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Wi rtment of Commerce PRIVATE SEWAGE SYSTEM
Safe dings Division Count y:
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanita i1NO.:
z Personal information you provice may be used for secondary purposes [Privacy Law, _- (1)(m)).
g'ipp t eresa City ❑ v Tpkhi State Plan ID No.:
CST BM Elev.. Insp. BM Elev.: BM Description: Parcel 61W- 4376 -35 -000
TANK INFORMATION ELEVATION DATA �y- z 4 ` ��• zzq�
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic yvt s�c, c �- ( Benchmark
Dosing Alt. 13M
Aeration Bldg. Sewer to
Holding _ St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Air I ntake ROAD Dt Inlet �---
ir
Septic >5 3 NA Dt Bottom
Dosing NA Header /Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP / SIPHON INFORMATION Final Grade tA t�
Manuf urer De d ov
Model Number GPM 13� , (O 10f to 169.
TDH Lift System TDH Ft o) � &V � ?, 5
oss Force Length Dia. I t t. To weu �Qirt� lWrtWn-
SOIL ABSORPTION SYSTEM S
BED/TRENCH Width Len r No Of renches PIT No. O Inside Dia. Liquid Depth
DIMENSION `1 1-5 oZ I DIMENSI
SETBACK
SYSTEM TO P/ L BLDG 'AM
WELL LAKE /STREAM LEACHING
INFORMATION Type Of Z CHAMBE � � Model Number:
System: ,
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over I xx Depth Of xx seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes []No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1. Ot /a of Inspection #2•
Location: 926 Florence Lane, Hudson WI 54016 (NW 1/4 SW 1/4 14 T29N R lg W � ) � 1442 Swee Grass Farm -Lot
1.) Alt BM Description=
2.) Bldg sewer length= 3o `
- amount of cover = IB _Z f " cevei
Plan revision require No
Use other side for addito ormation.
SBD -6710 (R.3/97) f�.t ,S t n 6PeNo,� Signature,, j �B�t
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40J6 Sanitary Permit Application Safety & Buildings Division
lvcc In accord with Comm 83.21. Wis. Adm. Code 201 W. Washington Ave.
r isconsin See reverse side for instructions for completing this application PO Box 7302
Personal information you provide may be used for secondan purposes Madison, WI 53707 -730.
Department of Commerce [Privacy Law, s. 15.04(i)(m)J (Submit completed form to county if r
state owner
Attach complete plans (to the county copy only) for the system. on 2aper not less than 8 -1/2 x 1 I inches in size.
County, _� r State to P rmit Number ❑Check if revision to previous application State Plan I. D. Number
� , vKr `C D 7
I. Application Information - Please Print all Information Location:
Prop rty Owner Name % Pro Location C� nZe "1 /4 /4, S 1 Y T I ,N, R/ or 46
Property O 's Mailing Add ss Lot Number Block Number
X61- �� Av 35
City, State Zip Code Phone Number Subdivision Name or CSM Number
S_ At � 5- e /
II Type of Building: (check one) ,s Pp' s ❑ City
X I or 2 Family Dwelling — No. of Bedrooms:_ � '� - l-4 ❑ Village
❑ Public/Commercial (describe use): Blown of
13 State-owned
III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest U-oad C� J
A) 1. $(New System 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Addition to Parcel Tax Numbe �
System Tank Onlv Existing System O a® -- / Y , -7 6 — 0 t)
B) Permit Number
❑ A Sanitary Permit was previously issued ql2q / I ' asg
IV. Type of POWT System: (Check all that apply)
S Non- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
❑ At -grade , t ❑ er is Tr atmen it ❑ Recirculating ❑ Other:
3 �Z -Sa (i0 3 /O e • �rt-� Y� Ll
V Dispersal/Treatment Area Information: —'/
1. Design Flow (gpd) 2. DispersalArea 3. Dispers o pp ication 5. rcrco:ation Rat e 6. System 176! on 7. Final Grade
Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) -r /_ 9i / �� Elevation
VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks
❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
VII Responsibility Statement
I, the undersigned, assume res on ibility for installation of the POWTS sho wTl4p the attached plans.
Plumbe Name (print) Plumber's ignature no s P/MPRS No. Business Phone Number
r 1
Plumber's Address (Street, State, Zip Code)
116
VIII County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps)
,Approved ❑ Owner Given Initial Adverse Surc ge Fee) ]L�
Determination f S. (rD zwd
IX. Conditions of Approval /Reasons f r Disapproval:
t,st� , � ,. e
t c_ Of +VAR.
AA
� S � ,yQ .vim D • S� . C 5� so=t � �/ � I t . � '! ���' y '
Co �� ` \�
SBD -6398 (R. 07/00)
1
G1'414�
10
- 011 ,
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epartment of Commerce SOIL AND SITE EVALUATION
Div,. r Safety and Buildings Page of
Bureau a Integratdd Services in accordance with Comm 83.09, Wis. Adm. Code
-Attach complete site plan on paper not less than B 1/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and 4 C f C) t
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
_ .
APPLICANT INFORMATION - Please pr' al I'hlbfmation. Reviewed by Date t S -Zeef
Personal information you provide may be used for seco pu iobses (P ivacy Law, s. 15.04 (1) (m)). g Z
Property Owner Property Location
tC Govt: Lot,,(/c,_) 1 /45CV 1/4,S / 4Y T Z ,N,R E (oaf
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
1 35 Keg ;� C at` 4 G coL3
City State Zip Code f °Phone Nurser ' r [ ' City [:]-Village [✓ Town Nearest Road
N c�fan Lo 5y01 "( t ° �'z" - 1 /� ur�So plc nc¢ /c-
New Construction Use: residential / Number of•bedrooms 5 _ Addition to existing building
Replacement Public or commercial - Describe:
Code derived daily flow 6P 00 gpd Recommended design loading rate bed, gpde - trench, gpd/f1
Absorption area required S 7 bed, ft 2 7 SU trench, ft Maximum design loading rate 7 bed, gpd /ft gpdht
Recommended infiltration surface elevation(s) �
n(s) Oar L ° °-'-' r - � 9 ' 6 ft (as referred to site plan benchmark)
Additional design /site considerations 4 64ffc U
Parent material O U- (" S 4 Flood plain elevation, if applicable ice/ ft
S = Suitable for system Conventional Tnd In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system S❑ U ❑ U 53 S ❑ U S❑ U ❑ S 5a U [Is R U
SOIL DESCRIPTION REPORT
Boris # Horizon Depth Dominant Color Mottles Structure GPD/ft
Boring Texture Consistence Boundary Roots
;.. , in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
1 v_9 312 --- lrnsbL r I t S
q -qi 1A 4 co m5
Ground
elev.
c' lo ft.
Depth to
limi' °tl•60 ��b 0 � ��'• �� ,
or
Remarks:
Boring #
{ 0 tv r 31z 50 Imab c 2
2 Z Ip q jd 5i I 2 m r _
38-99 Lit- 9 ko
Ground
elev.
Depth to
limiting
factor C up,
-29—in. Remarks:
CST Name (Please Print) Sign ture Telepfolie No.
Address Date CST Number
`/ d Z S 3 -3 01:?
PROPERTY OWNER STU SOIL DESCRIPTION REPORT
Pais
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Structure 2
Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
U a C S � $
% 2 Zy l� L3 J C —
Ground Zy_9c/ r j I S S M I
elev.
Depth to
limiting ,
factor _
in.
Remarks:
Boring #
o - ►I MY 312 S� ) lm m -cr C s pvf 2
a y 2 u -z q/
3 zto - y Cc rn n S4 CS — A
Ground
elev.
Depth to A .&a� � g � °� Q V
limiting b• / $Z. 'b
factor
gin. -
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # ► 0 to i' ��- 51 k fry ' r r s
it) y 51
10 r �I
/to S o m t c11� 8r
Ground
elev.
Depth to I ql. t. °� '� 85t•6o "j u.+ 89.fo C4 —
limiting
fact r `
v
in. Remarks:
Boring #
:.
r
Ground
elev.
ft. ,
Depth to
limiting
factor
in.
Remarks:
SBD -8330 (R.9198)
PAGE OF
i
NAME LOT #, S LEGAL DESCRIPTION how '/6(d/< S T Z 9 N R/ q E (or1' W)
,/SCALE: I "_ �(�
-/BM I ELEVATION ,
JBM I DESCRIPTION I Dac fl'�oc luiti
BM 2 ELEVATION �I(�•O�� ��
BM 2 DESCRIPTION -}pp�
SYSTEM ELEVATION »pec Y/• bo 6nr.,e F.0 X
ALTERNATE ELEVATION y(,�or 91.60 4,w•r �i$.Gd
CONTOUR ELEVATION ,(�
1
1
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CpUN
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SIGNATURE DATE
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 (POWTS) 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-
10567-P (R.6/99).
Table 1: System Design Specifications
Sanitary Permit Number3$
Number of Bedrooms
Design Flow - Peak (gpd)
Estimated Flow - Average (gpd)
Septic Tank Capacity (gal) a n I
Soil Absorption Component Size (ft 5 oo - � e. �
Type of Wastewater DoHlestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absor tion Component
Design Flow - Peak (gpd)
Maximum Influent Particle Size (in) 1/8
Maximum BOD (mg /L) 220
Maximum TSS (mg /L) 150
Table 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 b an individual certified to service septic tanks
p Y
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 se d outlet filter shall be assessed at least
once every 3 years by inspection. Th outlet filter all be cleaned as necessary to Pns�
proper operation. The filter cartridge sh no 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 confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank may be 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
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP C'- RTIFICATION FORM
Owner/Buyer &V 4 otelem TOt*
Mailing Address / 10 S AfAk 10 EWt , , 0 PARS
�1 SSdJi
Property Address Z*r 01 w GQAsS �
(Verification required from Planning Department for new construction)
City/State Act Parcel Identification Number ,00 – 7 6 – 35 – coo
LEGAL DESCRIPTION
Property Location 0E '/.,N '/., Sec. a3� T 0 N -R1 Town of Awo
Subdivision Lot # ' 0
Certified Survey Map # — . Volume . Page #
Warranty Deed # Volume Jf Page # 5 —
Spec house 0 yes X no Lot lines identifiable ; yes 0 no
SYSTEM MAINTENANCE
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.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
master plumber, journeymanplumber, restrictedplumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than In full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage'kposal system with the standards
set forth, herein, as set by the Department of Commerce and the Departmen�of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and ieturned to the Se Croix County Zoning Office within 30
days of the three year expiration date. ;
SIGNAtCkt OF APPLIC ANT �'~ DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the property described above, by virtue of a warranty deed recorded in Register of"Deeds Office.
' L \ � �� �Lu - I
SIGNATURE OF APPLIt4NT 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
STATE BAR OF WISCONSIN FORM 2 - 1998 636221
WARRANTY DEED KATHLEEN H. WALSH
REGISTER OF DEEDS
Document Number
VOL 1572 PAGE 156 ST. CROIX CO., WI
RECEIVED FOR RECORD
This Deed, made between — 01- 03-2001 1:30 PM
]RICHARD 0 !1'011!r WARRAN TY DEED
Grantor, EXEMPT N
_ -- CERT COPY FEE:
and 1� FRFSA R_ T1P_P_ — COPY FEE:
wi f_ "Y ;p____ TRANSFER FEE: 146.70
husband end - -- — RECORDING FEE: 10.00
-- PAGES: 1
Grantee.
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate in 4t ('rni x County, State of Wisconsin.
Nc >cortl�ny Ate1,
35, Plat of Sweet Grass Farm, Town of Name and Return Address
, St. Croix County, Wisconsin. ACU' 5 r`p
Huds
/7(r4- Aae-
S, , �- ✓� OR,¢K, i2t�J
sSrn!
o2n 1376 -�s -ono _
Parcel Identification Number (PIN)
This is not homestead property.
(is) (is not)
I
Exceptions to warranties: easements, restrictions, rights -of -way and covenants
of record.
Dated this 2Eith_ day of rTB member , ? -
�t a n c n„ (SEAL) / - �'�� (SEAL)
�—'r - '
Janet P. Stout
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin, n
` r
r,.
St f`rni K _ County. � � � > I`.�
authenticated this day of Personally came before me this 28th dfy,Of
1
narPmhar Z0On , the above n$rned
I,- ,
to
TITLE: MEMBER STATE BAR OF WISCONSIN cured the foregoi l 7_ g Oi',hSv
([f not, me known to becthTe !fit }
Instrument and aIRA blue WISCONSIN
authorized by §706.06, Wis. Stats.) KEN J BAST
T AS DRAFTED BY
_.. _._
THIS INSTRUMENT W
Janet P. Stout
1353 Awatukee Tr.
Hudson, WI 5401 6 Notary Pub c. State of W lco
My commiss, is//p/,errmanen . (If not. state expiration date:
(Signatures may be authenticated or acknowledged. Both are not es `"' — ' �)
necessary)
• Names of persons signing in any capaclry must b typed or printed below thOr vgnature. wscon5in 1993 K
1 Bi3nk Co., 1 .
STATE BAR OF WISCONSIN Milwaukee. Ms.
WARRANTY DEED FORM No. 2 - 1998
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Fd Wd00: 0002 Iti 'OZQ 'ON XIdJ p;;W SiH uo tI onJIsuoO uosa;;punrg : WOad
1101Cartnkh" Road
Hudson, WI 54016
Phom: (715) 386 -4660 Cr oix Co unty
Fax: (715) 3864686 Zoning Depa rtment
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To: ,13R From: 2ON/ fG
Fam 3Q( — �a (o S Date:
Phone: Pages
Re: S)��I TAI �Z PC K M / 7— CC:
❑ Urgent x For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle
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