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HomeMy WebLinkAbout020-1412-60-000 Wisconsin Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH1 O 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 Ellefson, Dar~1.'Donette Hudson Townshi CST BM Elev: b~ l Insp. BM Elev: ~ ` BM ription: --~-~O-,~t~ SG~ e~ s l ~d ~-y o ~. , b . . . t a TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic IZ Dosing - W Aeration I'~_ Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG ~ Vent to Air Intake ROAD Septic 1 ~,~~\I (JV .~0 _ ~ p D j K S Dosing Aeration Holding PUMP/SIPHON INFORMATION l~Y~t,C.l~,c_ Manufacturer Demand Model Number TDH Lift Friction System Head TDH Ft Forcemain gth Dia. ' t. to Well SOIL ABSORPTION SYSTEM ~- ~ ~--~-~(/ 9.ISZ IBUTION SYSTEM BEDITRENCH W idth / Length No. Of Trenches PIT DIM IONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ ~ a0 / /f~ ~~ SETBACK SYSTEM TO P/L B WE LAKE/STREA LEACHING Manufact , C, ,gyp INFORMATION CHAMBE ' ~'6f--~ /~ D / ~( 7ypt Of System: l~~~y~/`~r^~` ~ ~~ ~~ IT .. Model Number. ~~ ELEVATION DATA county: St. Croix Sanitary Permit No: 453283 0 State Plan ID No: Parcel Tax No: 020-1412-60-000 Section/Town/Range/Map No: 10.29.19.2598 STATION BS HI FS ELEV. Benchma ~ ~ ~ ~ 0 3 6 / ~ r, 3~! Alt. ~St t ~`~5 io2.~ BI wer S ~ G l7'~~ SUHt Inlet ~ ~~ s'~' • ~ ~ ~ ~ / t SVHt Outlet ~.. q / ~P~ ~/ Dt Inlet Dt Bottom ~- Header/Man. -fig `~3 -~ 3 Dist. Pipe ~ O I - ~}-~g ~3,g3 Bot. System S O ~ ~ Z Final Grade ~,,,~, ~ 3 ,~~ 9 ~ - ~~ St Cover f 2,Z~ / o/- 3 . 2 ~ 7 ~/ l- ~s 2. Z. ~ ~ V,rut ~ ~ (.cue s-I-.~~i. Head Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake N Length ~ D Dia Pipe(s) --') ~ Length I Dia LF~' Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only ~Y~ ,~.~ Depth Over p Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Centor Bed/Trench Edges Topsoil ~] Yes No -1 ~F ~_, Yes U No COMMENTS: (Include code di crepencies, persons present, etc.) Inspection #1: I /~~/'}b(~y1/~ Inspection #2: / / Location: 641 Wild Flower Ln ~SE 1/4 SW 1/4 10 T29N R19W) Burkhar t Prairie Lot 6 r ~ Parcel No: 10.29,19.2598 1.) Alt BM Description = ~ ~Ur-'~ ~-'~ -»"~ / "'"1 ~ ~ ~-~Pjr+, ~` ~~G~c{ ~~„S-~ 2.) Bldg sewer length = `~ Q I ~_ ~ ~~~~ ~ -Z ~ f / ~d (Q -amount of cover = /v I ~-~ Plan revision Required? Yes « r-~- it - ----,I ---- -- __ _ _ _ - -~- - - , ---, ---- --~ ~I Use other side for additional information. ~_~"~_ ~ ~ / ~_ - __.------------____-- G~~ `~ SBD-6710 (R.3/97) Date Insepctor's Signatur Cert. No. mac, ~t~~L~vu~ ~ Zo~~3 ~~otll I-~~'4.~ - Ls~- Z I I I ~ ~ ~ N O rn o. ~ a^ ~ y ~ U/ N ~p N a ~ Q O ~ ~ N C 3 O m D ~ ~ ~ ~ v 3 c o. o W Q M I ~ O 1 ~ ` a Z c 0 m a ~ z ~ ~ ~ n C ~ ~ Q j ~ ry ~ r ~ ~ N I ~ a ~ Z o_ ~ fn g m O o. ~ < v a ~ ~~ N O C W 'O (D o. ~ 3 Z ~ ~ m o ~ ~ (D N C> .0~. ~ ,~ W N O i ~ a N ~ ~ ~ d ~ ~ o ~ D ~ o-~iv a mo?~?: 7~~, ~ N } Q ~ C O O c ~~ o y ~ ~ r. y < j ~ / x N ~ S d CD ~ N 0 O a y~ ~ ~ y m ? ~ ~ w O ~ - N ~ ~ a ~ O ~ j O < ~ O N: ~ O ~ ~ O N O O p ~. ncnpi San c °: ~ ~ m o ' a ~d ~~ 0 3 3 + '* ' i , o Z ' ' 2 -' ~ m a r° o Q Q ~ J N IV ' O ~ N ~ O ? O 'v ~i ~ ~' ' co 4 a ', , a ~' ~ o ~ J o ~' m ~ N N ~ ~ W W C ~ » C N , 3 .. Q = ' 000 ~ ° ' ~ SS Sc~ N y (~1 ;. ' N ~ . a o q °, ' ~ I N ~D N OI ' ~ ~ ~ ~ a :: ~~ ~ j a A ~ ; ~. ~ fD C Z Z x D ~ ~ ~ y C 7. N d 7 O A Z CO'f '~ ~ LS j d A ~ j m ~ o W ~ c O ~ ~ ~ Z ~ O ° :' ~ y ~ < Z ~ W A T C a 'I d ~. ^: m ^! A~ C ~1 0 ~• O 0 ~• H ~~ A 1 ~r O~ O A W QO ;r ~ ,C "" V ti Safety and Buildings Division ~ County S ~ ~ ~ 201 W. Washington Ave., P.O. Box 7162 ~ ' ~scons~n Madison, WI 53707 - 7162 ' Sanitary Permit Number (to be filled in by Co.) De artment of Commerce (~8) 2+66-3151 ~2~~ Sanitary Permit Appli n State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal i forma~~{~c~~ 4 t ~v iiss.,.... may be used for secondar ur oses P iva 15 y p p r c , s . Project Address (i(~differ nt than mailin address) ~IDW~~ ~P Ni ~~' ~, ~ t "' I. Application Information -Please Print All Infor ~~ MAY 2 7 2004 Property Owner's Na me ' 5 T. CROIX COUNT`S ZONING ~ ~ ~ Parcel N . ZS~I Lot Block N AN obi ~ OFFICE .e SoN ~ 6~d -lyl~-~b-a a~ Property Owner's M ailing Address Property Location ~I ~RQew ,, ll S~ ~b S~ t S i 1V City, State ~ Zip Code ~ Phone Number , ,6, ect on f / ~~,St)N , ~ (~' ~ ~ ~ o (circle one) a 9 ' II. Type of Building (check all that apply) ~ ~ T I E or W N; R y ^ 1 or 2 Family Dwelling -Number of Bedrooms Subdivisio Name CSM Number ^ Public/Commercial -Describe Use -- -- (~ ~ ~ , ~A.1-rlp/t~ t - ^ State Owned -Describe Use Z K ~~-$~ City ^Village Qi'owtuhip of ~kP3 Ur' ~ _ III. Type of Permit: (Check only one box on line A. Complete line B if applica e A' New S stem Y ^ Re lacement S stem p y ^ TreatmenUHolding 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 IV. T of POWTS S stem: (Check all that a 1 ) Non -Pressurized in-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Cot-4tructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter thing Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) V. Dis rsal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation (oUU ~ SS7 a`?V 5. X13 VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank ~ ~, ` a O I ' y ~Ph~ Aerobic Treatment Unit Dosing Chamlxr VII. ResponsibiUty Statement- I, the undersigned, assume ra'spottsibility for installation of the POWTS shown on the attached plans. Plumber's Na me (Print) ~' 8 ~ Plu is gnature MP/MPRS Number Business Phone Number ` f rn or~ r~>`es ea a as 9~~ ~ ~ 5 - ~~~-~~~~ Plumber's Addre ss (Street, City, State, Zip e) t ~~~ ~'' ~ ~ ~' t~~(bS~)~ ~ l VIII. Cotmt /De ent Use Onl ~jApproved ^ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No tamps) Surcharge Fee) ~ ^ Owner Given Reason for Denial ~~ r ~ Q IiX. Conditions of Approval/Rt~sons for Disapproval SYSTEM OWNER: 1 Septic tank, effluent filter and dispersal cell must all be.servlced / maintaintd as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code/ordinances. SBD-639$ (R. 01/03) ~~wv~•~ p.aw ~w me a.ounq ooq) rot me system on paper no[ less men DI/L x 1 r ineaeS in size ~N~~ SAN ~ ~oNe~e ~ ~ ~~ ~ SUN ,}- ~~AI U~ ~~~~~~F~`a~~- ~p~~~? ~~ c~a I p~''\ S~A t~Q a~~ ~m~~~ (j~`~e n~ a f 5~~~'~ ~~~. ~p~.~1 ~ Ylurh be ~ - J 1 m (~~U n1~Ps~~ (~ SI~~~~y ~~,s~~~~ S~.e~ i~ JrS v IU ~s !. S~ ` No r~~e r 1 v I 1 t l ~' ~U~ d~ Sic, W~,~a ~~o~~K ~N~ IV /~I o~-ve~K ~AN~ ~oN{ ~`,Q ~~~~~sON `PI~~ ~ ~ ~Unk~p~~~ `~~,a,R~~ e ply ~mAwk (jo~a ~ a ~ s~~, E lev' 101. ~ 1 ~ ~a \\ ~('~NV\,Jt S 3x`~~ Su A\k ~~~ B~ ~e~~~ rn,~~~C ~ ~ ~ o~ Sfipk~ ~I~v" ~~ , ~~; ~IUMbe ~ - S; rn ~~u m~n~~ ~, . ~~~~~~y ~X~S~~w~ S l.e,P LU ~ v ~~~~ ~ ~ ~ ~1~~ eZ ~A~~ ;' Wisconsin Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings 4....n.a~,...e ,.,irr, (~nmm Rte, Wic arlm rrv1P ~,~% ~/9~ n.O-~-. 1783 Page 1 of 3 A.C.E. Sal & Site Evaluations -- -- - ~ County Attach complete site plan on paper not less than 8'/ x 11 inches in size. Plan must St. CroDC include, but not limited to: vertical and horizontal reference point (BM), direction and parcel I D percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. . . 020-1412$0-000 Please print all information. gy ~ Date Personal irdormation you provide may be used for secondary purposes (Privacy law, s. 15.04 (~) (m)). Property Owner Property Location Dan & Donette Ellefson Govt. Lot SE 1/4 SW 1/4 S 10 T 29 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 1011 Green Street 6 Plat Of Burkhardt Prairie City State Zip Code Phone Number ~ City ~j Village J Town Nearest Road Hudson ~ WI 54016 715-381-3089 Hudson 641 Wild Flower Lane 1~' New Construction D~~ Yr' Residential /Number of bedrooms 4 Code derived design flow rate 600 GPD J Replacement _f Public or commercial - Describe: Parent material Glacial ouiwash Flood plain elevation, if applicable na General comments and recommendations: Soil conditions field verfied by Kevin Grabow 4/12/04. Install two trenches at elev. 99.50' using 28 leaching chambers. Boring # ~ Boring >104" i R Pit Ground Surtace elev. 99.97 ft . Depth to n. limiting factor ate Soil Application Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP *Eff#1 D/ft~ *Eff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 1 0-9 10y2/1 none sil 2fsbk mfr as 2f,1m 0.6 0.8 2 9-16 10yr4/3 none sil 2fsbk mfr cw 1fm 0.6 0.8 3 16-22 10yr4/6 none si- 2fsbk mvfr Lwv 1fm 0.6 0.8 4 22-32 10yr5/4 t rNla~.+o f2d 7.5yr /8 sil 1fsbk dl cvv 1f 0.4 0.6 5 32-37 7.5yr4l6 none obb gr I Osg dl cw - 0.7 1.6 6 37-54 5yr4/6 none obb gr Osg dl Lwv - 0.7 1.6 7 54-104 10yr5/4 none s 0 sg dl - 0.7 1.6 Boring # .J Boring 1/ Pit Ground Surface elev. 99.93 ft. Depth to limiting farctor ~9fi~~ in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz- Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GP *Eff#1 D/ft~ 'Eff#2 1 0-14 10yr'2!1 none sil 2fsbk mvfr as 2f,1 m 0.6 0.8 2 14-28 10yr5/4 none sil 2fsbk mvfr cw 1fm 0.6 0.8 3 28-32 10yr5/4 none sl 1msbk mvfr cw 1vf,f 0.6 1.0 4 32-57 10yr5~ none s Osg dl aw - 0.7 1.6 ~ 5 57-64 5yr4/6 none gr Is Osg dl curt - 0.7 1.6 6 64-96 10yr5/6 e s Osg dl - - 0.7 1.6 * Effluent #1 = BOD ~ 30 < 220 m Land TSS >30 150 mg/L * Effluent #2 = BOD a 30 mg/L and TSS <,,,30 mg/L CST Name (Please Print) Sig ure~ CST Number James K. Thompson 5--- 3602 Address A.C.E. Sal & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 4232004 715-248-7767 ~ `s w.. fs ''~ l~ / ~` ,6 Property Owner Dan ~ Donette Ellefson Parcel ID # 020-1412-60-000 Page 2 of 3 Boring # ---) Bonng ' Pit Ground Surface elev. 99.90 ft. Depth to limiting factor >98" in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots 'Eff#1 *Eff#2 1 0-13 10yr2/1 none sil 2fsbk mfr as 2f,1m 0.6 0.8 2 13-18 10yr4/3 none sil 2fsbk mfr cw 1fm 0.6 0.8 3 18-26 10yr4/6 none sil 2fsbk mvfr cw 1fm 0.6 0.8 4 26-36 10yr5/6 see rn~ma f2d 7.5yr5/ sil lfsbk dl cw 1f 0.4 0.6 5 36-42 10yr5/6 none :obb gr I Osg dl cw - 0.7 1.6 6 42-50 5yr4/6 none gr Is Osg dl cw - 0.7 1.6 7 50-98 10yr5/4 none cobb gr 0 sg dl - 0.7 1.6 ^ Boring # ~ Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots 'Eff#1 *Eff#2 ^ Boring # :.J Boring pjt Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots 'Etf#1 *Eff#2 ' Efnuent #1 = BOD ~ 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS<30 mg/L and TSS < 30 mgll 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. ' SOIL AND SITE EVALUATION 1783 Page of s • PROPERTY OWNER: Dan & Donette Ellefson PARCEL LD.# 020.1412-60-000 ~ , '~,...~.;i_ AC.E. Soil & site Eval~fa~it'a~ns REPORT MEMO Comm 85.30(3)3 applied to discount Redox. features described in H#4 of of borings # 1 & 3. Cc~(,- de -mac. l3ey,c.f_ Too o.p /of Sf~ WTI ~'lawc~ AsSc~.rned ¢,led` = /C~,~~ 1 ane \ i'l ~f ~ ~ 1, loot; n9 o.~-'~cs~dwrce d ~.,.~c ~I 6r m ^ ~_ ~~'~ ~UO.03' s cs ~r, a- ~~'3 99.9' = S8- P ^ a2 ^ 83 99, y9' .~----~' 5ca/~: / _ ~/O' -~ no ctpPrc c, able $Io,Oe t~rc~~ Sysfcrr) ar'e0.. a 3 ~~ ,. ~~ o. ~, Q~ 3of.3 v ti 1783 ~ SOIL EVALUATION REPORT Wisconsin Department of Commerce Page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Cade A.C.E. Soil & Site Evaluations Attach com to site Ian on not less than 8'~ x 11 inches in size. Plan must County ~ p PaPef St. Crooc include, but not limited to: vertigl and horizontal reference point (BM), direction and percent slope, scale or dimemsions, north arrow, and location and dstance to nearest road. Parcel I.D. 020-1412-saooo Please print all information. I'~ersonal information you w ~j 5~~6 '~ ~~~o Property Owner Dan & Donette Ellefson `' Property Owners Mailing Addr 1011 Green Street r ~ - ,-~. State ~49ttd~ 61~tt~®umber Reviewed By Date Law, s. 15.04 (t) (m}). , Property Location Govt. Lot SE 1M SW 1/4 S 10 T 29 N R 19 W Lot # Block # Subd. Name or CSM# 6 Plat Of Burkhardt Prairie `f City _f Village ~ Town N~rest Road Hudson ~ WI 54016 715-381-3089 Hudson 641 Wild Flower Lane City New Construction Use: 1/ Residential /Number of bedrooms 4 Code derived design fkanr rate 600 GPD J Replacement ~ Public or commercial -Describe: Parent material Glacial outwash Flood plain elevation, ff applicat>fe a General comments ft•~ and recommendations: Soil condrbons field verfied by Kevin Grabow 4/12/04. Install iwo trenches at elev 9.50' sin leaching chambers. Boring # ~ Boring . /J Pit Ground Surface elev. 99.97 ft. Depth to limiting factor > 104" Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/Ftz in. Mansell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 `Eff#2 1 0-9 10yt'2/1 none sit 2fsbk mfr as 2f,1m 0.6 0.8 2 9-16 10yr4/3 none sit 2isbk mfr cw 1fm 0.6 0.8 3 16-22 10yr4/6 none sit 2fsbk mvfr cw 1fm 0.6 0.8 4 22-32 10yr5/4 f2d 7.5yr5/8 sit lfsbk dl cw 1f 0.4 0.6 5 32-37 7.5yr4/6 none obb gr I Osg dl cwr - 0.7 1.6 6 3 -54 5yr4/6 none obb gr Osg dl cw - 0.7 1.6 Comm 85.30(3)3 applied to discount Redox. features described in H#4. a Boring # ~ Boring N Pit Ground Surface elev. 99.93 ft. Depth to limiting factor >96~~ in• Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roois GP D/ftz in. Mansell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 1 0-14 10yr2/1 none sit 2fsbk mvfr as 2f,1m 0.6 0.8 2 14-28 10yr5/4 none sit 2fsbk mvfr cw 1fm 0.6 0.8 3 28-32 10yr5l4 none sl 1msbk mvfr cw 1vf,f ~ ~~ 4 32-57 10yr5/6 none s Osg dl aw - 0.7 1.6 5 57-64 5yr4/6 none gr Is Osg dl cw - 0.7 1.6 64-96 10yr5/6 none s Osg dl - - 0.7 1.6 `Effluent #1 = BOD ~ 30 < 220 mg/L a~ CST Name (Please Print) James K. Thompson Address A.C.E. Soil & Sfte Evaluations 340 Paulson Lake Lane, Osce TSS >30 < 1 mg/L (fluent #2 = BOD < 30 rrx,1JL and TSS <30 mg/L Signature CST Number 3. 3602 Date Evaluation Conducted Telephone Number WI 54020 4232004 715-248-7767 ~ Property Owner Dan & Donette Ellefson b $~ b`~ Parcel ID # 020-1412-60-000 Page 2 of 3 $ Boring ~ Boring # • Pit Ground Surtace elev. 99.90 ft. Depth to limiting factor >98" in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence ry Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-13 10yt2/1 none sil 2fsbk mfr as 2f,1 m 0.6 0.8 2 13-18 10yr4/3 none sil 2fsbk mfr cw 1fm 0.6 0.8 3 18-26 10yr4/6 none sil 2fsbk mvfr cw 1fm 0.6 0.8 4 26-36 10yr5/6 d 7.5vr5/8 sil 1fsbk dl cw 1f 0.4 0.6 5 36-42 10yr5/6 none Cobb gr Osg dl cw - 0.7 1.6 6 4 -50 5yr4/6 none gr Is Osg dl cw - 0.7 1.6 Comm 85.30(3)3 applied to discount Redox. features described in H#4. ~--"' Boring # J Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots /ft~ in. Munsell Qu. Sz. Cont. Cdor Gr. Sz. Sh. *Eff#1 *Eff#2 ^ Boring # ~ Boring Pit Ground Surface elev. ft. Depth to limfting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD ~ 30 < 220 mg/L and TSS >30 < 750 mglL * 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 wntact the department at 608-266-3151 or TTY 608-264-8777. ~C~C- dJe -mac. (3e.n~ ~: Togo o.p /a~ S~. u~;ld ~'lowc~ ASSc~med e.Ied` _ /C,?7,cb' lane \ ht. ~ I~bcri^~ ~,..>c l1 41 m ^ ~~ s cs -~-, 99.9 ~ ~ P E . d. f~CE-.cm of '_ Sca/c: / ~ S/O' ^ So;l ¢/a lua ~,'or~ ~o; E • /oC~+.~cd ~Ono~. S~t.(e -~ no QpPrcc.,~able $ I o~0e ~i/'a u~ ~ system a.,^ea. ~ J O ~ ~l1 ~~ 03' J'3 3s8, ^ a2 ^ 83 • 9q y9' ~~, 3of3 ., Wisconsin Department of Commerce DivisiGn of Safety and Buildings ~~l (~i'/i'1 ~~~/ SOIL EVALUATION REPORT Page / of 3 in acxordance with Comm 85 Wis. arlm ~c~a ' County G Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must Jr • ~l"~ include, but not limited to: vertigl and horizontal reference point (BM), direction and parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Q Z Q"/L/~2 ~~pQ QQ(~ Please print all information. w Date Personal information you provide may be used for Privaq Law, s. 15.04 (1) (m)). GG,~?~^~ eZ..li ~l / `'f Property Owner ~ D 1 J~ ~ - ~ " ~ ~~ Pro rty Location 2 S~~ J"4 Go .Lot - 1/4 S w 1/4 S 1(~ T 29 N R (Q E (or~ Property Owner's Mailing Address L ~ ~ 2002 Lot Block # Subd. Name or CSM# ~ ~ ~ ~ ~ur~ ~ - City State Zip Code honk CC~i ;n , ~,. ,;, __,. ~ ,r.~,rvc or-Fad,- City ^ Village ~ Town Nearest Road ®New Construction Use: ® Residential /Number of bedrooms 3_y Code derived design flow rate `3 GPD ^ Replacement ^ Public or commercial -Describe: ' Parent material ~ i~ I ~ Flood Plain elevation if applicable i(/ / ~ ft, General comments SysT2~ 2(-GV , 9 y ~ d ? and recommendations: ~~~~~.{%(/!~/ '~~~~e~C~UV~ ~1~+ "' l-e v • 99.20 Po-~-}our -e ©Boring # ^ Boring 4~ ~~ 9 ` ® pit Ground surface elev. O - c~-~ 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 d-IZ (O r31~ ~ i I 2 m~r ~5 I v~ . 5 . $ 2 ~ -3~ ~ ~ ~ i 1 s k mfr ~ S - - 5 - $ -42 I C 3 -~ ~ .5 y (~, '~ 1 n->Sbk r - - s 5 , g Boring # ^ Boring '® pit Ground surface elev. ~ ft. Depth to IimiGng factor ~ in , _ . Soil Applfption 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 I~ ~ 312 -- r eS ~ v - 5 _ B 2 i5- y - 2 ~ - , 5 .$ 3 C ~1.5 ~ ~ s- ~ 3 ~- - ~" . 8' ~•,,,.~. •• ~* • - ~~~s - ~~ ~ u~ ~ ~ ~~~ a~w ~ ~a ~str ~ i au mgn_ - etttuent #2 = BODs < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature ~ CST Number v ,~ ~ Address Date Evaluation Conducted Telephone Number SBD-8330 fR07/001 Parcel ID # Page ~ of Properly Owner Q~ ~l~ L~-~ Boring # ^ Boring I ®, pit Ground surface elev. ~~. ft• Depth to limiting factor ~~ in. Soil Application Rate tion x Descri d R Texture SVucture Consistence Boundary Roots GPD/ft2 Horizon Depth in. Dominant Color Munsell p o e Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Z I-?~ y ~ - ~ ~g - - 5 - g g ~ C -~ ~ r - -- . 5 - U Boring Boring # ^ pit Ground surface elev. ft. Depth to limiting factor in. SAiI Appliption Rate tion Descri d R Texture Structure Consistence Boundary Roots GPD/ft2 Horizon Depth in. Dominant Color Munsell p ox e Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring Boring # Ground surface elev. ft. Depth to limiting factor in. pit Soil Appliption Rate tion scri D d R Texture Structure Consistence Boundary Roots GPD/ft2 Horizon Depth in. Dominant Color Munsell p ox e e Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Efff#2 'Effluent #1 =GODS > 30 < 220 mg/L and TSS >30 < 150 mglL '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. 560.8330 (R.07/00) '. {. PAGE 3 OF~ ~jAMF' h~~ n TOT# h T EGAL DESCRIPTIONS ~ ~S4Jt4 .S /D T 29 .N.R. I ~ E(or)I~ SCALE:I"= yQ BM 1 ELEVATION /OU- G BM 1 DESCRIPTION ~~ o -~ ~ ~ ~/~ ~~e BM 2 ELEVATION ~y (9 0 BM 2 DESCRIPTION ~,D <~ ~ ~ v~ ~ ~-~ SYSTEM ELEVATION 99 fl d ~ SYSTEM TYPE YV I O y ~l c~ S y ,~ ~~~n _ .+ CONTOUR ELEVATION `~~ Z d 1 ~ r ~,' ~,~ a,y, l <a~ ~ ~~~s~ ~%~ Z B 3~ ~ 99 00 ~~~ ~/ ~~ ~!`, ~ Y ~g,r - _ .TUBE ' ~ - ~- --~_------ DATE ~~ `,~ ~ -~~ ~ . regu~atans (i.e., weuonda, minlmum Iot sI=e, pcesse to pareN, etc.) 8efon purchoeing or- developing any porut eontae~ "•e 3t. Gola County Xonlnq Ofllee and tha Town of Huds (or advice. . •~~ ~~ 02o-~~i 2 -d2-~~9' ~ co~yT~r~uN~.~lgFtwaY _~-' ~ ~ rH ~ N00'01'67"'E 009.06, ~ r` o n~ 8 i I• ~ 0 8i.~.~.-.~ '3 ~ ~ r , .a..<..,..,1 ~;~, ~ ~ ~~ ~ w ~ - ~ ter' I ~ ~ I _ ~~-1 _~C.Qt~3~Y ~ 1.~A'; iii: : •'~a ~I ni i i~ / StX1'01'S7"W 385.21' ~ ~ ~ N fr \~~ o~ . i //41 ~ ~ t0 ~ N I N V ~ ~ .~ g Iza~ 1 ~r.sr I \ b ;~ \ \ ~S A I~ I \\ \\\ 'tea 4~•~ . •~ti°v ~ ~ I ~ ~ $ ~ ~ ~ ~ I~l I ~ \ \ a p ~°'?ay~ ~ ~ \ ~~- @~F„_ ~`` `` Ip° ~\\\ C~ ~ ,, ~ \~ `. i~ $ • ~ \ m ut a tv N .• / `gyp \ ~ \ P N g N ~ \`` -~``` \~\\\ \ ~ tN R'~ AA I~ N~ =• v O m m i l\ta~` ~ m ~3~~ L r ~/`\~ ~~~~ ~ ~ ~ \ Ifi ~ ~ ~ y a ~ ~;; .m m G~~ y~ m 3 ~ H i _ . NORTH_SOUTH 114 LINE ..` _ ^ . _ . _ . ~~~+ ~ _ I I ~ fA TOTHL F.~1 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 (POWYS) 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: System Design Specifications Sanitary Permit Number 5'3 Number of Bedrooms Design Flow -Peak (gpd) (~C3tj Estimated Flow -Average (gpd) D"0 Septic Tank Gapacity (gal) ~ a , Soil Absorption Component Size (ft2) $5 Type of Wastewater omestic Table 2: Soil Absorption Component -Limits of Reliable Operation Septic Tank Component Soil Absorptio Component Design Flow -Peak (gpd) . g' Maximum Influent Particle Size (in) I $ 1/8 Maximum BODS (mg/L) a U 220 Maximum TSS (mg/L) 1 Sp 150 ~ ~~ Tab le 3: Maintenance Schedule 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 Septic 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 sept' and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filte shall be cleaned as necessary to ensure prop_ er oration. The filter cartridge shou 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 without being in full compliance with OSHA standards for entering a conhned 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 Comrn 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 surface 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 - - Management Plan fora Septic Tank and Soil Absorption Component Plantings of deep-rooted trees and shrubs directly over or within ten feet of the component should be avoided since root intrusion into the component may obstruct wastewater flow. When system fails, we will replace with another system at owner's expense. Alternate area must be left undisturbed. St Croix County Zoning Office 386-4680 Boumeester & Sons Excavating 386-9020 Tri-County Sanitation 386-2130 3 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND .: ,. ' "~;,: OWNERSHIP CERTIFICATION FORM '' OwnerBuyer a ~~s~~ Mailing Address I ~ ~ ~ ~i~ N ~ . Property Address ~P `~' ~ W ~ 1 ~ ~ l 0 ~~ ~ ~ ~ ~ V1 P ~ ~~ (Verification required from Planning Department for new City/State w1P.S o "' ~ ~ Parcel Identification Number ~ a ~ ~ ~ ~ ~ ~ ~ U - ~ ~ ~ .C.zs~~ LEGAL DESCRIPTION ~ ~ ~},~ ~ Property Locations '/,, S ~ '/,, Sea ~ ~ . T~N-) W, Tov~rrt of ~#~S ~ ~ subdivision ~ ~ ~~ 4 ~ ~'~ ~ ~`~ ~ ~~ "1 I ~~-P~ ~- ~ ~ .Lot # ~ _. Certified Survey Map # ~~ :Volume ~~ ~ .Page # s ~ Warranty I?eed # l ~~ ~ ~ ~~ S Volume oZ S ~ Page # ~~_. Spec house ^ yes. no Lot lines identifiable ~tl yes ^ no SYSTEM 11RAINTENANCE~ Fmpr+oper use and maintenance of your septic system could result in'its premature failure to handle wastes, Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees,to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, journeyman plumber, restrictedplumber or alicensed pumper verifying that (1) the on-site wastewaterdiaposal system is is proper operating condition and/or (2) after {nspection and pumping (if necessary), the septic tank is leas than 1/3 full of sludge. Lwe, the undersigned have read the above requiremtnts and agree to maintain the private sewage disposal system with the standards net forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your sepde system has been maintained must be completed and returned to~the St. Croix County Zoning Office within 30 days of the three year expiration date. ~- ~ ~ ~~~ ATURB OF APPLICA DATE ~. •~rDWNER 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 ~ ;described above, by vi a of a warranty deed recorded in Register of Deeds Office. SIGNATURE 0)r ' PLY DATE •••••• Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. •••••• •• Include with this application; a stamped warranty deed from the Register of Deeds office .a copy of the certified survey map if reference is made in the warranty deed U 2516 P 111, I STATE BAR OF WISCONSIN FORM 2 - 1999 Document Number WARRANTY DEED This Deed, made between James D. Henry and Allen C. Nvha~en Grantor, and _Daniel D. Ellefson >i~nd Donette J. Ellefson, husband and wife _ Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin space is needed, please attach addendum): Lot 6 at of Burkhardt Prairie in the Town of Hudson, St. Croix ounty, Wisconsin. Recording Area -7J,ii~~ KATHLEEN H. IiALSH REGISTER OF DEEDS ST. CROIX CO.. MI kECEIV:ED FUR RECORD 02/ 25 /:20@4 11: 00AI! WARRANTY REED EXEI4f'? It REC FEE: 11.00 TRANS FEE: 355.50 COPY FEE: CC FEE: PAGES: 1 Name and Return Address The First National Bank of Hudson Attn: Pat PO Box 187 Hudson WI 54016 oao-Iola-6o-o00 Parcel Identification Number (PIN) This is pot homestead property (is) (is not) Exceptions to warranties: Easements, restrictions and rights-of--way of record, if any. Dated this o~o ~h day of February , 2004 * ----- Signature(s) AUTHENTICATION authenticated this day of * -- ---- TITLE: MEMBER STATE BAR OF WISCONSIN (If not, _ authorized by § 706.06, Wis. Stats.) /. * ames D. Henry _~~..-____._ * Allen C . Nyhagen - ---..__-.-- . - -- _.. ACKNOWLEDGMENT STATE OF Wlsc t)N 5 t ~ _ ) C- ) ss. ' ~['. C~'~ County ) Personally came before me this _pw__~~ day of _ February _ , 2004 the above named James D. Henry and .Allen C. NyhaQen __-._._. THIS INSTRUMENT WA5 DRAFTED BY Attorney Krishna Ogland __ Hudson, WI 54016 (Signatures may be authenticated or acknowledged. Both are not necessary.) to me known to be the person(s) who execltl instrument and acknowledged the same. _~ c~ • Names of persons signing in any capacity must be typed or pruned below their signature. lnfom~ation Professionals Co., Fond du Lac, wI STATE BAR OF WLSCONSIN 800.655-2021 WARRANTY DEED FORM No. 2 - 1999 My Commission is ermanent. (If not, state expiration date: ~~ ~~~a c~ q = W2p ZZ n ~~ J ~ QF-Z hr~ ~ ~~ J q-ZrQ'~ Jl7a. JZ O~ ~ _J ~ ZQ~at-OW~...a~~y Z ~~ ~-' Oc2 ZJ=dpr¢Pp0~17J3~WN ~ X~ ~a ~i ~_ ~~`. W~V¢Fay~.Zray3~W ~ ¢ ~~ ~- ~~ y3o=3ZjQWpizNUVWi j ~~ _---~~ W ~ pJJJ ZW~~ QZ _~ ~~ 0 ~ W '-'al7W=Wy o UH ViU~ ZVJU~- ~ O ~" --~ -y ¢ F Q ~ ~- ~= li~pMpq ¢ O ! p33pZwNp~aWa3~ jW ~`~. ~ ~~ ooi _ Wl'7~OWJ"'~F'I-~qW ~ z a~ ~ ~F~ ~ O\ ~ ~I GI Z.ZrWF-WOf'gUQZp}p 0 ~R~ ~ ~ .` \v~\\ I . °I S~?I 32~¢~Vl WAX°a¢Vl ` ~" ~~ ~ ~. 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