HomeMy WebLinkAbout040-1014-40-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
561088 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:
Pressley, Ronald J. Troy, Town of 040-1014-40-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
/A.--\ 6M 04.28.19.58A
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURED~ S CAPACITY STATION BS HI FS ELEV.
Septic S., I -760 Benchmark 1-7 163.1
~ GSGti. .'t 4, cJ
Alt. B ; (kA, o a, 3 /QE.
Aeration Bldg. Sewer
Holding St/Ht Inlet el 7 - n
4•~
TANK SETBACK INFORMATION St/Ht Outlet 6-44. q7, 16G
TANK TO P/ WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic 7 166 / 166 i _ Dt Bottom
Dosing Header/Man.
Aeration Dist. Pipe `y. 9S.
✓r
Holding Bot. System $ ,S CIS • IZ
9`S . t
PUMP/SIPHON INFORMATION Final Grade `r?. 64
Manufacturer Demand St Cover
GPM~a,. G o 3.3 /6a- y
Model Number
TDH LFriction Loss System Head TDH Ft
Forcemain Lengt ia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT D ENSIGNS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ? 14( V
z I C'-.Gt__ SETBACK SYSTEM TO P/L BLDG WELL a LAKE/STREAM LEACHING Manufacturer:
INFORMATION Type Of System: J CHA uBET OR Model Number: `
L_ I l~ 7 N 4
DISTRIBUTION SYSTEM 1 d• / =Z7
P '~S
Header/Manifold 11 Distribution x Hole Size x Hole Spacing Vent to Air Intake
L Pipe(s)
Length 0,6Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Dept of xx Seeded/ odded xx Mulched
Bed/Trench Center • 5~ Bed/Trench Edgc3~ Topsoil ` es R No Yes No
COMMENTS: (Include co/de discrepencies, persons pr\esent, etc.) Inspection #1: / / Inspection #2:
Location: 517 Tower Road Hudson, WI 554016 (NW 1/4 SW 1/4 3 T28N R19W) metes & bounds Lot Parcel No: 04.28.19.58A
1.) Alt BM Description = F•I T" G.a 04 G t,,,s ol- L-041C. a
2.) Bldg sewer length
- amount of cover = r Q~~ ,b 6k FQ it ~O J'SJC.
Z i•
Plan revision Required? ❑ Yes No 12
Use other side for additional informatlo J
SBD-6710 (R.3/97) Date Insepctor's nature Cert. No.
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1,y, County,
r Safety and Buildings Division Cr'Zjl
201 W. Washington Ave., P.O. BAf 7162 Sanitary Permit Number (to be filled in by Co.)
Madison, WI 53707-71
%~a~
ILI"
lknitffy emit Application s 4 of State Transaction Number
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate gfAN"J►~ernal unif
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS am a; ed to Project Address (if different than mailing address)
the Department of Safety and Professional Servies. Personal information you provide may be used for sec
purposes in accordance with the Privac Law, s. 15.04 1 m Stats.
J~'~r1? / Otter
I. Application Information - Please Print All Informa
liap
Property Owner's Name Parcel #
cf- Ca SsI aw®-Id C660
Property Owner's /Mailing Address Property Location
1 / / o eta (o Govt. Lot
City, State Zip Code Phone Number y. Section ~T r 1, _T /7/(/ ~ I? Wt ~d ~ T ~ -I t~ circle one)
II. /type of Building (check all that aPP1Y) Lot # N; R E or W
I or 2 Family Dwelling -Number of Bedrooms ` Subdivision Name
QU f/rf, i ~ Block # ✓t'►~
❑ Public/Commercial - Describe Use ll~
❑ City of
❑ State Owned - Describe Use [C -IM Number ❑ Village of
® Town of
2 Q; ar ~ ~
III. Type of Permit: (Check only one ox on line A. Complete line B if applicable)
A' ANew System ❑ Replacement System ❑ Treatment/Ho I ding 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
IV. Type of POWTS System/Component/Device: Check all that a I Qy,'Jc,44
Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil A4
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) r$
V. Dispersal/Treatment Area Information.
Design Flow (gpd)~ Design Soil Application Rate(g7) Dispersal Area Required (sO Dispersal Area Proposed (s System Elevation
3 //y - A lei 4~ 9 ~
VI. Tank Info Capacity in Total # o Manufacturer
Gallons Gallons Units a 2 to u H =
New Tanks Existing Tanks AI n 1 /O k . ~
r/ a v v, y rn P. 5 0-.
Septic or Belding-T k x 30 75 d 1 P Co
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumbers 'gnature MP/MPRS Number' Business Phone Number
Plumber's Address (Street, ity, State, Zip Code)
J c/s-o
~l3
stig
VIII. County/Department Use Only
Approved Disapprove Permit Fee Date Issued Issui gent Signature
Iven Reason for •al 1$1/7-5-06 3 113
IX. Condi~#~~easons for Disapproval 1000,
1 Septic tank, effluent MW and
dispersal cell must all be setvteea 1 maintained
as per management plan provided by plumber,
Z At *"o i rltquktartlants must. be maintained
`offs psr N Dods F or~rioK~
Attach to complete plans for the system and submit to the County only on paper not less than s trz x 11 inches in size
SBD-6398 (R. 11/11)
Pg of -L
Private On-Site Wastewater Treatment System (POWTS)
Index and Title Sheet
Owner: ~d0 04,
Project Name and System Type: ~r~17Ve le~~f /Y1 Ca 1"4~J117c
Location: `2& er Reo .
Street Address
Legal Description 1
/r'(~ ✓ ~TvCrm1X
Township/County
Design Criteria (Check one):
Holding Tank Component Manual: In-Ground Soil Absorption Component Manual:
❑ SBD-10571-P (6/11/1999) ❑ SBD-10567-P (R. 6/1999)
❑ SBD-10855-P (3/2007) Version 2 J4 SBD-10705-P (N. 01/2001) Version 2
Contents: Page 1: ~qEp,
Page 2: P/
Page 3: K10 V
Page 4: r _
Page 5:
Page 6:~
Page 7:
Page 8:
Page 9:
Attachments:
Plumber/Designer:1__Ve4/7IS c Signed: L, m de
IL O-A
Credential Number: c9 4 / 7
Date: ,314 ~00
It
I
Pg co of Q6
Private On-Site Wastewater Treatment System (POWTS)
PLOT PLAN
FILE INFORMATION PROPERTY LOCATION
Owner c0,,
e0l) alb q- C'mrdle Press '/4 ,Section
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PIN # OCi Village, own of
S f erACounty, WI
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ft
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Leaching ft
Chamber System Elevation
ft .S ft
Soil Absoratlon System Plan View
``nn( ft
~W
ft
I
ft Leaching Trench 1
Vent Or Observation Pipe Chambers
4" Dia.
Trench 2 Header
Leachinl;a Chamber Specifications
Manufacturer And Model
EISA Rating Q sq ft per chamber Soil Application Rate gpd/sq ft
30 gpd Design Flow + s Soil Application Rate _ EISA = Chambers
2 rows of chambers each.
Multi!Ip Ind Cap.:
1
C~~ f Y
8" ~x
FRONT VIEVII SID YIEW TOP VIEW
Quick4 • • Chamber Specifications
Size (W x L x H) ........34" x 53" x 12" (86 cm x 135.cm x 31 cm) Louver Height ..............................8" (20 cm)
Effective Length ......................................................48" (122 cm) Invert Height 8" (20 cm)
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r POWTS OWNER'S MANUAL AND MANAGEMENT PLAN
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Roo ~N IeV Septic Tank Capacity al ❑ NA
Permit # Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer le ❑ NA
Number of Bedrooms 100 d/bedroorn NA Effluent Filter Model S~ ❑ NA
Number of Commercial Units X NA Pump Tank Capacity al X NA
Estimated flow (average)* al/day Pump, Tank Manufacturer ® NA
Design flow (peak), estimated x 1.5* al/da Pump Manufacturer iz NA
Pump Model $1 NA
Soil Application Rate s al/day ft
Pretreatment Unit X NA
Influent/Effluent Quality (NA❑) Monthly Average** ❑ Sand/Gravel Filter ❑ Peat Filter
Fats. Oil & Grease (FOG) < 30 mg/L ❑ Mechanical Aeration ❑ Wetland
Biochemical Oxygen Demand (BODO < 220 mg/L ❑ Disinfection ❑ Other:
Total Suspended Solids (TSS+) - Manufacturer: Model:
5 250 m /L Dispersal Cell(s)
Pretreated Effluent Quality ❑ Monthly Average*** X In-ground (gravity) ❑ In-ground (pressurized)
Biochemical Oxygen Demand (BOD5) < 30 mg/L ❑ At-grade ❑ Mound
Total Suspended Solids (TSS) < 30 mg/L ❑ Drip-line ❑ Other:
Fecal Coliform (geometric mean) <_10 cf i/100m1 ❑ Leaching Chamber Manufacturer
Maximum Effluent Particle Size 1/8 inch diameter Model dUtt* - # Laying Length/Chamber
*Wastewater Flow Verification and Calculations: Soil Application Rate e 7 gpd/ft2 Area Req.
(Other than bedroom based) Infiltrative Surface/Chamber-ESIA Raring o?~ ft2
WCCe Sa ry it Minimum Number of Chambers ..4
❑ Aggregate Design Flow/Loading Rate= ft2 min
Values typical for domestic (non-commercial wastewater Materials: all materials must comply with WI Adm. Code
and septic tank effluent. COMM84 and be installed per manufacturers specifications
***Values typical for retreated wastewater. and approval letters.
DESIGN CRITERIA
❑ "Wisconsin At-grade Soil Absorption System, Siting, Design & Construction Manual" (Converse et.a1.1990)
❑ "Wisconsin Mound Soil Absorption System: Siting, Design & Construction Manual" Converse, J.C. and E.J. Tyler.
Publication 15.22
❑ "Design of Pressure Distribution Networks for Septic Tank-Soil Absorption Systems" Publications 9.6
❑ "Design of Conventional Soil Absorption Trenches and Beds". R.J. Otis - ASAE Publications 5-77 and "Design Manual -
Onsite Wastewater Treatment and Disposal Systems". EPA 625/1-80-012 October 1980
❑ SBD - 10570-P (R.6/99) "At-Grade Component Manual Using Pressure Distribution"
❑ SBD - 10567-P (8.6/99) "In Ground Absorption Component Manual"
11 SBD - 10705-P (N.01101) "In Ground Soil Absorption Component Manual" Version 2.0
❑ SBD - 10628-P (N.6/99) "Recirculating Sand Filter System Component Manual"
❑ SBD - 10656-P (N.6/99). "Split Bed Recirculating Sand Filter System Component Manual"
❑ SBD - 10572-P (R.6/99) "Mound Component Manual"
❑ SBD - 10691-P (N.01101) "Mound Component Manual" Version 2.0
❑ SBD - 10595-P (R.6/99) "Single Pass Sand Filter Component Manual"
❑ SBD - 10657-P (R.6/99) "Drip-line Effluent Disposal Component Manual"
❑ SBD - 10573-P (R 6/99) "Pressure Distribution Component Manual"
❑ SBD - 10706-P (N.01101) "Pressure Distribution Component Manual" Version 2.0
❑ Drip-line Effluent Dispersal. Component Manual for Multi-flo Onsite Wastewater Treatment Units
MAINTENANCE AND MANAGEMENT
MAINTENANCE MONITORING SCHEDULE
Service Event Service Frequency
Inspect condition of tanks At least once every ❑ months ears Maximum 3 s.
Pump out contents of tank s) When combined sludge and scum equals one-third 1/3 of tank volume
Inspect dispersal cell(s) At least once ever ❑ months ja ears Maximum 3 s.
Clean effluent filter At least once every ❑ months C ear s
Inspect pump, um controls & alarm At least once ever ❑ months ❑ ears J& NA
Flush laterals and pressure test At least once eve ❑ months ❑ ears 0 NA
Valves At least once ever ❑ months O ears B NA
Other: At least once ever ❑ months ❑ year(s) ja NA
Page of '
START UP P~lc~j~
WTS check treatment tank(s) for the presence of painting products or osier cheriucals that
For new construction; prior to use of - the PO
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.
OPERATION
The property owner is responsible for the operation and maintenance of the POWTS and submission of required reports: The quantity
and quality of the wastewater stream will affect the performance and longevity of your POWTS. The installation of water-saving
appliances and fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine or waste from water
softeners, iron removal units, other clear water treatment devices and foundation drains should be discharged to the ground surface
whenever possible. Note: this does not include laundry waste, showers, dishwater, etc.
This system is designed to handle domestic strength wastewater, however the disposal of food based greases and oils, vegetable/fruit
peels and seeds, bones, and food solids such as those produced by a garbage disposal should be minimized. Toilet tissue is the only
paper that should be discharged into the system. Other non-biodegradable items such as baby wipes, tampons, sanitary napkin,
condoms, cigarette butts, dental floss, and cotton swabs should not enter the system. Chemicals such as petroleum products, paint
disinfectants, pesticides, antibiotics, solvents, etc., should not be flushed into the system as they can seriously damage your POWTS
and contaminate your drinking water supply.
Maintain a regular steady flow by spreading laundry washing throughout the week. Avoid vehicle traffic over all system components.
Compaction of snow over the dispersal unit may cause it to freeze up.
❑ Valves
Valves shall be operated in the following manner:
❑ Alarms
Alarms should be tested on a regular basis by the home owner. If an alarm sounds, contact an individual licensed to service
POWTS, There is normally a 1 day reserve under regular operating conditions, however water should be conserved until any
problems with the system are corrected to prevent back-up of sewage into the dwelling or surfacing.
INFECTIONS
Inspection shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master
Plumber Restricted Sewer, POWTS Maintainer or Septage Servicing Operator (per the attached Maintenance Schedule).
ja Septic Tanks Component
Tank inspections must include a visual inspection of the tank 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 backup or ponding of effluent to the ground
surface. Access openings used for service or assessment shall be sealed and/or locked upon completion of service. Any
defects shall be promptly corrected. Exposed openings greater than 8 inches in diameter shall be secured with an effective
locking device to prevent accidental or unauthorized entry into the tank.
When the combination of sludge and scum in any tank exceeds one-third (1/3) 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 NR113, Wisconsin
Administrative Code.
The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to manufacturer's
specifications. Provisions are to be made to retain solids in the tank. Filter cleaning may be necessary at more
frequent intervals than stated in the maintenance schedule to keep the system operating.
❑ Pump Chamber/Treatment Tanks Component
The inspection must include a test of all electrical equipment such as pumps, alarms and floats. A visual check must be
made for leaks, backups, surfacing, missing or broken security devices and other hardware and the condition of any filters.
1 be promptly taken care of.
needs or repairs shall
Any service
® In-Ground Gravity Component Dispersal Cells
The inspection shall include recording the levels of Ponding, if any in the observation tubes and a visual inspection for any
must be
evidence of surface seepage or discharge. Any discharge to the ground surface mu promptly reported to the regulatory
impending
authority. Ponding at depths greater than 75%.of the height of the component may indicate overloading or hydraulic failure necessitating more frequent monitoring. page_:~
of
START UP
use of the POWTS check treatment tank(s) for the presence of painting products or o er chemicals that
For new construction; prior to
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.
OPERATION
The property owner is responsible for the operation and main tenance of the POWTS and submission of required reports: The quantity
water-saving P
and quality of the wastewater stream will affect the performance and longevity of your POWTS. The installation o Ovate g
appliances and fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine or waste from water
softeners, iron removal units, other clear water treatment devices and foundation drains should be discharged to the ground surface
whenever possible. Note: this does not include laundry waste, showers, dishwater, etc.
This system is designed to handle domestic strength wastewater, however the disposal of food based greases and oils, vegetable/fruit
peels and seeds, bones, and food solids such as those produced by a garbage disposal should be minimized. Toilet tissue is the only
- - -paper--that should be-discharged-.into_the-system.-Otherrio -biodegr- - dable items such as baby wipes, tampons, sanitary napkins
-a- - - - - -
-
condoms, cigarette butts, dental floss, and cotton swabs should not enter the system Chemicals such as petroleumproducts-, paint;
disinfectants, pesticides, antibiotics, solvents, etc., should not be flushed into the system as they can seriously damage your POWTS
and contaminate your drinking water supply.
Maintain a regular steady flow by spreading laundry washing throughout the week. Avoid vehicle traffic over all system components.
Compaction of snow over the dispersal unit may cause it to freeze up.
❑ Valves
Valves shall be operated in the following manner:
❑ Alarms
Alarms should be tested on a regular basis by the home owner. If an alarm sounds, contact an individual licensed to service
POWTS, There is normally a 1 day reserve under regular operating conditions, however water should be conserved until any
problems with the system are corrected to prevent back-up of sewage into the dwelling or surfacing.
INPECTIONS
Inspection shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master
Plumber Restricted Sewer, POWTS Maintainer or Septage Servicing Operator (per the attached Maintenance Schedule).
ja Septic Tanks Component
Tank inspections must include a visual inspection of the tank 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 backup or ponding of effluent to the ground
surface. Access openings used for service or assessment shall be sealed and/or locked upon completion of service. Any
defects shall be promptly corrected. Exposed openings greater than 8 inches in diameter shall be secured with an effective
locking device to prevent accidental or unauthorized entry into the tank.
When the combination of sludge and scum in any tank exceeds one-third (1/3) 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 NR113, Wisconsin
Administrative Code.
The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to manufacturer's
specifications. Provisions are to be made to retain solids in the tank. Filter cleaning may be necessary at more
frequent intervals than stated in the maintenance schedule to keep the system operating.
❑ Pump Chamber/Treatment Tanks Component
The inspection must include a test of all electrical equipment such as pumps, alarms and floats. A visual check must be
made for leaks, backups, surfacing, missing or broken security devices and other hardware and the condition of any filters.
Any service needs or repairs shall be promptly taken care of.
0 In-Ground Gravity Component Dispersal Cells
The inspection shall include recording the levels of ponding, if any in the observation tubes aanndvisual inspection for any
evidence of surface seepage or discharge. Any discharge to the ground surface must be promptly reported to the regulatory
authority. Ponding at depths greater than 75%.of the height of the component may indicate overloading or impending
hydraulic failure necessitating more frequent monitoring. Page .7of~
❑ Mound, At-Grade, In-Ground Pressure
The inspection shall include recording the levels of ponding, if any in the observation tubes and a visual inspection for any
evidence of surface seepage or discharge. Any discharge to the ground surface must be promptly reported to the regulatory
authority. Ponding greater than 75% of the height of the component may indicate overloading or impending hydraulic failure
necessitating more frequent monitoring.
The pressure distribution system is provided with an opening at the end of each lateral to be used for flushing. The laterals
should be flushed at least once every three (3) years. Pressure checks of systems with multiple laterals should be done to
ensure that equal distribution of effluent is occurring to promote the longevity of the system.
REPORTS
Reports for maintenance, inspection, and monitoring shall be submitted in accordance with COMM 83.55 Wisconsin Administrative
Code.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to ensure that the system is
properly and safely abandoned in compliance with Ch. 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 other 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 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.
The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation
must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed
as a last resort to replace the failed POWTS.
❑ 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 CONTIAN 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 D n4rg #Pw/iL~ Name Uen~ cu
Phone Phone
SEPTAGE SERVICING OPERATOR (Pumper) LOCAL REGULATORY AUTHORITY
Name Agency, Sjj- rOtK Oaf'
Phone Phone /
10/2006 K:\WPDATA\EH\POWTS OWNER'S MANUAL.doc
Page 9- ofz
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer q~ I+ Pr )
Mailing Address 7aoec
Property Address '5QAe
(Verification required from Planning & Zoning Department for new construction.)
City/State 1-1U(6 Parcel Identification Number
'Wj
LEGAL DESCRIPTION
Property Location L'yU~ `/4 ~Z '/4 Sec. , T N R W, Town of Ira'✓
Subdivision Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # , Volume , Page #
Spec house yes no Lot lines identifiable yes no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
I
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin.
Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning &
Zoning Department within 30 days of the three year expiration date.
I/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the
property described above, by virtue of a warranty deed recorded in Regist of Deeds Office.
Number of bedrooms {~e~
r t 3
C..... ~ /
SIGNATURE 0 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.
(REV. 08/05)
i
r
o1 a RECD/V
Wis. Dept. of Safety and Professional Service V~ OIL EVALUATION REP 'f3~ Page
Division of Safety and Buildings 201
cord with SPS 385, Wis.. Adm. Code
o C~
Attach complete site plan on pape I an 8 1/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.~lfn
percent slope, scale or dimensions, north arrow, and location and distance, to nearest road.
Please print all information. Revie d by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). fI 3
Property Owner Property Location
le V Govt. Lot A 1 /45 /4 S T N R E (or
tit) qC C
Property Owner's Mailin Address Lot # Block # Subd. Name or CSM#
ti
City State , Zi Code Phone Nu
Zip tuber ~ []City Village own Nearest Road
New Construction UseE3 Residential / Number of bedrooms Code derived design flow rate 6411_1&&_CV1r11 60 JILA; (A GPD
® Replacement ® ubli or commercial - Describe:
Parent material S~!'I SQi7~P Flood Plain elevation if applicable e . r ft,
General comments
and recomme n Corr V e~/di7 4 / ~ ~1 -gr -Ir
dations. l v!/'Jd / 0i7 C,4ps
Boring # ❑ Boring
F7/ 0 Pit Ground surface elev. ~ft. Depth to limiting factor ~ ~ in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft :
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * 02
462-4
7/ O o
Y g
tt
Boring # ❑ Boring 7
EP pit Ground surface elev. n ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/fl 7
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * ff#2
r
/ - S
4 - S
~t
* Effluent #1 = BOD > 30 < 220 mg/L and TS >3 < 150 mg/L 1 * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name Please Print) Signature CST Number
2~
Address Date Evaluation C nducted Telephone Number
SBD-8330 (RI 1/11)
r
Property Owner Parcel ID # Page oC._
Boring # Boring
® Pit Ground surface elev. ft. Depth to limiting factor T in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence, Boundary Roots GPD/ft '
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ` ff#1 ff#2 1 *1 / G6
v v r o %
- s 4
Boring
❑ Boring #
Pit Ground surface elev. ft. Depth to limiting factor in Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots ff#1 GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
Boring # Boring ® Ground surface elev. ft. Depth to limiting factor in.
Pit Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots ff#1 GPD2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
t
• Effluent #1 = BOD s > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD 5 5 30 mg/L and TSS < 30 mg/L
The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to
access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay.
M-8330Test (RI 1/11)
l Page
Parcel ID #
Property Owner
n Boring
Boring #
*~.1 ®Pit Ground surface elev. ft. Depth to limiting factor in Soil lication Rate
Hori-zlori Depth Dominant Color Redox Description Texture Structure onsistence, oundary Roots * ff#1 GPD ff#2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
,6
n•
1 ✓
' 05 I~L- --121
Boring
❑ Boring #
ft. Soil Application Rate
Pit Ground surface elev. Depth to limiting factor in.
Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots * ff#1 GPD ff#2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
Boring# Boring Ground surface elev. ft. Depth to limiting factor in.
® Pit Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots * fffkl GPD ff#2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
* Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOO 5 5 30 mg/L and TSS < 30 mg/L
The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to
access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay.
SBD4330Test (RI l/Il)
j PLOT PLAN
CWNEH '~pS /E / SCALE 1"=~ FT. n A;G 4°f
BORING ELEVATIONS BENCHMARK ELEVATIONS n
B-1 BM #1 DESCRIPTION OF #1
B-2 BM #2 DESCRIPTION OF #2/WOOQ~~
B-3
B-4 LEGEND--- BM (BENCHMARK)
B-5 0 a SOIL BORINGS
WELL NORTH
NOTES :
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r s
uru. Greer' work shoe bollh
CMC4e
Gr y , o s,~d p ~U
vie// J f
~f fit, '
C or~~
~r~(,;Z~~
1710 221483 715-647-4682
CSTMO SIGNATURE CSTMO# CREDINTIAL# TELEPHONE DATE
Parcel 040-1014-40-000 06/03/2013 08:57 AM
PAGE 1 OF 1
Alt. Parcel M 04.28.19.58A 040 - TOWN OF TROY
Current ❑ ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
0 - PRESSLEY, RONALD J & CAROLE
RONALD J & CAROLE PRESSLEY
517 TOWER RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 517 TOWER RD
SC 2611 SCH DIST OF HUDSON
SP 1700 WITC
Legal Description: Acres: 12.600 Plat: N/A-NOT AVAILABLE
SEC 4 T28N R1 9W W 748 FT OF NW SW EXC Block/Condo Bldg:
P58C AND D AND P58F
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
04-28N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
2013 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 11/09/2009
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.600 88,000 190,200 278,200 NO
PRODUCTIVE FORST LANDS G6 7.000 56,000 0 56,000 NO
Totals for 2013:
General Property 12.600 144,000 190,200 334,200
Woodland 0.000 0 0 J*
Totals for 2012:
General Property 12.600 144,000 190,200 334,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 129
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Assessed values not finalized until after Board of Review.
Property information is valid as of MAY 26 2013 10:26PM .
OWNER CO-OWNER(S)
RONALD J & CAROLE PRESSLEY
517 TOWER RD
HUDSON, WI 54016 PROPERTY DESCRIPTION
SEC 4 T28N R19WW 748 FT OF NW SW EXC P58CAND D AND
PROPERTY INFORMATION P58F
Pry Address:
Parcel ID: 040-1014-40-000 517 TOWER RD
Alternate ID: Municipality: TOWN OF TROY
School Districts:
SCH DIST OF HUDSON
Other Districts: DEED INFORMATION
WITC Volume Paae Document #
Section Town Ranae Qtr Qtr Section Otr Section
04 28N 19W
Lot. LAND VALUATION
Block. Valuation Date: 20091109
Plat Name NOT AVAILABLE
Code Acres Land Value Improvements Total
5.600 88,000 190,200 278,200
TAX INFORMATION 7.000 56,000 0 56,000
12.600 144,000 190,200 334,200
Net Tax Before: .00 Total Acres: 12.600
Lottery Credit: .00 Assessment Ratio: .0000
First Dollar Credit: .00 Mill Rate: 0.000000000
Net Tax After: .00 Fay Market Vabie: 0.00
Amt Due Amt. Paid Balance
Tax .00 .00 .00
Special Assmnt .00 .00 .00 INSTALLMENTS
Special Chrg .00 .00 .00
Delinquent Chrg .00 .00 .00 Period En Date Amount
Private Forest .00 .00 .00 '1~ .
Woodland Tax .00 .00 .00
Managed Forest .00 .00 .00 31 l l/ _ p
Prop. Tax Interest .00 .00
Spec. Tax Interest .00 .00
Prop. Tax Penalty .00 .00
Spec. Tax Penalty .00 .00 1
Other Charges .00 .00 .00 OL \
TOTAL .00 .00 .00 \ _ Q~v
Over-Payment .00
0
PAYMENT HISTORY (POSTED PAYMENTS)
General Special G
Date Receipt # Source Tvce Arnount Tax Status Assess. Status Interest Penalty Tot
FORM 339-WARRANTY DEED TO JOINT TENANTS. (Section 230,45 Wisconsin Statutes) R. C. NILLCR CO., MILWAUKCt
L310954.
This Indenture, Made this ....._.............................day of..... -.....Juno..................................... A. D.,1,9...7.2--
between lierbsrt...Cudd...and..C.onstanc.e...Cudd,...husband...and..wife,...and..each..in..their..nwn ,right,
i
...........part...qs....of the first part,
and....._.Rona1d.J...t?ressley...and... Caxnle..Ao..1)xeeo~ey.,..~?usba d..aa?d..w ee...........
as joint tenants, parties of the second part.
Witnesseth,. That the said part..i0a....... of the first part, for and in consideration of the -sum of -
One..and.:no/lOfJ:..(. 1..OQ.)..Dollar .an~1..Qtk~ox_.v,s.7,uab ..e4 e 4~e on
•
to........ them ...............in hand* paid by the said parties of the second part, the receipt whereof is hereby confessed and ,
acknowledged, have,,..... given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by
these presents do.......... iye, grant; bargain, sell, -remise, release, alien, convey and confirm~'pnig, the sai arties of i
p
the second part, in joint, tenancy, their heirs and assigns forever, the 'following'described real estatd, 'situated in the
County of.......... 5t. CxOiX .......................and State of Wisconsin, to-wit:
A parcel 'of land located in the W2 of the SW~ of Section 4, T28N, RC 9W, Towki o ;Troy,
St..Croix County, Wisconsin described as follows: Beginning at thk%l.,ab=''~r:o- said.
Section 4; thence N005014019 (true bearing) 2646.911 along the West li__0'•of said S~I~
of~Section 4; thence N89°36150"E 74$,5101 along the North line of said SA of Section 4;
thence S0°5014011W 1640.761; thence S89°04!W 267.061; thence N620141W 114,001;.t~ence i
Southwesterly along a 1001 radius curve concave Southeasterly whose chord bears
S580251W 172.061; thence S0°561E 33.00! thence 189°041E 265.001; thence SO0$.0t-1011K
.900.001-; thence S890041W 500.001 along the South line of said SWt of Section 4 to the
-point of beginning. r i
A.1so,. a_roadway easement 66 feet in width located in the SJ of the SW~ of Section 4,
T28N, R19W, Town of Troy, St. Croix County, Wisconsin, being all lands lying 331
radially and at right angles each side of the following described centerline of i
roadway:- C.omehding at the SW corner of said Section 4; thence NO°5014011E -(true
bearing) 933.001 along the West line of said S4 of Section 4; thence N89*041E 1
4$1.97 to the point of beginning; thence N89°04it 1784'85f, thence,easterly along 111
a 1909,-~861.-radius curve concave northerly whose chord bears N83°191E 382.69!;.thence
N77 0341E 80.4,41-more or less to the centerline of present State Triink• Highway 35; . II
except said present State Trunk Highway 35 right of way,
Also, a roadway easement located in the SW4 of the SW~-of Section Lys- T2$N, R19,W,
Town of Troy; St. Croix County, Wisconsin, described as follows: Commencing at.the
SW corner of said-Section 4; thence N0°5014011E 933.00' along the West line of said
SW~.of Section.4; thence N890041E 233.971 to the point of'beginning- thence
• S0*!ZIE-3;3,001; thence N89°041E 248.Q01; thence N0°561W 66.001, thence- N62,5141W
114.001:; thence Southwesterly along a 1001 radius curve concave southeasterly
whose.chord bears S580251W 172.061 to the point of beginning.
TRANSFER
$12--. "
FEE
Together, with all and singular the hereditaments and appurtenances thereunto belonging or in any wise
- 1
apperi inih ;,and all the estate, right, title, interest, claim or demand whatsoever, of the said part of the first
part, either in law dr equity, either in possession or expectancy of, in and to the above bargained premises, and their
hereditaments and appurtenances.
To have and to hold the said premises. as above described with the hereditaments and appurtenances, unto
the said parties of the second part, in joint tenancy, and not as tenants in common, and to their respective heirs and
-C
i
assigns FORESTER. {
1
'BO~It PkkE _ ~