HomeMy WebLinkAbout020-1376-50-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village x Township
Gilles, Todd Hudson Townshi
CST BM Elev: Insp. BM Elev: BM Description:
l d ~' Z ~~ v
TANK INFORMATION
' ELEVATION DATA
TYPE MANUFACTURER CAPACITY
Septic
Zs o
'n
Aeration
olding
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD
Septic y y0 / ~ Z ~ i
Dosing
ration
Holding
PUMP/SIPHON INFORMATION
county: St. Croix
Sanitary Permit No:
395172
State Plan ID No:
Parcel Tax No:
020-1376-50-000
STATION BS HI FS ELEV.
Benchmark
y~Z~
ryas
ao
Alt. BM ~ A,!
4 r '
Bldg. Sewer s/j g~./
Ht Inlet ~, O n
y ~ `
Ht Outlet ~~ 3~ q
Dt Bottom
Header/Man. ~~ , Q
Dist. Pipe ~
iC 8'. z D Q/ ~
((rt
Bot. System ~ ~ g, ~ 6 ~ ~ ~ 9
Final Grade
y. ~
~v _ Z
St Cover
DIMENS OI NS ~
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM G Ma f urer:
INFORMATION CR ~5
Type Of System: + r .~. r UNIT Model Number:
DISTRIBUTION
Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
,p ~ i/n
Length -/~ ~ Dia 7 Pipe(s) ~ ~ ~
Length Q 3 , ~s Dia Spacing ~'" ~
/ ~ ~
SOIL COVER r Pracciirp Svctpms ~nlv rx Meund Or At-Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed(rrench Edges Topsoil ~ Yes ~ No ~ Yes ~ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~/ ~Z / OL Inspection #2: / /
Location: 957 Florence Lane H/u~dson, WI 54016 (SW 1/4 NW 1/4 14 T29N R19W) Sweet Grass Farm Parcel No: 14.29.19.2311
1.) Alt BM Description = ~ 0 t `~6~p.,~~ py~ y`~ ~P~ ~`'' r~ ~` ~ _('('
2.) Bldg sewer length = ~- Z ~ ~ ~~ ~ ~q~.gL4 ~ ~ t~ d ~ 't"r'G~5 C l
- amount o/f cover = > ~~+'r r
3'JIbS~~r/~~',,,, V~s ,y.`~l/dd ~K a~~.V,vn,d'~v Y'rd+, Gam'
Plan revision Required? ^ Yes No G~ L ~
Use other side for additional information. ` Z 0 S
Date Insepctor's Cert. No.
SBD-6710 (R.3/97)
SOIL ABSORPTION SYSTEM / ~ .~1 _ ~ _ _,
Safety and Buildings Division
201 W. Washington Ave., P.O. Box 7162 C~tY
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~~~ Madison, WI 53707 - 7162 S'te Address
~~
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7
,
De artment of Commerce
sanitary
Sanitary Permit Application 3 ~sj ~Z
7n accord with Comm 83.21, Wis. Adm. Code, personal info n '~y. pr~vifley ^ Check if Revision
ma be used for ses Privac Law, ~ ".~"'L--. ~'
I. Application Information -Please Print All Information '~•..r`' ~ ~, .,~~
°~
~
State Phtn I.D. Number
.,;
`
~
.
Property Owner's Name ';,': ~ ,k Parcel Number r l
Property Owner's Mailing Address C y~ ~, roperty Location
P
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~ ~ ~ / ->'`t "+, 5~N5~ - ^.,~ / /
C
/ C~ 54 ~ ~; S / `[ T ~ ~N. R ~ E
City, State Zip Code '~~`' ho r / ~ Lot Nt~tt~ti~ Block Number
'~C~ ,!" ,.+'`,~~ . ~ °'~ Subdivision Name CSM Number
~
~ ~S
7~S
-
,L- •
/
7 tv !
~
II. Type of Building (check all that apply) ^City
'
^Village
~l or 2 Family Dwelling -Number of Bedrooms ~
//
^ Public/Cotnmercial -Describe Use (~gwnship /l'7'
~ X 3 •
~ Nearest Road
^ State Owned ./ 2
l
,, , /
III. Type of permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable)
A. _ For Couuty use
1 ~ New 2 ^ Replacement System 3 ^ Replacement of 6 ^ Addition to
S stem Tank Oral E ' stem
Permit Number Date Issued .t
B. ^ Check if Sanitary Permit Previously Lssued
IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use)
44 Non -Pressuuized in-Groin 21^ Mound 47 ^ Sand Filur 50 ^ Constmcted Wetland `~ '
~
22 ^ pressurized In-Ground 41 ^ Holding Tank 48 ^ Single Pass 51 ^ Drip Line
/
45 ^ At-Grade 46 ^ Aerobic Treatment Unit 49 ^ Recirculating 30 ^ Other
V. D' ersa1/ltieatment Area Information:
Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate stem Elevation Final Grade
Elevation
Rued proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch)
.7 ~~sss r
~~
-
- D , ~~~ S ~ :~ ~
~D ~ / /
VI. Tank Info Capacity in .Total Number acturer Prefab Site Steel Fiber Plastic
Concrete Constructed Glass
Gallons Gallons of Tanks
New Existing
Tanks Tanks
Septic or HoMing Tank / (} ~
~J ,,;~ /~ tJU f L,l~--•~~
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume responsibility f lion of the POWTS shown on the attached pleas.
J~ C~ / /~~ Pltrmbe ' Si lure J ,/MFRS Number Busi~ss Phone)Num~}ber
lJ ~ N / GAL l G'L~~ C/ ~ r ~~ ~S^ ~~/c' O~~ ~S '- ~~S
~
Plumber's Address (Street, City, State, Zip
Coded , / ~ ) _
/
i / v
VIII. Count /De artment use vm
Sanitary Permit Fee (includes Groundwater Date Issued Issu' Agent Signature (No Stamps)
~Approvcd ^ Disapproved Surcharge Fee) .
^ Owner Given Itntial Adverse ~ 2.ZS ~ ~~
Determination
IX. Conditions of ApprovaUReasons for tsapproval ~ ~~, ,, n s ~ I ~A ~ ~~ ~,~ ~~y
s ~~ ~ ,
fete plaaa (W We County only) for the system on paper not less than 81/2 x 11 trachea In size
SBD-6398 (R. OS/O1)
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Wisconsiri Department of Commerce SOIL AND SITE EVALUATION ~ 3
Division of Safety and Buildings Page of
Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1!2 z t 1 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and ~ ~ C ~ O 1
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION -Please print lnf~n~aa?iort. R iewed by Date
Personal information you provide may be used for secondary rpps'es (Privacy I~w, s. 15.04 (t) (m)). ~ _~ ~ 1 ~ ~ ~ _ ~~~'-~j,
Property Owner ' i ~ ~ Property'location
1~ 1 ~ s~i C~~ ` ' .. - < ~ Govt. tot ~ W 1 /4yt.~/ 1/4,S / L. j T z ~( ,N,R t E (or~l
Property Owner's Maailing Address ;= , ' , ;. ;apt # ~lock# Subd. Name or CSM#
3j 3 ~a ~`~ '"rtr ~ Sv ;~ Sti~ee} ~~ra~5
City State Zip Code F~tlone.Nurraf~r ""''
v:.=Jr==
.
it: ^ Cii~ ^ Viila e Town Nearest Road
9
~ )SWIG-lam
cl:~ S~lc~lln ( ( ;~ f f~~ s~ ~ /~-P ~~ /a r..e
..
_
~
..
_
New Construction Use: Residential /Number of bedrooms _3_y Addition to existing building
Replacement ^ Public or commercial -Describe:
Code derived daily flow ~ 6 ~ gpd Recommended design loading rate ~ bed, gpdfft2 ~ ~ trench, gpd/ft2
Absorption area required bed, ft2 7 ~d trench, ft2 Maximum design loading rate •~_bed, gpd/fl~ ~ trench, gpolft2
Recommended infiltration surface elevation(s) 9 ~' S ~ ft (as referred to site plan benchmark)
Additional design/site considerations u~~/f'
~~~
Parent material ~ y ~ W ~ .S Gl ft
Flood plain elevation, if applicable /
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
^ S ® U
U = Unsuitable for system [~S ^ U ~ S ^ U [`~ S ^ U C~S ^ U ^ S ®U
SAII I'1FSCRIPTION REPORT
Boring #
Ground
elev.
99~ft.
Depth to
limiting
factor
(l ~ in.
Boring #
Ground
elev.
99,~ft.
Depth to
limiting
factor
l l R in.
Horizon Depth Dominant Color Mottles Structure i B
d Ro
t GPD/ft2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. stence
Cons ary
oun o
s Bed ,Trench
1 ~-~ /0 3I z- i t l rr-,a k mfr ~ 5 1 v~ - Z~.
~- i -1-Iz ld rye - 5i 1 Z~ ~I~ ~Y` ~S - ~~ ; . ~o
3 y2-~ ~~yr`i~y C'_2P7.5 y~~ s;( ~k ~ s - .5 ;.
Remarks:
0-~ /~ ~31Z 5r~1 Ima k. mfr ~~ I v~ •2 ; • 3
Z rt5- iD r `~ `f 5r ~ 2 Irrab r~r C 5 ~' ~ ~
3 y~-il 1 ~ ~ m.S Ds ~ ~nnf c =~ -~ ' • ~
r-
~fS=SSr r
$tJ S
Remarks:
;ST Name (Please Print) ture Telephone No.
Q r~ ~ l2V ~a -~ / ~i.s'' zv7~ t/aG8'
4ddress Date CST Number
Z i ~ ~ a .'` " f. So h ~ se ~ 4. ~ SyG z- 5--- ~/-G/- ~ c~ zs-3 3 G
PROPERTY OWNER S ~ ~ ~' SOIL DESCRIPTION REPORT
PARCEL I.D.#
Boring #
Ground
elev.
~_~ft.
Depth to
limiting
factor
112 in.
Boring #
~~,
f
Ground
elev.
~~ft.
Depth to
limiting
factor
1~_in.
Boring #
5
Ground
elev.
1~7. (o5tt.
Depth to
limiting
factor
) I~1 in.
Boring #
Ground
elev.
ft.
.,_.
Page Z of 3
Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench
6-~- is Iz. 5~ I I bk ~,r c~ ~v~ - 2 ~ -3
Z 1--4z lv y~ ~' I m c s - -'
Remarks:
1 -1 11~ r~3~2 ~ - 'r c ~ 1 v-~ , 2 '
Z 1~-y I ry~y ~~ ~
~~~`b`f ,
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench
t o-1g 1D r3 z. 5' I ~ ~ v~ - Z~- 3
3 4~-1~9 y ~r ~j ~ s -- . ~;. B
Remarks:
Depth to
limiting '
factor
in.
Remarks:
SBD-8330 (R.9/98)
• ~'~,
PAGE~OF
NAME S-frv~f- LOT#<5O LEGALDESCRIPTION~'/.,Uw'/4,s/wTa9,N,RI~1 E(or)C~~
I
I
i
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BM 1 ELEVATION ~6(j . (~
BM 1 DESCRIPTION{op o~ Z a JG U•~D~ C
BM 2 ELEVATION ~ ~~ 7U
BM 2 DESCRIPTION ~, o ~ .L ~ •' ~u~ ape
SYSTEM ELEVATION `iS, 5~
ALTERNATE ELEVATION I S. s'S
CONTOUR ELEVATION ~~
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' 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: Svstem Design Specifications
Sanitary Permit Number
Number of Bedrooms ~/
Design Flow -Peak (gpd) ~j~}
Estimated Flow -Average (gpd) c7'~
Septic Tank Capacity (gal) / , G -
Soil Absorption Component Size (ftz) z _ ~
Type of Wastewater Domestic
Table 2: Soil Absorption Component -Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow -Peak (gpd) l _ ~
Maximum Influent Particle Size (in) 1/g
Maximum BODS (mg/L) 220
Maximum TSS (mg/L) 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 se and outlet filter shall be assessed at least
once every 3 years by inspection. T out et felt r shall be cleaned as necessary to ensure
groper operation. The filter cartridge of 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
G
,
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 freatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within fhe 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
Management Plan for a Septic Tank and Soil Absorption Component
Plantings of deep-rooted trees and shrubs .din:c~fy over or within ten feet of the
component should be avoided since root intrusion into the component may obstruct wastewater
flow.
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ST CROIX COi71V'I'Y
SEPTIC TANK MAINTEI~IANCE AGRBEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer D 3 ~~ ~O/l~~ r ~
=
°
Mailing Address S7 ~~'~~cE ~ ,C~QS~/ ~,r .~~/,~ ,TUS
>
v~
~~/ p' ~
properly Address
7
tom/.
(Verification required from Planning
for new construction), ~-~
City/State ~~ ~ Parcel Identification Number 4 ~ ` /3 ~ " `~ -00
DEC=AL DESCRIPTION ,/ ,,~ /
t/4 /~% ~'!,, Sec. ~, T„~N R ~ W, Town of /`r(/~v'~'
p~p~ty Location .~
Lot # ~___.
Subdivision -~~~~ ~~''~
Certif ell Survey Map # ,Volume , .Page #
Warranty Deed # ,_ ~~/J Y ,Volume ~~'"~O .Page # r.
spec house ^ yes ~o
Lot lines identifiable yes ^ no
SYSTEM 1•~IAIN'I7+ ANCE
Improper use and maintcnan:.eof your septic systemcould result is its p~tunfailureto handlewastes. propermaintcnance
consists of pumping out the sep$c tank every three years or sooner, if nulled by a licensed pumper. What you put into the system
can affect the function of the septic tank as a tt~eatment stags in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certificatr°a form, signed by the owner and by a
masbCrplumberlonmcytuauPlumbcr, restrictedplumber or a licensedpumPcr vorityinS flat (1) the on site wastewaterdisposai sYstcm
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is Less than I/3 full of sludge.
with the standards
I/vne, the undersigned have read the above requirements and agree to maintain the private sewage Sd~sposal f ~~~ ~~~tion
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, Office ~~ 30
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning
daps of the three care iration date.
7 1~1'~1
DATE
SIGNATURE OF APPLICANT
OWNER CERTIFICATION our knowledge. I (we) am (are) the owner(s) of
I (we) certify that all statements on this fo ~ are true to the best of myo Deeds Office.
fire property cn'bed a ve, by virtue of a warren deed recorded in Register
7 ~ ll~/
DATE
(~A OF APPLICANT
artmcat. ««««««
s««««« Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Dep
«« Include with this agglication: a stamped warranty deed from the Register of Deeds office
a copy of the cxrtifed survey map if reference is made is the warranty deed
STATE BAR OF WISCONSIN FORM 2 - 1998
WARRANTY DEED
oocurr>arn Number {n~" 1,~~~PAG~ ~~~
This Deed, made between I .
RICHARD O. STOUT and JANET P. STOUT,
husband and wife,
Grantor,
and TnDD D CT LFS and STAC3L~L GI.LLF,
htaUand and_ wi fp ~
Grantee.
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate in 5t . CrO1X County, State of Wisconsin:
Lot 50, Plat of Sweet Grass Farm, Town of
Hudson, St. Croix County, Wisconsin.
-~~` (SEAL)
,~ Janet P. Stout
~~~
P.Q 8~(s1
RIYER~LL~w16~t
020-1376-50-000
Parc~i Identification Number (PIN)
This iS riot homestead property.
(Is) (is not)
Exceptions to warranties: easements, restrictions, rights-of-way and covenants
of record. ~~
Dated chts 2 2nd day of June , 2 0 01
(Z,~~. CQ ,S-t~ (SEAL,
* Richard O. Stout
AUTHENTICATION
Signature(s)
authenticated this day of
(SEAL)
TITLE: MEMBER STATE BAR OF WISCONSIN
DEED
EX
CERT I~PY FEE:
CITY FEE: 2.00
TRANSFER FEE: 147.90
IN6 FEE:
R 10.00
CS
' Recording Area
I . -~__.- ___ _- -~.._ . _____
~r Name and Retum Address
ACKNOWLEDGMENT
State of Wisconsin,
St. Croix
ss.
County.
(SEAL)
Personally came before me this 2 2nd day of
June 2001 ,the above named
Richard O. Stout and Janet P.
Si-oLt
_ to
__ ~.__..._ ... ....tie TAI~Y R4d~I~~rrri the foreaoina
Es49158
REGISTER OF DEEDS
ST. CROIX CO., WI
RECEII~EB Fi1R RECORD
p6-~-~OQ1 3:45 PM
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