 25 0 100 200 300 SCALE IN FEET S Igh 1 ' 27WE 1371 . 49 ' 425 . 00 ' 1 381 , 49' i \ \ i . I \3 5 6 Ilx -cc\u-, ,- s-Y\I 124, 295 Square Feet Lo 95 , 009 Square Feet . ■0 ,Tr Lok (2 . 85 Acres) Tri. (2 . 18 Acres) up\.cl Oim Nh1) CCI-' (1/ Mhm M,m Z J . \,.7 --------70-- -______-----' ------------ '0'.‘ ----- ---- '' ------_____ ------- ---__. 408 7--- 1 ----- - .,- N 0 s 30 4_ 22_______ 1 648 2----,)---- 0 --__ i \ z ,:")---------- ---___ _ ------L-_ 131 2, / /v - , ,u . 14oil 648 0 ,. 40 so . • (,)c --- _ ------- --- 0 ! --------,---__ \ 120 20 1 3 ./ 88, 039 Square Feet (2 . 02 Acres) .■,\,1 , ■,.. 9 91 , 087 Square Feet m 7 \c, (2. 09 Acres) 10 NI. NICano S " 06. 1 " , Z N ."'R' u2 'oq 426. 8 11 .02E ' - N 'I 1 '02 3 , I= 1 I 1,.c ,, u3,_ 12 .„., ., cu 1 91 , 183 Square Feet NI° 89,900 Square Feet (2 . 09 Acres)Acres) ill'' N3 (2 . 06 Acres) o'irn 13 ,I. ,-, 96 , 172 Squa lco z ( 2 . 21 Acr 1 ' ° 369 . 16 ' 18 3 1 _ _ _ _ .22N 0049'05E 55q9 , -Th ,-. ■ - N 196 . 13 ' _ c40 . 00 ' 7 114 76 ' ()----- --0 • 2353 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page l of 3 Division of Safety and Buildings in accordance with Comm 85,Wis.Adm.Code A.C.E.Soil&Site Evaluations Attach complete site plan on paper not less than 8N x 11 inches in size. Plan must County Croix include,but not limited to:vertical and horizontal reference point(BM),direction and St. percent slope,scale or dimemsions,north avow,and location and distance to nearest road. Parcel ID. Please print all information. 020-1287-60-000 Rev' wfed B���'/��_R) ��Q/D�a�te Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). Q�,�� O(2--- - V""`y Property Owner Property Location Dan&Gretchen Pederson Govt.Lot na SE 1/4 NW 1/4 S 21 T`�29 N R 1 W Property Owner's Mailing Address Lot# Block# Subd.Name or CSM# 514 Prairie Lane 6 na Wells Fargo Station City State Zip Code Phone Number J City J Village ] Town Nearest Road Hudson 1 WI I 540161 (715)386-0122 Hudson 1 Prairie Lane J New Construction Use: M' Residential/Number of bedrooms 4 Code derived design flow rate 600 GPD t!f 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 0.5 gal./sq.ft./day loading rate. Recommended infiltrative surface elev.=92.50'. Ex.dispersal cell elev.=92.50'. 'I Boring# J Boring e Pit Ground Surface elev. 96.40 ft. Depth to limiting factor X104 in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/It2 in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 1 0-14 10yr3/2 none sit 2fgr mvfr cs 2fm,1c 0.6 0.8 2 14-26 10yr4/3 none sil 2msbk dsh cw lfmc 0.6 0.8 3 26-32 7.5yr4/6 none gr si lcsbk dsh gw 2vflfm 0.4 0.7 4 32-36 7.5yr4/6 none Is Osg di cw 1 vf,f 0.7 1.6 5 36-46 10yr4/6 none s Osg dl gw - 0.7 1.6 6 46-84 10yr5/4 none s Osg dl aw - 0.7 1.6 7 84-104 10yr6/4 none s&gr Osg dl - - 0.7 1.6 2 Boring# J Boring Pit Ground Surface elev. 96.48 ft. >99" in. I}� Depth to limiting factor Soil Application Rate Horizon Dominant Color Redox Description Texture Structure Consistence Boundary ry Roots GPD/ft* in. Munsell Qu.Sz.Cont Color Gr.Sz.Sh. *Eff#1 *Eff#2 1 0-17 10 r2/1 none sil 2f g r mvfr cs 2fm,1 c 0.6 0.8 2 17-28 10yr4/4 none sil 2msbk dsh cw lfmc 0.6 0.8 3 28-37 10yr4/4 none gr sl lcsbk dsh gw 2vflfm 0.4 0.7 4 37-42 7.5yr4/6 none gr Is Osg dl cw 1vf,f 0.7 1.6 5 42-99 10yr4/6 none Ifs/Is/s Osg dl - - 0.5 1.0 k#5 consists of stratified layers of 10yr4/4 Ifs 1* 4/4 Is&10yr5/4 grs too numerous to differentiate. Loading rate reflects most restrictive soil texture within horizon. *Effluent#1=BOOS>30<220 mg/L a TSS>30< 50 mg/L *Effluent#2=BOD5<30 mg/L and TSS<30 mg/L CST Name(Please Print) ' mat •: CST Number James K.Thompson .... t- 3602 / Address A.C.E.Soil&Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane,Osceola,WI 54020 11/2/2013 715-248-7767 J , Property Owner Dan&Gretchen Pederson Parcel ID# 020-1287-60-000 Page 2 of 3 3 Boring# J Boring lti Pit Ground Surface elev. 98.41 ft. Depth to limiting factor >114" in, Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIft° in. Munsell Qu.Sz.Cont Color Gr.Sz.Sh. *Eff#1 'Eff#2 1 0-16 10yr3/2 none sil 2fgr mvfr cs 2fm,1c 0.6 0.8 2 16-24 10yr4/4 none sil 2msbk dsh cw lfmc 0.6 0.8 3 24-28 10yr4/4 none gr el lcsbk dsh gw 2vflfm 0.4 0.7 4 28-32 10yr4/4 none Is Osg dl cw 1 vf,f 0.7 1.6 5 32-90 10yr5/4 none s Osg dl gw - 0.7 1.6 6 90-114 10yr5/4 none Ifs/ls/s Osg dl aw - .5 1.0 1 1 H#6 consists of stratified layers of 10yr4/4 Ifs,10yr4/4 Is&10yr5/4 grs too numerous to differentiate. Loading rate reflects ost rictive soil texture found within horizon. I 4 Boring it Boring 16 Pit Ground Surface elev. 95.70 ft. Depth to limiting factor S9" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftx in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Eff#1 'Eff#2 1 0-33 10yr2/1 none sil 2fgr ds gw 2fm,1c 0.6 0.8 - 2 33-59 10yr4/4 none lvfs Osg dl aw lfmc 0.4 0.6 3 59-71 10yr4/4 none fsl/Ifs/Is Om dsh - - ("'2� 0.5 H#3 consists of an undiffemtiated mixture of 10yr4/4 fsl,10yr4/4 Ifs,10yr4/4 Is&10yr5/4 grs. Horizon also includes cobbles and transported limestone fragments comprising>50%of horizon by volume. Location unsuitable for inground dispersal cell. 5 Boring# J Boring iii Pit Ground Surface elev. 95.07 ft. Depth to limiting factor 80" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDl4' in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 - 1 0-32 10yr3/2 none sil 2fgr mvfr cs 2fm,1c 0.6 0.8 2 32-42 10yr4/3 none sil 2msbk dsh cw lfmc 0.6 0.8 3 42-53 10yr4/4 none gr sl lcsbk dsh gw 2vflfm 0.4 0.7 4 53-80 10yr5/4 none Is Osg dl cw 1vf,f 0.7 1.6 5 80-95 10yr5/4 none fsUlfs/is Om di - - 7-012) 0.5 H#5 consists of an undiffemtiated mixture of 10yr4/4 fsl,10yr4/4 Ifs,10yr4/4 Is&10yr5/4 grs. Horizon also includes cobbles and transported limestone fragments comprising>50%of horizon by volume. *Effluent#1=BOD 5>30<220 mg/L and TSS>30<150 mg/L *Effluent#2=BODE<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-$330(8.07/00) A.C.E.Soil&Ste Evaluations I :5;� .'a/uuo d/oie r/' X%e;sfing�4e elc 0# , c:/=yo' .i ...,'."'le11"92353 Lt„it 6(e--Es-Itch 4.-dsr3c n 5/y Prairi e Lase iludson, c.J/. 590/6 J xae le, We/S F eye. I"7 O 5(4/lw/y Sec,2, �ZfA, P/9a T. o/'/ ,dson, 3E.ccr yce.,W/ roc/.At O,W-/457-Co-az 4€ q Z.B5 acres uS/dA4 olr;✓euXcy ge/age k6.r{ 0 BPourd pad ji C)034/7,cc7ctl 1-- EXi.S6%j 1.b ANLA ti //// 4 5,diy„ /owcr �. P/Riri C /ere//owe/ ‹ .: / / r 5fcIteig. ASSUrad r /044'--�•, '. ' ' �� 0• Agi 1I/ / / ' ei • ' •0 n /oi o 10 • 414• J, - ' 9.o. B i r / , • / II /• / - 4 ' I , 4 . :rr- �. / 1u/ ace gilt!:92.501. ,6 S / I/ ,', ►Yla4 cWt(JJ / / 98 ,'97 L I lawn // / / �Q IIOW / / / 97./7 r/ a / $2 /' /// iltit *ate. •1-re c 5 • r aN / ,../ - t�o81/4 3 ssr, 0) O 3 o i 0 N y ~4 N i w r. rn 0 0) Q 0 ~ w I a ~ 3 I o 'O N ~ ~ w I > ~ n I o ~ x ~ I ~ c o I U Y N LZ C: a c CL o Z cn c 3 c LL O c co C: m O Q ~ 3 I v ~ M I rn z E z $ z a d a' w a m N H ~ O z c IX N avi Z N F N C, a o • fy a (n .c m N r_ ° O N Q N I Z CO Z o Z o C N O ~ V V O O R 0 0 2' L N G 'R w N LL A L a s N a O d N 2 ~1 N CO U) N j t 10 0 0 0 2 a 7 O N O co N c ~1 to J U O) O) V OT} O O ~V = O O O O O co O O =I +y0 M O O d V) N Q } u O O O ~ N C O O E R O N C U O O cx 7 CO O O O N O a CL LL O N O c0 m~ c o O 3 M V' L L O -0 ,t O N C M 'r. E E U N O 7 • r' O N S J O E a~ zt a a > • a y U d y C r~ a 0 ~ 3 _1 D U a 2 O v~ U STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS T'UX~ g z ~1~~ plc r'r~1 G SUBDIVISION / CSM# IA) LL C. L' `7i ~0 LOT SECTION ~ I TAN-R rl- 'W, Town of L)TJS I~ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERY NG W HIN 100 FEET OF SYSTEM I./ OW(E_ , ri<1 b,- iA ! j.a pus j /I! >o j ~ i i f -T -X--A ~ I I~` ~A~TFQ- r ~ ~1 i i ~jf µ INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK : I v t o I / R a N t / p i_ p S lam/ ALTERNATE BM: -~o~t Z~ PTIC TANK / PUMP CHAMBER / HOLDING.TANK INFORMATION Manufacturer: Liquid Capacity: a Setback from: Well House J`( Other~S(h-f ~t Pump: Manufacturer Model# Size Float seperationGallons/cycle:- Alarm Location = _SOIL ABSORPTION SYSTEM Width: 18' Length yv Number of trenches _ Distance & Direction to nearest prop. line: 9,-" 711 / /o~ Setback from well : House_ y ~ Other 51 l(~ p ELEVATIONS Building Sewer ST Inlet; ST outlet 17 PC inlet PC bottom Pump Off - Header/Manifold /0. 7, (,2 Bottom of ~ystem Existing Grade 7, y - loo.b? Final grade 7,~s= (r~ r, DATE OF INSTALLATION: PLUMBER ON JOB: , LICENSE NUMBER: INSPECTOR: 3/93:jt +VOYSecsi~~rrattrr>rYt~1rT(itlstr~ • 29.19 SYSTEM County: Labor and Human Relations INSPECTION REPORT tafetyland Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 3494 19 Permit Holder's Name: 1 ❑ City ❑ Village ❑XTown of: State Plan ID No.: HUDSON ST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: / , 60 __~_511__1< 020-1287-60-000 TANK INFORMATION ELEVATION DATA A9300153 lo b TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark ~,Gfai Dosing 67 Aeration Bldg. Sewer Holding St/~ft Inlet t/8~? TANK SETBACK INFORMATION St/ OR Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air intake Septic (3) ' NA Dt Bottom Dosing-- NA Headerl are. /(I 1,1e 7 Aeration NA Dist. Pipe 97,4 Holding Bot. System a tD JCr ade 3 1, 7 PUMP N INFORMATION 7c-, A, ck 7 Z~ ~ Ma ufacturer Demand ` Z6 Model Number GPM TDH Lift Friction stem Ft o ea Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED / TRENCH Width I Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I N DIMEN I G Man SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEA CHA INFORMATION Type Of tl F'''. cmlt, r /mar ~/J5 CH UNIT el Num el System: DISTRIBUTION SYSTEM Header ,r Distribution Pipe(s) ~r x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length _L Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Syste'r'ti - Depth Over Depth Over xx Depth Of xx Seed Sodded xx Mulched Bed /Tfe+~frCenter pL Bed ~ Edges Topsoil es ❑ No E] Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION : HUDSON. 21.29.19 (PRAIRIE LANE) t(l ~71 LC/y _~;YrC` 1 C.~C 14 x ° j ~.y~ Q lYr~,~>`EL~c / CC" r~ Plan revision required? ❑ Yes [-I'o / Use other side for additional information. d d SBD-6710 (R 05/91) Date Inspector's Signat a Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 3 SANITARY PERMIT APPLICATION ~.®IL HR COt, In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than Check if revision to previous application 8% X 11 inches In SIZ@. El 19,3,9941 -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION A4.14 LAW061 / 5-o'01 W/z FCC SF_ Y4 N w'/4, S 2 / T Zf , N, R E (or)S) PROPERTY OWNER'S AILING ADDRESS LOT # BLOCK # 8o x ot Z 8L CITY, ST,~4TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER e SYo/o 3d1= 274 / ~~er a 5~ ,~.f / TNEAREST ROAD II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLLAGE : iii 2 ❑ Public N 1 or 2 Fam. Dwelling-# of bedrooms ~ PARCEL TAX NUMBER( Ill. BUILDING USE: (If building type is public, check all that apply) /40 Z O / 2-$ 7 - GO 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. © New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 511 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 FV1 Seepage Bed 21 E1 Mound 30 El Specify Type 41 El Holding Tank 12 r] Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 17. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION L/-f-0 7 LO Feet Q Q. S Feet CAPACITY Site Fiber Exper. VII. TANK in alions Total of Prefab. Manufacturer's Name Con- Steel lass Plastic App. INFORMATION New istinGallons Tanks Concrete structed 9 Tanks Tanks Septic Tank or Holdin Tank 0 0 b Wd~ Q r I Li I El 11 E]_ I LE Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: Uarti ~G5 tNO~Gcch ~P- ~32~T 31 3~ Plumber's Address (Street, City, State, Zip Code): -7 90 /36,- y ~~w IX. C NTY/DEPARTMENT USE ONLY Groundwater ate Issue, Issuing Agent Signature (No Stamps) Disapproved Saaa~~~ / itary P rmit as (Includes Surcharge Fee) 9~ - ❑ ~5 Approved ❑ Owner Given InitialNa_S Adverse Determination X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: SBD-6398 (formerly Pib-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 3 Buildings Division. Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before-the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: r 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received :experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing, information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) . • Ih .raif~ /e~ ~i/IQ° 24G,v6~lii/o fc../c N 0 I ~ x ~ y TZ P ~J 1 y1 c ! IN e i tit-, i 0 ~ ar rn ~ - ~ ~ o ~ 0 _ yl 14 nD -4 .x ar .,i yt+ D e L't H i LY m o 0 i all 0 00, < l t4 ~ I I r! p 5 o P ~ (r1 E b n . Ciz G o i 1 s P s S' • ji I Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT o e Page I of 3 Labor'and Human Relations Divisiori of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUN-TY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but 'S' Ckbix not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION 5d M M 1 LLERRA GOVT. LOT -SIC 1/4 NJ L41/4,SZI T 29 N,R J 9 E (or) W PROPERTY OWNJ5$':S MAILING A RESS LOT # BLOCK # SUBD. NAME QR CSM # __rkou i 'WOK w4 w. #A 6 'Sr AM a N CITY STATE ZIP CODE PHONE NUMBER ❑CITY ❑V LLAGE OWN NEAREST ROAD 7Y Ul$'n.1J 6jr s-46) C( ) V ~Sa N C T N ° u u New Construction Use [a(j Residential / Number of bedrooms ( ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flowASb gpd Recommended design loading rate 0.7 bed, gpd/ft20.7 trench, gpd/ft2 Absorption area required 64S bed, ft2 4%19 trench, 112 Maximum design loading rate 0.7 bed, gpd/ft2 - trench, gpd/ft2 Recommended infiltration surface elevation(s) Eme.-i -94 •)6 ft (as referred to site plan benchmark) Additional design / site considerations Qesr 99.50 Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SY TEM IN FILL HOLDING ANK U=Unsuitable fors stem POS ❑U XS ❑U ®S ❑U 1~iS ❑U S ❑U ❑S 1U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Bourx~try Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tre & o 3 L 2 r m Z 0.5 O.6 r' < $ 0-24 my k V3 - L 1 a b~ r,~' C Z . 4 s Ground Z, 17-4-m p w,4 elev. fo3.s~ ft. Depth to limiting Remarks: Boring # C, Z .6 z -77 a O-4 s c t 03 Ground elev. 7-7- T'S YR kj~_ S*& Ilk psi. q4 m 01 6 lot_~a ft. Depth to limiting factor > /U00 77 L -1 Remarks: CST Name:-Please Print Phone: ~8D Address: 1~U pN 1 ...~c~ Signature: Date: ,7 93 CST Number: -34,-64 PROPERTY-OWNER "SA ih t hLj4,Q SOIL DESCRIPTION REPORT Page? of 3 .PARCEL I.D. # L8 i 6 W 6Lt ~'i4leCtd A Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ~:;:<v:;•.;.:.::: Bed Trench vnvx hin'vv:vi t 3 o -~5 ~ay►e 3 2 r i c. z S 3. is, /S-3k 16YA C _ I a,S o ~6 Ground 16yP, 4/4 5 M, 96 w, .-I .S6 elev. / -aa ft. Depth to limiting factor /0. 17 Remarks: Boring # A 12-38 /oy,, 4 3 srReAK C Ground... 3t-1i916vk4 d S i o.l ~g elev. ft. Depth to M it.A6m &-rv~ OF limiting Remarks: Boring # v:_ A o-14. ioyR 3 1 - L 1 C z o s 16.6 /4-31 16 \lie :+/-Z sk C Ground 1~ 3I-~a /d k 4/4 S rti 01 1 677 0,1Z elev. sib Sy 4 '-y a~ I N 1' Depth to limiting factor 7. Remarks: EAUbGK 4r Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) ~ 60 i ~t l 66' S ~s3 I a0 ti N w S -ALL. J~ 41~ I 4 ' ~I 13S ~-c a~ A PE. ar Sw l-6-r cop e k ter ~ LJE,.Ls Fitt4o r t PA4 3 0~3 • DOCUMENT NO STATE BAR OF WISCONSIN FOR:\1 3-1982 HIS SPACE RESERVED OR RECORDING OAT. QUIT CLAIM DEED 431~~1 l~~, 941 . .6?4 REGISTER'$ OFFICE ST. CROIX Co., Wi John-- A.-Elbert, _ Peed for Record - ~,2n ~2 quit-clan s to Er i c---J ,...Lund_e11 at 3 1q. M . - Register of Deeds - . - - St. Croix County, the followin¢ des~rihed real estate in . wET_.V TO State of R'iaconsin: Eric J. Lundell New Richmond, WI 54017. Tax Parcel No: . .All that part of the NE', of the NW4 lying Sly of the Railroad right of way; The SE`4 of the NW':,; The E`z of the SW',, LXCEPT: part to Alfred L. Ekblad in Volume 498, page 484; part to Leslie L. Swenson in Volume 498, pages 504; part to Donald F. Johnson in Volume 500, page 521; and hart to Donald L. Jordan in Volume 580, page 354, ALL in Section 21-29-19. z sq.~ tlUt hnnu,strad prnnrrtc. 1 t ~ is m!t. 1 ~ 9 1 r ter /jI 19 t.; L) (SEALs .John A LIbvrt E:.\ l. SEAL) t~t AUTHENTICATION ACKNOWLEDGMENT ~T.ATE: OF \V-I~;CONSIN ti C l r o i ti un[c. „t ! r llc .in:e Fi',r.. au, tills Gt dal „f c, . i r i tile above flan,.-i \ y nun known to b- the p,-r4on ` l c':n o+ceuted ti.e n°_ui;;_ ..,sh-t.ntr,nt :><r ! .r~ Zm ,tee. the sau;c. Susan P. Gary- , 3 t . ~I I [1 E \ Stan ! t 1.;. t V r ,-.-inrt t: hrr.t...• 9~ I`~,rtwt. ~KTr~ ~'tath n. 24 Stock No. 13003 I - tilt o - " O In 1 r• H •-3 Soy ` s O < c m a w •v N.- r; o ~ ~ ~ c ~=w c~ _s (.7 z H. '4 O ~c 00 ry y : n O G rt~ G: (C S S rt 7 (D rt m CA N G •D •D F. ~ G rn ~ ~ w w r: m ~ G •'t RO c. rt ~G r : N O rt rD £ S ~ :O C'i 0 O m M A) rt 4., >r rD ; m ni ` Y 0 00 m 14 CL L-m m r: o Co W O ^ n < 12- rT CO O O.U. a rt mz r o £ m a s D: y r` C Cn r. m ~ gn- G O (D n p... c w (D D O r+ H N CO O (D m G m r". t O ~•-•o T. G (D ry a ' v m a w rt rri 0 :1 r%. 0 CD r xQ}}??~ Q.:o-~ a v o a :a "1 dv O M A w O rD ~o .r. ^X GQ ;o (D B cp , Q ,yam a m I S T C - 105 i SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER Fcr(_ ADDRESS PS - Z FIRE NUMBER CITY/STATE _ ~1,..e A~ So l Lt ZIP- f S?~ PROP ERTYI,/~LLOCATION: S'F 1/4 , _I,✓ 1/4 , SECTION --Z -I, T Z7 N-~ TOWN OF_At `_SO11 , st. Croix county, SUBDIVISION_Ld~J/S -~a /b 0 _ST~; n l i , LOT NUMBER_~v 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 septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1). the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/Ile, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. C Zoning Officer within 30 days of the three year expirati rodate. SIGNED: DATE: St. Croix co. Zoning office 911 4th St. Hudson, WI 54016 STC-100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result ~n delays of the permit issuance. ,should this development be intended for resale by owner/contractor,(spec house), then 1a second form should be retained and completed when the property` is sold and submitted to this office with the appropriate deed recording. Owner of property ~11'i La n AGE-/~ ~~a ! Location of • property 5 t- 1/4 Nw 1/4 , Section Z / , T L9 N-R Z' Township _Hu JSo r, Mailing address E4< AASoh GlJZ ~~c7/L Address of site S'yQ i~ Subdivision name_114g1 f S7t'/i'a ~ Lot no. /o . Other homes on property? yes No Previous owner of property Wo„1I 3 Total size of parcel Z.BS' 14c, Date parcel -was created Z- 'Are all corners and lot lines identifiable? Yes No is this property being developed for (spec house)?,-f Yes No Volume_ I and. Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description .references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. q9 /D (o/ and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly Nocor d0 the office of County Register of deeds as Document signatu a of applicant Co-applicant Dat of signature Date of Signature ST. CROIX COUNTY WISCONSIN ZONING OFFICE r r r r N I n n n ST. CROIX COUNTY GOVERNMENT CENTER OEM$6 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 May 19, 1998 Joanna Smith 701 Congressional Blvd. Suite 330 Carmel, IN 46032 RE: Existing septic system inspection serving Lot 6 in the Wells Fargo Station Addition, Leal: SE %4, NW %4, Sec. 21, T29N-R19W, Town of Hudson, St. Croix County Dear Ms. Smith: On May 12, 1998, an inspection of the septic system on the James Roberge property, 514 Prairie Lane, Hudson, Wisconsin. At the time of the inspection, the septic system appeared to be functioning properly, however there was approximately 7-8 inches of ponded effluent in the drain field vent. The septic system serving Lot 6 in the Wells Fargo Station Addition was installed on October 71 1993, and was sized for a three bedroom house. A Wieser 1000 gallon septic tank discharges to a bed type drain field- 18 ft by 40 ft. The system was inspected by staff from this office on October 7, 1993, and was installed as a code compliant system. Ponding results when microscopic bacteria and sludge plug the soil pores forming a clogging mat. This clogging mat decreases the soil's ability to dispose of the sewage effluent. Over time, this clogging mat becomes thicker, causing less liquid to percolate through the system. As this mat becomes progressively thicker it leads to failure of the system. To prolong the life of the system, remember to have the septic tank pumped once every three years or when the tank becomes 1/3 full of sludge and scum. Other efforts to prolong the life of the system could be as simple as fixing or replacing plumbing fixtures with water conserving fixtures, reducing shower time, washing dishes when the dish washer is full, avoid using a garbage disposal, using a wash machine with a suds saver feature, etc. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system. This inspection of this sewage disposal system was based on a surface inspection of said system, and did not involve any excavation or chemical analysis. Accordingly, there is the possibility of hidden defects in the system not discoverable by this inspection. This does not in any way warrant or guarantee the continued proper functioning or operation of this system. It is recommended that the system should be pumped once every three years. The water test results will be forwarded to you as soon as we receive them. Should you have any questions, please contact this office. Sin rely, ~t7 C fger~ Rod Es Assistant Zoning Administrator bf8~f418 THU 09:23 FAX 715 386 4686 ST CRX CO ZONING Q002 ST. CROIX COUNTY WISCONSIN ZONING OFFICE SY- OIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road sr cr,olx ti Hudson, WI 54016-7710 CouN;y (715) 386-4680 ZUNINGpFFICC SEPTIC INSPEC FIAT T REQUEST FORM C1 z Please specify desired test(s) & remit appropriate fee with application. Outside water lines are often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure that entry can be gained. ❑ Water (VOC's) $185.00 ~B'septic $50.009// .,O-Water (Nitrate & Bacteria) 45.009_ ❑ Nitrate & Bacteria L1 Water (Lead Concentration) 21.00 retest $15.00 Owner : ' Q 1 Requested by: :SGA5nn i k 'Inm Address: 1 r0.1YI;f ne_ Address-.161 C 1 1 d. 4C 330 AA\ -AdSOY1 W) ZIP 5y61 l^ C-lar m 0 ZIP y~p3. L Telephone hl: ) 32(o - 3LO 1 L Telephone N°: (8~) (o(, Z3LoCo x 3~"~ Property address (Fire M & Street) :5 1 q Prc6rI C ~HuAsw Location:, Sec. , T _N, R _W, Town of Realty firm: Lock Box Combo.Z D (4 Closing Date: Trw Vt Ste- a nC1 acid-i i csYI-- kLk Ct 56r TO-BE COMPLETED BY PROPERTY OWNER *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS Water sample tap location:_ -e_ h Q.~ n4 J Is the dwelling currently occupied? Yes No If vacant, date last occ pied: Age of septic system: oa Septic tank last pumped by: k1C. Date: Previous Owner's Name(s): Have any of the following been observed? OY BN Slow drainage from house. ❑Y BN Sewage Back-up into dwelling. ❑Y 4n[N_ Sewage discharge to ground surface or road ditch. OY .UK Foul odors. other comments relative to system operation: nQl(1e I certify that the above information is complete and true to the best of my knowledge. DATE:9 2 OWNERS SIGNATURE: Ax-eta cox 1/94 (0-D ('/1610 0