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HomeMy WebLinkAbout020-1369-07-000v+ Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). Permit Holder's Name: ^ City ^ Village ^ T n of: Bast, Kernon Hudson Township CST BM Elev.: Insp. BM Elev.: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~eK s ~ Dosing Aeration Holdin K SETBACK INFORMATION TANK TO P/ L WELL BLDG. vent to Air Intake ROAD Septic >c~p' > S) ~ Z r '~ NA Dosing NA Aeration NA Holding ELEVATION DATA <o.ag-i4, u4~ STATION BS HI FS ELEV. Benchmark ~ 3, c(~ ~03~18 c~o.a ~ Alt. BM 20/y" I'~t) ov.D3 Bldg. Sewer v a"~ ~ SO , Z St/ Ht Inlet S .6~- ~(p.D}~ St / Ht Outlet S g~ QIS, ga r Dt Inlet Dt Bottom Header /Man. Dist. Pipe ~"~~- a~c~. 4~ r Bot. System S a' ~ s. ~2 p r X13 • `F Final Grade St cover a_3$ `l~'•36 SOIL A ~~RPTION SYSTEM / l t~'"°~`~' "~` , ~' ` ( '~. f IS. / C.~rs~„-~ ~~A1i.L,,,..~- ~`f-1cAw~-b0~s = ~~:s~ T-~wA.t~Y~ e-rw TREN Width L ng No. f T e ties PIT No. Of Pits Inside Dia. Liquid Depth DIMEN N ~ ~~~ 02 DIMEN 1 N SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manu act rer: INFORMATION TypeO ~. Dr 3~~ ~0~ ~'~ CHAMBER OR UNIT A ° elNumber• g ` System: l~r,U , ~ Y odit, DISTRIBUTION SYSTEM +°~ '`° Header / M nifold ~j, 61 ~Q Distribution i x Hole Size x Hole Spacing Vent To Air Intake ~ Dia. I Length 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 ^ Yes ^ No ^ Yes ^ No COMMENTS: (In Jude code discrgpancies, persons present, etc.) ~~ ~~ ~,,,, u„~c ~,~-- ~.Q, S~ ,sue,,, Q s `~o ~-a- c~ g 3, g ~I Q S` -r=~ D _"_ .~:' ,, ~, 5, Inspection 1:1 I / 3/ ab Inspection #2: / __ /_ t- Zocation: 96 Old Hopkin's act, Hudson, WI 5401 1/4 SE 1/4 10 T29N R19W) - 1029192197 Hopki ' airie -Lot ~ ~ Io t,~ 1.) Alt BM Description = v.~~ S:u otr G'~es-(' Sr~.'C Cec"r'sf ~'`' i~,5) t ~~~`'~. r~,x 2.) Bldg sewer length = a $' r`n / r mount of cover = ~ I $'~ ~.. as (~ ~u,,,,,,~ , 3~~ A-~Ir~ ~fU~.~-~I~ y~- ~ Plan revision required. ^ Yes ~'No ~~ 3 ~ 0 Us o ~erfside fpr additional informDt~pn. ~}.t,~, `~~~""'' J~~~ °~°"` '~~'`~,1e ~ Date - • _0 (f Ins ector'sSi nature SB 6710 (R.3/97) 3 ~ `C~'~^^,p~~ t ~'~ ~jev~ "v~D'~-y,~ X~- 1. P 9 County: St. Croix Sanitary Permit No.: 363986 State Plan ID No.: -.---,-. Parcel Tax No.: 020-1369-07-000 ~~O °t`~ ~l ~ _- Cert. No. PUMP /SIPHON INFORMATION .. '_,.~ ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ~~. _. _ -~ ~llt 11~ ~ 6 4G 0 ~ j{OP / nitary Permit Application Safety & Buildings Division _...-~--" ~ In accord with Comm 83.21. Wis. Adm. Code 201 W. Washington Ave. PO Box 7302 ` iseonsin See reverse side for instructions for completing this application • Madison, WI 53707-7302 Department of Commerce purposes Personal information you provide may be used for secondan [Privacy I.aw. s. 15.04(I)(m)J (Submit completed form to county if no state owned.; Attach com lete tans (to the county co v onl )for the system, on a er not less than 8-1/2 x 11 inches in size. County State Sanita Permh Number 'heck if revision to previous application State Plan 1. D. Number Sl'- C ~ 3ro ~~ ~- I. A lication Information -Please Print all Information 12 Location: Property Owner Name .~~ Property Location ~ ~(~ ~ 1 /4 /4, S '1~ ,N, Property Owner's Mailing Address 4 : t Number Block Number "s° w --- s _ m ~ _ City, State ~ Zip Code P o um a ivision Name or CSM Number II Type of Building: (check one) \'„`. ~~° ~ ~ f B d l i N ' ~~~~' City wa e ng - o. o 1 or 2 Family Dwe l rooms: ~ ~ ~ l d ib n of ~To e use): ( escr ^ Public/Commercia - ^ State-owned " '- ~` ~ ~"' III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road ,T /e~ q) 1. [New System 2. ^ Replacement 3. ^ Replacement of 4. ^ Addition to Parcel Ta Number s) Z~~ /~~~Q S stem Tank Onl ~ Existin S stem / ~- B) Perms Numbert ~~ Date Issued -"2®~ A Sanita Permit was reviousl -issued v IV. Type of POWT System: (Check all that apply) Non-pressurized In-ground ^ Mound ^ Sand Filter ^ Constructed Wetland Pressurized In-ground ^ Holding Tank ^ Single Pass ^ Drip Line ^ At-grade - ^ Aerobic Treatment Unit ^ Recirculating ^ Other: V Dis ersaUTreatment Area Information: ~ " ~ ~ - l. Design Flow (gpd) 2. DispersalArea 3. Dispersal Area 4. Soil Application 5. PercolattorcRate• 6. System Elevation 7. Final Grade Required - Proposed Rate (Gals./day/sq. t3.) (Min./inch) Elevation VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing Crete structed Tanks Tanks . ^ ^ ^ ^ c T.t'c - .~ r ^ ^ ^ ^ ^ VII Responsibility Statement I, the undersi ned, assume res onsibilit for installation of the OWTS shown on the attached tans. Plumber's Name (print) Plumber's Signature (no st ps): .p4P/MPRS No. Business Phone Number umber's A dress (Street, City, State, ip C e) VIII County/Department Use Only • ^ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) 'l~-pproved ^ Owner Given Initial Adverse Su~harge Fee) t / ~ ~ ^ , I~itM br'~'~-' Determination .t7fl ~ -2e- , IX. Conditions of Approval /Reaso4s fpr Disap re oxal: , ~r(~ ava.r t-.~;,-Ir+~k'src ~ 6.~+.,.v~~' 3 oe~R.a.. ~ ~ n - ~ 1~ ~I~PYra..t- ,r~a;~ nna+~.~~ui~. t~o.2~s...~c- at~~ ~ ~ uo ~,... ~ t t'tt.o+M.w~dt~~KS { V v ., e..G~~~~~ °~+-; vwr...~' ~s.- d2.eaef; 36 ,,( S~ y~ ~'`^r~ ~ 2 ~' . _ Oeaeteer~ ~_ /,~~ ~~r`us~ SBD-6398 (R. 07/00) o. n..na:...-.. n:.,:..:,. SanitarS• Permit Application ~arcry oa nuuwu~a a.~.~a~., A ' In arcurd isith C'umm 83.21. Wis. Adm. Coda vg . Washington 201 \A PO Box 73C i `~ Scc rc~crs~ siclr tier instructions lilt completing this application Madison, WI 53707-73C n SCO/fs I'rrsonal intiirmation ~~ou provide mad he used tier secondan purposes • Submit com I~ted form to count if n~ ( p ~ y Department of Commerce I'rivac Law. s. 15.Od(I)(m)J I } state owned Attach coin Ictc lans Ito the count. co v onh~l tix thr ss~tcm - ~ x 11 inches in size. County tilatc Sanuart I'crmu Number ^ ('heck i1 rrv i~ rrviou~licauon ' a Plan 11). Number • ~. 1. A lication Information -Please Print all Information L 'on: Property Owner Name ~ ~~ Pr 'Location Property Owner's Mailing Address 1. bet Block umber / ~~ ~~ 2~~!~ 7 City, State l.ip Code ('hone Num .fie division Name or CSM Number II Type of Building: (check one) ~ ^ City O Village ^ 1 or 2 Family Dwelling - No. of l3ednxnns: Town of ^ Public/Commercial (describe use): ~ O State-owned III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nrarest Road C LJ9f p) L I]f New System 2. ^ Replacement 3. ^ Replacement of 4. ^ Addition to Parcel Tax Numher(s) "'~~ Svstem "tank Only Existin S stem i920 ^ ~-- B~ Permit Numhcr Date {ssued ^ A Sanitary Permit was re~~ioush issued IV. Type of POWT System: (Check all that apply) '~ '~~ ^ Sand Filter O Constructed Wetland Non-pressurized In-ground r ^ Mound ^ Pressurized In-ground )p ta2S~ ^ Holding "tank ^ Single Pass ^ Drip Line O At-grade ~ l° (62-S~D Aerobic 3'reatment Unit D Recirculating ^ Other: 9 .zr _ . ~ ^ V Dis ersaUTreatme 1. Design Flow (gpd) nt Area Information: ' ' ~ ' 2. DispersalAre:t 3 Disprrsal Area 4. Soil Application ~. Percol3tton'Rate• 6 System Elevation 7. Final Grade vation El Q6 ~ Required - ' Proposed Ratc (Gals./daylsy tt.) (Min./inch) . e . ~/ ass f6 3 00 • VI Tank Manufacturer Prefab Capacity in Total # of Site Steel Fiber- Plastic lass C Information Gallons Gallons "Tanks Con- Crete on- g structed New Existing 3'anks "Tanks ^ D ^ ^ f ~ Z r O ^ O D D D VII Responsibility Statement assume res onsihilih~ tier installation of the PO shown on the attached tans. the undersi ned 1 , , Plu er' ame int Plumber's Si attire (no s) 'toH'FMPRS No. ~um~'i~~ & Perk Tes ing etr'~ o Business Phone Number ` ' y g .Z ~/!~!~ 7/3 -~3,f ~ X64 Plumbe s Ad ress treet, ify, .rate, Zip Cbde) Spooner, WI 54L..~1 VIII County/Department Use Only d sued U t I Issuing Agent Signature (No stamps) ^ pisapproved water Sanitary Permit Fee (Includes Groun a e s Approved ^ Owner Given Initial Adverse i i Su •harge Fee) ~s ~ ~ ~~~~~ ~ on nat Determ o IX. Conditions of Approval /Reasons for Disapproval: ~ ~ ~ ~~ 6~Q0-- ~ ; ~ z ~. ~s /• 2" /7.7 Fogerty Plumbing & Perk Testing 28288 McKenzie Rd. ~ Spooner, WI 5480 ~'` ~ ~~~ ~~zi~~~ ~~r~ ~~N,~s : ~l/~ ~r ,tom ~i s~ P~/ ' T°~ -- y3 7S ~ <od~ BST - ~ 7 S ~ LtivL CoT '~~ / `Pv ~ /~1'~F' / /er7.O d +~~ = A•c r ,&,~, Tod of ~' ~ vc /o3,a X = 1!o/t.~~~.s ®_ wfiYL ~-/ad ~tT~~ 7~~' /51GT- ~'~ •~ C~tc~r~~ T,~ont, a ~ CC.r~ C.rrvE g~ ~~ ~i-ice ~~ x g-2 30' `°r~~ X <m 7~'u I tk Z. x 8 3 2 ~ fhb .f90TE: ~.~'E~C'ff ~i~E'i¢- ~3sv~ ~ e ~~. ~v-~-vo a-v~+,t. ~~ ,.. 60' 0 ~ . ~ zz. I ,r/0 ~J'S ~ iU.E~s~r, ~ ~ 1 a-~ . ~ Bx3 ' x 6-I I I ~ ,i ~~~ ~ _ ~ ~-- 325 ' --~ I . _ ~ Q3 9 ` I / ~ 2 -- dCy ~/oPr~r~r/s ,,,tey - ~-- 1 Fogerty piumbing & Perk Tesdag 28288 McKenzie Rd. Spooner. VYi ~~~j ~l~~wo,~ ,~3~ ~/~pa /' r fl~~~'-z ~~ .~3 #`y ~( ' (~a) ~~ Qs.Y/ ~-6..tS l> C~Ur~~ut~~s o ~~ y /i~Pnvcfl~ € ~/ p~: F j6~•S ter # ~ ~~~ ~ = yo' ,rt df ~ To~ v ~ / ~'wch'~ PYG ~. bAD' d #a 7y~ e f- /'~vc /2t'pE ldS:a A = BoRxN~ . = J~vu~ LoT CoR,v~'R ©= t.s F'LC ~ Se ~ F~~ ~Ny ~Rr o ~ sysr~'a- ~/ ~ _ /, ado s.T ~/z~BE'~- ~~4T~,Z A-rao yo Gds ~ a.3- l~'~~ ~% i~ ~l~ I '~` t ,~ ~--- ',~r" f ~_ sj aj (/3 ~. i I 1 ~~ ~I ~~ 00 _I ~A II II (~ f~ i ~~~. I 3, Wisconsin Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must inGude, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Revfewed by Personal infomration you provide may be used for secondary purposes (Privacy law, s. 15.04 (1) (m)). Property Owner Property Location Govt. Lot 1/4 .~ 1/4 S Property Ownerai~~ddress Lot # Block # Subd. Name or ..~. © 'r City State Zip Code Phone Number ^ City ^ Village Town New Construction Use: ~( Residential /Number of bedrooms T Code derived design flow rate _ ^ Replacement ~ ~~ ~^ Public or commercial -Describe: Parent material ~~~~~ Flood Plain elevation if applicab~f•~ Page ~ of ~~ ~ ~~~ 3 ~ -®I -ov D Date l TZ_ N R E(o CSM# v ~ ,e.~E Nearest Road i GPD General comments ~,, ,,,,'!' p "'' and recommendations: ; ^~ / P~'~ElVE~ '`, ~,1 r ~ r f ~ ~ F 200Q ', ;I ~`r_, ST CR[ax © ^ Boring 9~ y, ~ ~~' ~OtvINGpF1=iCE ~ , Boring # Pit Ground surface elev. .~ ft. Depth to limiting factor 7 •, n ' ~~` r-~__._._ / p rCation Rate '$ Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bound odts.'. ! ~ GPDlft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - 'Eff#1 'Eff#2 Z .J L a32 in s • j ' £' 3 31-3s - ,~ G • 7 t. i --~ qs. `f~8 `f Boring # ^ Boring ? (/~ pit Ground surface elev. IOD.o fL Depth to limiting factor ~~ in. r Soil Apptiption Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftZ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'E(f#2 Z ~_ ~ ~ 2. - L - . Z 3 .s-_ --- ._ i ss.~f~ 1. ~ ~ ' Effluen t #1 = BOD_ > 30 < 220 ma/L and TSS >30 < 1 50 mall ' ' uent #2 = B00. < 30 mg/L and TSS < 30 mglL - CST Nam (Please P ' S' natur~____ CST Number Address Fogerty Plumbin & Perk Tes#ing Dat valuation Conducted Telephone Number 28288 McKenzi ~ /-°- ~~~` ~ -~60~ Spooner, WI 54801 t R y Property Owner /°~'~ Parcel ID # • ^ Boring Page 2 of ~ Boring # ILJ Pit Ground surface elev. ~ tt, Depth to limiting factor ~' 90 in, Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in• Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. s= 3 .L ~ ~ 3 - s~ L aa.ro/63.~~0,1 -- 3v 'Eff#1 ~ •Eff#2 7 .Z Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bounda Soil Application Rate in. Munsell Qu. Sz. Cont. Color ~' Rood GPD/ft~ Gr. Sz. Sh. •Eff#1 ~ •Eff#2 Boring # ^ Boring ^ pit Ground surface elev. ft. Depth to 1(miUng factor In. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bounda Roots Soil Application Rate in. Munsell Qu. Sz. Cont. Color ~' GPD/ft Gr. Sz. Sh. •Eff#1 •Eff#2 'Effluent #1 =BODE > 30 < 220 mg/Land TSS >30 < 150 mg/L • Effluent #2 = BODa < 30 mg/L and TSS < 30 mg/L The Dept-rhnent of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at G08-26G-3151 or TTY G08-264-8777. SB0.8330 (R.W00) /2 y' ~. X 7s' x--30 X 13 3 S' x n- ~ 1,/ d~ lf~ y~A~''' r ~~~ / 11. ~ c ~L T ~ ~ l ,~ ~ ~ ^~ I. I~ ~I ~I Fogerty Plumbing #221180 28288 McKenzie Rd. Spooner, WI 54801 (715) 635-9609 ~~ ~- ~~~ ~~ ~o ~ ~--o~ GmT ~ f B~ ~ ~3o17'm~ ~~ ASC S'rAz"X/~~ /mA~ ~' 2 =rK~• $iw~ Je~ mf fbliR~D ~LiE'~'u1 w~ui fp. pd . e ~ ~uw0 GmP L~t'tiesr, cat ,~Gcv~ 9s s8 ' Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 . Labor and lduman Relations - ~' Divisinn~~f Safety A Ruildinas '- ____-~ ---:.~ ~~ ~ ~~ .,., ..~ ~./'s .AJ~ n_~_ 111 GVVV~Y ..~~~~ i~~ ~~ a VV.V V, ••~V• •.v.... vv4v COUNTY but Plan must~tj Attach com lan on a er not les than 8 1/2 x 11 inches in size let it St. Croix , p p p . e s e p s not limited to vertical and horizontal reference point (BM), direction and °fo of slope, scalear' i~? PARCEL LD. # dimensioned, north arrow, and location and distance to nearest road. t ~ 020-1010-70-000 I4N ,:.r~,~ APPLICANT INFORMATION-PLEASE PRINT ALL INFORMA`T REVIEWEDB DATE , .. - ~~ PROPERTY OWNER: PR6'tF ~i~CATION Kernon Bast GOVT L01`''1d'BG 1/4 ' 1/4,S10 T 29 ,N,R 19 ~ (or) W PROPERTY OWNER':S MAILING ADDRESS `LOT # BLOCK#. S .NAME OR CSM # 848 LaBAr e Rd. 7 na - Hopkins Prarie CITY, STATE ZIP CODE PHONE NUMBER ^CITY ^VILLAGE ®fOWN NEAREST ROAD Hudson, WI. 54016 (715)386-7775 Hudson Olk Hopkins Pi. [ ~ New Construction Use (x] Residential / Number of bedrooms 4 ( ]Addition to existing building j ]Replacement [ ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate • 7 bed, gpd/ft2 ' 8 trench, gpd/ft2 Absorption area required 858 bed, ft2 750 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 •8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 96.90 ft (as referred to site plan benchmark) Additional design !site considerations trenches 4.00' below grade spaced to code Parent material outwash Flood plain elevation, if applicable na ft S =Suitable for system CONVENTIONAL C~ S^ U MOUND C~ S^ U IN-GROUND PRESSURE ~E7 S^ U AT-GRADE iJ S^ u SYSTEM IN FILL ~] S^ U HOLDING TANK ^ S ~I U U=Unsuitable for s stem SOIL DESCRIPTION REPORT Boring # 1 Ground elev. 100.9 ft. Depth to limiting f+90 Boring # :.. :::.2.. . :. . ................. Ground elev. 101.1 ft. Depth to limiting factor +90" Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Horizon in. Munsell Du. Sz. Cont. Color Gr. Sz. Sh. Bed Trertdi 1 0-9 10yr4/3 none sl 2mgr mvfr gw 2f .5 ~ .6 2 9-90 7.5yr4/6 none cos ~- Osg ml na na .7 .8 ~~ qq ~a o ~,a ,p~ ~- Y8 8y Remarks: 1 -10 10yr4/3 none sl 2msbk mfr gw 2f .5 .6 2 10-16 10yr4/4 none sil 2msbk mfr gw lf. .5 .6 3 16-90 7.5yr4/6 none cos Osg ml na na .7 .8 .~ ~~' ~ ~,~ 2 Remarks: CST Name:--Please Print Gary L. Steel Phone: 715-246-6200 Address: 1554 200th. .New Richmo WI 54017 Signature: ~ Date: 11-17-99 CST Number: m02298 PROPERTY OWNER Kernon Bast PARCEL I.D. # 020-1010-70-000 Boring # 3 Ground elev. 99.8 ft. Depth to limiting f+90" Boring # >` 4 s ................. Ground elev. 97.6 ft. Depth to limiting factor ~[]n n Boring # .................. 5 Ground elev. 97.3 ft. Depth to limiting factor +90" Boring # .................. ................. .................. ................. .................. ................. .................. Ground elev. ft. Depth to limiting factor SOIL DESCRIPTION REPORT Page-~.--of 3 , Horizon Depth Dominant Color Mottles Texture Structure Consistence Bour>dazy Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 0-8 10yr4/4 none sl 2mgr mfr gw 2f .5 .6 2 8-90 7.5yr4/6 none co Osy ml na na .7 .8 b 1' ~s s Y$ ~'~` ~` Remarks: 1 0-10 10yr4/3 none sl 2myr mfr gw 2f .5 .6 2 10-17 7.5yr4/4 none is Osg mvfr gw If .7 .8 3 17-90 5yr4?~ none cos Osg ml na na .7 `.8 Remarks: H-3 non-contiguous sil 10yr5/4-mott. 7.5yr5/8 lens 10x25" 1 0-8 10yr4/4 none sl 2mgr mfr gw 2f .5 .6 2 8-90 7.5yr4/6 none cos Osg ml na na .7 .8 Remarks: Remarks: SBD-8330(8.05/92) 1 ~ ~~ STEEL'S SOIL SERVICE Gary L. Steel Kernon Bast 1554 200th Ave. CSTM2298 NE4SE4 S10-t29N-R19w New Richmond, WI 54017 MPRSW-3254 town of Hudson (715) 246-6200 lot #7-Hopkins Prarie This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. The location of the test may or may not be as shown as permanent Iot lines mere not established at the time the test was conducted. N `~ /i"=40' /~M.= top of 1" pvcpipe Cel. 100.00' /~lt. BM.= top of 1" pvc pipe C el. 105.00' ~'~ Gary L. Steel 11-17-99 . ' l~ Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT Page ~ of in accordance vntn Comm tf5, wis. Ham. ~,ooe County ~ ust Pl 11 i h i i 2 ~ d an m nc n s ze. x es Attach complete site plan on paper not less than 8 1/ include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. .Z ~ .-- / ~N ~ ~-- ~,- ~~ Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~ '~~ ~ ~ ZOQ9 Prop rty Owner Property Location ~' ~ Govt. Lot ,G 1 /4 ~ 114 S p T,Z N R E Properly Owner's Mailing Address Lot # Block # Subd. Name or CSM# P YJ' L~ ~~ City Sta Zip Code Phone Number ^ City ^ Village Town Nearest Road ~/Xo~ a ( F _ Ff Gr o/1/ o c ~ ,mss New Construction Use: Residential / Number of bedrooms _ ^ Replacement ^ Pubi' or commercial -Describe: _ Parent material General comments and recommendations: Flood Plain elevation if applicable LJ Boring Boring # Pit Ground surface elev. /DDTQ ft. Depth to limiting factor 7 ~iZ in. Soil A lication Rate mi C l i tion D R d Texture Structure Consistence Boundary Roots GP D/ff Horizon Depth in. nant o or Do Munsell p escr e ox Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Effft2 ~ _ 3 7 L Z .~-- ru G 3 0 - ~-- s ~ !mar/ - /. / 4 60 , ~ O l /^ r B I~/r Y ~f "Q Boring ~ Boring # ^ Pit Ground surface elev. _ ft. Depth to limiting factor in. Soil licetion Rate ri H th D r D i t C l tion Redox Descri Texture Structure Consistence Boundary Roots GPD/fP zon o ep in. om nan o o Munsell p Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 •- ~" 'Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 15o mg/L - tmue c ~c ovu = av ~ ~ ~y~~ a..u ~ ~.~ _ .+~ , ~,~ CST Name (Please Prin ~-^ ignature CST Number Address ate Eva uatwn Conducted Telephone Number ~~.~('Q" Guy ~ ~, ti ~ ~o/ -~ ~s~ ~ pd _ Code derived design flow rate GPD Property Owner Parcel ID # _ Page _ of Boring # ^ Boring ^ Pit Ground surface elev. _ ft. Depth to limiting factor in. Soil ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2 Boring # ~ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil plication Rate Horizon th De Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ff? p in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2 a Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate i H D th ant Color i D Redox Description Texture Structure Consistence Boundary Roots GPD/ff or zon ep in. om n Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2 " Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L 'Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.6/00) Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In-Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWT$) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In-Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- Table 1: Svstem Design Specifications Sanitary Permit Number Number of Bedrooms Design Flow -Peak (gpd) (oe'O Estimated Flow -Average (gpd) Septic Tank Capacity (gal) 2(o O Soil Absorption Component Size (ftz) aD '°°° ~•Z w.4~k g~• Type of Wastewater Domestic TahlP 2~ Steil Abserntien Component -Limits of Reliable Operation --- --------r-- r---- Septic Tank Component Soil Absorption Component Design Flow -Peak (gpd) cY0 Maximum Influent Particle Size (in) 1/8 Maximum BODS (mg/L) 220 Maximum TSS (mg/L) 150 Tab le 3: Maintenance 5cneau~e Septic Tank Inspect and/or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years Seatic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the Management Plan for a Septic Tank and Soil Absorption Component filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of scum and sludge in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not.removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. Manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8-inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No one should enter a septic or other treatment or holding tank for any reason withouf being in full compliance with OSHA standards for entering a confined space. The atmosphere within the septic or other treatment of holding tank may contain lethal gases, and rescue of a person from the interior of the tank maybe difficult or impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are shown in Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shall include recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surtace seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human health hazard. Traffic around or over the soil absorption component should be avoided particularly during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to more intense, and earlier, organic clogging of the soil. 2 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/~gcr ~.ei1/o~ , ~-rTT Mailing Address 0'`~b' Lo, /S~-~o~ ~~ ~~ ~1~T ~~~- `~l~ Property Address ~ ~~ C ,~ S (Verification required from Planning Department for new construction) City/State f~G~~d7''~ t~y..Z' ~©~~ Parcel Identification Number ODD -/36 7 -D 7 -~ LEGAL DESCRIPTION Property Location ~ '/~, Ste' %<, Sec. /o , TAN-R,1~VlT, Town of l~~l~s'a/~ Subdivision ~da/lirr/I ,~.~iP.t~ ,Lot # ~_. Certified Survey Map # ,Volume r-- ,Page # ~~ Warranty Deed # ~B,S-.~'~ ,~ ,Volume l ~/3 ~ ,Page # Spec house ^ yes J~ no Lot lines identifiable ~ yes ^ no SYSTEM MAINTENANCE Improper use.and maintenaticeof 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 masterplumber, journeymanplumber, testrictedplumber or alicensed 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 day of the three ye r exp~ tion date. _-~ ~/ /~ SIG ;ATURE OF PLICANT 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 pro erty described bove y virtue of a warranty deed recorded in Register of Deeds Office. av ~~~ ~' i 3 i SIGNATURE OF A ICANT DATE ****** Any information that is tnis-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 YQI. 1436FaG~ 516 ~osss~ Document Number WARRANTY DEED REGISTER Of DEED5 ST. CROIX CO., WI This Deed, made between, Jean M Hendrickson RECEIVED FOR RECORD Grantor, Oli-21-1999 8:30 AM and,Kernori J Bast and Donalda J Speer-Bast YtYNiAMITY DEED husband and wife, as survivorship marital property Grantee. ElIEf~T N Witnessath, That the said Grantor, for a valuable consideration of one dollar and CERT COPT ~~ COPY FEE: other valuable wnsideratlon conveys to Grantee the below described real estate in TRIER FEE: X50.00 St. Croix County, State of Wisconsin. RECORDING FEE: 10.00 PRGES: 1 This is not homestead property. Together with all and singular heroditaments and appurtenances thereunto belonging; And Grantor warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except Recordi Area aasamanta, covenamta , and rastrietiorfs of record, Name and 12etum Addreas and will warrant and defer)d the same. FIRST FEDERAL SAVINGS (Parcel Identification Number) 201 SOUTH SECOND 020-1010-70 HtmsoN, wi sao16 Part of the NE'/. of SE'/4 of Section 10-29- I9 described as follows: Beginning in the center of Scott Road at the NW comer of Lot 1 of Certified Survey Map, filed in the office of the Register of Deeds for St. Croix County, in Vol. "3", Page 651; thence N89°48'13"E 551.0 feet along the N line of said Lot 1 to an iron pipe mo^tunent; thence Sly along the E line of said Certified Survey Map to the SE corner thereof; thence N89°48' 13"E 759 feet to an iron pipe stake; thence Nly parallel to the E line of said Section 10 a distance of 924 feet to an iron pipe montunent; thence W 1320 feet to the center of Scott Road; thence Sly along the ceaterline to the point of beginning. Dated this [,day of , 1999 lr~ ~ h ..l~'' ~, n M Hendrickson AUTHENTICATION Signature(s) authenticated this _ day of al ~~ I type or print name TITLE: MEMBER STATE BAR OF WIC (If not, authorized byQ70ti.06, wis. Stets.) THIS INSTRUMENT WAS DRp Robert F. Wall (Signatures may be authenticated or aekna necessary) ACKNOWLEDGMENT STATE OF WISCONSIN COUNTY ST. CROIX Personally came before me this ~Sday of ~^ ~ ,~+`1 1he above named Jean M Hendrickson to me known to be the person(s) who executed the foregoing instrument and adtnowledge the /n, ~ type or pool name ~~' ~eriP. ~ • ~~1 Yn 'i~f Notary Public County, . S~• OiX ~My commis~~ ~ permanent. (If not, elate expiration date: CJ D~•) of persons signing in any capacity ah°uld be typed or below their signatures. ~a d ~ r ~~ 1 r ~ ~ i ~ i i ~~ g~ e~ ~... I I ~ i r i ~ r ~~ ~i 1 _rl~ ! ~1 ~h , ~ ~ t.4~ ~~.~ ~~~fi~, NZ ~~ .F' ~~ i, i~ p '~a z ~~ =• ~ t ~ R r =~ ~ 1 f a ~ _ ~ ~~ x e Diu i ~ ss/ q ~ ~~ t i '~'~S r ~. 1 1 N' ~-1 r L _J I 1 L N ~ ~ ; ~ '~--~ r '1^-- i I i Awlii /y! w q ws~o UnrPL,tTTtD LdMAS OINSD DY OTl1tRS i E .~ n @ i ~ ~ ~. ~ ^ ~: ~. ~~ ~" ,' ~ ~ R~ is +~~ .''~~~~ R f t i ~ ~ k ~ ~ ~ ~ 4 ~ ~ ~~~~ ~~r Y ~ ~~~~~ ~~~ ;= ,~, ~~ ~ ~ ~~ ,i ~3 ~~r~~~~~=a N 'I.i ~Y.iy jYNM N~ ~~le~j;~~a~t ,x~ ~q1t~ ~~~:~ .~i ~ Y N M P~Ylel11`!~ ~' aYr=~=~"a~i~#i $Qptlt~l~ltiy=~Y:~~ ~1t ~Si~~;4~~~~ n~swassas~wisi ~y ~t~~~~~~~!~~KI ~~ n«1<~<~eP1AM1 ~~ ~/1 a f i i M i i 1 N M M ~ i~~~~1~Si~,3'~z~~l n<•111l1<~~n~i ', 9pp'21'u"v ~I.oa' - U-3'r tMS a' n+C wc~l~ C/ nK 3C~/~ SI~LCl~4TTAQ I~6l~Q,~ ~1.~IGIr9,.~ ra inr~rAi._I~OJw. ~. (oq~ o L~ K+N Sanitary Permit Applicati n Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. PO Box 7302 ~~~~~~, See reverse side for instructi s for completing this application Madison WI 53707-7302 aepsrtneent afrGnmmeree Personal information you pr tde ay be used for secondary purposes [pri cy La , s. 15.04(1)(m)] , (Submit completed form to county if not state owned. Attach com fete lans to the co co on for the stem, on a er not less than 8 -1/2 x 11 inches in size. County State Sanitary Pe rt Number Check if revision to previous application State Plan I. D. Number - .. - 3b 3 ` I. A lication formation -Please Print all Informat' n Location: Property Owner ame ~ Property Lacatio ~T / 1/4 1/4, $ab 'Q N, o Property O is ailing ddress Lot N r Block Number ~B ~ 1 S"l ~ City, Stat / Zip Code Phone Number Subdivision Name or CSM Number II. Ty a of Building: (c k one) of Bedrooms :~ Dwelling o or 2 Famil ~ 'ty ~ Village . y ,~^ ~["~ ib ): i l d bli /C ^ P Town of es e se _ ommerc a ( c u l/ ¢ O ^ Stiate-Owned i / m ~~ S^ P 1 ax N s ` ~ ~ .. III: T e of Perm' : Check onl one o on line A. C eck box li B if licable Ay) 1. New 2. ^ Replaceme ' 3. ^ R lacement f 4. 5. 6. ^ Addition to I S ste S stem 1 Tan Onl Existin S stem ) Pe~it ber~ Date Issued "' A S Permit was reviousl .issued IV. Type of OWT System: (Check al~that appl on-press rized In-ground M d ^ Sand i r ^ Con ructed Wetland ressuriz d In-ground ~ ding Tank ^ Sin ass ^ Dri Line ^ t_ ~ erobic Treatme Unit ^ Re 'rculatin ^ Ot r: is rsal/Treatment Area Inf V ation: . 1. Design Flow (gpd) 2. Dispersal Area e 1 4. Soil A lication 5. P olation Rate 6. stem Elevation 7. Final Grade Required Pro to (G sJday/sq. ft.) (M' ./inch) Elevation dt~ o , ~~ 9 ° VII. Tank Capacity in ~ otal # of anufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Co - glass New Ex' ing Crete stru ted Tanks n ' ^ ^ ^ ^ C 2 '- ^ ^ ^ ^ ^ VIII. Responsibility St ement I, the undersi ed, as me res onsibili for installation of POW o on the attach la s. Plumber's Name (print) Plumber's Signature (no ps): ~~IPRS No. B ess Pho Number ~ ~ ~-.. 2.Z 0 3 0 Plumber's Address treet, City, S e, Zip Code .Z-p ~' Zl"~2' 0 IX. County/Department Use On ^ Disapproved Sani ermit Fee (Includes Groundwater Date Iss Issuing Agent Signature (No stamps) ,Approved ^ Owner Given Initial A erse ge Fee) ~ ~ ,-~'' ~ ~ ~ s~~ ~ -.~ Determination • -' _ _ X. Conditions of Appr /Rea on r a pr vale ~, - ~ ~j ~~,Z ~p 36 S~s~^^" ~ e ~~. ~ ~Q[~r'~teua~ T-.rw~ p ~ / ~J(A~J o Ir i l0 ~ S _ S~ S t ~f ~ 1 _ ~ . p ~ ,r / ~_ ~ A. Fogerty Plumbing #221180 28288 McKenzie Rd. Spooner, W~ 54801 (715) 635-9609 ~ ~~~w. a~~ ~~~ ~v~j'-o~ ... X S ~ T7~ufi #3 rs s«~: I ~3 TitL'.tiG~f ~3 -mss > X ~~ 'Dr r ~/~ ti N r ~ ~ ~ ~ - ~ ~~ I Y R°~!~'- S, r ,~s~'- I L oT ~dl 7 ~~ ~~ /~E. S'r'Az'~~~ /~~ l ~`~" c~l~suT -- _ I fbaREO ~2 y ~ ~ ,~~ r ~ ~,~`ui gyp, y6 . ~,t,dR ' ~ i I ° ~ ~~~ ~ ~ so ~ F,cerr . ~ sys~~'.w~ ~ O a.~ ~R ~ ~ -X. ~ I -- G~i~ ,ri ~ _-