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HomeMy WebLinkAbout020-1412-40-000Wisconsin Department of Commerce Safety and Building Division ~ n PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) 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 Preferred Build rs Hudson Townshi CST BM E~: ~ ~ Insp. BM Elev: BM Description: I/ TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic loos Dosing Aeration Holding TANK SETBACK INFORMATION ~r~i, ~~(~,-~P/II TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ ~~ ~~~ ~S ~ ~s~ -~~ Dosing ' ' ~~ ~. ' ~ ~/ ~ .--._. Aeration Holding PUMP/SIPHON INFORMATION S r ~~ ~ to Manufacturer Demand Model Number P~ ~ ~~ TDH Lift ~/ / ~ riction o em H Ft Forcemain / Leng ~ ~ ia. ^ ~/ Dist. t Well / ~ SOIL ABSOR O YSTEM ~ ~ l 9 _ ~ ~ ~ county: St. Croix Sanitary Permit No: 430682 0 State Plan ID No: Parcel Tax No: 020-1412-40-000 SectionlTown/Range/Map No: 10.29.19.2596 STATION BS HI FS ELEV. Benchmark 2 3 7b o , a Alt. BM Bldg. Sewer ~P• (~~ St/Ht Inlet 1~1$ ,LZ SUHt Outlet 7- Dtlniet ~/ ~~J~ p~ .D Dt Bottom Z.a 1.3 Header/M n. ~/ ^E' ~~ Dist. Pipe s~ ! 7 ~` 1J / Bot. System ~ 2 ~ ~ S ~ ~~ 6 Final Grade v St C ~ r i ~,~ , ~ 7 ~ BED/TRENCH Width r Length ~• 3 ~ renches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ 8 j O 3 SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manture :_ INFORMATION CHAMBER OR Type Of System: ~Q~,aJ ~ ~ ~~~ ~ ~/ UNIT Model Number: i DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Spacing Vent to Air Intake i // Length Dia l Pipe( Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Onlv Depth Over ~ Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center ~ ~~(~ Bed/Trench Edges ~ ~ '1 ~ ~ Top Yes No ~~ COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~/~/~~~L Insp~c~~ ' Location: 635 Wildflower L~a~n~e/~HLu~dson, WI 54016 (SE 1/4 SW 1/4 10 T29N R19W) Burkhardt Prairie of 4 P/arcel No~10L.29.19.2596 1.) Alt BM Description = /%'"~~" ' ~ GVW~ `~ ~~ SD1~~S - ~ljt ~ I`''~~~ 2.) Bldg sewer length =~7 ~, /Q[,~~~ ~~~ Q-B `~ p~,t fit - amount of cover = 30 ~ Q ~ ~ ~.J (/ "• ~~ Plan revision Required . Yes No ~ : ~~?~~ - Use other side for additions formation. I___-_ _ I-~ i~ - ~t!" __- __,. C~~J. (J__ to ~ --- _ __ _ _- ---- j/ Date Insepctor's Signature ~ C^/~~~ Cert. N . SBD-6710 (R.3/97) ~ fig Safety ut ~n d g ounty t T, ` ~ ~ 201 W. Wash ngton i ,~~~~5,~ Madi , WI 53707 - 7162 anitary Permit Number (to be filled in by .) Department of Commerce (08)260-~-ISI rr(~(,+~; ~ l:. ~~ ~ (s~ ~ p~ Sanitary Permit Appile tion T Y sate Plan LD. Number X COUN In accord with Comm 83.21, Wis. Adm. Code, personal info ation~u ~ ~e iCE F p ~ may be used for secondary purposes Privacy La .04 -} .4 ,. ,r,e~" ~~ roject Address (if different than mailingaddress) . r , [. Application Information -Please Print All Information /( }^ ~ t Propert wner's ame t ~ Parcel # Lot # Block # / / /~ ~ r Property Owne s Mailing Address P operty Location ~~ ~ ~ ~ r ' / S~ %. ~tMG Section City, State Zip Code Phone Number , , M of ~ era -aa ~ - as s3 C~ r~'e T ~ `N; R E o~ II. Type of Building (check all that pply) i rd,+ ~ ,Cwl or 2 Family Dwelling -Number of Bedrooms Subd vision Name M Number ` ^ Public/Commercial -Describe Use , w . ~ . ~ /~-~ / ^ State Owned -Describe Use ^City_^V'llage ownship of III. T ype of Permit: (Check only one box on line A. Complete line B if applicable) A' New S stem ` y ^ Replacement System ^ TreatmendHolding Tank Replacement Only ^ Other Moditicati n to Existing System B• ^ Permit Renewal ~Pennit Revision ^ Change of ^ Permit Transfer to New List Previous Pennit Number and Date Issued Before Expiration Plum Owner v~ _~~ ` IV. T of POWTS S stem: Check al{ that a 1 - -/a O .Non -Pressurized In-Ground ^ Mound > 24 in. of suits a so' ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter Leaching Chain ^ Drip ine ^ Grave s Pipe ^ er expla' V. Dis ersaVTreatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required sf) Dispersaal rea Pro ed System Elevation ~ r Y.~ q~~ VI. Tank Info Capacity in To[al Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Taiilcs Septic or Holding Tnnk /O~ _ A^/,~ e~G/~-~ `~ Aerobic Treatment Unit w ~ I Dosing Chamber r.. / VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plum er's Name nn Plumb Sig lure PItS Number - Business Phone Number GlT aao~s ~ his- ~d S- ~~ Plum er's Address (Street, City, State, Zi Code) ~ ) ~•- I/ / ~s ~f VII ount /De artment Use Onl Approved ^ Disapproved Sanitary Permit Fee (i ludes Grou tdwater Surcharge Fee) ~/ ~~ Date Issu d l Q suing Age Sign re mps) ^ Owner Given Reason for Denial D (O ~ 3 QJ IX. Conditions of Approval/Reasons for Disapproval n Ct a~Dlt~ ~(~'~~ ~ ~D-~ ~!'~~~,~L 7 ~~ Attach complete plain (to the County only) for the tystem oa paper not less than 81/2 x l l inches in size s h. 0 SBD-6398 (R. 01/03) 3- ~ ~d0 'Z~ sy q ~ /oo~ ~ sr- 7so y,~-Q ~/~" I'~ Ho` ~ P~ ~-_a ~ 9~~~s~ G~a.~ 7 a- v PUMP CHAMBER CROSS SECTIOrJ Af\1G SPECIFICA~rI0A15 'i'~C.I. VENT PIPE ~ 25' FROM DOOR, WIAIDOW OR FRESH AIR INTAKE 18" M 1 A.I. INLET * A D c ELEV. FT. D ~Ar,F c;F APPROVED LOCKIAIC MAAIHOLE COVEF `i"MIN. 1 B" /"i I A1. I I I~~ I ~ ~ ~I' ~ i ~ ~ I ~ ALARM ~ tl 1 I ~ I ON ~ I . I --~ -1 OFF ~~.~ PUMP -~ COAICRETE BLOCK SEPTIC E DOSE TANKS ALARM PUMP RISER EXIT PERMIZTED OIJLy IF TA1JK MAAiUFACTURi`R HAS SUCH APPROVAL MANUFACTURER: V PROVIDE AIRTIGHT SEAL *APPROVED JOINTS WITH APPROVED PIPE 3' ONTO SOLID SOIL SPEGIFIGATIOf~JS S TAAJK SIZE : ~ ~ GALLOAJS MANUFACTURER: 1..rL[ ,/ y~ I/ MODEL IJUMgER: SWITCH TYPE: _ MANUFACTURER: ~ ~ MODEL iJUMDER: I ,~ ~~VV // - IJLIMBER OF DOSES: ~ PER DAy DOSE VOLUME /,, II~JCLUDING BACKFLOW:. `"` GALLONS CAPACITIES: A=~~IIJCHES OR 37(D GALLONS J~ INCHES OR ~ Z, r~ ALLOAIS C=JJ~r1(_tUCHES OR C~ GAtt01J5 D ~ J INCHES OR -1..5~"'"GALLOAJS SWITCH TYPE: ~ NOTE: PUMP ANO ALARM ARE TO OE MINIMUM OISCHAR6E RATE..~_6PM INSTAlLEO ON SEPARATE CIRCWTS VERTICAL DIFFERENCE DETWEEN PUMP OFF AAIO DISTRIBUTION PIPE.. '~~FEET C~ + MIAJIMUM AJETWORK SUPPLY P/RESSUR~,E/.. .. '2"'S~ FEET f/~,3 -~ --L.~ FEET OF FORCE MAItJ X l~~o F/ooFtFRIC71oN FACTOR.. "~1- FEET = TO A y1JAMIC HEAD = f ~ EET f _.. I~ IAITERAJAL DIMEfJ510AJZ OF TAAJK: LENGTH ;WIDTH . -;LIQUID DEPT~~ SIGIJE D: LICEA.ISE NUMBER: ~ ~D ~~ ` DATE: ~jVENT CAP WEATHERPROOF JUNCTION BOX 12"M I U. I GRADE I I COA]DUIT ~-- ~GOULDS PUMPS APPLICATIONS Specifically designed for the following uses: • Effluent systems • Homes • Farms • Heavy duty sump • Water transfer • Dewatering SPECIFICATIONS • Solids handling capability: '/<" maximum, • Capacities: up to 60 GPM. • Total heads: up to 31 feet. • Discharge size: 1'/z" NPT. • Mechanical seal: carbon- rotary/ceramic-stationary, BONA-N elastomers. • Temperature: 104°F (40°C) Continuous 140°F (60°C) intermittent. • Fasteners: 300 series stainless steel. • Capable of running dry without damage to components. Motor; • EP04 Single phase: 0.4 HP, 115 or Z30 V, 60 Hz, 1550 RPM, built in overload with automatic reset. • EP05 Single phase: 0.5 HP, 115 V or 230V, 60 Hz, 1550 RPM, built in overload with automatic reset. • Power cord: 10 foot standard length, 16/3 S1TW with three prong grounding plug. Optional 20 foot length, 16/3 S1TW with three prong grounding plug (standard on EP05). ® 1003 Goulds Pumps Effective July, 2003 B387t • Fully submerged in high grade turbine oil for lubrication and efficient heat transfer. Available for automatic and manual operation. Auto- maticmodels include Mechanical Float Switch assembled and preset at the factory. FEATURES ^ EP04 Impeller: Thermoplas- tic semi-open design with pump out vanes for mechanical seal protection. METERS II FEET 10r 9 a o ~ a w x _v 6' a ~ s 0 a a 0 ~ 3 t0 •~ 0 Submersible Effluent Pump .. EP04 & EP05 Series ^EP05 Impeller: Thermoplas- ticenclosed design for improved performance. ^ Casing and Base: Rugged thermoplastic design provides superior strength and corrosion resistance. ^ Motor Housing: Cast iron for efficient heat transfer, strength, and durability. ^ Motor Cover: Thermoplastic cover with integral handle and float switch attachment points. ^ Power Cable: Severe duty rated oil and water.resistant. ^ Bearings: Upper and lower heavy duty ball bearing construction. AGENCY LISTING S A, Canadian Standards Assodation y File # LR38549 Goulds Pumps is ISO 9001 Registered. Goulds Pumps ITT Industries 0 2 4 6 $ 10 12 m~/h CAPACITY I n ~' m y o 7 m 3. ,.~ N 7 .C fp N O C tD r (.~ S A W O C O ~ NO a ~ d '0 N V C cnzD I m ~ D ~' ~ Q. c° 3 I ! O I o Z C '0 ~+ c0 c (~ d S+ y Q o °' m I W a I ~ N a I z 0 I ~ ~ ~ O ~_ ~ 3 ~ ~ a ~ I ~ o S c II W C N y ~ a z m m 3 Z m o ~ ~ O m x <_. m in M ~ N N .n. d7 O O N ~ ~ ~ N aye I ~ •a ~ ~ ~ v m o oo~v~-,v n 3 N d N O~ d ' 06 ~ Oµ ~ O O. 3. ~ > f~ N 7 ~ N ~°'~' ~ ~ ~ 01 N fD p ]~ W OZ O- ~ N O O C y 'C p (D fD• d 3 ~ 7 'O ~ _O N ~ 7c c ~ p- `~ K G1 ~ (D ~~N'd~ 7 f ~ 3 ~ ~ m ~ Q I ~°~•mm~ O N f~D O ~ N C N ~ ~ ~ O 7 _O ~? O - - -., y d p < O ~ co ~~~ I ~ ~~ I o I °o a o O I 3 m o d I A O c O f1 ~ ~ 3 '~ ~ '~ C 'O k r ~ ~ * . ~ ~ ~ ~ ~: 3 ~ ~ '~ ~ ~ 1 ~ ~ ~ ~ W~ _ C O N t J O ~ N N Q c0 1~ p [Xl N W O O N G. ~ ~ ~ O m ~ O 7 N O C N y S O ~ ~ . . rn a ca'„ a ~ ~~ ~ ~ N ~ A N ~p 0 0 I O ~ ~ f1 r ~ N ~ ~ A A O i I 3 Q ~~ 2 ', '0 ~ ~ '0 a '~ ~ ~ °: O O O y ' ~ r( C C G 4 ~ G 7 ' ~' A W ~ ~ v o :: ~ ~ m ~ ;' v n ~ ~ ~ ~ 3 °-' ' ~ :.. ~ ~ o ~ I , - ? o ~ ~ I f o m I p I ~ I ~ N A a Ol ~ I I -' ~ b1 3 o C i A T Z ~ ~ T ~: ~ a i A Z O ~ 3 m ~ o o. ~ 3 '' Z ; c ~ ~ o i 3 ~ ~ !^, z i -° f w A ~ ~ I T C 3 d i I i y A fi i l ~ ti l N h ti b oro o e i ~ ti ~ ~ Safety and Buildings Division County ~ ~ ~ 201 W. Washington Ave., P.O. Box 7162 S~ iscons~n Madison, WI 53707 - 7162 Sanitary Permit Number (to be Tilted in by Co.) Department of Commerce (608) 266-3151 L~3~ (P d~ Sanitary Permit Application State Plan I.D. Number .O In accord with Comm 83.21, Wis. Adm. Code, personal information you provide may be used for secondary purposes Privacy Law, s15.04(1)(m) Project Address (f different than mailing address) I. Application Information -Please Print All Information j .,S ' Pro rty Owner's Na me 1 Parcel !t Block X OZO'/C//"Z- ~ -fJlf;) Property O ner's M ailing Address Property Location ~ Z ~6 ~ ~ S i t t t t Ci S ect on ' ' ' '-~- ='-~ ty, tate ~ Zip Code Phone Number a~y tg~a _ ~ f _ ~~ ~G~ /circle one) ` ~~~ II. Type of Building (check all t t apply) ~ E or W ` N; R ~ or 2 Family Dwelling -Number of Bedrooms ~ ~' Subdivision Name SM Numbers ^. Public/Commercial -Describe Use 3 ~~ ~Q,(ic?,t4 ~/ ~ - ^ State Owned -Describe Use - ,~t~ss ^City ^Villa a !CJ T nship of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A' New System ^ Replacement System ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System B. ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner 1V. T pe of POWTS System: (Check all that ap ly) Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter Leaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) V. Dis ersal/Treatment Area Infor ation: ,~ ~ Design Flow (gpd) Design Soil Application Rate(gpdst) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation y~ sts ~= 3 9 - D / 5 . T o VI. Tank Info Capacity in Total Number M re r an ufactu Prefab Site Steel Fiber Plastic Gallons Gallons of Units ~n ~ ~ p ~ ~ / ~J ~ Concrete Constructed Glass New Existing /' f(~/ ~~fi~-~'~C Tanks Tanks Septic or Holding Tank ~®~O O©~ / Aerobic Treatment Unit ~/n ~Pu /l i Ch be os ng am r i ~ W(,~ e VII. Responsibility Statement- I, the "undersigned, assume responsibility for ' tallation of the POWTS shown on the attached plans. Plumber's Na me (Print) y` ~rG Plumber's g e M MPRS Number Business Phone Number ~- ~3.~? ~~ a~~- ~s Plumber's :Addre ss (Street, City, tale, Zip 0 N U ,~ ~-~ ~ 6 0 V I Count /De artment Use Onl Approved ^ Disapproved Sanitary Permit Fee (includes Groundwater Surchar a Fee ~ y~ (J~ g ) ~ ~ J Date Issued ~~ Issuing A ent Signature N ps) ^ Owner Given Reason for Denial 7 ~ a. D IX. Conditions of Approval/Reasons for Disapproval ~ti~.<~ ~ l~ j ~~~ ~` SYSTEM OWNER: , f~~%i%~':~ ~ ~J q' J Septic tank, effluent filter and (/~/(,~yl,,~~jr( (~2. CZ ~~~~ dispersal cell must all be serviced /maintained /~ as er management plan provided by plumber, Cot~'Jl~h ~3"~~ ~ SyS~n ~ ~~~~ V(/i ~~ ~ '~ Zg 2. All setbac req arne ~ 3fo ~~~~ ~~~, as per applicable codelordinances. ~ v~ ~, n ~ - TEsr~~ /~RE~1 u ~ .tX.l~ O~ .~^. , vv ' ' - Attach comp~te~ ~ the ~~ y) for the systeg~on,p~~^~~ •_~j'~~ -~~JM1/~ ~z~~l SBD-6398 (R. 01/03) //~~ y ~ wV( ~ r ~- cJs~n~ ~ e~ ~v,~~ ~ r s~~~~ ~ /~-/bo ~ - `- D i-y N~ 37 ~f -/o .~ ~~~. M~~ ~° °~ ,, ~ ~ - ~a ~~ T ~~~ ti~~ / 13 ~ E T/, 9G. So . Z S" ~ r-a,~ q~ ~=3 ~ ~2 ~P° aa~3~ . ~ .~ ~ ~- vs~n ~ e~ ~v~~ ~ Z~00 G~-~ ~ uEzr~u~a~~~ ~ ~~~~ ~~- N ~-~aO ~ ~ i`' o y N ~' ~~~ ~ ~rtir -/ _ bpd ' 7- /' %(~ ~ '7° ~ , , a - la ~~ -,~-L T /~ 13 ~ -- E r/~ IG.So ,_ q~ Z5 Ta 3 ; ~~.yS e d` ,~~ l ~b ~ ~j ~o 0 ~ep~ P aao3s~ ~~~ I `- ~~ PAGE~OF~ /~J,rI1~ v~ TOT# y T L DESCRIPTION sf= ~S~11a ~S /~ TZ 9 ~N R: /4~ y' BM 1 ELEVATION /00 • ~ BM i DESCRIPTIONS D a ~ j ~ Jc p, ~~2 BM 2 ELEVATION ~ ~~ ~r BM 2 DESCRIPTION ~o p o-t ~ , DYG ,P,'D~ e SYSTEM ELEVATION cJ(. S d ~ SYSTEM TYPE ~b /t u ~ ~-~.~ o nA ~ ~ .+ - CONTOUR ELEVATION ~~. 52) 3 ~ 9 Sd ~ ~_ l ~ ~ 5~ U~ ,~'~'`` ~,t SIGNATURE ti ~ ~ ~~ .~j B_Z 1~ Z~ i'~ rv r o' 1~ ~ /O ``~"~ ~6 q95 I \~~ .~~ fir' ,~D L 7 ~ ~ C ~~ 3~ • , Wiscon ,DeparLY~ent of Commerce SOIL EVALUATION REPORT Page ~ of 3 Division f 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 include, 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. ~Z CS '/ y/ ~- ~0 -Q~ Please print all information. R ~ Date Personal information you provide may be used for sewn ary pu 1) (m)). ~~ ~ L Property Owner rope Location ' 2 ~ -~ Govt. t~~ 1/4jw 1/4 S (~ T Z~ N R (~ E (or~W Property Owner's Mailing Address of # Block # Subd. Name or CSM# C~ n ~ 2 s7 cr~i~ x , -, ~ ~7U P -2~ City State Zip Code P u ;n,~~: ~;~_~_-~ ,; ~ ^ ty ^ Village ^ Town Nearest Road -m,,,_,~ C,~ ® New Construction Use: ~ Residential / Number of bedrooms ~- "t Code derived design flow rate ~f Co GPD ^ Replacement ^ Public or commercial -Describe: Parent material ~" ~ ' ( ~ Flood Plain elevation if applipble ~ ft, General comments S ~ i /L ~ e(-c v - 9Cr ~ s ~ , n~wt~.`f- ~,~~,~ 2 p `~ o-~ ryS-le-,~,. -e-P..~ • (a and recommendations: J~ ~-- I G • ~ ~ ~ 3~ta~ CQ~PS ~- 9G- 9~ 1~- ~e~~.~.r~~d w n°~i au~-~-~ Boring # ^ Boring ® '7 7 pit Ground surface elev. t l0 ft. Depth to limiting factor ~ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 I o-II [ 2 - ~ SCI 2 ~~ Iv~ -5 . S 2 (1- 9 l y - Si cl Zmsbk ~~ - 3 Z9-(o5 lU. -- rr,5 r~ 1 c-s - . ~ t. Z Boring # ^ Boring ' I ®pit Ground surface elev. ft. Depth to limiting factor ~ 't _ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 i 0-12 ll~~ 2 Sil r ~-5 I v~ . 5 .F Z i2 - ~ l y -_ 5i c.l m~ c5 - . y 3 3Z -try ~ ~t I - 5 ~ 1 ~, _ ., i , Z - ~ ---._ ... -----5 ., _ ~ •••y.. ~.... .. -.. _ w .ny.~ uuuen~ irc = tsvvs ~ su mg~L an0 155 _< 3U mg/L CST Name (Please Print) Sig ~ • ~ / ,~- CST Number r ~- - . ~-t' " ~ ~ Vic.; ry?~~r C-~.- ,/~ -; -=----- '~ 1 -~ -~ Address Date Evaluation Conducted Telephone Number ~ ~ l'~/ ~ ,~~ /f ~ yl~~l~'" //' /j ,/~, ; ~~~~/" 11~ -r_~~ -/ice ~/ ~ G / 1~ ~:.Ll~ SRrI-~?T~i !ammm :.~' .' Parcel ID # Page ~ of Properly Owner _ Boring # Borin ~y~ Pit Ground surface elev. -"f"1 ~ ft. Depth to limiting factor ~_ in. Soil AppligGon Rat l dox Description R Texture Structure Consistence Boundary Roots GP D/ftz Horizon Depth in. or Dominant Co Munsell e Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 2 U-~ l - ~~ 3 2 ly - ~ ~ ~ S~~I ~ r c3 c5 l v~ - . 5 ,~{ 3 ~ -- ~r,5 _ ~ r ~5 - _ i U Boring Boring # pit Ground surface elev. ft. Depth to limiting factor ~n• S.oil Appliption 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 'Eff#2 Boring Boring # Ground surface elev. ft. Depth to limiting factor in. pit Soil Appligtion 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 '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. sso-ssao ~e.o~roo~ r " ~ ,. PAGE~OF~ nr a ME /U ~ I1 a ~n,P y~ LOT# ~ LEGAL DESCRIPTION S/= % Sa! 14 ,S /~ T Z 9 .N. R. / 9 Elr___rY~/) SCALE: 1"= ~~ BM I ELEVATION /00 • d BM i DESCRIPTION ~a D a -~ ~ ~ Jc p, ~pe BM 2 ELEVATION ~ ~~ BM 2 DESCRIPTION •~o P o ~ ~ ~ D al'G ,' e SYSTEM ELEVATION ~J(. S 6 ~ SYSTEM TYPE ~[7~u~,n-}<<or~o. ~ _ + - CONTOUR ELEVATION ~~. SZ3 3~ Y9 Sa ~ i /O ~q~S~ b q9~5 5~ SIGNATURE ~ ~-a~ r 3~ /~ ~-~,- • a ~-__-- - . reguiotane tl.e., wanondt, minlmum lot die, pcceee to parcel, rtc.) Before purehoalnq or developing ony poreel con/ad "•e St. Cross County Toning Oflks and the Town of Muds for advice. ~.r '~/ 02a-/mil 2 -d2-~~~- ~aJ~Y?:1~~ ~L m~.~ -t95t~. ~ co4!M'rY:~uNK ~±laHwav_~n~ ~ ~ ~ ~ IMf10'?AZ7t~ Q 'tN NOO'01'!i7"E 009.Oa' fi.1Z2.81' ..~_. ._ _..,...__ ._.__._....._ _. _...._.._~. N ~ ~ ........ N. ...... 7........ ( Z ~ .... r ...... ~ O. ~ r. . i ~k;~~ ~ ~ S00'01'57"W 3F35.21' ~ ~ ' pJ '° izs A ~ ~~ ~ \~1Ji/ ~ ~ t4 f0 ~ ~ N D ~ r V ~e ~ZO~ °~ `\ ° >r s art: ~ ~• ~ - ~ ~' ~ ° ° ~, ao~°ororw \ ~ \ ` A P \ w ~ ~ ; ~ ~ ~ ~ \\ ~~ ~6~ ~ ~r J~' ~R ~~~ 1 .\ 4 \ ~ .Np ~ \(~' I to I \ .••' ~F \ fA V/ a~ .~`o ip ~ \\ ~ -- 9 i~ ~ \ m cn e. W N .. ~ ~ ~ j \ ~ \ ~a W r'1i N m O ~ ° \~~ \ qt rA ' ~ \ ~ orJ~ \/J.~' j.\.. N ~ ~/ \ Y ~~~~~ rtf ~ ~ ~ D m y a m ~ ~ ~ H ~ Ivoarl•isotmf t/a UNE a ~ _. ._._._._._. ~~ ~ _ ~ ~ I to .. 9 nn ~ ,. r .. ~~erY ,~n~i r~ .~.x w ~ ic~l9~ ~: TGTHL F.t~1 Jan-28-04 11:06A ST CROP COUNTY SBPTIC TANK 1Vf~~INTENANCB A(IR;B~BNIBNT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer PREFERRED BUILDERS, INC / ~nn~~ ~, ~/~ r~~ Mailing Address 1325 COUNTY ROAD D VADNAIS HEIGHTS, MINN 55019 Property Addt~ess City/State 635 WILDFLOWER LANE (Verification rognired from Planing Deputmeat for new HUDSON WISCONSIN 5401~arcel Identification Number DZd -~ y~2- ~1-~U LEGAL DESCRIPTION . Zsq~ SE r 5W yh Ste. 10 _ T_ 29, .N_R~_W, Town of HUDSON Pt+opaty Lot~tion /,, Subdivision LOT 4 BURKHARDT PRAIRIE .Lot# 4 Certified Survey Map # LOT CSm ~ Volume 16 _ pie # 4407 Wturitnty Deed # ~ S3 01 ~ .Volume ~5~ ~ .Page # ~D C~ Spec house ^ yes ~ no Lot Imes identifiable ~ yes O no P.02 SYSTEM MAIIVTENANCE Imptnper use and mainbenanoeof your septic system could resait is its prematuir+e faiha+e to haadk wsstes. Proper mamteasnce oaadas of pumping out the septic tank every three years or sooner, if Hooded by a licensed pumper. What you pat into the system can affect the fuactio~n of the septic tank as a treatment stage is the waste disposal system. 'lire property owner agrees to submit to St. Crow Zoning Department a c«tificadon farm, signed by the owner and by a masberphaaber, jouQaeymaaplumbec, restricted plumber or a licensed pumpex vecifying that (I} the on-site wastewatitrdiaposal system is in pt+oper opeating oonditioa and/or (2) after inspection and pumping (if necessary), the :optic teak is leas than 1/3 full of shrdge. Uao, the undersigned have read the above requirements and agree to maintain the private sewage disposal system wide the standards set for9i, hereiq as :d by the Department of Commerce and the Department of Natural Reaoaroes, State of Wisconsin. Qertification statigg @~at your septic system has becn maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the throe year expiration daft. ~ s~ ~ - SIt3NA'TCJRE OF PLICANT QZU~h~ D~ATB --=~, OWNER CERTIFICATION I (we) certify drat ali statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the destat'bed above by virtue of a warranty deed recorded is Register of Deeds Office. 1i ~9~4~y OF APPLICANT DATB ssrsss Any information that is mis-represented may r+esu(t is the sanitary pe:anit being revoked by the ?•o~aing Department. s""sss •' Iadude wttlr this appUcation: a stamped wactsaty deed from the Register of Deeds office a copy of the certified sarvey map if refereaae is made is the waaaaty decd POWTS OWNER'S MANUAL & MANACatmltly I rL.NIV Page ~ of ~- FILE INFORMATION Owner E~ ~U/t~D~~s Permit ~` 2 ~ DESIGN PARAMETERS Number of Bedrooms 3 ^ NA Number of Public Facility Units ~NA Estimated fbw (average) 3GC~ al/da Design flow Ipeakl, (Estimated x 1.5) ~SU al/da Soil Application Rate ~ ' al/da /ftZ Standard Influent/Effluent Quality Monthly average' Fats, Oil & Grease (FOGI 530 mg/L Biochemical Oxygen Demand (BODE) 5220 mg/L ^ NA Total Suspended Solids ITSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand IBODsI 530 mg/L Total Suspended Solids (TSS) 530 mg/L ~NA Fecal Coliform (geometric mean) /100m1 Maxunum Effluent Particle Size Ya in dia. ^ NA Otfier: ^ NA `Values typical for domestic wastewater and septic tank effluent. svcrFM SPECIFICATIONS Septic Tank Capacity / QQ (~ al O NA Septic Tank Manufacturer ~,{/j~~,1? O NA Effluent Filter Manufacturer ~ O NA Effluent Filter Model fit -' 1 b f~ ^ NA Pump T~k Capacity ~ al ^ NA Pump Tank Manufacturer St/ DNA Pump Manufacturer ^ NA Pump Model ~ O NA Pretreatment Unit ^ Sand/Gravel Filter O Mechanical Aeration ^ Disinfection ^ Peat Fker ^ Wetland ^ Other: NA Dispersal Cellis) In-Gro gray` ^ At-Grade ~ ^ Orip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other. ^ NA man ~ ravrarv~C a~:neuv~ Service Event Service ~~~~ Inspect condition of tanklsl At least once every: ^ month(s) (Maximum 3 years) Z -3 ear(s) ^ NA Pump out contents of tanklsl When combined sludge and scum equals one-third IY91 of tank volume ^ NA Inspect dispersal ce(lls) At least once every: ^ ear(s11s) (Maximum 3 years) ~ ~ 3 ^ NA Clean effluent filter ~S ~~-Q-~7~ At least once every: month(s) 13 ^ year(s) ^ NA Inspect pump, pump controls & alarm At least once every: 3 ^ ryneoa~~ j(s) ^ NA ' ^ month(s) ^ NA Flush laterals and pressure test At least once every: ^ year(s) O~r~ ( 11s1 ^ NA At least once every: ^ Y ar Other; ^ NA MAINTENANCE INSTRUCTIONS inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tanklsl to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) 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 condinion and requires the immediate notification of the local regulatory authority. When the combMed accumulation of sludge and scum in any tank equals one-third IYaI or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter 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 512 months, shall be perfom~ed by a certified POWTS Maintainer. A service report shall be provided to the bcal regulatory authority within 10 days of completion of any service event. Pace Z of Z START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tankls) for the presence of painting products or other chdmicals that may impede the treatment process and/or damage the dispersal cell(s1. If high concentrations are detected have the contents of the tankls) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cellls) in one large dose, overloading the cellls) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. 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 POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. 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 chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or 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 replacemejnt system: [t~/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 that time. ^ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ~~ T alua ' a o m9 ank b e ai '~1ZOf-/18 TTY ~D~ A/ t^DNS772tlGTION ^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name ~~, ~ ~~~, Phone ~ ~ ~-~- ~ ~" POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name S . C ( 2lM~lN Phone ~!S- 3g~o- (p (7 This document was drafted in compliance with chapter Comm 83.22121(b11111d1&lf) and 83.54111, 121 & 131, Wisconsin AdmirdstrOtive Code. _.. ._ ._._ .. ... _........~~----:r......... . ... STA C [iAR OF o5 0 NSIN r0 OZ Q! 999 gocument Number I WARRANTY DEED This heed, made between Jatnes Y1. Henry and Allen C. Nyhagen, a/Wa Allan C. Nyhagca "- Qranto~r, and Preferred Builders, Inc. Grantee. 4rantor, for a valuable consideration, conveys to Grantee the following doscnbed real estatt in St. Croix _ County, State of Wisconsin (if more space is needed, please attach addendum): Lots 1, 3, an~Burkhardt Prairie, located in part of the 5autheast 1/4 of the Southwest 1/ of Section 10, T29N, R19W, Town of Hudson, St. Croix County, Wisconsin; being Lot Z of Certified Survey Map recorded in Volume 16, Page 4407. KATHLEEp R. MAL5H REGISTER OF DEEDS ST- CROIX Ct]- , YI REC>»IYED F'OR RECORD 01/2912004 @4:30Ptt NARI2AN'~Y DEED EX~pIpT at 14&C FEB: 11.00 7'RAIiS FF„E c 556.20 COPY FEl; t CC FiiE PAGES: i Reoonlin~ Aria Noma M1p ,~~yrn~~~ ANC. ~J LA t7 '! ~E 2C0 Y F,L~'ia~. • '~ia).,~a. Part of 020.1010.20.300_ _ _ Purccl Identification Number (P1N) This is eot _ homestead property, OQ): (is not) $xceptions to warranties: lrasornents, restrictions and rights-ofway of rocord, if any, Dated this ~~~ day of ~ 2003 ~~ sr • ~,._.. ~~ awes D. Han _~. _-.. " „~- • Allen C. Nyhngea, /Wa Allen C. Nynaaea Ai)THENTICATION SiSnature(s) Samos A, Nenry and A11ee C, Nyhagen, a/k/a Allan C. Nyha~en -' ~~, authanticntad this day o~'f''~.J~CGI~~ ___, 2003 TITLE: (If not, /(.~ ~ ~' authorized by § 7 6.06, Wis. Stats.)s~2~r/il, ~~~ THIS INSTRUMENT WAS (7RAFTE/D''BY Attorne Kristine Ogland u on, '~36 d """ (SiErtatures may be authenticated or acknowledged. Bad arc not necessary.) ACKNOWLEDGMENT' STATE OF WISCON5TN ) ss. _. .._ _ County ) t'crsotiaRy came before me this ,day of _,,,,, ~thC 8bovo namnd to me known to ba the person(s) who executtd the foreEoing instrument and acknowledged the same. Notary Public, State of Wisconsin Ivty Commission is permanent. (If not', oleic expiration data: persons stgn,ng m nny capacity must be typed or printod below their signature. ~ kdorr,wtion rror.saoiroa cmncenv. Few du lie, wl STATE BAR OF'WISCONSIN eco~ess'so2~ WARRANTY DEED FORMNo.2-t999 C~RTI FICATE OF SURVEY - FOR: PREFERRED BUILDERS NORTH 0 60 120 SCALE: 1 INCH = 60 FEET UNDERGROUND UTILITIES NOT LOCATED OR SHOWN EASEMENTS, IF ANY, MAY EXIST. THERE WAS NO EFFORT MADE TO RESEARCH RECORDED OR UNRECORDED EASEMENTS. BEARINGS SHOWN ARE BASED ON THE PLAT OF BERKHARDT PRAIRIE. SUGGESTED BUILDING ELEVATIONS BASEMENT FLOOR = 918.6 (12CRS) TOP OF FOUNDATION = 926.7 GARAGE FLOOR = 926.3 *LOWEST BUILDING OPENING = 925.0 LOT AREA = 101,906 SQ. FT. / 2.339 ACRES LEGAL DESCRIPTION: LOT 4, BURKHARDT PRAIRIE, PART OF THE SE1 /4 OF THE SW 1 /4 OF SEC. 10, T29, R19, TOWN OF HUDSON, ST. CROIX COUNTY, WISCONSIN PROJECT LOCATION: 635 WILD FLOWER LANE g26.0 ::__3X00_= __® _2_0-~~ - ~ IS•DO ® I 10•p4 ~ o g26.0 o G p,R. o ~- o - 00^'10.00 6 00 __S~~- 12• o DETAIL ~ m PR~~USE~ ° o _ o - ~ 44.00 -~ `~\ ~ i g26.0 ~ ~~ -16.00 ~'~--~ 10 •p0 DENOTES SOIL BORING PER PRELIMINA~R~Y_PLyA--T _~~_ ~V~'°-t rd~.~ ~~~ Y ' ~~C~ ~ NV II ' ~\s c p N s \~~1' .•'' •. N ~ ~~ ~ DANIEL L. ~/~ i 11'il1Fi~AE8 / / ~ 2456-008 ~ / ~~ STLLWATER ~ ~~ MV i ~I~1gND• ... '~oQ 15s ~~~ ~~ DESCRIPTION PROPERTY LINE EASEMENT LINE DENOTES IRON MON. FOUND hereby certify that this survey, plan or report was prepared by me DENOTES IRON MON. SET or under my direct supervision and that I am a duly licensed Land DENOTES 10' OFFSET HUB Surveyor under the laws of the a O{ Wisconsin. DENOTES EXISTING ELEV. DENOTES PROPOSED ELEV. DIRECTION OF PROP. SURFACE DRAINAGE al DANIEL L. R ES ~ROPOSEDCONTOURS License. No. 2456-008 ate 1-28-04 1902 South Greeley Street Suite #3 GWO Building Stillwater, MN 55082 Phone 651.275.8969 Fax 651.275.8976 dlt-csls@ mcleodusa .net CORNERSTONE LAND SURVEYING, INC I ~_ II cn ~ m ~ z s v ~ y O CD 7 d ~ .C ~p N [1 ~ ~ A ~p c o ~ N a ~ d OV ~ N 3 ~_ 0 ~ ~ ~ A N m co ~ c W o ~ . o p m ~ ~ ~ O i ~ a N C. f/1 ~ ~~ n a m c m z c ~ ~: ~ ~, o d 3 °' m I ~ ao i ~, a i j a z 0 v O O 3 I ~ G ~ W fD a m o ~ _ N i ~~ o' g ~cn~„v p am v, ~ ~ D ~0 3 ~~ ~ A°a, ~ n~ o~ 'o a g a~ c ~ d m° v m -o m am ~a'o ~ z ~~ ~ ~ ~ m ~.~ ~ ~ ~ o vo~om~mc~u~ow~' t o ~' fD• ' `D V~ 3 0 ~. a~ Q ~ d C fD 7 (A Q ~., ~ N ~ d ~_ d f0 C ~ i,, d d O f V=i a O_ ~ O ~ ~ (p 01 ~ ~ ~ C O ~I V ~ fD O y. O. ~ O C ~ .C.. O X Q C ~ ~ O d y ~ ~ .~. j d O (D t~A O o g °o ~. e W ~ ~ :t O A ~ ~ ~ O N N ? tl31 W ~* C ~ a a Orn ~ A N O O ~~ O gOg O N ~ . ~ovo e~ d••~ D o ~ y O C C. N A ~' ~ ~ s ~ 01 C fSD O ~ a eWO A a °o :' 3 w z f w m c a 3 m o c o' A ~ d ~ ~ .~ gt C O N O. N O O ~ ~ 7 ~ ~ ~ N O O O ~ O O ~. O N ~ Q 3 ~ :: A W c d a ~ N A z ~ ~ ~ r± A (Z 7 m ~ o A Z ~ ~ ~ ~ d A~ A~ rte. O A'+ O `~ ~1 ~• ~~yy,,~,,~ • vV O ~• A VC 0 O~ l ti A N O w V d0 V ~ N ~ ~ a ti ~