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HomeMy WebLinkAbout018-1086-10-000 Wisconsir, Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division ' a INSPECTION REPORT Sanitary Permit No: 408269 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)]. ~e Permit Holder's Name: City Village X Township Parcel Tax No: Gary, Bill Hammond Township 018-1086-10-000 CST BM Elev: Insp. BM Elev: BM escription: 1411 Ov r TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark CA) IMti~ ~ Z S Z z d. 2 Z 4 Dosing s Alt. BM ~A) ,a zz Aer Bldg. Sewer ~ 9-4S 2-0 Holding Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL ZE ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. 3-sue ~ Aerati n Dist. Pipe 3.6I . ZS Holding Bot. System 20 q s6 Final Grade PUMP/SIPHON INFORMATION Manufacturer DePlm~and St Cover 40,w Model Number t 3k~3% TDH Lift Friction Loss System Head TDH Ft a~ $ 1\0 .70 .Bv orcemain Length ► Dia. 2 fr Dist. to well, SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of TreasGws PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / 'q.-5- 44J,41s SETBACK SYSTEM TO P/L BLDG (WELL LAKE/STREAM LEACHI cturer: INFORMATION Type Of System: , CHAMBER O 9 S LIN Model Num DISTRIBUTION SYSTEM 1a ,AC161 r-o=Jc. bm17 D. l Mfle4 D Header/Manifold Distribution I ` x Hole Size x Hole Spacing Vent to Air Intake D Pipe(s) 9 D t/~ Length Dia Length Dia ` 7-Spacing 3' SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ~F ❑FI Yes ❑ No Fn] Yes No 9WMENTS: (includ code T q encies, persons present, etc.) Inspection #1:~/ / y Z Inspection #2: n`b / b~ / a2 Location: 889 162nd St amm/oWI 54015 (NW 1/4 NSW 1/4 20 /T29N R17W) Hammond Oaks o 10 Parcel No: 20.29..17.630 1.) Alt BM Description = F 0't t-'sq8 r pAv f I /fta~Gkt~a~ s~ G0rW, 1V)KV Wel~ #r S G(J , (~w t y 2.) Bldg sewer length = 20 l amount of cover = >'12 a S°d c vo-.' CJ 3, Contour 2- = Plan revision Required. Yes No Use other side for additional information. SBD 6710 (R.3/97) AE:a Insepctor's Signature Cert. No. Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 St. Croix ~sconsin Madison, WI 53707 - 7162 Site Address Department of Commerce U-7 01 ~JS 5 314' `f Y99 t &d-A d S-j'' Sanitary Permit A plication Sanitary Permit Number In accord with Comm 83.2 1, Wis. Adm. Code, personal information you provide may be used for secondary purposes Privacy Law s15.04 ❑ Check if Revision I. Application Information - Please Print All Information RECEIVED State Plan I.D. Number 767436 Property Owner's Name Parcel Number ~ J~ -100/ 2 Bill Gary JUL 1 8 2002 Property Owner's Mailing Address ST. CROIX COUNTY Property Location 14635 Forest Blvd N ZONING OFFICE NW'/4; NW%<; S20; T29N, R17W City, State Zip Code u r n Lot Number Block Number Hugo, MN 55038 651-442-2990 0&&( 10 Subdivision Name CSM Number Hammond Oaks ll. Type of Building (check all that apply) - 11 El city X 1 or 2 Family Dwelling -Number of Bedrooms 3 t~/71/ age Vill El Public/Commercial -Describe Use 40 X Town Hammond ❑ State Owned n j , d W%A /P X 7S Gf IS~• r S A, Nearest Road 1 d p CJ ,`7 = 9 162"d St III. Type o Permi . (Check only one bo n line A (numbering scheme for in ernal use). Complete line B if applicable) A. 1 X New 2 ❑Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use System Tank Only TExisting System B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Type of Permit: (Check all that apply numbering scheme is for internal use) 44 ❑ Non -Pressurized In-Ground 1 X Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland 22 ❑ Pressurized In-Ground 41 o mg Tank 48 ❑ Single Pass 51 ❑ Drip Line 45 ❑ At-Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other V. Dispersal/Treatment Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation System Elevation Final Grade Required Proposed Rate(Gals./Day 'SgTt.) Rate ✓ Elevation /241 (Min./Inch) f 450 450 ft2 450ft2 N/A 97.45 99.24 VI. Tank Info Capacity in Total Number anufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New Existing Tanks Tanks Septic 1000 1000 1 Skaw Precast X Pump 642 642 1 Skaw Precast X VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Pl Sig ure MP/MPRS Number Business Phone Number Thomas D. Gustum 227618 715 658-1344 Plumber's Address (Street, City, State, Zip Code N13450 937th St New Auburn, WI 54757 VIII. 96unty/ De artment Use Only pproved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Da Issued uing A nt Signature (No St S) Surcharge Fee) ❑ Owner Given Initial Adverse Determination 71 IX. Conditions of Approval/Reasons for Disapproval s){ l 1~ t~ d /¢.2c~ bwcl~vi /Ie~d S coc>!~ (Camp J03 • X3'1 ~~+e on P r~r,bun,~ pt;v.~2Q-»u~ 6~ tits~.te~ > as' > s~ ee ~t di Z llim h lX~ ~ ~cwn, I Attac omplete plans tot ounty only),for the st paper not less t~ 1 inches in size SBD-6398 (R. 05101) Safety and Buildings • 401 PILOT CT STE C WAUKESHA WI 53188-2439 TDD (608) 264-8777 Vksconsin www•commerc www.*Wsconsin.gov .gov Department of Commerce Scott McCallum, Governor Philip Edw. Albert, Secretary July 10, 2002 CUST ID No.227618 ATTN.• POWTS Inspector THOMAS GUSTUM ZONING OFFICE GUSTUM SEPTIC SERVICE ST CROIX COUNTY SPIA N13450 937TH ST 1101 CARMICHAEL RD NEW AUBURN WI 54757 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 07/10/2004 Ident N ers Transaction ID N k767436 SITE: Site ID No. 647741 Bill Gary Please refer to both identification numbers, Town of Hammond above, in all correspondence with the agency. St Croix County NW1/4, NWIA, S20, T29N, R17W Lot: 10, Subdivision: Hammond Oaks FOR: Description: Mound, 3 Bedroom Object Type: POWT System Regulated Object ID No.: 861016 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: This system is to be constructed and located in accordance with the enclosed approved plans and with the "Mound Component Manual for Private Onsite Wastewater Treatment Systems" SBD-10691-P (N.01/01) and the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems" SBD-10706-P (N.01/O1). In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. In addition, the owner must comply with the operation, maintenance and monitoring duties as described in section VIII of the mound component manual. A copy of this information must be given to the owner upon completion of the project. Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. Access to the filter for cleaning must be provided per Comm 84 product approval conditions. A Sanitary Permit must be obtained from the county where this project is located in accordance . requirements of Sec. 145.135 and 145.19, Wis. Stats. j~lf`* Inspection of the private sewage system installation is required. Arrangements for ' spectQ Qk"pN"ith ~ designated county official in accordance with the provisions of Sec. 145.20(2)(d), tats. SgF the T~ F SF~. l A copy of the approved plans, specifications and this letter shall be on-site during constructi~ en to inspection by authorized representatives of the Department, which may include local inspectors. permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. THOMAS GUSTUM Page 2 7/10/02 In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 Julia A Lewis-Osborne POWTS Reviewer 2, Integrated Services WiSMART code: 7633 (262) 548-8638, Fax: (262) 548-8614 jlewis@commerce.state.wi.us cc: Leroy G Jansky , Wastewater Specialist, (715) 726-2544 Mound System pg 1 of 6 Cover Page Project Name: Gary 450 GPD Mound System Owner's Name Bill Gary Owners Address 14635 Forest Blvd N Hugo, MN 55038 651-442-2990 Legal Description NW 'F NW Sec 20 T 29 71 N, R 17 W Township Hammond County Saint Croix Subdivision Hammond Oaks Lot# 10 Parcel ID# Q ~ Table of Contents TftOMAS U' GUSTUM g P9 12M 1 Cover page 2 Mound Sizing Calculations 3 Pressure Distribution Layout and Dynamics 'S~CaN 4 Dose Tank / Pump Curve 5 Management and Contingency Plan 6 Plot Map total # of pages: 6 Designer Name: Tom Gustum License D1201 Jf Date: 7/5/2002 READ Ph. 715-658-1344 ~ J LW Signature: $ !0? _Wd FETY &-BL~ . DIV Mound System Design Methods Used p per "Mound Component Manual For Private Onsite Wastewater Treatment Systems" (Version 2.0) SBD-10691-P (N.01/01) Nv11~ C per" Pressure Distribution Component manual for Private Onsite Wastewater Treatment Systems" (Version 2.0) SBD-10706-P (N 01/01) Spreadsheet provided by: 3bAdvisement N12486 220th St, Boyceville, WI 54725 Ph: 715-643-6068 email: 3ba@3badvisement.com Mound System Page 2of 6 Mound Sizing Calculations Project Name: Gary 450 GPD Mound System Site Conditions Design of Entire 11 Project Type: i or 2 Family Dwelling • Cell depth at upslope edg (D % Slope: 8 % Cell depth at downslope edge # of Bedrooms: 3 Distribution cell depth (F): 9.5 in. Depth to limiting factor: 27 in. Cover thickness over edge (G): 6 in. Absorbtion rate of fill material: 1 gal/ft2/day Cover thickness over center (H): 12 in. Absorbtion rate of in-situ soil: 0.4 gal/ft2/day End slope width (K): 8.4 ft. Effluent quality Eff#1 . Fill length (L): 91.8 ft. Max BOD effluent value: 220 mg/I Upslope width (J): 5.0 ft. Max TSS effluent value: 150 mg/l Downslope width (Toe) (1): 10.0 ft. Fill Width (W): 21.0 ft. Design of the Distribution Cell Basal Area System Design Flow: 450.0 gal/day Basal area required: 1125 ft2 Distribution cell width (A): 6.00 ft Basal area available: 1200 ft2 Distribution cell length (B): 75.0 ft Area of Distribution Cell: 450.0 ft2 Observation Pipes Contour Elevation of Mound: 6.70 Location from end of cell (Z): 12.5 ft System Elevation of Mound: 07_ Final Grade of Mound: 99.24 ft ound Plan View Observation, Pipes Z I-KI I Tilled ArealFill Material L Mound Cross Section Final Grade Observation Pipe Synthetic Fabric G Distribution Cell 4 d d f System Elevation <=:<:::::::>::::>:::< > Co ::€e : verMaterial D ..:.:::.:.:::....1, Fill Material Tilled Area Forcemain System Slope Contour Notes: Fill material to consist of ASTM C33 Sand Distribution cell aggregate to comply with Comm 84.30(6)(1) Synthetic Fabric covering on cell per Comm 84.30(6)(8) Distribution Cell to have minimum 6" aggregate below lateral and 2" above. Mound System Page 3 of s Pressure Distribution Calculations Project Name: Gary 450 GPD Mound System Lateral Layout Lateral/Manifold Design Lateral elevation: 98.0 ft Lateral diameter: 1% In. Rows of Laterals: 2 Lateral spacing (S): =ft Manifold type: center • Lateral to cell edge: 1.5 ft Orifice diameter: o.12s In. Lateral discharge rate: 7.83 gpm # of Laterals: 4 System discharge rate: 31.31 gpm Distal Pressure: 5 ft Manifold diameter: 2 . In. Lateral Length: 37 ft Manifold length: 3 ft Orifice Spacing/Distribution Forcemain Friction Loss Orifice spacing (X): 24.00 Inches Forcemain length: 91 ft Orifices per lateral: 1g Forcemain diameter: 2 In. Avg. ft2/Orifice: 5.92 ft 2 Friction loss in forcemain: 1.909 ft Lateral Side View Manifold Lateral Lateral x x x x x x x x x x x x 2 2 Lateral Length Lateral Length Lateral Plan View Lateral Length Turn-up wfball valve or cleanout plug T I S 0 Orifices on bottom of lateral equally spaced PVC laterals and forcemain to comply with specifications per Comm e4.30(2)(e) Forcemain connection via tee or cross to manifold at any point Clean Out Detail Observation Pipes Clean-out plug all valve Final Grade or b 1N atertight cap or plug Lawn Sprinkler Box Slot Note: Closet Collar 6" IvIInImUm may be used in Long Sweep 90 I place of 3/8" bar ortwo 45's L 3/8" Bar Lateral Mound System Page 4of 6 Septic, Pump and Dose Tank Project: Gary 450 GPD Mound System Tank Information Dosage Volume Pump tank manufacturer: Skaw Precast Does forcemain drain Pump tank size/model: 642 back to tank? Pump tank gal/inch: 16.47 Lateral void volume: 15.6 gal Tank bottom elevation (inside): 90 ft Dosage to absorbtion Cell: 78.2 gal Septic tank manufacturer: Skaw Pr91cast Forcemain volume: 15.9 gal Septic tank size/model: Total dosage: 94.1 gal Pump and Filter Total Dynamic Head Pump Manufacturer: Little Giant Are laterals highest point? y Pump Model: 9EH if not, enter highest elevation: 0 ft Effluent Filter: SimTech 110 System head (distal x 1.3) 6.50 ft t n - I Cl.,� IV Vertical Lift ("D"to lateral) 6.95 ft Note:Access opening of sufficient size to be provided to allow removal of filter. Opening to terminate at or above grade. Friction loss in foreemain: 1.91 ft Pressure loss from filter: L J ft Total dynamic head (TDH): 15.36 ft Pump Tank Diagram Watertight Locking Cover 4 inch 't With Warning Label Minimum. Finished. Dose Tank Levels Grade In. Gal Alternate Outlet A Reserve 193 317.3 Location: Elect.;per Comm B Pump off to Alarm 2.0 32.9 16 28 and Force air NEC 300 C Total Dosage 5.7 94.1 Weep Hole A D Effluent depth for pump 12.0 1 197.6 phon Si Total Capacity: 39.0 642.0 Siphon B Device' Pump Curve: 9EH D FLOW- LITERS/HOUR 0 1000 2000 3000 f 30 10 8 y 7,5 w �20 W Pump must be capable of: 31.3 GPW. ii "' s and head pressure of: 15.4 Feet =10 i 2.5 0 0 0 20 40 60 SO Little Giant FLOW- LLONS/MINUTE 9EH PUMP PER ORMANCE CURVE 115V 60HZ L 31 .� Mound System Management Plan pursuant to comm 83.54 W. A. C. page 5 of 6 *Owner's Responsibility: The component owner is responsible for the operation and maintenance of the component. The county, department or POWTS service contractor may make periodic inspections of the components, checking for surface discharge, treated effluent levels, etc. The owner or owner's agent is required to submit necessary maintenance reports to the appropriate jurisdiction and/or the department. Septic Tank: -3 / MAY F0 /L TAI\J4 CL- C-A AJ dJ -Septic tank(s) are to be inspected routinely and maintained by department approved individuals when necessary in accordance with their approvals. The use of chemical/biological "treatments" is not required or recommended. If such additives are used, make sure they are approved by Department of Commerce, Safety and Buildings Div.. Effluent filters are to be removed & cleaned as necessary, with provisions to keep solids from passing the septic during removal. No more than 1/ o an vo ume may be occupied by sludge/scum. :3 year inspQ ion: an as grea er an vo ume sludge, tank contents must be emptied and dispos o in cco nce with NR 113 Wisconsin Administrative Code by an approved individual. If the inspector does not recommend pumping of the septic tank, then the owner must be notified of when pumping should be done as to not exceed 1/3 sludge volume. Septic tank should be routinely inspected to be watertight and of good repair. Pump/Dose Tank If an effluent filter has been installed in the pump/dose tank, it must be removed & cleaned as necessary, with provisions to keep solids from passing to the mound component during removal. The pump, float switches and alarms must be inspected at least every three years for proper operation. Pump/dose tank should be routinely inspected to be wa a ig and of good r air. Mound and Lateral System The mound system component must remain free of ponded surface water prior to pump operation. If 4 inches or more water level is detected in the observation pipes, the owner must be notified of possible problems/failure. The designed daily flow capabilities of the component should never be exceeded. Trees and any other deep rooted vegetation should never be planted, or allowed to grow anywhere on the component. Activities OTHER than mowing/maintenance (i.e. excessive walking, pets, vehicles, etc...) could compress the component and reduce it's absorbtion capabilities and/or possibly cause it to freeze in winter conditions. Lateral distribution pipes should be flushed out/tested every 18 months using the cleanout o' onent to remove scum a ma c o Performance Monitoring: Performance monitoring must be done at least once every three years following the installation or at the time of a problem, complaint, or failure. Contingency Plan: If the septic tank, pump tank or any of their components therein (including floats, alarms, pumps, etc) become defective, the defective tank or component must be replaced immediately to ensure that the system can operate as designed. If the mound component cannot accept wastewater or ponds wastewater to the surface, the component must be repaired or replaced in it's current location by either: extending basal toe to provide added absorbtion area; or by removing the clogged bacterial mat,aggregate cell, and distribution piping within the mound and replacing said components in order to return system to proper working order as req u i red. u v m ~ Plot Map _ N ~ L r H Y Y N m z 0 0 as > gN Property Line m o U U m_ E~ ~ a 0) W N a zmz E4 2 I ~N or\' n _N %8 dolS , , mU xz J I I I I m O I 1 q.~ a¢ N 1 I Q I 1 l I 1 lx 1 I I ~ 1 X ,N I 1 I I ~ ~ O D w I i i i A~~ 1 to p, I 1 1 1 1 1 r ~ i+M I I 1 I I. ° CO 0) l m 0 S 5 r7 1 1 1 1 1 I 1 1 I 1 1 1 I f I I I 1 I I ~ cr I 1 1 I 1 = 1 A %9~doIS = I i i i 1 I 8i I i i ~ 1 1.c w m I 1 1 1 ' US CI4 L C I I I ' Co O 1 I Q r U ~ a ~ I i i i 1 rlL ~ N I I I 1 1- j ~ QI I 1 1 1 ' '(V N Cd w w l o o ° 0 c_ or- 0 t!~ I ° Cf) C7 u~ S U in 'n M a N N Z Q Z Q I M ~Zj O O !Z w N 0) O O WU` p g Sri 2 CO I (Y) 0) O1 U o- (L m w co ^ I p < V) J J > > 0 1 u7 (n W W I 11 11 II I Y C 0 E M= co m I U ~E I (D o N I E E COO ~O I E 5 a 0n o g I 0 n 1 l6 U 11 w I 13 0 J N -0 I a~ N I MU I I I I I ~ RNV Street Page 6 of 6 co Q U m Q 1612 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 2 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Gustum Septic Service Attach complete site plan on paper not less than S'/= x 11 inches in size. Plan must County St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel I.D. Please print all Imbrmatlon. !D ~~I iewed Date Personal information you provide may be used for secondary purposes (Privacy Law, s.15.04 (1) (m)). L' Property Owner Property Location Gary, Bill Govt. Lot n/a NW 1M NW 1/4 S 20 T 29 N R 17 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 14635 Forest Blvd N 10 n/a Hammond Oaks City State Zip Code Phone Number J City J Village a Town Nearest Road Hugo MN 55038 651-442-2990 Hammond 162 Street ld New Construction Use: d Residential / Number of bedrooms 3 Code derived design rate GPD J Replacement J Public or commercial - Describe: T 4-0 Parent material loess Flood plain elevati n, if apR ficable n/a General comments I UL 1 6 2o02 and recommendations: Boring added to existing soil test submitted 11-2-99, to move mound site. 2 ST. CRO/X FFI CE I I '1 I Boring # J Boring LJ 0 Pit Ground Surface elev. 97.3 fL Depth to limiting factor 29 in. Soil Applicalan to Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots PD in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Ef1#2 1 0-10 10yr3/2 none sil 2msbk mvfr as 10m 0.5 0.6 2 10-18 10yr3/4 none sil 2msbk mvfr cw 1f 0.5 0.6 3 18-29 10yr4/4 none sil 2msbk mvfr Cher - 0.5 0.6 4 29-38 1 r4/6 c2-3p 10yr7/ - Oy 7.Syr5/8 sil 2msbk mfr - 0.5 0.6 * Effluent #1 = BOD? 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD5 <_30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature: CST Number Tom Gustum 227618 Address Gustum Septic Service Date Evaluation Conducted Telephone Number N13450 937th St., New Auburn, W154757 7/9/02 715-658-1344 n C 4MIS AA18 J I I I I { Cn Mm 1 ~ I m fl 0 { g s.3 1 a~ ,3 1 CL 08 30 CL ur w co o w lS' N { It It II r r c n I A 03 to (D CD o w c Cc) 0 0 0 G o IQ7 3 " a l o a 3 °c C C~ C { m Cl) -0 = i i J , , 1 1 ~ D i i to M { S I 1 W I N a 0 I 1 N f i i l ~ 'O + ; i 1 m m 1 I I slopei5t% _ 1 f N , , r 1 CD M cVO f C o f f - F t~ N co l n I l 1 { N~ n_ f ' WWj 1 1 I r Z -+c i ..Slope-8% It l { Ho~~ ~ s ~MTe I = z3:Z m - ~ i& ~ a W oun AWftd d%N Jotd - CC) Wisconsin Department of Industry, Z SOIL AND SITE EVALUATION Page / of Labor and Human Relations Division of Safety and Buildings in accordance wi Attach complete site plan on paper not less than 6 1/2 x 11 inches in si n mu Coufa include, but not limited to: vertical and horizontal reference point (BM rirection ana ,,w; ,Lj percent slope, scale or dimensions, north arrow, and location and dis a to nearest road. Par, d. . # { s d • /oily. .S©• Q~ A~Irby Date APPLICANT INFORMATION - Please print all informAtion. Review Personal information you provide may be used for secondary purposes (Privacy Lkw, 15.04 (t>~( X' fy 1..,- 2 114 Property Owner OM a ep 4AAJ Q Ci0RIP - 9110, Property Location n ij ~ Govt. Lot ~ l4 /VW1/4,SW2T~f N,R l ~ #(or) W u S O t+Q %A 1 10 AJ III Property Owner's Mailing Address Lot # Subd. Name or CSM# 332- hliuatSoTA ST G AST I yo ~p 1_114,AfM,0,VD / Z- City state Zip Code Phone Number Nearest Road w Y. ST. PAUL H A3. 5510 c (051 )222.5555 ❑ City ❑ Village ff-Tcwn 4-4 1(00 [r] view Construction Use: Eg esidential / Number of bedrooms 3 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow y~D gpd C Recommended design loading rate _jbed, gpd/ft2 5, trench, gpd/ft2 Absorption area required _ bed, ft2 37J trench, ft 2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2 Recommended Infiltration surface elevation(s) Su •7 ft (as referred to site plan benchmark) Additional design/site considerations .,~7 Flood plain elevation, if applicable N~T It Parent material evs # &me QeNSF T/ l1 S = Suitable for system Conventional Mou In-Ground ,P_resswe AT-Gra;__U System in Fill Holding Tank S U -IT U = Unsuitable for system ❑ S LrJ U S❑ U ❑ S Lr U El s El s 1:1 SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots P /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed j trench I l o •r A0 X z/ - 4. rf'Si& ; Z- w / 1& ; . S 2- 1 /o Yee 3/3 1f~tiIP, AeAd ck, . S . Ground P • /D YX 3! Ati! 7' C Z • 3 elev.+ jP -46 f I f MO ,S/G 17~5~1~. M~7GI~ • 2- ' ' 3 Depth to limiting factor ; in. 29- Remarks: Boring # •/D /O Yie ~ L. /7'5.6 ~v W . ; . S 2 ` Z 40 /Ovt 313 Si L. 2-Fsh e f cw , s ; • G. 3 2• 0 - PL tsh c s z. 3 00. Ground +1+ /~tofS /cL / S . ; •3 elev. L Depth to limiting f ctor in. Remarks: CST Name (Please Print) RpQ•f- Signature Telephone No. 7~s• 38~ • , s Address Date CST Number P & Associates Net,. 2-- if f .2 x 4r 3 7 5 Prrivate ivate Sewa e n V 655 O'Neil Rd. Hudson, Wis. 54016 w PROPERTY OWNER (JH >I ~D L AA)d SOIL DESCRIPTION REPORT Page Z of 3 PARCEL I.DI L !D Aft M 0 A )D 4A tz' S S O Borin # Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots QeDlft in. Munsell Qu. Sz. Cont. Color Gr. Szz.. Sh. / Bed , Trench Ground 'i? /'0 we SiL 2 r d s elev. s 7r Wt. /KO Depth to limiting factor S ; )-!7-in. YX 37 Remarks: Boring # Ground elev. tt. , Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Structure GPD/fe Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trencl Boring # Ground elev. tt. Depth to limiting ell, factor 'n. Remarks: Boring # , Ground elev. ft. , Depth to limiting factor in. Remarks: SBDW/-8330 (R._ 08/95) 4 Wisconsin Department of Industry, SOIL AND SITE EVALUATION / Labor and Human Relations Page of Division of Safety and Buildings in accordance wi IR' 8ti;.~IVIS. CoyntK y Attach complete site plan on paper not less than 81/2 x 11 Inches in si n mud, • S Include, but not limited to: vertical and horizontal reference point (BM ~irlaCtlon and ; j+f}~ 3 T • lt- 10 percent slope, scale or dimensions, north arrow, and location and dis nce to nearest road. Pardela. . # O qq. VV 010 APPLICANT INFORMATION - Please print alllnformAtion. -Review Date Personal information you provide maybe used for secondary purposes (Privacy t~w, 6. 15.04 (1i C' s Property Owner H V M B I eD L A/3 Q ifbRj> 10 Property Location (.'J nn ~ So t Govt. Lot A141114,S iV . T N,R l7 (or) W 'f'IO ~~41 ~0~ ~ I . Property Owner's Mailing Address Lot f- Subd. Name or CSM# 332- hiLwtsoTA 577. EAST lyoq ~O -M.MO,v17 o~~s Z. city state Zip Code Phone Number Nearest Road iV Y. 151' PAUL MN. yS/0 (&5/)222-555 5 El city El Village Er- Town I&b []'New Construction Use: [9 esidentlal / Number of bedrooms 3 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow. ~~0 gpd c Recommended design loading rate bed, gpdtle trench, gpd/112 Absorption area required 315 bed, ft2 37J trench, ft2 Maximum design loading rate bed, gpd/it2 - trench, gpd/112 Recommended infiltration surface elevation(s) .s~4a• 3 ft (as referred to site plan benchmark) Additional design/site considerations Parent material 16 6 S O &E QCNSF D7/-,: r Flood plain elevation, If applicable /V, tt S = Suitable for system Conventional,, Mou In-Ground PPre5w AT-Grade System in Fill Holding Tank I El S ❑ S U j EE S❑ U ❑ S I J U ❑ S ff'u U = Unsuitable for system ❑ S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 In, Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 1. p /O 1L Z~ G Ifs W16 S k w / t . Y.. S 11,41 YA 3/3 AU -,orA- Cc* o- S* (06o Ground 3! J ~L l ( s/J OW17 C Z • 7 q3. ell ft. /o Elie fIf mots Vc !f'S~bk A" '17' - •L •3 70 re Depth to limiting factor zt_In. Remarks: Boring # 10 /o vie 2l - L Ifs w /f . y . s~ 2 Z o4 /O Si L 2-FSh~ f cev . S : • G. '73 -A AP 04.11V 'o 1 Ground l o -f t+ /c lyqlje /#"A/6 elev. Z Depth to limiting L Ft L- f ctor In. Remarks: CST Name Please Print Signature P~ (Please Print) Roarmr 21j(3RicIAT Tele ne No. ~~s• 3gc. • ~ s Address Date CST Number Ulbr:cht & Associates ~~t.4375 Private Sewa Consultants V 655 O'Neil Rd. Hudson, Wis. 54016 rP 3 a f 3 `Ulbricht & Associates Private Sewage Consultants 655 O'Neil Rd. Hudson, Wis. 54016 SST ZZ~~7S N S 3 6 Ilk- G o i sE~,t 'h, (3 3 A ~ ~a r 2 r W,64- 13.25 r i 0 ' In ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 1'11 Cr7CA Mailing Address 4- 91L)d Property Address vVI (Verification required from planning Department for new construction)_ CtK City/State Parcel Identification N ber' O / - 0 6 ' U - U LEGAL DESCRIPTION Property Location W %4, tO0 V4, Sec. T2.N-R LL- subdivision Town of m W&j Subdivision A aw yno J 64K5 Lot # Certified Survey Map # , Volume . Page # Warranty Deed # 6'5C , Volume L Page # ! Spec house ❑ yes ff o Lot lines identifiable ❑ yes ❑ no SYSTEM MAINTENANCE 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a mastorplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewaterdisposal 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. Uwe, 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 Zoning Office within 30 days of the year expiration date. Z- 7 SIGNATURE OF APP ANT DATE OWNER CERTIFICATION 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 descn above, by virtue of a warranty deed recorded in Register of Deeds Office. / SIGNATURE OF PLIC DATE Any information that is mis-represented may result in the sanitary Permit being revoked by the Zoning Department. Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed J 1942P 0 9 3 K~AATHLEEH H. VAL.SH REGISTER OF DEEDS ST. CROIX CO.. VI Document Number Document Title RECEIVED FOR RECORD 08-05-2002 11:45 AM St. Croix County AFFIDAVIT EXEMPT # Occupancy Affidavit REC FEE: 11.00 TRANS FEE: ~rf(r u.,, A' • Co,yey_T,7d G~epr.e SS COPY FEE: 2.00 CERT COPY FEE: Name - (Owner) Typed or printed PAGES: 1 being duly sworn, states, under oath, that: 1. He/she is the owner/part owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume 17 92 Page o?Q0 Document Number GAOSt. Croix County Register of Deeds Office: Recording Area Nam and Ret rn Address A parcel of land located in the AAd of theMd '/e of Section d Lv tuwX r Y T_ °L N - R 7 W, Town of ,~..,.~und , St. Croix ) y~ 3,5 ,~rrrs-~ C~1u~ N County, Wisconsin, being duly described as follows (include lot no. and o M w< 5503 subdivision/CSM or detailed legal description): I-o A- 10, 'kA-4v,,% d be- ICS Ski, 19; u[sf oi~, 01 E- - I DSC - / 0 - Coo 1-6vin wto tJ I U w inSL+ , 40 Parcel Identification Number (PIN) As owner of the above described property, I acknowledge that the septic system serving this residence is sized for a 3 bedroom home, or a design flow of SO gpd. The design flow is calculated by assuming 150 gpd for 2 individuals per bedroom. There are currently 9 occupants living in this residence; 6 occupants are permitted based on the design flow. Therefore the septic system serving this residence is code compliant. However, understand that if there are intentions to exceed the number of permitted occupants, the system will need to be modified to accomodate any increased wastewater flows and/or contaminant loads. I also acknowledge that I will make this information available to any future parties interested in purchasing this property: S" Dated this s" day of AL.iA. _4L * I,J. rsa r * * Signature(s) AUTHENTICATION ACKNOWLEDGMENT STATE OF WISCONSIN ) )ss. authenitcated this day of St. Croix County. n,~, P.,ersonally came before me this S day of .2G.~;7- the above named t-Ll. ff. TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the person(s) who executed the foregoing authorized by § 706.06, Wis. Stats.) instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY ~p f Notary Public, State of Wisconsin (Signatures may be authenticated or acknowledged. Both are not My Commission is permanent. If not, state expiration date: necessary.) Date: ,-4 "THIS PAGE IS PART OF THIS LEGAL DOCUMENT - DO NOT REMOVE" This information must be completed by submitter document title, name 6 return address. and PIN (if required). other information such as the granting clauses, leggal description, etc. may be placed on this first page of the document or may be placed on additional pages of the document. Note: Use of this cover page adds one page to your document and $2.00 to the recording fee. Wisconsin Statutes, 59.517. V. 1 ! 42PAGf 290 ' STATE BAR OF WISCONSIN FORM 2 - 1998 Ea 59635 WARRANTY DEED KUHLEEN H. WALSH REGISTER OF DEEDS Document Number ST. CROIX CO., WI This Deed, made between Humbird Land Corporation, a RECEIVED FOR RECORD Minnesota Corporation ' - 10-22-2001 9:30 AM WARRANTY DEED Grantor, and William H. Gary III and Melissa J. Cepress EXEMPT M as joint tenants CERT COPY FEE: COPY FEE: TRANSFER FEE. 68.70 RECORDING FEE: 11.00 Grantee. PAGES: 1 Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St Croix County, State of Wisconsin: Recording Area //Name and Return A dress Lot 10 H nd Oaks Subdivision,Town of Hammond, St. Croix County, (y 11115 f /A/10 ZZ? W Visconsi ~ /j/~j~j. 018 108640-000 cel Iden i umber (PIN) This Is not homestead property. (is) (is not) Exceptions to warranties: Subject to notes, easements,restrictions,covenants and rights of way of record, if any, including but not limited to those for drainage,water retention ponding,and or utilities as may be shown on the plat of Hammond Oaks Subdivision recorded in Vol. 8 of Plats, page 2, St Croix County, Wisconsin. The warranties of this deed, either expressed or implied are limited by the grantor to the grantee, or anyone in the chain of title, to the consideration expressed herein, that being the sum of $ 22,900.00. Dated this 21st day of September 2001 Humbird Land Corporation . by President . Austin J. Baillon - AUTHENTICATION ACKNOWLEDGMENT STATE OF WISCONSIN ) ) ss. Signature(s) Ramsey County. ) Personally came before me this 21st day of authenticated this _ day of_„_ September 1 2001 _ the above named Austin J. Baillon TITLE: MEMBER STATE EAR OF WISCONSIN to me known to be the person(s) who CXaCUted 1:e foregoing (If not, instrument and acknowledge sthe same. authorized by § 706.06, Wis. Stats.) la THIS INSTRUMENT WAS DRAFTED BY , PAUL A. SAlLLON Paul A. Baillon, Attorney at Law ' Paul A. Baillon - NK;.Aa, hor,Y;kra ~soTa Notary Public, State of Wiscons' (Signatures may be authenticated or acknowledged. Both are not My Commission is permanent. ( not, state exp • n: cessary.) January 31 2005 ) .Names of persons signing in any capacity should be typed or printed below their signatures STATE BAR OF WISCONSIN WARRANTY DEED FORM N..2 • 1998 INFORMATION PROFESSIONALS COMPANY FOND DU LAC, WI 80"55-2021 2422 Enterprise Drive Mendota Heights, MN 55120 * PIONEER LAND SURVEYORS • CIVIL ENGINEERS (651) 681-1914 FAX: 681-9488 engineering LAND PLANNERS • LANDSCAPE ARCHITECTS 11 625 Highway 10 N.E. Blaine, MN 55434 * * * * (763) 783-1880 FAX: 783-1883 Certificate of Survey for. BILL GARY House Address: 162nd Street 1049.0 N00023'21 "IN 187.98 1056.1 0 - I I I I I 39 I I I I TH I I 0 1048.2 - I - I PROPOSED 1043.6 0 to SEPTIC 0 < ?30U " / AREA / 0 / 0 CY) LL Y cr+ V,tl~e CJLU'1S`si F l4''TS r< ~ TM N 1045.70 Z I Il® 1-r~ai'~~ag®~ x 1054.1 w 1 1050.1 I ~ I 7 I F I 7 I z I 1 Q I i O LA I x 1047.4 1058.1 a I z I a x 1053.3 I o I W 1042.7 x 1053.0 3 9 CY, I ~ ~ 11 TOP OF BLOCK = 1045.6 '(0 1 va can t 0 1 1048.7 1050.5 047. 1053.9 1058.8 CID _271 0 Op 1 046.7 20.00 34.00 T 20.00 1 00 00 I 0 $ PROP. HSE of 1054.1 1057.6 V) r 8' POURED 34.00 I . 1 r. 1 WALKOUT i C v n GARAGE 1048.4X 1050.9 19.4 o • r Pl.1742►AGE 290 II STATE BAR OF WISCONSIN FORM 2. l"ll 659635 WARRANTY DEED KUHLEEH H. WALSH REGISTER OF DEEDS Document Number ST. CROIX CO., WI This Detd, trade between Humbird Land Corporation, a RECEIVED FOR REM dllnaacta Corporation 10-22-2001 9:30 All WARRANTY DEED Grantor, and William H. Gary 111 and Melissa J. Cepren EXEMPT I as ioint tenants CERT COPY FEE: COPY FEE: TRANM FEE: 68.70 RECORDING FEE: 11.00 Grantee. - PAGES: I Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St Croix County, State of Wisconsin: Recording Area Name and Retum A dress Lot 10 Hammond Oaks Subdivision,Town of Hammond, SL Croix County, /4~9~ Q Wisconsin 41/1 019-1096.10.000 Parcel Idemificatim Number (PIN) This is mot homestead property. (is) (is not) . Exceptions to warranties: Subject to notes, easements testrictions,covenaots and rights of way of record, if any, including but not united to those for drainage,water retentionpording and or utilities as may be shown on the plat of Hammond Oaks Subdivision recorded in Vol. 9 of Plats, page 2, SL Croix County, Wisconsin The warranties of this deed, either expressed or implied are limited by the grantor to the grantee, or anyone in the chain of tide, to the consideration expressed herein, that being the sum of S 22,900.00. Dated this 21st day of September 2001 Humbird Land Corporation • e by President e Austin J. Bailton AUTHENTICATION ACKNOWLEDGMENT STATE OF WISCONSIN ) Signature(s) ) u' Ramsey _ County. ) Personally came before me this 21st day of authenticated this _ day of_ September -----.2001 die above named Austin J. Baillon TITLE: h6NMER STATE BAR OF WISCONSIN to toe known to be the perxuWs) who execudad the foregoing Of not, instrument and acknowledge the same, authorized by; 706.06, Wis. Stott.) 14 THIS INSTRUMENT WAS DRAFTED BY AUL A SAXLON Paul A. Balllon, Attorney at Law ' Paul A. Bailbn NrtIC ar NFYlrA Notary Public, Sute of Wisco (Signatures may be authenticated or acknowledged. Both we not my Commission is pdamanent. ( not, s to • g-snsy.) January 31 _ 2003 'Names of penorn signing many capacity should be typed or printed below heir signatures WARRANTY DEED STATR RAR Or WISCONSIN FORM PN.1 • 1M INFORMATION PROMMOVALS COMPANY FOND DU LAC, WI WO-53.2021