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020-1011-00-050
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division Sanitary Permit No: INSPECTION REPORT 579019 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: Marquis, Philip & Cecelia Hudson, Town of 020-1011-00-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 73- 3S OJ i-LA- 10.29.19.46A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Be chmark LJ~ /doo l".7 AL611 73.33 A- Alt. ; ( 2 , 1 / l • Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht outlet ,'7 °73.3? TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet ` _.7 Septic Dt Bottom Dosing % Header/Man. e I _1A 10 Aeration Dist. Pipe • ~ ~3 .ti?j 9.1 '17, q5 Holding Bot. System /d. 017-06 PUMP/SIPHON INFORMATION Final Grade 3•'b (167.63 Manufacturer GPm~tand St Cover c-_ Z , !J Model Number , C~ TDH ift Friction Loss System Head TDH Ft Forcemain Dist. to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia-_ LDIMENSIONS 3 Z le h,G SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: / 4vG 6 ~x /~7 UNIT Model N1,umbe : l L4 DISTRIBUTION SYSTEM y~~J b('j,L_ /(P =~3Z t35 G U.: L p- HeaderMlanifolcj. it Distributio\ x Hole Size x Hole Spacing Vent to it intake Pipe(s) \ Length_~ Dia~ Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil 7.63 Yes Rpi; No j Yes NCOMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 1022 Scott Road Hudson, WI 54016 (SW 1/4 SE 1/4 10 T29N R19W) NA Lot 2&3 1 I f Parcel No: 10.29.19.46A 1.) Alt BM Description = t ` ` `5 \vIe-ija 2.) Bldg sewer length = t . ' cj S - amount of cover Plan revision Required? ❑ Yes Xon. NO 7 ~ Use other side for additional informat/ {J J SBD-6710 (R.3/97) Date Insepctor ignatu Cert. No. PLOT PLAN PROJECT Phil Marauis ADDRESS 1022 Scott Road Hudson Wi 54016 SW 1/4 SE 1/4S 10 /T 29 N/R 19 W TOWN Hudson COUNTY ST. CROIX SYSTEM ELEVATION 94.2/94.1 5' below grade 7/12/15 3 DATE BEDROOM CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32 BENCHMARK V.R.P. Bottom of siding/ ASSUME ELEVATION 100' Filter Zabel A-100 ❑BOREHOLE O WELL *H.R.P. same as benchmark Vent >6 Quick4 Standard _ of Cover Leaching Chamber SMe 1/4 10, with 20.0 ft2 of Area - 12 „ 5.6ft^2/pair of end (p~ 4' Long All piping sh I be ASTM SDR 30/34, within 3 4" Grade at System Ele on 10' of tank, ' ng shall be ASTM F891 Existing 3 tL Bedroom House ' Diverter Valve to be installe2-3' X 66' 15' cells with >3' Box spacing jBB*-11 0% Slope System has failed due to 4' 47' 25' to p.l. defective biodiffus~r 14 chambers 3 0' B-2 y !g !g Vents 37' W Fence Line 20' to Property Line c 1 s°~4 RECEIVED Safety and Buildings Division coun 201 W. Washington Ave., P.Q. Box 7162 Sanitary Permit Number (to be filled in by Ca.) ison, WI 53707-7162 JUL 13 2015 A 119 0MMUNnj, &fiw9emit APP is State Transaction N In accordance with SPS 38321(2), Wis. Adm Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary S purposes in accordance with the Privacy Law, s. 15. i m , Stars. L Application Information - Please Print All Information Property Owner' ,Nam , et P I Parcel A) ~o V . W, 1 1-1 A A6 Property owner's Mailin Address Property Location v 2 ~ Sr- Govt t of City State Zip Code Ptlone Number S (on C/ ck o T N; R - W II Type of Building (check all that apply) Lot # 3 Subdivision Name 2 Family Dwelling - Number of Bedrooms r Block # ~ i ❑ Public/Commercial - Describe Use _ ❑ City of I CSM Number ❑ Village of - ❑ State Owned - Describe Use _ ,l sod own of ;4 Z III. Type of Permit: one be A. om let, 1' e B if a plicable) A. ' ew Sys 1. System r en R t Other Modification to E ' g System (explain) Date l ~Y 7Ll/ aolding Permit Renewal ❑ Pennit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous P u~per. $ Issued on Owner of POWT'S S Com onent/Device; Check all that a 1 ressudzrd In d Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil Tank Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis rsal/Tr atment Area Infor ation: C Design Flow Dcsigo Soil Beaton Ratc(gpdsf) Dispersal ea Required Dispersal Area Proposed (s Elev on Oct Cal Z VI. Tank Info Capacity in Total # of Manufacu= Gallons Gallons Units U New Tanks Existing Tanks /A 1 bO' ~r ~O qe r, V) Ln D- D U' Septic or Holding Tank f i Dosing Chamber ponsibility for installation of the POFVTS shown on the attached plans. VII. Responsibility Statement the undersigned, ass 4-X - Plumber's Name (Print) Plum gnature MP/MPRS Number Business Phone Number Plumber's Address (Street, City, State, Zip ' VIII. Countv/De artment Use Oniv Approved CZer Permit Fee Date Issued Issuing Agent Signature Given Reason for -I S +00 J' DL Conditions of A~~pppprovaMeasons for Disapproval orf SYSTEM'WER: ',b 3. ~1' S~, CU►t(.L . 1 fn t.1 1. Septic tank, effluent filter and dispersal cell must be serviced / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per 3pplica1134t=c6od .the system and submit to the County only on paper not less than 8 rr x 11 inches in site SBD-6398 (R. 11/11) . Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 7/12/15 Owner: Phil Marquis Location: SW /4 SE1/4 S10 T29 N,R19 1022 Scott Rd. Hudson Manuals Used: In-ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cross Section 4-6. Maintanance and Contin ncy Plan 7. Filter Cross Section 8. Existing Septic Tank For Signature License number #22 PLOT PLAN PROJECT Phil Marauis ADDRESS 1022 Scott Road Hudson Wi 54016 SW 1/4 SE 1/4S 10 /T 29 N/R 19 W TOWN Hudson COUNTY ST. CROIX SYSTEM ELEVATION 94.2/94.1 5' below grade 7/12/15 3 DATE BEDROOM CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32 BENCHMARK V.R.P. Bottom of siding/ ASSUME ELEVATION 100' Filter ZabelA-100 ❑ BOREHOLE O WELL *H.R.P.✓✓same as benchmark Vent >6" Quick4 Standard of Cover Leaching Chamber Cale = 1/4" _ 10 with 20.0 ft2 of Area 12" 5.6ft^2/pair of end caps 4' Long All shall be ASTM SDR 30/34 within Grade at System Elevation piping , 34" 10' of tank, piping shall be ASTM F891 Existing 3 14- Bedroom V House 10' Q` BJB M* 5' Diverter Valve to be installe2-3' X 66' 15' cells with >3' Box spacing 0% Slope System has failed due to 4' 47' 25' to p. I. defective biodiffuser O-E chambers 30 ' B-2 b , Vents 37' Fence Line 20' to Property Line Cross Section of Infiltrator Quick 4 Leaching Chamber Typical cross section for 2 of 2 cells Quick 4 Standard Leaching Chamber with 20.0 ft2 of Area per Chamber 5.6ft^2 pair of end plates To be >1' above grade Finish grade elevation Typical Installation 99-01 Vent Grade Vent 3' 4„ _A ~30/34 =ank 3' A Long 1 „ S' Long 1 „ 36" Grade at System Elevation Grade at System Elevation Spacing 5' 2-3' X 66' Cells Same on other end Observation tubeNent At end of cell A 16 chambers per cell B System elevations: A_94.2' B 94.1' ST. CROIX: COLINT'° SEPTIC TANK MAll`v''I'l N ANC'E., GRF M1sI'vT AND t_)WNERSI-1111 (~1{;IZ`C1t lt:`;~.'I1~ 1~ FORM Owner/Buyer Mailing Address Property Address s /U ZZ.----- / 44t-w- Neuification required from Planning Zoning, I)epattnrnt lot new cons`illiction.) City/Stale - - --d-sofl- - "`milel ldczitiI:icat:ion N111 tber - _ - ~ LEGAlL, DESCRIPTION Property Locationj'4-.2 , scc."1 N W, "Town of Subdivisio~l .:Lot ~fz'Zt-3 . Certified Survey Map # ~ Warranty Freed # Spec house yes nu lot. line identifiab s yes uo SYSTEM MAINTENANCE AND OWNER C;lERTIl+ICA110N Improper use and rnainterrance of your septic System could result in its pr.~rriiittrre failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, it needed, by a licensed pumper. What you put into the systern can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner )maintenance responsibilities are specified in §C'onun. 83.52(1) and uu Chapter 12 - F;t. Croix. County Sanitary Ordinance. The property owner agrees to submit to St. Cron Coun(y Planumt, Sc Zoning 1.)eparirncnt a certification f6im, signed by the ownet and by a master plumber, journeyman plumber, restric[ed plurrtber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspec~ion aid pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirertterrts and agree 1o mair rain ilia private sw;wage disposal systern 'A'iIll( he standards set forth, herein., as set by the T)epartjilent of (;ommercc and the L)cparunent ol'Natural Resources, State of WiscoUSlrr. Certification stating that youur septic system has been uraintained must be completrn l and returned to ilre .`it. C icon Comity 111amrirtlr Gonuig Department within 30 days of the three year expiration date. 1/we certify that all statements on is foram ate: sue to ihc" best of ruylotn k nowledP)U. 1/we anvare the owuer(s) of the property described above, by vnI,, of a atranty deed recorded in Register o1 Dees Is Office. iglu r o ~edroo 41" OF APPLICANT(S) - ~'I ra D A [F "Any information that is misrepresented may result in the sanita'ty pcrrrrit being o!voked by the Planning & Zoning 1)epal7.n"uew.include with this application a recorded warranty deed fiom the Registeu of'l)eeds CIffic-e and it copy o.fthc; certified survey map if reference is made in the warranty deed. (REV. 08/05) POWTS OWNER'S MANUAL $ MANAGEMENT PLAN Page of - FILE INFORMATION SYSTEM SPECIFICATIONS Owner =0,>f79,,,, Tank Manufacturer Manufacturer: t,U~~ ❑ NA rmit # eptic El Dose ❑ Holding Volume: ~ (gal) Pe Tank NA DESIGN PARAMETERS Number of Bedrooms: ❑ NA ❑ Septic ❑ Dose ❑ Holding Volume: (gal) Number of Public Facility Units: ANA Vertical Distance Tank Bottom(s) to Service Pad: (n) Estimated (average) Flow : (gal/day) Horizontal Distance Tank(s) to Service Pad: (ft) Specific servicing mechanics must be provided if vertical is >15 feet or Design (peak) Flow = (estimated x 1.5): (gal/day) If horizontal is >150 feet. Specific Insttvctlons to be provided on back. In Situ Soil Application Rate: y J (gaUday/tt2) Effluent Filter Manufacturer: ❑ NA Standard (Domestic) influent/Effluent Monthly average Effluent Filter Model: Fats, OH & Grease (FOG) !530 mg/L Pump Manufacturer: NA Biochemical Oxygen Demand (BO05) s220 mg/L ❑ NA Pump Model: Total Suspended Solids (TSS) 'x150 mWL High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer. NA (BOD5) >220 mg/L _AA ❑ Mechanical Aeration ❑ Peat Filter (TSS) >150 mg/L ❑ Disinfection ❑ Wetland Pretreated Effluent Monthly average ❑ Sand/Gravel Filter ❑ Other: (BOD5) 530 mg/L Soil Absorption System (TSS; <10,m9/L A n-Ground (gravity) ❑ In Ground (pressure) El NA Fecal Coliform (geometric mean At-Grade ❑ Mound Maximum Effluent Particle Size t~ in dia. ❑ NA ❑ Drip-Line ❑ Other: Other: NA Other. ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency hen combined sludge and scum equals one-third ('h) of tank volume Pump out contents of tank(s) ❑ When the high water alarm is activated [j month(s) Maximum 3 years) [3 NA Inspect condition of tank(s) At least once every: ear(s) ~ ear(s) (Maximum 3 years) ❑ NA Inspect dispersal cell(s) At least once every: ❑ onth(s) Clean effluent filter At least once every: oath(s) [3 NA ear(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) El NA ❑ year(s) Flush laterals and pressure test At least once every:. ❑ month(s) NA ❑ year(s) Other: At least once every: ❑ month(s) NA C3 year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certi bons: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper). Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface, The soil absorption system shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface, The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any treatment tank equals one-third or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator (pumper) and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of <_12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 30 days of completion of any service event, GMW-005 (02/05) Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil absorption system. If high concentrations are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will be discharged to the soil absorption system in one large dose causing an overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the treatment tanks and soil absorption system: acids, antibiotics, baby wipes, cigarette,' butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, and water softener brine discharge. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with s. Comm 83.33, Wisconsin Administrative Code: • All piping to tanks, pits and other soil absorption systems 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 (pumper). • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at the time of their permit issuance. A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be r litated and barring advances in POWTS technology, a holding tank may be installed as a last resort. ❑ 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 TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE. .r ADDITIONAL INSTRUCTIONS: S 5 POWTS INSTALLER POWTS MAINTAINER, Name CC~LI(~t.i/ r Name 9 Phone l~^ Phone SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name v NameS~ ld ` Phone Phone 7 J J _ This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. _ Q a1# ~ 3 cat d t r k - _ k o 1 k t ~ d k r. C O ~ ~ r D r.a r c~ Q CID w i CD, I sz,, CROTX C RO'X COUNTY ZONING FOR UTILIZATION a~ TZON STATEMENT I"CL This, to AN EXIS?'ING SEpT LC TANK certj.fy that et-v.i•ng the 1 have inspected the se tL,. ~E p c tank Pr~ Section resi deuce 1~~ N 1 o c a t c c! t. ; the tank Upon iris R / 9_ . and baffles to Aect1on, I cer. ti fY W Town f'unrtior,in that ~ 9 properly. be in good condition, and h I have t otrrlct appears t i r) tie tme serviced: U ll.ow ~ 7' back occ - 0--j- Z- ur p'r'om absorption Yr~ s _ - no' A13Proxlmate volume oZ en skip ne), l line} IIJacity: 47~ gth of time; gallons "strttct.ion: Prefab Concrete J"1,-111ufact Steel user: (If known) Other rj~tu A c:) E' o f 'j' (Tt known),; ddb ~ ature) cc-, (Name) Pleas (1' 1.e) - ase pr-,t - - 2 (I.,xcense Number 1=)n t_e ("ca 1-zn t O be Statutes) or c Liompleted b li Code) censed Dis er (NR plumber (5.145. P 113 Wisconsin OE,, WiScC~f)S i n Administra t-.i v !dumber (applying, for sanitar _ - - _ -1 _ Iti acce Y Permit) Certifj.cation- vnclitionxng tr2e above I ceztif statement ~onfor•m tot Y that regard b g ex.zstin r: Sc~I~~ zc 1.r1„ he requiremen shod auk tot of g qjR: pect10n opening a r outlet ILHR 83, W• Adf my knowledge tan); baffle) , Code (excew i 7. Name 9 At 1:oI- Signa .Ur ZG _ Nl'/MPRS ~"-G~' Wisconsin Department of Commerce SOIL EVALUATION REPORT "'-"on of Safely end Buildings page/ ! of J In accordance with Comm 85, Wis. Adm. Code Affacr complete site plan on paper not less than 8 112 x I I Inches In size. Plan must County s~. G/mar Include, X- but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, end locallon and distance to nearest road. Parcel 1.1). Lot 2 D 3 O' OO • 00 Please print all lnformaflon. R 3 - oz o•/o//• o o da Personal k+1--non Date You provide na,y he used Iw aeconda7 PuToses (Prrvaey Lew, s. t5.04 (t) Im)i, Property Owner GZ~~YvJ / ltor► TC~}n! • GUS t17 Se t1 - 131,G Property Loca S4 /O Property Owners Matiing Address Lot sW 114 1/4 S T Z/ N R ` (a) W (7 Z 2 SAO G~ Lot !74 Subd. Name o► CSM1! City State /Zip` Cod e ' p e Z 3 5 Y2 GG ff do ~fv~Sio~l W~. 5yO/~ 44 "lln ❑ IY ❑ Village Town Nearest Road [-j New Construction Use: Residential/ Nu a derived design Now rate a (XRepiacemenl ❑ Public or commercial - Describe: GPD r'arent material /b~„S $ 04 ,5&MOR f/ General comments Flood Plain elevation 11 applicable n /V dG?~' Zvi} and recommendations: - 'die • S~•T~' So%Tit 41,4:- F/I Boring # ❑ Boring V, Pit Ground surface elev._ f1 Depth to timllMg factor pl, OW Rate Horizon Depth DorMnant Color Redox Description Texture Structure Consistence Bound Roots APPI In. Munseti Qu. Sz. Con- Color - IOy Gr. sz. sh. .EttN1 TOM / • s/G sd~e 1114 f- . z . 3 /Qye 3 SiL ZfS~iC •j„ 75R 4" 3 .s A_ Z Fa] Boring It Bar ng ~ Pll Ground surface elev. 7 R. Depth to tindfing factor in. Horizon SON Depth Domhmnt Color nedox Description Texhxe M Structure Ron Rafe Consistence Boundary Routs GPDAIIi In. Munseti Qu. Si. ConL Color Gr. Sz. Sh. 0 ' l ~ ~ O yjr 'EfINI 'EI192 14*A 77 J40 3 •,3 io S/G l s K ~,P t,~J . 2 • S Si L Rtsh /lYrfi' LZ, S Effluent Ni = SOD, > 30 < 220 mgll and TSS >30 < 150 m91L Eltiue nt ill BOD CST Name (Pls_ 30 mgn and TSS < 30 IngIL DG~~ Signature CST Number Address Dale Evaluation Conducted Telephone rhrrrrt►er es oc~l. ~Dp 7/S•~3dG'~l~ S Private Sewage Consultants 655 O`Neil Rd. Hudson, Wis. 54016 (1•DIt%iKIA{ Property Owner Parcel to R noting * ❑ noting Pop of F31 apil Ground surface elev. it. Depth fo Ilmiling lacior In f loizon Depth Domtnanl Colt Redo, Descripllon Texture Structure Consistence Bota,d ;R(:, ts in. Mansell Qu. 5z. ConL Color ary Gt'DNI Gr. Sz. Sh. .001 'Eff/2 f .2... . 3 3 .3 Orr noting if ❑ Boring El ❑ pit Ground surface elev. R. Depth )o Nml" factor In. Halton Surd Mon Rale ~pih Oomfiani Color Rod ox Description Texture Structure Consistence Boundary Roots ' GPD/il: In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'EHaa1 'EIf92 U Boring fi ❑ Boting ❑ pN Ground surface elev. R. Depth to dmlling factor in, ! Iorizon Oeplh Dominant Color f2edox bent lpflon Texture Structure Sog AppNtatlon ft~ In. Mansell Consistence Boundary Roots GPDM Qu. Sz. Cont. Color Gr. Sz. Sh. 'Elul 1 •EBN2 EMuent iii = BOD, > 30 < 220 mglL and TSS >30 < iso mg& • Effluent #2 = BOD < 30 _ mg1L and TSS < 3() mglL The DeparUnenl Or Commerce is an equal opportunity service provider need nd employer. If you need assistance to access services or material in an alternate format, please contact the department at 608-26&3 151 or TTY 608-264-8777, Srb•ft!l11►R lcrylflr - ,f - o 'rot - W4 (10 q§ 5.0 A)PO , F11 57406- A- poW j3t aRH ~ ~ 1.5v s 32 ~ V 00 'Sil l4.3 1 100 i 13s ALL NON-CONFORMING THE TMENT TANKS SHALL BE BANDONED PROPERLY • PE COMM. 83.33. r S'1 $ if lallltl: ~ Ge ~(s ~ ~2dzG 3 'J( (o¢ 4,- sysi. ~Yod - y r 'v plop . Lr,v~- o I a~i o° a o0 3 0 o v I O O 00 0. 0 0 'es ~ I g° o I $ I ~0 1 N m N m LL co c C) o 0 I mmm aw N 8;' O O (h w m Y •O N l~6 y .m.. 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Z D a N o m cc' D CD a c CA) CD 0 ~r o°CL a, can w' 0 0 2 n r N o N3 " o Q y o u cn eul 0 ~ 0 o ° a 0 I O c~i N y y A O f7o D ~f Nw-. A 0 _0 Cl) O O =r CCD N rn 0 0 N - ~ fQ w Co m N ° 00 Cl) z Z z o D o 0 O O c o CD ti• c N N 0 0 C CD o 3 _ 7 Z ZCD (A ) cn ? 2 ° w D o o w a r' a. c ' ca M m ° Z O (n w y M '0 0 w v CD a CD 0 w n C ~z CL CD N I i yy O S I a I ' I 'ti I 0 I ~ 0 0 I a 0 CA Op A ~ w e» O e o CD o CL Parcel 020-1011-00-000 04i09i2007 05:03 PM PAGE 1 OF 1 Alt. Parcel 10.29.19.46A 020 - TOWN OF HUDSON Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - MARQUIS, PHILIP A & CECILIA M PHILIP A & CECILIA M MARQUIS 1022 SCOTT RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description " 1022 SCOTT RD SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 6.093 Plat: N/A-NOT AVAILABLE SEC 10 T29N R1 9W SW SE BEING LOT 2 CSM Block/Condo Bldg: 11/3083 6.093AC EZ-U-1318/200 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 10-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/13/2004 768641 2615/326 WD 12/15/1998 593786 1387/116 WD 07/23/1997 1130/490 WD 07/23/1997 1128/602 QC more... 2007 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 6.090 91,400 167,600 259,000 NO Totals for 2007: General Property 6.090 91,400 167,600 259,000 Woodland 0.000 0 0 Totals for 2006: General Property 6.090 91,400 167,600 259,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 119 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 VVfconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of Labor and Human Relations -r Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St. Croix not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # O w dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Joseph Klewicki GOVT. LOT SW 1/4 SE 1/4,S10 T 29 N,R 9 3(or) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 2312 D. Cresent View Dr. suite 204 na csm pending CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE MOWN NEAREST ROAD Hudson, WI. 54016 (719 386- Hudson Scott Rd.'0~1, [x] New Construction Use [ Residential / Number of bedrooms 3 [ ] Addition to existing building [ ] Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/ft2 - 8 trench, gpd/ft2 Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 . 8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 105.75 ft (as referred to site plan benchmark) Additional design / site considerations alt site trenches @ 104.25 & 101.40, el. Parent material - outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem 91S ❑ U KI S ❑ U ® S ❑ U ®S ❑ U ®S ❑ U ❑ S 4'] U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Or. Sz. Sh. Bed Twich 1 0-10 10yr3/3 none 1 2msbk mfr 9W 2f .5 .65 2 10-28 10yr4/4 none scl 2msbk mfr gw if .4 .5 Ground 3 28-84 7.5yr4/4 co s Osg ml na na .7 .8 elev. 105.4 ft. N Depth to,'"'.) limiting; factor I Remarks: Boring # - 1 0-6 10yr3/3 nonP-,-w- 1 2msbk mfr gw 2f .5 .6 2 2 6-13 10yr4/4 none scl 2msbk mfr gw if .4 .5 3 13-84 7.5yr4/4 none co s Osg ml na na .7 .8 ggGround l Ulgv.7~t. Depth to limiting fag 4" Remarks: CST Name:-Please Print Gary L. Steel Phone: 715-246-6200 Address: 1554 200 Ave New Richmond, WI. 54017 Signature: Date: CST Number: 4-18-96 cstm 02298 PROPERTY OWNER Joseph Klewicki SOIL DESCRIPTION REPORT Page -2 of . PARCEL I.D. # pending Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 0-10 10yr3/3 none sl 2msbk mfr 2f .5 .6 2 10-84 7.5yr4/6 none co s Osg ml na na .7 .8 Ground 101'."75 ft. Depth to limiting factor +84 Remarks: Boring # 1 -g 10 r3/3 none sl 2m r mfr 2f y g gw 1.5.. 6 ...........tip. 4 2 -14 7.5ry4/4 none s1 2mgr mvfr gw if .5 .6 3 14-84 7.5yr4/6 none co s Osg ml na na .7 .8 Ground Depth to limiting factol84„ Remarks: Boring # 1 ~-8 10yr3/3 none sl 2msbk mfr gw 2f .5 .6 5 2 -15 7.5yr4/4 none sl 2mgr mvfr gw if .5 .6 3 5-80 7.5yr4/6 none co s Osg ml na na .7 .8 Ground elev. 104.4 ft. Depth to limiting factor +80" Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) s~ STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 Joseph Klewicki New Richmond, WI 54017 MPRSW 3254 SW4SE4 S10-T29N-R19W (715) 246-6200 town of Hudson I N 1"=40' BM.= sw corner of cement base of tel. ped. C el. 100, l0i 2►~~ 10 ~M 'ly c Cl 1, ~ 03 6-' c TOD GAry L. Steel 4-18-96 /t-/ /-/t/, PA /t-,l RECEIVED T. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT wrier, 3N • S'2.1:> - City/State U D,v S pfd/ Legal Description: S•~2 GG ~ ~D~ ~O~e, , , 30~ 3 Lot 2 6,3 Block Subdivision/CSM # Sec. / O , T_~f N-R/W, Town of PIN # D20 /D// a©• ~d-a SEPTIC TANK DOSE CHAMBER BOLDING TANK INFORMATION: 60 ieye-9 Tank manufacturer 6 . Size ST/PC Setback from: House Well P/L ~Sa Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location ~~vS~ Czl/s SOIL ABSORYT'ION SYSTEM: /3/6 Type of system: Width 3 Length ?a Number of Trenches 2.. Setback from: HouseWell P/L Vent to fresh air intake > ~"e O ELEVATIONS: LL E Description of benchmark d S /V/~G---- Elevation Description of alternate benchmark 4, x.45 Elevation D ,f0 C,~ V-0, Building Sewer AIJA- STAIT Inlet T3. ' ST Outlet f3,33 ' PC Inlet PC Bottom Header/Manifold Ton of.T/PC.. ManhnlP C-1- 4V O 5 ~ PuG ctgdm Q► 70 T 1 # 2 M of TOP E Its Tl,06-' 3 l~`z~jQ~1 6-A5 Nom" poc ~4P (oC 10 s LJ. ql' cop N ~ w 5t aF /P- ion mo 02 1 vf T, ,,v+' o~°~° (30 5 3, ~i 0010 13.33 lob iq o •i , li ~ S~ q3~ is 51,E X I I F-- i b ~ ~ 11 q 5i Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 420480 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: Gustafson, Jean Hudson Township 020-1011-00-100 CST BM Elev: Insp. BM Elev: BM ption: ~ lob -6 Db - d TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Be mark t o Z) Be 4 .'3 ~o~ f. 3 l Do, o Dosing Alt. BM h /A N Aeration Bldg. Sewer Holding St/Ht Inlet ~3• G~ TANK SETBACK NF ATION St/Ht Outlet y O 133 TANK TO P/L W LL BLDG. VenE-3 ke ROAD Dt Inlet 2 Lob i' Septic > rn ' ~ t ` f ~ Dt Bottom ~v Dosing Header/Man. q3. Z~ Aeration Dist. Pipe l ( I t, Z 2- Holding Bot. ystem Final Grade PUMP/SIPHON INFORMATION i Manufacturer Demand St Cover G u lrn,Ae A,4- S , 9~ t Model Number - " ~TDH Li riction Loss System Head JTDH Ft cemain Leng Dist. SOIL ABSORPTION SYSTEM A-5 r _ . I e BED/TRENCH Width I 4 Length, No. Of T nches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 'Z SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Ma r, Aall, INFORMATION CHAMBER OR 1 Type f System: ( ' UNIT Model Number: V t~ > ( rv DISTRIBUTION SYSTEM` Header/Manifold Distribution . L Ix Hole Size Ix Hole Spacing Vent to Air Intake f G. Pipe(s) } v~ t,-ii ljil 4 Length Dia Length Dia Spacing i SOIL COVER x Pressure Systems Only xz Mound Or At-Grade Systems Only Depth Over C _ .'LA_l Depth over 1xx Depth of 1xx Seeded/Sodded 1xx Mulched Bed/Trench Center / t Bed/Trench Edges Topsoil Yes ] No r~ Yes i,1 No (0 COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~0 /Z-5 / 02- Inspection #2: / / Location: 1022 Scott Road Hudson, WI 54016 (SW 1/4 SE 1/4 10 T29N R19W) NA Lot 2 & 3 Parcel No: 10.29.19.46A 1.) Alt BM Description of5 2.) Bldg sewer length - amount of cover = Plan revision Required? Yes to x n Use other side for additional information. U ~C//y~C~- - ~(v d SBD-6710 (R.3/97) Date Insepctor's ignature Cert. No. r Safety and Buildings Division County Nvisco'nsin 201 W. Washington Ave., P.O. Box 7162 57 G,e 0/ Madison, W11 '53707 - 7162 Site Address. A0Z2- Department of Commerce 0-11~_D?/ ►I~ /`/OpfonJ Sy 4, 4 Sanitary Permit Application Sanitary Permit Number In accord with Comm 91.21. Wis. Adm. Code, personal information you provide 0 Check If Revision may be used for second ses Pdyac Law, sly. 1 m 1. Application ]Information - Please Print All Information State Plan I.D. Number ~ u / Frop),-. rty Owner's Name Parcel Number D 2D + t0 D ~-ey • G as _r1f /Zc~E,4/l) /3 /,/t o.c 6,"t O • /o//. oo • /po ;2 ttyOwner's Ma[ling Address 71 Property Locadon 4, v ~ /92 2- 5,14 jz~ .S~i uS~ u.s /o Tly N,RIf It City, State Zip Code Phone Number I-Atl urbe Block Number 7/37 i 3 o.J Gtr y oars S 40/ lo i« CSM Number' ~S 3 -12- S *!Y aG /JD 3 a 3 It. Type of Building (check all that apply) 11City ll or 2 Family Dwelling - Number of Bedrooms ` ✓1 oVillage 0 Public/Commercial - Describe Use 14Towrshi P ❑ State Owned Nearest Road 1/101: ~ ,C/1~ ll,~:~' % ~ ~ LO 1 t~!~ ! % (.'~i ✓ l ~ . III. Type of Permit: (Ghee Fro box on line A (numbering scheme for Internal use). Complete line B if applicable) A. 1 El New 2 Replacement System 0 Replacement of 6 Addition to For County use System sulk Only Existing 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 2111 Mound 47 0 Sand Filter 50 0 Constructed Wedand 22 Pressurized In-Ground 410 Holding Tahk 49 0 Single Pass 51 11 Drip Line i 45 0 At-Grade 46 0 Aerobic Treatment Unit 49 0 Recirculating 30 0 Other V. Dis ersai/'Treatment Area Information: Design Flow (gpd) Dispersal Area / Dispersal Area Soil Application Percolation Rate System Elevatio Final Grade Required ✓ Proposed Rate(Gais./bays/Sq'Ft.) (Min./Inch) ~I'll Elevation .7 VI. Tank Info Capacity in Total Number Man^~gfacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks _z ZLtef~7(Z p~ Co rote Conttucted Blass t t' New Existing ' Tanks Tanks Septic or fielding Tank &7 - Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume responsibility for Installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's S P/MPRS Number Business Phone Number.' z1/hR~ eGrr- Zzl~ 3 S. 7/s -3 fG - J Plumber's Address (Street, City, State, Zip Code) VIII Count epartment Use Only Approved 11 Disapproved ' Sanitary Permit Fee (includes Groundwater Date I) Surcbnt ge Fee) 0 41 Owner Given Initial Adverse !TD Detenninadon / , U. Conditions of Approval/Reasons for Dt Rpproval U ~1517it~s(~~ -A,,~ l C~vtll~+hOh~4/ X3.3"3 //V_ eompl e p o e e b e y) for a rystenr not less th x 11 tnchq gr%e © Is D-6 98 (8./35/17 pull CbL `.P. O 1 or OA,., A'iK y 8 q&.50 fXi 5r~a(r >i 51~ iate y~l NdU( D dr 5 O p 45 30 ; I 1 w Cwt a \ 1~% iol ICI 0- o a 1 1 1 fill V o a 1 1 ~ g•i 1 ;v1 ~ ~q I I 1( Wo X I I I Ill., o a00g = 1 I I I ccac -15 ~1 1 1 I _°~WJ 11 1 I M P?cooLL I I i ~ 01 i t I I 83 . Iof 1°I 1 I I I ALL NON-CONFORMING i THE TMFNT TANKS SHALL 13E BAP I .,ONED PROPERLY jq.0 ~E ;CC';'."JI.83.33. 5//vW-V rte) ~/s Joel-G. 3 ' x (af A r s y 5r 9y0' geq • ULDFAC111'-- ASSOCIATES CO. 655 O'Neil fioad • I Judson, WI 54016 neg..Uesigners of Engineering Systems 715-386-8185 Private Sewage Consuhints PROJECT INDEX PLAN IU # DATE OWNER 7e4,4) (rUSTA+F5'eAJ 3d~ l0 -SZ/ PHONE Sl AUURrss 102-2- $Lo F ~P. fljAS0,j Ct>%S LEGAL DESCRIPTION GD~"S 2? 3 CSM (/D/• . 303 7- --24;a, TOWN OF A-) COUNTY v~ LOCAL AUTHORITY/ SUPERVISION ,S/ e9*11C gdAl PROJECT DESCRIPTION: aI44lq -W 7- MpR5 '3'-1 120 3EP-T" Zt L13 21'C 117_ THIS POWT SYSTEM SHALL INCORPORATE PER COMM. Ulbricht & Associates Private 5 O'Neil Rd a Consultants 83.44(2)c A PROPER ZABEL 65 FILTER MODEL # Hudson, Wis. 54416 p /T ALL NON-CONFORMING TREATMENT TANKS SHALL BE ABANDONED PROPERLY PER COMM. 83.33. .i Pg.l INFILTRATOR SIZING WORKSHEET i P9.2 SYSTEM PLOT PLAN I P9.3 CROSS SECTION OF SYSTEM, WITH ELEVATI i it it 11 of Pg.4 „ OHS. o wE~~ p. or A,/ a ' ,Top to s v y8 9lp ,50 A~ ~ fx~sr~a(r ~'"~~a~ Npo. f~ 5 tem . NM • 0115' /11 stw • O Q4 of Ji m! d 06 lip 2 co ~ 30, w¢a ~ f-- w 1 Q' i l / v cn a. 0 a Y, All 0 0. I 1 aa.- 15'~ _~~J~ 1 F-?CIO~ col I~~ ~ - I I I ALL NON-CONFORMING i TREATMENT TANKS SHALL 7q.o~ `3E BAt% ONED PROPERLY E :CCU":`,t'A.83.33. t 4r Sy5i•/Oa py0' 'Al INI, I _RN 14 ~f ~f ~f I . w v' fill I i OG Q n k,~ N y ~ ~ V)ATt-f-oA) r-- v t 5 rtR,vc~ t dam/ IoM or AP 9.eo,f ,24 OF cat 105 ,nU I ff 9y•0 CVO 5-5 SE C T/ox) -9151 -)6- - o x 131 a Dt~jt1y&1ec-, s j w;~Zt 31- / sQ. Fr Tv T 14L S 9L-- c 7 A-1 /1,PM,0&tp 6,0 LIt7,& 7- C410 Iff Ir K q9 /I 1;ax i I / - - n • OWNER 's MAINTAINCE OF SEPTIC SYSTEM 1w~ ~ POWTS (landowner maintenance of ) Is srstemsible for proper operation and servicing a necessary Regular periodic inspections and system. Y for the safe healthy operation of.this The maintenance owner is required by code to submit all necessary /inspection reports to the control ling,authorities. SPECIFIC CONTACT AGENTS 5T. 1/ * Governmental authority/ ~0/x c')-y inspectors: 67-- Licensed o . * installer, responsi maintenance "Users" manual: l: ble for providing an operation/ * Licensed servdce / inspection agent other _57 than installer: .4Vr' Tr9-T%O.V 3~~ • X13 0 * Electrician , for pump, electric controls wiring units: IMPORTANT OWNER MAINTENANCE RE UIREMENTS i• Winter traffic (sledding area shall not ' shoveking, etc.) across the the cell, freezinpermitted, frost can/will penetrate into winter. g up the system. Discontinuos use in the lead t(a vacacupsn trip, resulting in no water use o freeze can also 2• Water conservation needs to be exerc' hydrolically overloaded and destroyed. T Or system can be designed for a maximum This svs~em was wastewater flow of 1150 gals. daily. 3• POWTS are not designed to disposal unit accomodate wastes from a Any introduct or any other unnatural sources of waste destroy garbage. ion of such waste materials will o ad and of was this system. 9 . /v6T ~ Sfas~ 6'-~e -7T .l~OW~ If a power 611tage occurs, or a ~i1 77 In a temporary overload of effluent,beins, mpedmay into cell, which may g pumthe recommended Y adversely impact the cell that a licensed pumper emp t a allowing the pump to return to dosin Y (l the deaosikage)ng. ta It nk, is Consult your installer immediatel g the correct amounts. 5• Neglect y for advice. of the vegetative erosion preventive cover (the cells insulation & traffic also ) can lead to failure. can destroy t he system. Compaction or heavy REGULARLY WATER THE VEGETATION OVERA SYSTEM!j NECESSARY TO the system beneath IS NOT sufficient alone to grass cover. Effluent in maintain a 6• Perio necessar ions by the owner into theys inspection , or his agents, is Pipes an inc.,o,., :___ystem: on the ~_p°r s ave een ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address S yd/ Y Property Address SQ` (Verification required from Planning Department for new cons(ruction)_ r1 City/S(ag Da-o..: /o/I -0 Dd Parcel Identification Number QE D J 1611-- `lD b LEGAL DE, SCRIP TION Property Location 51A) '/4, 15f~' y4 Sec. lo T Z y N_ R W, Town of Subdivision Lot # o2 q/3 Certiiled survey Map # S ~PGr , Volume , page # 3~ 83 Warranty Veed # S F3 ?T 6 Volwne /`38 7 , Page # Spec house U yes ~410 4 Lot lines identiliableAYes Ono . SYSTEM MAIN'T'ENANCE 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 heeded by a licen unp%. What you put into the system can affect t e function o ue septic tan as a reatmen 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 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. 1/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 slating flint your septic system has been maintained must be completed and returned to the SL Croix County Zoning Office within 30 days of the three year expiration date. G113~- I NATURE OF APPLICANT DATE OWNER CERTIFICA'T'ION I (we) certify flint all statements on this form are true to the best of my (our) knowledge. I (we) Am (are) the owner(s) of the property ATURdeE described above, by virt a of a warranty deed recorded in Register of Deeds Office. 1V ~ St OF APPLICANT DATE ***440 Any information that is finis-represented may result in die sanitary. permit being revoked by the Zoning Department. R4*• include with fills appllcallon: a stamped warranty deed from file Register of Deeds office it copy of the certified survey map if refetence'is made in the warranty deed rMsconsin Department of Commerce SOIL EVALUATION REPORT 3 rivislon of Safety and Buildings Pagel of In accordance with Comm 85, %Ms. Adm. Code Attach complete site plan on paper riot less than 8 112 x i i Inches in size. Plan must County s~ • e /p / Y- Include, but riot limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. Lot Z O 3 40 • O od ' 00 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. fit'- 3 • oz o•ioi/• o o --n Please print all Informatlon. R we y Date Personal Information you provide may he used for secondary purposes (Privacy Lew, s. f5.ed (f j (mjj. Property Owner GZ~~ ~0 Property Location Tt,tAl M• GUS f~7CSB~tI - G `S~ /O N R SW Su Z7 Fro-petty Owner's Malting Address v Lot 1 /4 1/4 S T (m) W l a 2 Z SAO p ~1 Block M Sbd. Name or CSMIt L-::z::z3 3 CS 5'Y2 6G 6d °~3 N rTr 1 4 ZOO ❑ 'ty ❑ Village Town Nearest Road ) ~ SZ/ New Construction Use: Residential / Nu ode derived design flow rate ~ GPO (KRepiacemenl ❑ Public or commercial - Describe: r'arent material X&I&SS GU .Srf.vpY Flood Plain elevation if applicable /V General cornmeinls n• DV-/- and recommendations: • s,• 59,4T".rt-4/~' f , oup • C'1o vim. I / 1 Boring # Boring 3 O r'--/--~' Pit Ground surface elev. 7 ! y ft. Depth to limiting factor Horizon bepth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil A GIPI~ lmlon Rate In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eit#t 'EH#2 / O• 'Ap,60e 3 .S • op yiQ3/ s L fS & c 5 s ~ shy S Boring # L1 Bor ng 9 y o PIl Ground surface elev. R. >~•~t.! Depth to limiting fact or In. Horizon Depth ;,1mI"s nt Color Sofl Ap Ncalion Rate Redox Description Texture Structure Consistence Boundary Is GPD/fl* In. Munsell Qu. Sx. Cont. Color Gr. Sz. Sh. ~ 1~ ' Eff# i 'Eft#2 •2(~ ~o ,e3/ SQL s ,~f~ w 3 f .Z S/G L s k ~.lij~ie W 2 . S• 3 '37 y/l,~ s~ L ash /1~fi' 2 S . s . Effluent 01 = Bobs > 30 < 220 mg/L and TSS >30 < 150 m /L CST Name (Please Print) - g 'Effluent 02 = BObs < 30 mglL and TSS < 30 mg/L ~0,~3~72/~~~•GGyT Signature CST Number Address l x~^~P 3 -1.57 Dale Evaluation Conducted Telephone Number tes o~~- ~ • ADD 7/S•~38~ •~l~ S Private Sewage Consultants 655 O'Neil Rd. Hudson, Wis. 54016 Property owner Parcel ID A Page of W noting Ar r❑ Storing r~~ lj ~ l ZQ L~..pll Ground surface elev. 17.~o 11. Depth to tlmiling factor In, Horizon Depth t3ominanl Color Redox Description Texture Structure Consislence Boundary Roots SoN APplicallon Rate rY GPD/fl' In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. •EIINI •EM o 2 140 ;;6, E 15 /74SA A*i_fi? W 7' .2_ .3 3 A45jle *A A/ A5 1. A noting ❑ Boring ❑ pit Ground surface elev. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Rgdox bescriplion Texture Structure Consistence Boundary Roots ` GPO/fl= In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Etf#2 ► noting 0 Lt) noting IJ Pit Ground surface elev. fl. Depth to limiting factor in, Soil Application Rate Horizon Oepfh bominanl Color F?edox Description Texture Structure Consistence Boundary Roots GPD/ll' In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. •Eifff 1 'Ef 02 - - - Effluent fft = eons > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent 02 = BOD, < 30 mg/L and TSS < 30 rng/L - r The Department of Commerce is an equal oppottunity service provider qnd employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or 7TY 608-264-8777. snn.e~~ntR eront O L~EGL PP- S it, A or fA 60 vt3• b 570~ A~~v fxl sy~aU- ' r~~ NOS' 1) 0 X15 ~s Of k D0-0- 1q.30 I II II i I I r it II ~3 i ~I I I II ~ ALL NON-CONFORMING ti e TREATMENT TANKS SHALL BE ABANDONED PROPERLY qq'~ - PE COMM. 83.33. 401-t, 3 'y Ai sysi.%~a - 9yo' {~~~te no io~ not 138 I w[ 116 STATE BAR OF WISCONSIN FORM 2 - 1982 5937$6 WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS DOCUMENT NO. ST. CROIX CO., WI RECEIVED FOR RECORD Joseph A. Klewicki and Tanae G. Klewicki, 12-15-1998 9:30 AM husband anwife, WARRANTY DEED EXEMPT I CERT COPY FEE: coneys and warrants to _ Jean M. Gustafson, TRAHSFER.FEE: 561.00 a single pferson, RECORDING FEE: 10.00 PAGES: 1 THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in St. Croix County, /2 F/I State of Wisconsin. 020-1011-00 PARCEL IDENTIFICATION NUMBER Part of the SWI/4 of SE1/4 of Section 10, Township 29 North, Range 19 West, St.Croix County, Wisconsin, described as follows: Lots 2 and 3 of Certified Survey Map filed April 24, 1996, in Vol. 11, Page 3083, Doc. No. 542664. This _ 15 homestead property, (is) Exception to warranties: Easements, restrictions and rights-of-way of record, if any. Dated this 11th day of December A.D., 19 98 (SEAL)7l (SEAL) Joseph A. Klewicki Tanae G. lewicki (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, 55. St. Croix County authenticated this day of , 19_ Personally came before me this 11th day of Decem3cier , 19. , the above named Josef A, Klewicki and Tanae G. Klewicki, husband and wife, TITLE: MEMBER STATE BAR OF WISCONSIN (If not, Br~,Cxl,„ _ - authorized by 5706 06, Wis. Stars.)' t} o be the per~b ho executed the foregoing Slat- 15" Wr and acknowl the ante. In" ;n THIS INSTRUMENT WAS DRAFTED BY Attorney Kristina Ogland g da Poulin Hudson, WI 54016 St. Croix Count Wis. Notary Public, Y (5lgnaiures may be authenticated or acknowledged. Both are not My commission is permanent. (Ir not2, state expiration date: necessary.) 11 / 19 / 000 19 • Names of persons signing m eny capaciu should be typed or panted below their signatures. STATE BAR OF WISCONSIN WI500n5O Legal Blank Co.. IM, WAkaANrl DFFD Form No. 1 - 1982 MiIWWkW, W15. FILED 10 AP R 2 4 1996 ► 11 oftaltum 5426G4 CEP T I EI ED S UP VE Y MAP Located in the Southwest quarter of the Southeast quarter of Section 10, Township 29 North, Range 19 West, Town of Hudson, St.Croix County, Wisconsin. Owned by: Joe Klewicki Po, 1022 Scott Road Hudson, Wi. 54016 L1 = N45°04'39"E 58.45' UN PLATTED LANDS ' 11~6~ I vv S 8944' 13"E 1 76,32' 33.00 _I---- 728.32 515.00' SHED WM M = CD co W ®HOUSE ~ N IL ®7r 0,3 NIv GARAGE ~ n11. Ill ; e+ m O X® 7T L2) m 515.00' 33.001.a~ _ I o N 89'44'130W 548.00' N Z - MSHED~ 1284•.56' o to I hl N 89' 44' 13"W 1317.,-;P6.'. • 1 21 : r ROVED ' 33.Q0' I 1 I ;i its r ; 4' '95 1 I . CX1 X 0.7l 1 " . (?AOIX COUNTY I CJ N t 4%#Af0ft*+3nsive Piard* I N ci I CD .>saning and w (1i s I- - - i I i3t~lS>4(N1it111ttAd 14 CU -+1 3 1 ~ i W aFt.UA:recorded NI n~ QI NI mttwn'M days of Wi OM O~ a1 0 V11 N J N Z I Q! I %I v Lot Acreages -U1`IUMshaVbe o ~I 00 Lot 1 = 1, 382, 020 Sq. Ft,. (31.727 'Ac) including ROW x; 0 10 0 1,,347, 433 Sq. Ft. (30,933 Ac) excluding ROW_ ~I u,r Q: NI z Lot 2 = 265,403 Sq.,Ft. ( 6.093 Ac) including ROW mi ' co of 262,`066 Sq. Ft. ( 6.016 Ac) excluding ROW of O~ ~I Lot 3 = 94,741 Sq. Ft. ( 2.175 Ac) including ROW 1 I ~I of 89, 036 Sq. Ft. ( 2.,044 Ac)~ excluding ROW o° I WI 1661 I~-I I ,r 100'-H I --A ~j Bearings referenced to the South 1 21 Qa line of the Southeast quarter 'of J1 S1/4 Cor Section 10, assun-md N89 47'41"W,. a :-~ex ; M1 z; Section 10 i ICI aol (St. Croix County aluminum a1 cap.) 1 Iti ~a 1285.00' '33.00'• a N 89' 47 ' 4.1 "W 1318.00' I` UNPLATTED LANDS_ - - SECOR. SEC. 10 • indicates 1 "X24" Iron pipe weighing 1.68 pounds ,t,~~! ~~~~i0St. Croix r Description. A parcel of land located in the Southwest quarter of the Southeast quarter of Section 10, Township 29 North, Range 19 West, Town of Hudson,- St,.Croix County,Wisconsin described as follows: Beginning at the South quarter corner of Section 10; thence North 00 degrees 21 minutes 11 seconds East 1281.96 feet along the North - South quarter section line to the Southeasterly right-of-way line of an abandoned railroad; thence North 45 degrees 04 minutes 39 seconds East 58.45 feet along said right-of-way line to the North line of the Southwest quarter of the Southeast quarter; thence South 89 degrees 44 minutes 13; seconds East 1276.32 feet along said North line to the East `line of said quarter section; thence South 00 degrees 19 minutes 47 seconds West 1322.09 feet along said East line to the South line of the Southeast quarter of Section 10; thence North 89 degrees 47 minutes 41 seconds West 1318.00 feet along said South line to the Point of Beginning, containing 1,742,165 square feet (39.995 acres) more or less, and being subject to all easements, restrictions and covenants of record. I,.W#rv", -G, _Johnson,,,r gigtsred Wisconsin Land Surveyor, hereby e:e _tilat under Idlr noon Q Of Joe, Xlevdicki, owner, I have surveyed and map ed the above de cribed ;prgperty; that such plat is a true and correct representation ofthe exterior boundaries of the land surveyed; and that I have fully,complied with.the provisio 's Hof Section 236.34 of the Wisconsin Statutes; the. St..,Cxoix Count ~r Subdivision Ordinance, and the Town of Hudson Subdivision Ordinance-to the best of my professional knowledge, u rstandipg and belief. AltA )A~ V22Aw oo C 0 Harvey G. 0bQ9on S-1899 4 Johnson Surveying, Inc. HARVEY Q. 216 Meadow Drive North JOHNSON = s Hudson, Wisconsin' 54016 S-1899 HUDSON = y~i < W IS O E SUR NOTE: Each parcel shown on this map is subject to state, county, and township laws, rules, and regulations (i.e., wetlands, minimum lot size, access to parcel, etc.). Before purchasing or developing any parcel contakct the St. Croix County Zoning Office and the appropriate town board for advice. . sVol. 11 Page 3083 (