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HomeMy WebLinkAbout020-1458-04-000 Wisconsin DepartmerltofCommerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 574355 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)]. Permit Holder's Name: City,+ Village X Township Parcel Tax No: Schmidt, Thomas M. & Carrie I Hudson, Town of 020-1458-04-000 CST BM Elev: Insp.BM Elev: IBM Description: Section/Town/Range/Map No: 7C�.Z� 1 q. 2i, e� 16.29.19.2940 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 0 Dosing Ytr1 �'Cj Alt.BM 1 L�s2 C_ L.(v cM if,-3z q, _ Aeration 4�2 1� Bldg.Sewer, In r?� Holding - _ ._ SVHt Inlet i�c+ i ��CLV°1s c' TANK SETBACK INFORMATION SVHt Outlet 11" $' I], TANK TO D/L WELL BLDG. Vent to Air Intake ROAD Dt rile cl LV c1i.4 4 Septic r - Dt Bottom Dosing Header/Ma I'h " -5- , Z q2- clfv Aeration i ` Dist. Pipe_ Bot. y stem ht' I Holding /lc x -7 7Y V2 , U Final Grade PUMP/SIPHON INFORMATION ` — ` t,� 4t, -" S, y5 `ly ' Manufacturer / Demand St Cover C, GPM Model Number EP o A-C 1K -J" -L7 -T- c% f G h CEO;,t TDH Lift " r Friction System H 4 TD Ft `1r 5 //r ;f�)�, f 4-C-; Forcemain Len th— Dia. „ Dist.to Well Yl n��tG z T S 2 Vic" a.4��- c CdZ``c c �` �� e �. SOIL ABSORPTION SYSTEM 11 0 C,&ilk -1 C P.(t 6 bi(,fie, ._St'�.�� > 'qd BED/TRENCH Width , Length No.Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia: Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L e JBLDG JWELL LAKE/STREAM - LEACHIN9 Manufactu - INFORMATION CHAMB„�RR Ty ,Of System: r /r -"LT•NIT Model Number: [_ DISTRIBUTION SYSTEM eaderManifold Distribution , x Hole Size x Hole Spacing ent Air Intake J( jri pipe _s) Length ? Dia Length Dia Spacing 3 � r 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 I +/� Bed/Trench Edges Topsoil Yes No Yes No COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / '�/ Inspection#2: / / Location: 596 Grange Rd. Hudson,WI 54016(NE 1/4 NE 1/4 16 T29N R1 9W) iWillow Bluff Lot 4 _y /Parcel No: 16.29.19.2940 1.)Alt BM Description= 2.)Bldg sewer length= ?j -amount of cover Plan revision Required? Yes , Use other side for additional nformation.� Date Insepctor's Signature Cert.No. SBD-6710(R.3/97) 1 / o ©� J /ic�S06. ( 9 t,j ale Tcp of- Prop v,e c� °Y lorrypos,d t.c�r,cSCr- jj'ctsGrrr n xtvr ufQA joco �0 a � Y • t- Coy-,- �, rJ V. I cj1�✓l � S�-ltl�� H J f((/J / Y L 6 T ` BILLq R RieP C, /G7h fY a 't 1 J3,m. I�o.oCJ C.t� I- cle--- sac_ Il lllllllllllilllllllllll 111111 8 2 5 2 8 4 8 Document Number Document'ritle TX:4208682 1 1000744 St. Croix Count Y BETH TH PARS PABST REGISTER OF DEEDS vit for a sin le POWTS Affidavit g O ST. cROIx co., wI servicing Two Structures via Private Interceptor Main RECEIVED FOR RECORD 08/27/2014 10:02 AM /terra° _ d_-6 EXEMPT *: Name—(Owner)Typed or printed REC FEE: 30.00 being duly sworn, states, under oath,that: PAGES: 1 He/she is the owner/co-owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Docun)bnt Number 971 0 with the St.Croix County Register of Deeds Office: Recordin Area A parcel of land located in the NE '/4 of the NE'/4 of Section_J§—,T29N— Name and Return Address R 19W,Town of Hudson, St. Croix County, Wisconsin,being duly Thomas&Carrie Schmidt described as follows(include lot number and 4subdivision/CSM or detailed 773 Moundview Rd. legal description: Hudson,WI 54016 Lot 4, Plat of Willow Bluff in the Town of Hudson, St. Croix County, WI 020-1458-04-000 Parcel Identification Number(PIN) As owner of the above described property, I acknowledge that a Private On-site Wastewater Treatment System (POWTS)serving the primary residence is sized for three(3)bedroom(s)with a design wastewater flow of 450 gallons/day(DWF is based on 150 gpd/bedroom @ 2 persons per bedroom). A maximum of sib'(¢)occupants are permitted; if the number of occupants exceeds the maximum for POWTS design,the system will be undersized to accommodate increased wastewater flows and/or contaminant loads and may be subject to premature failure. An accessory structure NOT to be used as a 2"a dwelling has been connected to the POWTS via Private Interceptor Main Sewer(PIMS) in compliance with SPS 382.30(12). 1 understand that disclosure of this information will be made to any parties interested in purchasing this property in the future. Dated this a7 day of &a T ,2014.. /,C>7- * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) )ss. St.Croix County. ) authenticated this day of Personally came before me this/r day of (year) �%NANS��/ fi '5915)/Cir (Year)the above named A. TITLE: MEMBER STATE BAR OF WlScqp7r,. to me known (If not, PV t tip person(s)who executed the foregoing 1 �t�ne d acknowledge the ame. Authorized by § 706.06, Wis. Stats.) ' i T t THIS INSTRUMENT WAS DRAFTED BY� �� i�t1����� Pamela Ouinn.Land Use Specialist _Community Development Dept. * _ c T SrTlLrc 5� Notary,Public, State of Wisconsin (Signatures may be authenticated or acknowledged. My Commission is permanent. If not, state expiration Both are not necessary.) date: Date: 0//'r-'gV f S "THIS PAGE IS PART OF THIS LEGAL DOCUMENT—DO NOT REMOVE" TMs information must be completed by subminer: document Title.name&return address,and-EIN(ifrequired). Other information such as the granting clauses,legal description,etc.may be placed on this first page of the document or may be placed on additional pages of the document.Nate: Use of this cover page adds one page to your document and$2.00 to the recording fee Wisconsin Statutes,59.43. St. Croix County 1000744 Page 1 of 1 Ax�'r�^' Celli County. :;: Industry Services Division 6� 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) RS X14 P.O.Box 71 PU N� Madison,WI RAID � � � v c ermit Application State Transaction AN b In accordance with.T0114 2I(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit /_ A is required prior to dbtammg a sanitary permit Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailm ddress) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary �/�/_ /r,� �� purposes in accordance with the Privacy Law s.15.0 1 m Slats. i & C/ I. Application Information-Please Print All Information 14(l Property Owner's Name _ Parcel# -ro wl.. Sc. V l i � v nor c� Property Owner's Mailing Address Property Location 7 73 Mow, r Z Govt Lot City,State Zip Code Phone Number ( y l Y., Section I j /-v— eo y,C� T �f N� R f�,(circleE°nW ,I-L Type of Building(check all that apply) �` k Lot# ---� -J — 2"1.r!" 2 Family Dwelling-Number of Bedrooms ,..A Subdivision Name i3e + `�t T i 1,J Block# Lit I d W 91 tlrl�- ❑Public/Commercial-Describe Use �— ❑ City of ❑State Owned-Describe Use CSM Number ❑Village of kTownof IIL Type of P rmit: (Check only one boa online A. Complete line Bit'applicable) A. New S s y ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner ^ IV.Type of POWTS stem/Coro onent/Device: Check all that apply) ,T .( Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grado ❑Mo"o>24 in.of suitable oil ❑Mound<24 in.of suitable soil ❑Holding Tank ❑Other Dispersal Component(explain) l6 m etreatment D°yice(explain) V.Dispersal/Treatment Area Information: Design Flow(gpd) Design Soil Application Rate(gpdsf) Disp al Area Required(sf) . D'persal Area Proposed(sf) System Elevation VI.Tank Info Capacity in Total #of Manufacturer Gallons Gallons Units ;,/ New Tanks Existing Tanks y J� (y I t) c-Q I Septic or Holding Tank Dosing Chamber / I t i✓ VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number CAM 3X6A0UFTTt � -)/5°?7858 Plumber's Address(Street,City,State,Zip Code) ? l-.t Rd Rr 1 d e =, �-4'7 VIII.Column /De artmen Use Onl Q'Approved ❑Disapproved Permit Fee 07d Date Issued ssuing Ag Sign r �( 4 ❑Owner Given Reason for Denial a u LX.Conditions of al/Reasons for Disapproval SYSTEM OWNER: M/077�Z i%�.c�?� UV(� (�h/l _ -]� v`tA- 1.Septic tank,effluent filter and ;W144f dispersal cell must b-e-S_e..rv_ieed/mai_ntained �Qd.��' � � do Q� 6"'UL L *- as per management plan provided by plumber. ` (/ as per applicab a co e�or mantes. an sub to the County only on paper not less than 81 x 11 inches in size SBD-6398(R0313) � 7` l �/ f� I I_�'t'i 6 , A CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Owner's Name: Owner's Address: '7-73 A4,n, LL J U I-e u I R Legal Description: C y o� ) , sc c lq 4J Township: 1A u -Co Countr. s Cl R � fY - Subdivision Name: Wd IOU.) .t)Lot Number Number. 7 Parcel ID Number. Q Q/y S-9 U y O C� U Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing &Cross-Section Page Filter Specs -1-5ep4l 7a.•k 1- l�u�p CV%olnnbrr Spec., Page 5 Maintenance Information Page 6 Management Plan Pagel PUvK0 (.L�1'UC , Page 8 � � � ;� f� Pc r•�" eha.-4e -- Ao Page 9 Attachments: Soil Test&House Plans - S .Ci-cik 6f.1 S-e p'' Tc. Nlaw►'ffAac e- Design Plumber �ilrlry�ctDt,le License Number. q o�f fvZ D Date -8 22 ^ 14 Phone Number -71 7� R- Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 20 SBD-10705-P(N.01/01). Page 1 44. 7q cc S r 7`1 7- o L 9 Li ,!e7le o. 72)p or PrOp 0 S Ae e-m f tti cta4o'A i000 o o 5 er/, ,C os z ya r k- ptoe Px-A co-n 0 t-, Oki prf• .,tl-y .i Yj r7l L T e.2 balk c11 elp Pei -Tod C� 1- dam- saw ��� 3 .Absgrption...§3 m Cross Section 9 . ft 4"Schedule 40 Final Grade PVC Vent Pipe With Vent Cap `/, !° J � Leaching --► Chamber +f— q3,-eft System Elevation ft r ft 3 ft Soil Absorui ion System Plan VIOW ft 3 ft ./�,� PUc� 1;rcc. A (G 3 ft Leaching Trench 1 'to P(A-v\ -Chambers 4-Die- Trench 2 Header Vent Or Observation Pipe �QJ IrxJear °� `� " �• Rye l Trench 3 Leaching Chamber Specifications Manufacturer And Model ro_- O I— y s-rQ,��p�Q EISA Rating -'�CD sq ft per chamber Soil Application Rate ' gpd/sq ft S� gpd Design Flow g ._. 7_Soil Application Rate -- a b EISA= 33 Chambers 3 rows of J�- chambers each, I I II Page_Of SEPTIC TANK E PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS v" PiX-V ENT PIPE 12" MIN. ABOVE GRADE E WEATHERPROOF 25 ' FROM DOOR , WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE — WITH CONDUIT MANHOLE COVER W1 PADLOCK 6 a�°SecQ WARNING LABEL OF Zy� _L=---4" MIN 1810 I N. •,\ �.$ MttJ. INLET , ��' �• WATER TIGHT SEALS GAS- , ' —q TIGHT : '►� VAPPROVEO FILTER JOINTS WITH o _E_ ► APPROVED -` ALM ARPROVED PIPE s 3 ONTO PIPE 3 --t— : ON I ONTO SOLID C SOLID SOIL I SOIL � PUMP OFF ELEV . gJILFT. OFF D I 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIO S SEPTIC / DOSE , ) TANK MANUFACTURER: W eScr� X Gct I, TANK SIZES: SEPTIC /000 GAL. DOSE VOLUME INCLUDING DOSE 600 GAL. Y.V6-1 -7FLOWBACK:1 11901 5- GAL. ALARM MANUFACTURER: bXAS CAPACITIES: A = f - INCHES = GAL. .MODEL NUMBER: SWITCH TYPE: �,ec�.GlhtCrt/ Jpa B = 2 INCHES = 7.S.�GAL. PUMP MANUFACTURER: C., = INCHES = MODEL NUMBER : _��7/ . .E�b�//� � D = ` INCHES GAL. SWITCH TYPE: ��ag�.l�Qh�c�/ r-lt�a _Q = ZV REQUIRED DISCHARGE RATE __Y�GPIt PUMP 8 ALARM WIRING AS PER ILHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE /mss FEET + MINIMUM NETWORK SUPPLY PRESSURE FEET + -130 FEET FORCEMAIN X q,11FT/100 FT. FRICTION FACTOR S FEET TOTAL DYNAMIC HEAD = 3-FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH WIDTH DIAMETER 6.7.6 G,P i LIQUID DEPTH SIGNED: I _ LICENSE NUMBER: a1 Lzo DATE: 1/88 � J TO wt -SIC !'N�d � MODEL .i: "' .0 4 SY, Submersible p i W t ' v i:w" ✓: .A... All i f{ I �+ A r< c T4 a;sa METERS FEET 10 -'-y-- MODEL:3871 25 6. 20 v '--.._..._.._..._ EP05 O _ — 3 10 z EPOW4 S _ Y 0 00 10 20 '30° 40- 50 USGPM 0 2 4 6 S 10 12 '011Ay CAPACITY Pump Specifications Features and Benefits '/1u and 1/2 HP •EP04 impeller-semi-open design U0'to 60 GPM with pump out varles to protect Maximum head to 32' ,mechanical.seal. Discharge size 1112"NPT •EP05 impeller-.enclosed design Solids:1/4'maximum for improved performance. Motor •Rugged glass-filled.thermoplastic All motors feature ball casing and base design provides bearing construction. superior strength and corrosion Single phase: 115V resistance. Materials of Construction •Cast iron motor housing for Cast iron efficient heat trahsfer, strength, Thermoplastic and durability. Stainless steel *Corrosion resistant threaded stainless steel shaft. *Available for automatic and manual operation. . •CSA listed models available. gaeration and feature:stainless steel hardware. a O O n W a to to d Z J W N a< * co m � Y o w Z �W .-. O �o EN=O Q U^ � o 1 O I=m �a OZ I cUa I O a p 1,1 m F- U �CY �~ °� m o��U z o(n 0 IL CL V) W F-W OO O W m Ow -,ww as D �� V) Wao > 0 0 - m 1-Q °cn ro co a D Q co a -°°��M� `�� mW� °! W O a O, W OAF-J1� f- N �-f�~ N� (� M Z t0 Ln° J 1� W V W -F- Lo ¢0. O Y 0 _ z J H O w pZ� V N O Z ..off==r-=3a= mY ow a w V— Q o�� zc�Zr_jZ) o cn oEnF- a o apoQwwowaw za ¢ z O U 0 J J O Q O z z C3 N o C J „Z b C z --------- --------- I - • 1 I I . 1 I i , 1 I I L J all „5 „Sir „� LJ all ! � �� ��.t is � \ i � •!- 1 i i n { LtJ 1t / I 4J , , O W ' I O Q 1 1 J U (n Q V) I i I I r • 1 I : i h I j z I r i • I I I 1 ' • • 1 __--____ �_.•. _--_____ 1 1 W FJ- „b8 O „6£ „95 START UP AND OPERATION Page of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process'and/or damage-the soil absorption.system. If high concentrations are detected have the contents of the tank(s)removed by a Septage Servicing Operator(pumper)prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will be4scharged to the soil absorption system in one large dose causing an overload that may result in the backup or surface discharge of effluent.and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator (P urn Per),priort o restor ing power to-the pump or contact a Plumber or POWTS Maintainer to assist in manually eratin g the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. Do not drive or ark over, or otherwise therwise disturb or area.within 95 feet down sloe _ � compact, the p of any mound or at grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the erformance and P prolong the life of the treatment tanks and soil absorption system: acids, antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drays (sump pump)discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps,medications,oils, painting products, pesticides,sanitary napkins,solvents,tampons,'and water softener brine discharge. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with s. Comm 83.33,Wisconsin Administrative.Code: • All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be rer»oved and properly disposed of by a Septage Servicing Operator(pumper). a After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be.utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance-and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a Suitable replacement area. *Replacement systems must comply with the rules in effect at the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology,a holding tank may be installed as a last resort. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation • must be performed to locate a suitable replacement area. If no replacement area is available a holding tank maybe installed as a last resort to replace the failed POWTS. ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. WARNING TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY.CIRCUMSTANCE. DEATH MAY RESULT.--ESCAPE,GR RESCUE..FROM 11fiM TERtOR-`O —rAttK1viAy-NOT RE-peSS4$tj' ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS MAINTAINER. Name r Name rrr �v` Phone 2 i o Phone a S w SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name rr-el LA V%. Name cr�o�sr _0" r Phone 7/ Phone f..5 3 This document was dr ed by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f)and 83.54(1),(2)&(3),Wisconsin Administrative Code. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Otn Tank Manufacturer: ❑ NA Permit# "1 �.� Septic ❑ Dose El Holding Volume: /pDV (gal) DESIGN PARAMETERS Tank Manufacturer: ❑ NA Number of Bedrooms: ❑ NA ❑ Septic Dose ❑ Holding Volume; to DO (gal) Number of Public Facility Units: P-IQA Vertical Distance Tank Bottom(s)to Service Pad: /..), (ft) Estimated(average)Flow: 300 (gal/day) Horizontal Distance Tank(s)to Service Pad: v (ft) Design(peak)Flow=(estimated x 1.5): (gal/da y) Specific servicing mechanics must be provided if vertical is>15 feet or (� if horizontal is>150 feet. Specific instructions to be provided on back. In Situ Soil Application Rate: ` 7 (gal/day/fe) Effluent Filter Manufacturer: -0 ol, 1e El NA Standard(Domestic)Influent/Effluent Monthly average Effluent Filter Model: SAS Fats,Oil&Grease (FOG) eW mg/L Pump Manufacturer: Biochemical Oxygen Demand (BOD5) s220 mg/L ❑ NA _ ❑ NA Total Suspended Solids(TSS) s150 mg/L Pump,Model; -..._ .3971- L`'.i'n O 11 r High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/12 Manufacturer: (B4ODO >220 mg/L JWNA *NA (TSS) >150 mg/L ❑Mechanical Aeration ❑ Peat Filter ❑Disinfection ❑Wetland Pretreated Effluent Monthly average ❑Sand/Gravel Filter ❑Other: (BODs) <_30 mg/L Soil Absorption System (TSS) s30 mg/L ArNA �,/ Fecal Coliform(geometric mean) s10° In-Ground(gravity) ❑ In-Ground(pressure) ❑ NA Maximum Effluent Particle Size in dia. ❑ NA ❑At-Grade ❑Mound ❑Drip-Line ❑Other: Other: ❑ NA Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) When combined sludge and scum equals one-third('/)of tank volume ❑When the high water alarm is activated Inspect condition of tanks) At least once every: ❑month(s)y likyear(s) (Maximum 3 years) ❑ NA Inspect dispersal cell(s) At least once every: ❑U rnonth(s) (Maximum 3 years) ❑ NA E4 year(s) Clean effluent filter At least once every: months) [1 NA ❑year(s) Inspect pump,pump controls&alarm At least once every: ❑month(s) i ryear(s) ❑ NA Flush laterals and pressure test At least once eve ry' El month(s) ,ANA El years) Other. At least once every: ❑month(s) - ❑ NA Other: ❑year(s) ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper). Tank inspections must include a visual inspection of the tank(s)to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined.sludge and scum and a check for any back up or ponding of effluent on the ground surface. The soil absorption system shall be visually inspected to check the effluent levels in the observation pipes and to check for any pending of effluent on the ground surface. The ponding of effluent on•the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any treatment tank equals one-third (' ) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator (pumper) and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code: All other services,including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months,shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 30 days of completion of any service event. GMW-005(02/05) 0 �r c,� r Property Owner �D o� �� M►u Parcel ID# 6 o� / �p [ 0d y of Page a Boring# o Boring G ri Pit Ground surface elev. �`] 3 ftc Depth to limiting factor � /'� in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu.Sz. Cont.Color Gr,Sz.Sh. •Ef{tq `Eff#2 L) 1 i- 6 S 7 ElBoring# ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate I Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff I in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. •Eff#1 •Eff#2 I i Boring# ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Applicaflon Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. •Eff#1 •Eff#2 I I Effluent#1 =BOD5>30<220 mg/L and TSS>30:5 150 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. ti 13 D-8330(R.07/00) c_d Lk h f -- SOIL EVALUATION REPORT page / of 3 Wisconsin Department of n of safe and Comm 85,Wis. Adm. Code Division safety with C DI in acp.c��ordance County s'j ��pQ/ e plan der n sntal reference point(BMj size.Plan on and Paroel I.D. Attach com�l� Q�0�4/ include,but n limped Pica l ercent slope,scale ilrte l� arrow,and location and distance to nearest road. R Dat p o� �tie print all information. Z� l Personal Information y Vide may be used for secondary purposes(Priv a . n Property Owner ��4 1/4 S f fp T N R I E(or Govt.Lot �1 E Property owners Mailing Address Lot# Block# Subd.Name or CSM# �� / �cQ . Wit I/o w 73 OUnD�Urew Village .WOwn Nearest Road Ciry State Zip Code Phone Number ❑Ciry ❑ aLA -804 gadso, �_ S'D GPR New Construction Use:(residential/Number of bedrooms Code derived design flow rate ❑Replacement ❑ Public or commercial-Describe: ft. Flood Plain elevation if applicable , Parent material General comments ��� , e w �✓ S and recommendations: Sf Ej,. °9�� 3 c _�--- kf ❑ Boring a f .I 00 in. Boring# Ground surface elev.rou 7�° � ft. Depth to limiting factor Soii A lication Rate F3 Pit D/N Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'Eff#1 'E1T#2 - a l F i D o S " (0 Boring# Boring !tw in. Da] I Pit Ground surface elev. ft. Depth to limiting factor soil A lication Rate GPD/fP Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots 'Eff#1 'Eff#2 In. Munsell Qu.Sz. Cont.Color GI Sz.Sh. / a 3 � 3 _ -S v s c s > < and TSS>30<150 mg/L 'Effluent#2=BOD <30 mg/L and TSS<30 Effluent#1 =BOD 30_220 mg/L CST Number CST Name(Pleas nt) J Signatur 0 a �� ev\ fn t`2 •P l -e So Telephone Number Address Date valuation Conducted P Y9 nn+nn+n mnw nm _ 4. '79 �O tY7 ST : Ah� AJF- Sic, I Ia 9 A) Q, co w Flew 9S 5- �ro�e�Sed 7op 04 �OC.t„ECCa'C't o,�. 4 OX Top of r/ Gard�. Lo � ,B �c Ekv•y.,4 1 PAS I (�ran�e Rd Sc a 14e- 4 V ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 7�nMA� &W Caft,& Mailing Address -7 -73 M6,44 V e o '��, N�d�a� WX 5461� Property Address (Verification required from Planning&Zoning Department for new construction.) City/State 04 g h Avl. Parcel Identification Number 6;jaij k 'A40nn LEGAL DESCRIPTION Property Location Ak '/4 , Sec. T a9 N RI Town of Ovi S&�j Subdivision Plat: W hIour 13L v-rF , Lot# . Certified Survey Map # , Volume , Page # Warranty Deed # 9q] (before 2007)Volume , Page# Spec house❑yes no Lot lines identifiable es❑no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner,if needed,by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in§SPS. 383.52(1)and in Chapter 12-St.Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning&Zoning Department a certification form,signed by the owner and by a master plumber,journeyman plumber,restricted plumber or a licensed pumper verifying that(1)the on-site wastewater disposal system is in proper operating condition and/or(2)after inspection and pumping(if necessary),the septic tank is less than 1/3 full of sludge. 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 Safety And Professional Services 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 Planning&Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s)of the property described above,by virtue of a warranty deed recorded in Register of Deeds Office. Numb r of bedrooms /� SIGNATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning&Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV.04/12) i i 8236291 State Bar of Wisconsin Form 1-2003 Tx:4193373 WARRANTY DEED 997130 BETH PABST Document Number Document Name REGISTER OF DEEDS ST. CROIX CO., WI 06/12/2014 11:32 AM THIS DEED,made between Matthew D.Hieb EXEMPT#: NA REC FEE: 30.00 TRANS FEE: 285.00 ("Grantor,"whether one or more),and Thomas M.Schmidt and Carrie L. PAGES: 1 Schmidt husband and wife as survivorship marital property ("Grantee,"whether one or more). Grantor for a valuable consideration,conveys to Grantee the following described real Recording Area estate, together with the rents,profits, fixtures and other appurtenant interests,in Name and Return Address i St.Croix County,State of Wisconsin("Property")(if more space is Leo A.Beskar needed,please attach addendum): Rodli,Beskar,Krueger&Pletcher,S.C. 219 Lot 4, Plat of Willow Bluff in the Town of Hudson, St. Croix Riv Main Street River Falls,WI 54022 County, Wisconsin 020-1458-04-000 Parcel Identification Number(PIN) This Is not homestead property. (is)(is not) Grantor warrants that the title to the Property is good,indefeasible,in fee simple and free and clear of encumbrances except: easements, restrictions and reservations, if any, of record. Dated d//� (SEAL) (SEAL) * *Matthew D.Hieb (SEAL) (SEAL). AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) )ss. authenticated on PIERCE COUNTY) •Ills.Y,,,µ• Personally came before me on * the above-named Matthew D.Hiela .*'?� TITLE:MEMBER STATE BAR OF WISCONSIN �� (If not, to me known to be the person(s) who zecuted'the foregoiii authorized by Wis.Star. §706.06) in tr ent and ackn /1 ged tl ame:- 1. Cr �j THIS INSTRUMENT DRAFTED BY: * Kathleen M.Bennett 'of Leo A.Beskar,Rodli,Beskar,Krueger&Pletcher,S.C., Notary Public,State of Wisconsin 219 N. Main Street, River Falls,WI 54022 My commission(is permanent)(expires: ) (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATION TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED ©2003 STATE BAR OF WISCONSIN FORM NO.1-2003 *Type name below signatures. INFO-PRO'Legal Forms•(800)655-2021•infoproforms.com St.Croix County 997130 Page 1 of 1 - y 1587 Wisconsin Department of Commerce #A LUATION REPORT Page 1 of 3 Division of Safety and Buildings in accordance'With Comm 85,Wis.Adm.Code Steel's Soil Service,Inc. Attach complete site Ian on paper not less County thaN A 11 inches in size. Plan must St.Croix include,but not limit4 to:vertical and horizontal reference point(BM),direction and percent slope,scale Pr dimensions,north arrow,and locatiort and distance to nearest road. Parcel I.D. _Please(print gH--"#Bonn R revved By Date aw Personal information you provide may be used for secondary purposes(Privacy L ,s.15.04(1)(m)). Property Owner Property Location Hieb, Matt Govt.Lot na NE 1/4 NE 1/4 S 16 T 29 gRd Property Owner's Mailing Address Lot# Block# Subd.Name or CSM# d 1271 140th St 4 na Willow F� City State Zip Code Phone Number J City �Village ld Town Nearest Road New Richmond WI 54017 715-381-5277 Hudson Grang New Construction Use: 16 Residential/Number of bedrooms 4 Code derived design flow rate 60 Replacement J Public or commercial-Describe:na f �S Parent material outwash Flood plain elevation,if applicable General comments and recommendations: Conventional system,system elev on 96.80ft.Trenches spaced and depth to code 4.75ft� Boring# Boring Jim Pit Ground Surface elev. 101.55 ft. Depth to limiting factor 100 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPD/ftz in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 1 0-12 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 12-36 10yr4/4 none sicl osg ml cs na .4 .6 3 36-100 7.5yr4/6 none cos osg mfr na na .7 1.6 c 9e•80 ST 93 Boring# I Boring VJ Pit Ground Surface elev. 100.55 ft. Depth to limiting factor 100 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 1 0-14 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 14-30 10yr4/4 none sicl osg ml cs na .4 .6 3 30-100 7.5yr4/4 none cos osg mfr na na .7 1.6 �Fs g Effluent#1 =BOD 5>30<220 mg/L and TSS>30<150 mg/L *Effluent#2=BODS<30 mg/L and TSS<30 mg/L CST Name(Please Print) ��ignaturZ�l CST Number David J. Steel 248956 Address Steel's Soil Service,Inc. Date Evaluation Conducted Telephone Number 994 200th St.,Baldwin,WI 54002 11/8/2004 715-684-5680 Property Owner Hieb, Matt Parcel ID# Pending Page 2 of 3 F3jBoring# I Boring 16 Pit Ground Surface elev. 101.35 ft. Depth to limiting factor 100 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 1 0-13 10yr3/1 none I 2msbk mfr cs 1f .6 .8 2 13-48 10yr5/6 none sicl osg ml cs na .4 .6 3 48-100 7.5yr4/6 none cos osg mfr na na .7 1.6 F—I Boring# 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 GPDM in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 ❑ Boring# I 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 P in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 *Effluent#1 =BOD5>30<220 mg/L and TSS>30<150 mg/L *Effluent#2=BOD5<_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. • f STEEL'S SOIL SERVICE INC. 3of3 ;David J. Steel Matt Hieb 994 200 ` St. CST-POWTSM NE1/4,NE1/4,S16,T29N,R19W Baldwin, WI 54002 Lic. #248956 Town of Hudson,St.Croix Co. Bus.(715)684-5680 Willow Falls, Lot 4 Fax.(715) 684-3449 Legend N 1"=40' )=Benchmark Ele. 100.00 ft Top of 3/4"pvc pipe =Alt Benchmark Ele. 100.45 ft Top of 3/4"pvc pipe ---- ❑ =Borings Boring Elevations Bl = 101.55 ft B2= 100.55 ft B3= 101.35 ft B4= 0.00 ft ]TD� r �� NORTH LINE OF THE NE1/4 OF SECTION 16 SM TOP OF IRON PIPE S89'49'34*W 2626.79' ELEVATION=851.9 N89°49'34"E 860.34' (N89'59'10-E) Y 1766.45' 9.74' 127 492.45' 328.15' NORTH 1/4 a <2s \ COR. SEC. 16 \ / NU TY \\ � LOT 5 2.21 ACRES U1. 96,149 n 96,149 SO. FT. DRAT .IOE DIAMETER IRON PIPE , t NACC CASEMfk 140 L.B.O.= 855.0 11AMETER IRON PIPE a, \ \ `C9 7_ E DIAMETER BY 18' LONG IRON i LBS. PER LINEAR FOOT w \G STORM—WATER DRAINAGE EASEMENT EVATION HWE 851.0 =� mss• �� M�r\ NG — THE LOWEST DOOR OR kCK LINE 3EMENT LOT 4 \ �/ / 4.79 ACRES " \ AND/OR DISTANCE <'� / 208,731 SO. FT. LOCATION ��a // L.B.O.= 855.0 ?RS OUTSIDE DIAMETER T WEIGHING 1.13 s 630 fp onstruction and 3d, underground or is to conduct Iement shall have no ��dtP / s, shrubs or other / : ition, function, or L17 / LOT 3 GRANGE ROAD lic utilities shall not ——— 2.88 ACRES )hibited obstructions. 125.284 SO. FT. L.B.O.- 855.0 i 7NSIN LAND SURVEYOR, HEREBY CERTIFY: ,VISIONS OF CHAPTER 236 OF THE