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HomeMy WebLinkAbout020-1445-04-000Wisconsin Dep^rtment of Commerce Safety and Buil*ng DivisiorY PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information ynu pYOVide maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Bast, Kernon Hudson Townshi CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION ~'~ . s< TYPE MANUFACTURER CAPACITY Septic ~ ,~: ~ ~ ,~.~ ~ ~ ~~ C Dosing ~. Aeration Holding <~/~~ ~ ~~~' %~~C- ' TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air intake ROAD Septic ~- <.- ~-- , ._ _ _ Dosing •, ,.--- _-_ Aeration Holding PUMP/SIPHON INFORMATION Manufacturer • __ Demand GPM Model Number ,, f,. TDH Lift' Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. CrDiX Sanitary Permit No: 45 0 State Plan ID ~, n/], Parcel Tax No: Section/Town/Range/Map o: 11.29.19. STATION BS HI FS ELEV. Benchmark f]~ ~?<~ /G ~ -~ /~C~ ~ `~ Alt. BM ~ /v [ • 3 5 Bldg. Sewer ~ SUHt Inlet lU i c?17.5 SUHt Outlet Dt Inlet '~\ Dt Bottom \ Header/Man. i3 `~ ~~ S . Dist. Pipe "i ice- "~ .'7 ~' c1S•G~ Bot. System ~ )~ •~ `i N • ~ 3 Final Grade St Cover ~,, BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS '~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR l3 + e -r! , ' ~' +v Type Of System: ~ 5 ~ `~ ~`~C r„~ <> ~ ~ ~~ UNIT Model Number. ~ ~ C - ~~,, u~~-= -~ ~ ~ c~- . ; ~ i~F cl-~ i ~ ~ DISTRIBUTION SYSTEM / y ye ~ ~ 1~- Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake + L r~ Length ~ Dia ~ Pipe(s) __l__~_____ -----~-_.~ Length Dia Spacing ~- > ~ ~~ + SOIL COVER x Pressure Svstems only xx Mound Or At-Grade Svstems Only Depth Over Depth Over xx Depth of xx SeededlSodded xx Mulched Bed/Trench Center Bed/Trench Ed es g To soil p ~! Yes ~~ No ,~ Yes I] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: J~ I ~`~ / L'{ Inspection #2: / Location: pending Wild Turkey Trail Hudson, WI 54016 (NW 1/4 SE 1/4 11 T29N R19W) Sunset Hills Lo 4 f Parcel No: 11.29.19. 1.) Alt BM Description = C f~J t? ~"~- c + •- ~ '" e -! ~ c~ ~ 4~r,/t ~ ~' ,~-'~ '~~ . I 2.) Bldg sewer length = (C:' - amount of cover = '4 t-~~~ ~~ '"~n revision Required? ~ Yes ';- No ~~~ I~ Il)1~ ~ ~ ~' y`_ j ' o i t other side for additional info to ~__ J i ' ' -' ---, ~ -6710 (R.3/97) Date Insepctor's Signature Cert. No. I ~ Safety and Buildings Division County ~ S~' C ~ ~ 201 W. Washington Ave., P.O. Box 7162 t2 ra ~scons~n Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by CoJ Department of Commerce (608) 266-3151 S.3 ~J Sanitary Permit Application State Plan I.D. ~iun ber I In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ,rJ may be used for secondary purposes Privacy Law, s15.04(1)(m) Pro'ect Addres (if dif Brent than mailing ddress) - ~ z~~ K S 7 Lam.. u• / I. Application Information -Please Print All Wormation Property Owner's Na me Parch ock /! Property Owner's M ailing Address L t ~ Property ation „ _ / S - ,f J ~.YiW Gtt'7~t ' ry N ~ ' ~ ' ~ City State Zi C d /s . a ,Section , , ~Ub ~ p ~' ~ o e ~~~ f~ _ Phone Number ~~~! ,. _ n (circle one) at I ~ II. Type of Building (c eck all that apply) - T N; R E or w t. Y g _ ~ ~ ~ ~ ~-1 or 2 Famil Dwellin Number of Bedrooms ~ L ' - C 1 7 ")-E Subdivision Name CSM Number _ ^ Public/Commercial -Describe Use ~ ~ C i t-___ SLt S ~ N')~ I - ^ State Owned -Describe Use ~~ (~ i ~ / ~ ~ £ ~ 1.~ G{i~ ~' r?~ ,` 1-Y ~c~ ~_. y ^City_^Village ^Township of 419.SOY _1<< III. Type of Permit: (Check. only one box on line A. Complete line B if applicable) A' i~Vew S stem Y ^ Re lacement S stem P Y ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System B. ^ Permit Renewal Permit R ,Change of ^ Permit Transfer to New List Previous Permi[ Number an-d Date Issued Before Expiration Plumber Owner 7 //~ ~ ~ ~ / a ~ ' 7 CJ lV. T of POWTS S stem: (Check all that a 1 ) i~lon -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter - ~_ ^ Constructe etland Pressurized In- round ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter Leaching Chamber ^ Drip Line ^ Gravel-less P~_ ^ ~} Qther (explain) V. Dis rsaUTreatment Area Information: (V ( ~ ,~ -;--7) -/ Design Flow (gpd) a D Design Soil Application Rate(gpdsf) .'l Dispersal Area Required (sf) 85 Di rsal Area oposed (sf) - System Elevation ~ Q~.s~ ~~ 9tQ,t~u 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 ~' ~ ~ \ ~ ~ •t ~ ~~ ~ L G.1 Aerobic Treatment Unit - / 1r j/~ Dosing Chamber VII. Responslbility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Na me (Print) Plu is S' nature MP/MPRS Number Business Phone Number ` - ~. din Yy.-tt ~aa g u 3 - ~a l I S Plutber's Addre ss (Street, Ci ,State, Zip ) ~ ~ U~ b ~ 1Z- .~~U1 r~ VIII. ount /De art ent Use Onl Approved ^ Disapproved Sanitary Permit Fe includes Groundwater Dat Issued Issuing gen i afore o Stamps) ^ Owner Given Reason for Denial ~ Surcharge Fee) ~1 ~ ~ V ~ ~ ~ IX. Conditions of Approval/Reasons for Disap"pro~val A,, ~~~~~~~~ ~ v ~ i~Ti;v12,~1~ /21~/L~(/TJ~~~~~j f"'(~ Y~t~ue G~h !/1~.6~G ~ -yt~f ~~~ i SYST M OWNER: Q 1 eptic tank, effluent filter and ~ ~" dispersal cell must all be servi ed maintained ` ~„ Q as per management plan provided by plumber. S ~ ~ ~ "'~ tained i b ~-C n e ma 2. All setback requirements must ' ble code/ordinances. ` SBD-639$ (R. 01/03) -••-~~ ..,....N.~.~ p~aus tw ioe ~.ouury omyt wr me syscem on paper aoc tens tnen tstu x t t mcnes m stze ~e~~oN ISAS~ S~u NSA.-~ ~1 ~ I I S ~~ ~ ~ ;M~a '_Iw- ioa.~s 3~ 87 SO ~ ~U1 J~ ~~~ ,. ~~,. ~ : ~- 4 ~ ~~ Q~ ~ J~ ,~, ~ / r'~'2v _ ~ lay s}p~ 1 pi -~ UU. 0 • ~ ~~ , ~~ ~ ~ ~ 1rn ~h,gp~ ~. aaag~y ~~, o 's .~ a~ ~~ ld ~U ~°~°~ Tom, ~ ~} gc,-sv (~ 94-oU >N ~~~~ ~~~ ~~ ~ ~ ~/ .,J 1rn ~bGh,gpS ~. ~~~guy >N ~ [ w ~~ z° . W ~LLLL fJf '" ° ~ ~~o 0 ~ "'~ W ® ~O~ Y. ~~o ~LLF _zz~ v~~ ~~~ OQp ~~U ® Nip ~ZU LL~~ o r~ W ~ ~~" ~ ~~ a A ~~ ~c°f~ J ®~~ ~ ~~ o~ ~ v N ZN~ ~-`~~~ ~ w a4 F a aoN ~,,,~ ~ ~ ~ ~ ~~ ~~ ~ ~ v °- a ~ ~ ~ ea ~ O ~ "~ ~ z x <n ~ ~ '~ ~~ ~~ ~~ ~ ? o ~ ,- ,..- r zsssr~ zzs I STATE HAR OF WISCONSIN FORM i - 2000 Docurrwent Tiumber WARRANTY DEED Thfs Deed, made between Brian H_. Raleigh and Michelle I... Ralei h, husband and wife, Grantor, and Kernon J. $ast and Donalda J. Speer-Bast, husband and wife, as survivorship marital property, Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estatevn St. Croix County, State of Wisconsin (the "Property") (if more space is needed, please attach addendum); See attached Addendum A. /+t * Brian H. Raleigh * Michelle L. Ralei¢~ 020-1013-70-000; 020-1013=60.000; 020.1013-50-000 Parcel Identification Number (PTN) This is not homestead property. Together with all appurtenant rights, title and interests. ~~ (is not} Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except Dated this _ ~" fn's day of May 2004 AUTHENTICATIQN Signature(s) authenticated this day of ~_ Che>IiBT~`' ' c Notar ~onsin TITLE: MEMBER STATE BAR ~~C ONSIN (lf not, authorized by § 70b.t)b, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED EY ^, Brent R. Johnson Lornmen .Nelson Law FFrm, Hudson, Wisconsin (Signatures may be authenticated or acknowledged. Hoth are not necessary.) of persons signing in any WARRANTX DEED Area ldame and Retum Address Edina Realty Title, Inc. 400 South Second Street Hudson, WI 540Ib ~°'"~?-~0l X19 ?61+:~ 1 4 KATHLEEN H. 1iALSH REGISTER OF DEEDS ST. CROIX CO., 1fI RECEIVED FOR REGARD 06/02/21i~4 89:15A![ 1lARRANTX DEED EXEMPT # REC FEE: 13.00 TRAiiS FEE : 1260.00 COPY FEE: CC FEE; PA6ES: 2 ACKNOWLEDGMENT STA'CE OF WISCONSIN ) ss. ST. CROIX County ) Personally came before me this _ ~ ~ day of May 2004 the above naxtred Brian H. Raleigh and Michelle L. Raleigh, husband and wife, to me known to be the person(s) who executed the foregoing instnunen' d aclrnow edged the same, Notary Public, State of WISCONSIN Ivry Cotrunission is permanent. (If not, state expiration date: ' I I • D'~. ~ .) must be typed or printed below the;r signature. STATE BAR OF WISCONSIN FORM No. I -1000 INFO-PRO (800)855-2021 www.infoproforms.com ~~ U 2~86~ 217 ADDENDUM A TO WARRANTY DEED PIN: 020-1013-70-040; 020-1013-60-000; 020-1013-50-000 GRANTORS: BRIAN H. RALEIGH AND MICHELLE L. RALEIGH GR A,NTEES: KERNON J. BAST AND DONALDA J. SPEER-BAST Legal Description Located in part of the NW t/4 of the SE °/a of Section 11, T29N, R19W, Town of Hudson, St. Croix County, Wisconsin; including part of Lot S ofJoshua Hills recorded at the St. Croix CotmtyRegister of Deeds Office; described as follows: Commencing at the S %4 corner of said Section 11; thence North 00 degrees 33 minutes 37 seconds East,. along the west line of the SE '/4 of said Section 1325.63 feet to the south line of the NW %4 of the SE %a; thence South 89 degrees SS minutes SO s~wconds East, along said south line, 13.67 feet to the point of beginning; thence continuing South 89 degrees SS minutes SO seconds East, along said south line, 876.02 feet to the west line of Lot 1 of the proposed Plat of Sunset Hills; thence North 00 degrees 18 minutes 4S seconds East, along said west line, 347.77 feet to the north line of said Lot 1; thence South $9 degrees 27 minutes 39 seconds East, along said north line, 377.45 feet to the west line cif a Tawn Road (Tanney Lane); thence North 00 degrees 18 minutes 4S seconds East, along said west line, 33.04 feet; thence South 89 degrees 27 minutes 39 seconds East, along said west line, 19.14 feet; thence North 00 degrees 3S minutes 36 seconds East, along said west line, 33.00 feet to the south line of Lot 10 of said proposed plat; thence North $9 degrees 27 minutes 39 seconds West, along said south line and the south line of Lot 9 of said proposed plat; 434.50 feet to the west line of said Lat 9; thence North 00 degrees 36 minutes 12 seconds East, along said west line, S 11.98 feet, thence North O 1 degrees 19 minutes 09 seconds East 74.93 feet; thence North 89 degrees 44 minutes 56 seconds West 831.74 feet; thence South 00 degrees S4 minutes 40 seconds West ] 403.69 feet to the point of beginning. Page 1 of 1 Q3f 13f 20D1 16: 21 71-53B6~7473 _- ,, C~"V CAT .,... _ _,._._.__-.w_.. _,__.._.._...~. PAGE 01 ._ G ~ ~, .. ~AA'C~I ~41Mi~AA'IOeQIQIt Nliltfb4:~' _,,,,,~,, ~~ ~'~ ~4:4~rs~'/,, ,~.~ °t';, Sec../~.~,~ T,~W-R,.~.~„W, 'X"Qw~ of ~1~.C,'cr'~~/C~ ~. Salldiividem ,,,,~ ' (,S ~, Lot # .,,,,,~,_. ~~ s~aa+r~ey M[eP +~ ~ Yol+u~e , , Fage ~ Wlel~'naty Iw#+~ed !~ _~,~c:.f~.c~~~ . _:....-~..~...~' volull~o ~~~ , s»~ ~ ~~5~..,...... Spec hana0 jzf yes C) fta Lot Iii identit~abla~~rci ®~~o ,n h-~nap~ar oea gad eA' ~t ~Ptia system could rand In lt~ prenu~t~a~e thllure ~o be,~Ee*, Paper ~ t~ tl~* Il~aalioa oP ~ "r vaveer. K ~se+~ad by # tieea~o~t p~wr. Whet ~n ppi ~Sto ~ , «~o Ialc a a #~l ele~+a ~ tha N ~! s~-weean. "~ ~ •~, to ~oabeutt w St. c~aix ~vsimq~ Dayatl~ • v~ilioadoe ibs~n, d~owod ~y m. ow~r ~ ~r e ~0~~e 1 i09f 4 ~~C~Ofadp~Itl~Nf ®at~~I~ 1bW ~~) iha os-e~N wrpla#~hsdl~q~l M ar prayer +a~er. oooa~aa for (~, ` lm~ wad (i1~ aoaae~r~,lhu ,~plk ~ ~ haq~tl~ tr~;~un~t.h~r. ~ ~"' ~ ~ ~ ~ .: ' ~ ~ ro matami~ tsu pdvne puce diryaaai ye1,~r. ~,..drasdrN~r ~ 1a~.i ~ ,~ be aep~anent of t+ti~1 ~ ~aue ~~ a«-. ~ ~ , -~.~.: ~~ ,- , ~ +a to ~ ~l, Grro;A CAar~r Zar~ t~6oa trNhle ?o ~..,~~, ,.;-~, ,,. ~. ' ~ {we ~ ~ t ~tl ~ an.y~ ,re srua h, ab-e ban a!' e+~- (+wcp k~-1~e, i (w-e) rro (~)1ka ~ a~' ~ vhtae oP # r~ dopd nsca~clal 1n A+~HMr Af Iha~ C1~ec. ~ , ,.,~' 17A ~ . .y~.,. :: sN'44 r ~s ,°'.~ ' ~~ , '~ ~ '~ ~' _ ie lhs ~ P rvm~o~nd by ~ F~i~ wl,'•*`~ ~M~~_~ ~yl *~'; a =~It~ deed the l~pfsler aP >:Mals ot~il+a a Apr ~ 4eo ~ earwr tip if ~ it rmtde M l~llt t-.~tny ~ T ~~o~x ~c~ul~rrx B~3PTIC 7fAAfIG 1MlA.IN~NA~iC~ ,+A(~~B13MRN"C' AND OWNBI~I-IlF C~I~'~IFICATION I'C1RItiI 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 3 Number of Bedrooms Design Flow -Peak (gpd) 0 v Estimated Flow -Average (gpd) `7 Septic Tank Capacity (gal) Soil Absorption Component Size (ft2) Type of Wastewater Domestic Table 2: Soil Absorption Component -Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow -Peak (gpd) ~ p u Maximum Influent Particle Size (in) r g 1/8 Maximum BOD5 (mg/L) ~; ~j 220 Maximum TSS (mg/L) ' S(~ 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 Nolding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shaft be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the -, Management Plan far 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 confrned space. The atmosphere within the septic or other treatment of holding tank may contain lethal gases, and rescue of a person from the interior of the tank maybe difficult or impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are shown in Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shall include recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of 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 i 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 3 Safety and Buildings Division County , i n i 201 W. Washington Ave., P.O. Box 7162 seo s n Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 266-3151 ~ /s3 ~ /,~ Sanitary Permit Application State Plan .Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ma be u d f /'e y se or secondary purp oses PUy~,j„aw c15„04(~(m) ._. Proje -Add ess (if different than mailing address) 4 r .. ~"~ I. Application Information -Please Print All ortriation' •~- ~ ~ / J/ l~ ~u~~ t W ""~' Property Owner's Na me i. i.. °, ~ U 1. 4 Parc_ I-N L t Block /! O ~~~` Property(O~wner's M ailing Address ~ ~ - r . N._.. ~:....___ I Property Loca ..__z ! Ciry, State Zi ode • t .. ~~'~, ~~ '/.,Section ~_ P Phone Number ~~tJ/~j ~~„s ~~ ` ©/~ ~ (circle ) II. Type of Buildin (check R~E ll th T ~ N V~ g ; a or at apply) ~ u~~ /~ _7 w ~1 or 2 Family Dwelling -Number of Bedrooms Subdivision Name CSi1t1 Nu ber . ` ^ Public/Commercial -Describe Use ~ ~[,L 4 ~ ^ State Owned -Describe Use ~ ~DI,Sj^. w ~"' Z3 ^City_^V~ lage Township/o'f ~ ~/ G 5 III. Type of Permit: (Check only one box on line A. om lete line B if a licabl `~^ P e) A. New System ^ Replacement System ^ Tr ent/Holding Ta Replacement Only ^ Other Modification to Existing System I3. ^ Permit Renewal ^ Permit Revision ^ Change ermit Transfer to New t v' Per to Issued Before Expiration Plumber ner N. T e of POWTS S stem: (Check all that a 1 ) Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ o < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank Peat 'ter ^ Aerobic Treatme nit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter Leaching Cha ber ^ Dri Line ^ vel-less Pipe th r (ex lain) V. Dis ersal/Treatment Area Informatton : l.Gt. _ Design Flow (gpd) Design Soi pplication Rate(gpdsf) Disper al rea Required (sf) 'spersal Area ed (sf) System Elevatior~ ~ C G VI. Tank Info Capacity in Total Number Manufacturer refab Site Steel Fiber Gallons Gallons of Units Plastic Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank „_ / ~O Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume sponsibility for ' tallation of the POWTS shown on th attached plans. Plumbe ' Na me (Print) ' Plumber s natu /MPRS Number ~^ Business Phone Number Pl b ' um er s Addre ss (Street, City, Sta ,Zip Code VIII. ount /De artment Use Onl Approved ^ Disapproved Sanitary Permit Fee ncludes Groundwat r Date Issued Issu' g A ent Si lure S m s) Surcharge Fee) ~~ f~71 (l~ ~ , ~ ^ ~ ~ ~ Owner Given Reason for Denial TT / ,~ CJ ~ •eatal/Reasons fo isap t~vai ` C_ eptic tank, a !u®nt filter and c(p~ n,. ~ ~1~ .Q°a¢-~Sy /'YI,~,t,, dispersal cell must all be servi d ~ w " ~1 ce / maintained lvt,, ~ f U e / ~ ~ as per management plan provided by plumber. 2. All setback re uir '>~ ~ ~ ~~ ~~ ~ ~~ ` q ements must be maintained 0 ~'~ Q ~ 'y'" - as per ap licabl [~ ~ p ~Q.tn-iGl.~.. e code/ordinances. ~!~ a~ ~p~p QLC~"~o~' ~ . S~ ONE C / `'- ~'O )~~_ ~ ~ ~s~ `~ '' ~ (~ \, .~ ~ ~ ~ ~' '~- `~ =-~i ' ~ ~~ ~ 0 o a ~ ,, ~, ~' '' ~ ~ ~~~~~~~ ~ ~ ~~ ~ ~~ ~~ y ~ ~3 °', ~' C` f r s © ~ "~ . ,~ W O i ~ ~~~ \ '^`~ V ~~ ~ ~~ ~~~ ~ ^~ Ott `l ~ ~ ~ ~ ,6 ~ ,' ~' ~~ p o Q o ~~ ~~ ti ~~ ~~~ O T ~ ~1. ~~~ o' ~ ~~ ^~~ n ~ RECEIVED ~-' ~ . ~ ~ ot~onds JAN p g SOIL ALUATION REPORT - ~ p~ ~ ~ 3 2004 ~ae,~s~,~,an ~ ~~~~~ ~.,~ ~ 5T cRor K. Pew . scale arm, n~ ~r+o,n ,arid to nean~st road. ,~ ,.o. 0 2 0 • is/3.70 • oaa Ploase print all lrMorrnatlon. t7a~e ~ww~ro~aw~aemre.yea+~~o~a«rat~r~.s.,so~c+)E~!• 7 ~,(, b ~~~~N /~i4LE/5 li.%... ~ , ~' ~~- Str vas . ~l T 2`f n, R ! f ~{«~ w s G.~! . ,.ac # t ~ subd r~ ar CS,~ o~~. /~{v~.So~ s~ z~coae > /u/. 5yo/G t71s 381~'9QOS o~- ^+ ®,Tawn ,+~ ~o~v T.~tiEy !-N ~~-+ use: ~ ~ ~ t,earoorrs caaB ~:a~ d - as coo ^ Rr+rerrt t3 Pr~c or oaat+erci~ - Deycrbe: and • /~K~•q- TES TAO ~ S Sv !•Y"s9-~GE ~~ /1-.~J j.U 9~2o v-vo ~ ~ U ~Qp.lZ- ~ Groea>d surface e,e~+. ~~ n. F,orrxon ~~ Dottrittarr< Rertox t^. >liNs~ei Qu. Sz Cant. Color ,5 t7epm to rm~rg tac~or ~~ ~. Texttse Siructire C,oroe eoundary C~: S~. Sh. _ . Sol Rage Roots 'E~1 '~ ~-~ goy 3~ -- ~s ice, 3f . ~ ~.Z 2 G•~S r L r~ /.Z 2 ~~. - 3~ -- ,3aring lk ~ ~ c~+our,ds~ceele,-. ~ o l • ~,~ ~-,~ ~ 9 ;,, > ~' Rem DepAh Domirser~ Redact Des<x~lption Texture Strudue C.a>soe Bax~dery Rods CPDNI~ ~• Qu. S'z. Coat. Color Cu Sz. Sh. '~1 ' z ' ~ ~ L .wr C /. Z • ~• S~ S ---~ S l~ a2 c - 7 S /~. s~ ~ lI ~ /. ~ _zlo •• ~, ~ = ewu ~ 3El < zm mgt and T5s >30 < 150 mgR. ' eauenc #2 =eon < 30 mgA. and TSS < 30 ~ . csT ~thte~e ,~ A Oebe Evon Candrxted Telephone Nun6er ' ~/o v . z • ~, 7rs• '7~a • 3 yy2.. o.:• __, Associates """`C sewage Consultants 2812 ~ 0th Ave. Spring Valley, Wt 54767 -~ N1czaA:u~QaN~r~~ av. C 5 r ~S ~ ~a-~ w~.~ v~.s~"" b.~- a~ ~ua,a~ ,,,~ 1 ~~$ I .i,,n¢l, ~ tee,, Q svvs~f lf~l~s . ~. I....:.._.J ~~. ~[ LAV[ffR7Swtdixw7lCV_ - ~~ a.+e}~ar W ia~av+gj wxw - s!. ar70~ ~@ ~ ~ RBdtnc ~ Text~ae a Core~stenve Swufdary Roots in. M[a-ses Elu. Sz. Cait. Cobr Ca`r Sz. Sh. `~ 'Ei~2 i D• /D y/~ 3 LS .~-~- S 5. w. 3 • 7 / Z 3 ~• ~.s ~ s o. ~.~ cs - -~ Z ~ s . ~~ ~ R ~ ~ ~ Roos ~ o~- ~ - r ~ ~ Rods ~. Mcr~e~ Qu. Sz. t:ont. C.okx . S`t. Sh. ; ' 6 A Q~ emu} ( ~ ~gp V~W~ni S[YiOW e1 11 9/ °""~ MSMX R~' Q11~ RP~C 1'~Ot1 P~s +{"tea ~~yy~~ / ~~..{/~_ ~EOdAIB /.~~!$LtL'~UfC ~ ~1~Y ~ipp~6 ws ' ~ ~ p{ iR~L W! 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N •~~. 3 D r~~ V ~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of_2 FILE INFORMATION Owner / Permit #/ DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units ,.. ^ NA Estimated flow (average) QQ gal/day Design flow (peak-, (Estimated x 1.5) ~ gal/day Soil Application Rate t al/day/ft2 Standard Influent/Effluent Quality Monthly average" Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODE) _<220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODE) Total Suspended Solids (TSS) 530 mg/L _<30 mg/L Q9, NA Fecal Coliform (geometric mean) ° fu/100m1 Maximum Effluent Particle Size Ya in dia. ^ NA Other: ^ NA *'Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity I ~0 al ^ NA Septic Tank Manufacturer ~ ^ NA Effluent Filter Manufactu erg ^ NA Effluent Filter Model ~ ^ NA Pump Tank Capacity al ^ NA Pump Tank Manufacturer ^ NA Pump Manufacturer ^ NA Pump Model ~ ^ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: ANA Dispersal Cell(s) ~In-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA M4INTFNANCF C(_HFr1111 F Service Event Service Frequency Inspect condition of tankls) At least once every: ^ month(s) (Maximum 3 years) yearls) ^ NA Pump out contents of tankls) When combined sludge and scum equals one-third IY31 of tank volume ^ NA Inspect dispersal cellls) At least once every: ^ Y@a~' ~lsl (Maximum 3 years) ^ NA Clean effluent filter At least once every: month(s) yearls) ^ NA Inspect pump, pump controls & alarm At least once every: ~ ea~~sjls) Y ^ NA Flush laterals and pressure test At least once every: ' ^monthls) ^yearls) ^ NA Other: At least once every: ^monthls) ^yearls) ^ NA 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 tankls) 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 cellls) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third IY31 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, pretreal:ment units, and any servicing at intervals of S12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. ~ Pagg _ ~ of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal celllsl. If high concentrations are detected have the contents of the tanklsl 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 cell(s) in one large dose, overloading the cell(s) 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 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 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 ' '~RD}~l8 n~ a o ing tank b e ai a ~D ~- A/~ CaN57Rtl~t n ^ 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 5' POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name s-r, C l d U ZO~II ICJ Phone '"'/S- 3g(O_ (0 (7 This document was drafted in compliance with chapter Comm 83.22(211b)1111d1&lf) and 83.54111, (2) & 131, Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP C;~RTIFICATION FORM OwnerBuyer ,~C~~2n/G»~ y~~ f~'- Mailing Address _ ~l,C$' G~y,I~~- ,Qp , ~,,r/ ~,~- ~o/~ Property Address 7~~~ 5 (Verification required from Planning Department for new City/State ,~/~~, u.~ parcel identification Number ~--_ LEGAL DESCRIPTION Property Location ~iJ frl,.( ~/., ~'/., Sec. ~ T~N-R~W, Town of Subdivision ~c~r/SE~,~/(~(yi Lot # Certified Survey Map # Q d ~ l Volufne Pa e # - / g Warranty Deed # 7 ~ ~ 5 l ~ Volume ~ ~ Co Page # Spec house ~es ^ no Lot Lines identifiable~es ^ no SYSTEM MAINTENANCE Improper use and maintenaaceof your septic system could result is 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 PmP~Y-oar agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, journeymanplumber, restrictedplumber or a licensedpumpervenifying that (1) the on site wastewatezdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is lass than I/3 fiill of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Deparnaent of Natural Resources, State of Wisconsin. Certification stating that your septic system has bees maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. ~"~`" h i ~ i ~ y SIGNATURE OF APPLICANT DATE OWNER CERT'IF'ICATION I (we) certify that all statements on this form are true to the best of my (our) losowledge. I (we) am (aro) the owner(s) of the property described abov~o~, bey virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT 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 offce a copy of the certified survey map if reference is made in the warranty deed . ,•,~ ~ J 2586P 216 4> ~ •~ • I STATE BAR OF WISCONSIN FORM i - 2000 iJocument Number WARRANTY DEED This Deed, made between Brian H. Raleigh and Michelle L. Raleigh, husband and wife, Grantor, and Kernon J. Bast and Donalda J. Speer-Bast, husband and wife, as survivorship marital property, Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (the "Property") (if more space is needed, please attach addendum): See attached Addendum A. Area 7645 1 4 KATHLEEN H. 1lALSH REGISTER OF DEEDS ST. CROIK CO. , MI RECEIVED FOR RECORD 06/02/2004 89:15AM MARRANI'Y DEED EXQpT # 8 REC FEE: 13.80 TRAIiS FEE: 1268.00 COPY FEE: CC FEE: PAGES: 2 020-1013-70-000; 020-1013-60-0OO;OZO-1013-50-000 Parcel Identification Number (PIN) This is not homestead property. Together with all appurtenant rights, title and interests. (~~ (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and &ee and clear of encumbrances except Dated this ~Z day of May ~ 2004 AUTHENTICATION Signature(s) authenticated this day of ~_ GheC~~ , c ~{aNotaC ~ons~n TITLE: MEMBER STATE BAR O'F'WI~C ONSIN (If not, authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Brent R Johnson Lommen Nelson Law Firm, Hudsog, Wisconsin (Signatures may be authenticated or aclmowledged. Both are not necessary.) of persons signing in any capacity must WARRANTY DEED /~ * Brian H. Raleigh * Michelle L. Raleigh~- Name and Return Address Edina Realty Title, Inc. 400 South Second Street Hudson, WI 54016 ~'"~?-le l X19 ACKNOWLEDGMENT STATE OF WISCONSI ST. CROIX N ) ss. County ) Personally came before me this ~ ~ day of May 2004 the above named Brian H. Raleigh and Michelle L. Raleigh, husband and wife, to me Imown to be the person(s) who executed the foregoing insttumen d aclaiow edged the same. * Notary Public, State of WISCONSIN My Commission is permanent. (If not, state expiration date: typed or printed below their signature. STATE BAR OF WISCONSIN FORM No. 1 - 2000 INFO-PRO (800)655-2021 www.infoprofomts•com ~3 M1 F f ` ,. .;, w 2586P 217 ADDENDUM A TO WARRANTY DEED PIN: 020-1013-70-000; 020-1013-60-000; 020-1013-50-000 GRANTORS: GRANTEES: Legal Descriation BRIAN H. RALEIGH AND NIICHELLE L. RALEIGH KERNON J. BAST AND DONALDA J. SPEER-BAST Located in part of the NW '/4 of the SE'/, of Section 11, T29N, R19W, Town of Hudson, St. Croix County, Wisconsin; including part of Lot 5 of Joshua Hills recorded at the St. Croix County Register of Deeds Office; described as follows: Commencing at the S %4 corner of said Section 1 l; thence North 00 degrees 33 minutes 37 seconds East, along the west line of the SE '/a of said Section 1325.63 feet to the south line of the NW '/< of the SE'/<; thence South 89 degrees 55 minutes 50 seconds East, along said south line, 13.67 feet to the point of beginning; thence continuing South 89 degrees 55 minutes 50 seconds East, along said south line, 876.02 feet to the west line of Lot 1 of the proposed Plat of Sunset Hills; thence North 00 degrees 18 minutes 45 seconds East, along said west line, 347.77 feet to the north line of said Lot 1; thence South 89 degrees 27 minutes 39 seconds East, along said north line, 377.45 feet to the west line of a Town Road (Tanney Lane); thence North 00 degrees 18 minutes 45 seconds East, along said west line, 33.00 feet; thence South 89 degrees 27 minutes 39 seconds East, along said west line, 19.14 feet; thence North 00 degrees 35 minutes 36 seconds East, along said west line, 33.00 feet to the south line of Lot 10 of said proposed plat; thence North 89 degrees 27 minutes 39 seconds West, along said south line and the south line of Lot 9 of said proposed plat; 434.50 feet to the west line of said Lot 9; thence North 00 degrees 36 minutes 12 seconds East, along said west line, 511.98 feet, thence North O1 degrees 19 minutes 09 seconds East 74.93 feet; thence North 89 degrees 44 minutes 56 seconds West 831.70 feet; thence South 00 degrees 54 minutes 40 seconds West 1003.69 feet to the point of beginning. 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