HomeMy WebLinkAbout020-1376-60-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buil;ling 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)].
ermit Holder's Name: City Village X Township
Emerson, Bruce Hudson Townshi
.ST BM Elev: Insp. BM Elev: BM Description:
Z ~~
x.53 ..~
r~ r\iw TIA\I 1'fATA
iAIVK mrcnrcm~-I tvly
TYPE MANUFACTURER CAPACITY
Septic
zr
Dosing
Aeration ~-
Ho g
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD
Septic y SrI ; ~ ~ ~
~-
Dosing _~ _
Aeration ~=
o ding
PUMP/SIPHON INFORMATION
county: St. Croix
Sanitary Permit No:
395156 0
State Plan ID No:
Parcel Tax No:
020-1376-60-000
STATION BS HI FS ELEV.
Benchmark
Alt. BM
,03
~~:~L
Bldg. Sewer ~ `
S t Inlet 2_ Z 9 ~. 33
t Outlet z ~~ ~~
Dt Inlet
Header/Man. ~ ~s
Dist. Pip-"e/~
~`~~cr ~ G: vo
3 'f2 • ~3
S. ~o
Bot. System
L
'' ~ ~• 3S 9/• /~
Z_LS
Final Grade ~ -~f Q r ~ ~
St Cover
cturer Demand
M
Model Number
TDH Lift ion Loss System Head TDH Ft
Forcem ' Length Dia. Dist. to well
SOIL ABSORPTION SYSTEM r
BED/TRENCH
Width S
Length
No. Of Trenches
PIT DIMENSIONS
No. Of Pits
Inside Dia.
Liquid Depth
DIMENSIONS 3 ~ G~'3 S- r 'j_
SETBACK SYSTEM TO P/L BLDG WELL [,gKE/STREAM L G
AM~E R Manufact er:
'
INFORMATION Type Of System: 4 Mod I Number:
S `/S ya - '
111CTQIQIITIAAI CVCTGM
Header/Manifold
~ ~
Length - (Z Dia ~ I Distribution
Pipe(s)~+ i i
Length /~ Dia ~ Spacing x Hole Size
_~ x Hole Spacing
/ Vent to Air Intake
7~s ~
~r~u f~/'\\/CO __ w____..__ e~___a_.v_ A.-L. .... \IL....~A n. wr_r Anne x~ieremc ~ mw
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched
BedlTrench Center Bed/Trench Edges Topsoil (~ Yes [] No ~~ Yes ~~ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~~/_~/1L~ Inspection #2: / /
Location: 913 Florence Lane Hudson, WI 54016 (SW 1l4 SW 11414 T29N R19W) Sweet rass Far ( ,//.~ Parcel No: 14.29.19.2321
1.) Alt BM Description = T+~~S(<~~ ~po /
2.) Bldg sewer length = ~8'
-amount of cover = ~/ ~ ° ~ //~
~•)o6s~rv~c~;oti ~ rs rn.ee ~ ~a ~ rh 5 ~
Z er ~/t-.~~ ~ l~ - ~o -w n"
Plan rdVision I•tegwred-r ~ Yes No ,.®~ jL .1~_~~'
Use other side for additional information. ~ A ~ ~ L
Date Insepctor's ignature Cert. No.
SBD-6710 (R.3/97)
,~
q /3 ~,p LN. Sanitary Permit Application Safety & Buildings Division
In accord with Comm 83.21, Wis. Adm. Code 20l W. Washington Ave.
~~~~~ See reverse side for instructions for completing this application PO Box 7302
Madison
WI 53707-7302
I71en>trtrnent u~t Gotnrnerca Personal information you provide may be used for secondary purposes
[privacy Law, s. 15.04(1)(m)J ,
(Submit completed form to county if not
state owned.
Attach com lete lans to the coup co onl for the system, on pa er not less than 8 -I/2 x 11 inches in size.
County State Bonita Permit Number ^ Check if revision to previous application
`x State Plan I. D. Number
~T = c~.o ~X. 95
/ lv
I. A lication Information -Please Print all Information Location:
Property Owner Name
~
! p9erty Location
~Pro
/
C
`
-}
J~ ;-,~y_.. >- ~
,J(~/ 1/4SW 1/4, S~ T.29,N, R
~ (or
Property Owner's Mailing Address ~ ~ ,, ~ er Block Number
b
Lot Num
~~~~u 'L.-4.~ ~ /
~
~V
City, State Zip Code ~ t Subdivision Name or CSM umber
~ ~ ~ s~-ror ~ ~ ~ ~~ >~~~~3~~3 ~~r ~ ss
II. Type of Building: (check one) ,_ , ~ '~ ~~'~ ~
of Bedrooms :~ ~
1 or 2 Family Dwelling - No ~ C'h'
^ Village
.
~T ~
!'' Town of
,-,
^ Public/Commercial (describe use):_ ~
~
~
~~ A
, e,~y
~
~
^ State-Owned
•`
.,
' ~
~ . t-X/
~ y, j r F~
1
~e, / ~..,.... Nearest a ~~ ,/
•G
t
/
~
2 3 ~ q ~ • ~ '~ s.~ ~ ~ i i r p Parcel Tan Number(s) O _ 3.7 6
III. T e of ermit: Check onl one box on line A. Check box on line B if a licable) l ' oZ ~~ / 9 . a3a
A) I. New 2. ^ Replacement 3. ^ Replacement of 4. 5. 6. ^ Addition to
S stem S stem Tank Onl Existin System
B~ Permit Number Date Issued
^ A Sanita Permit was reviousl issued
IV. Type of POWT System: (Check all that apply)-
Non-pressurized In-ground ^ Mound ^ Sand Filter ^ Constructed Wetland
^ ressurized In-ground ^ Holding Tank ^ Single Pass ^ Drip Line
G/L /Q~
T
.(J/
^ At- e ^ Aerobic Treatment Unit ^ Recirculatin Other:
V. Dis ersaUTreatment Area Information:
1. Desigri Flow (gpd) 2. Disper Area . Dispers
~~L 4. Soil Application 5. Percolation Rate
/
h ~. m on 7. Final Grade
Eleva
n
Required 56b roposed S inc
)
Rate (Gals./day/sq. R. (Min.
~ l~
~J //Gf ~
6 a
C~ ~"
-
VII. Tank Capacity in • Total # of Manufactur r Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing Crete structed
Tanks Tanks
~~~ UffG~U7"j ^ ^ ^ ^
^ ^ ^ ^ ^
VIII. Responsibility Statement
I, the undersi ed, assume res onsibili for installation of the POWTS shown on attached lans.
Plumber's Name t PI 's ignatu o s): RS o. Business Phone Number
///~~ v~,~s ~ ~3/~~5~" is-~ -9~~~
Plumber's Address (Street, City, State, Zip Code)
`
'~'
~
rat: ~ a
~ 5~~
~~ ~
~
IX. County/Department Use Only
^ Disapproved Sanitary Permit Fee (Inc~des Groundwater Date Issued Issu' Agent Signa (No stamps)
Approved ^ Owner Given Initial Adverse Sarc ge F~)2 ~ ~ ~ ~'
Determination
X. Conditions of Approval /Reasons for rsapprova : ~~~ s, ~~~
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,Wiscon~wn Department of Commerce SOIL AND SITE EVALUATION
Divisiori of Safety and Buildings
•• F~urea0 0~' Integrated Services in accordance with Comm is. Adm. Code
~~
/,. I r
~ ' ~'~ ~~ ~ ~~~~ Ccfu t1!
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. ~r`i.xrtUsf +
include, but not limited to: vertical and horizontal reference point (BM), di ' Wand ~ . ^'~ ~, ~ ~ . ~{'~
percent slope, scale or dimensions, north arrow, and location and dista ,a'fo;;nearest;fpad ~ parcel t.D: #
a ._
i _. i
APPLICANT INFORMATION -Please print all information 4 ~: viewed,.dy
~~
Page I of
Date
Personal information you provide may be used for secondary purposes (Privacy La(~, s. '15.04 (1) (rri)f. -, . - t
Property Owner Prop!9r~y.)cgp~ '
U ,Govt. Lot~~ , , 1l4~ 1/4,S ~~ T~C( ,N,R /~( E (or)
Property Owner's Mailing Address \# + ~sk#( ' ~d. Name or, CSM#
~ ~ 3 ~ 2t~ fir. ~.Q~ -~ ~. ASS
City State Zip Code Phone Number ^ City ^ Village ~ Town Nearest Road
n O- (1~ q-~~~31 t--/~~s~ n ~~~,,.~,~ X14 ~
® New Construction Use: Residential /Number of bedrooms 3~ ~ Addition to existing building
^ Replacement // ^ Public or commercial -Describe:
Code derived daily flow C~ ~ U gpd Recommended design Loading rate ~ ? bed, gpd/ft2~trench, gpd/ft2
Absorption area required v~S ~ bed, ft2 7 S'~ trench, ft2 Maximum design loading rate ~ ~ bed, gpd/ft~~_trench, gpd/ft2
Recommended infiltration surface elevation(s) ~,A~ ` 9 3 ~ 7 ~ Law" r/ 2 ~U _ft (as referred to site plan benchmark)
Additional design/site considerations ~~er G!/ • ~O lipw-er ~!D- ~ U
Parent material ~ U -4- W ~ S ~ Flood plain elevation, if applicable /// ~ ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
u Unsuitable for system [mss ^ u ~ s ^ u ®s ^ u ®s ^ u ^ s ®u ^ s ® u
Boring #
Ground
elev.
9 •7()ft.
Depth to
limiting
f for
~in.
Boring #
Z
Ground
elev.
9t~ • Ztlft.
Depth to
limiting
f~tor
l inI in_
SvIL uE5crf11'1IVn t-ttrvlrst
Horizon Depth Dominant Color Mottles Structure d R
t GPD/ft2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence ary
Boun oo
s Bed ,Trench
i p- IU ~/ -- ,~ l ma rn-~ I v~ ~ ~ ~ ~ 3
2 -zy ~l ~'1 I n-~,b' rn cs - . Z ; - 3
Remarks:
~ o-g /0~ ~3 3 s~ I m~b~C ~~ E ~ I v~~ . 2 ~ . 3
3 2s-9~ ID • ~ ~n n, ~ d l c. s _ .1
-4- Q3. ~O r ,
Remarks_
:ST Name (Please Print) Signature Telephone No.
4ddress Date CST Number
2/ ~3 ~ sil ~o G(l /..S'r~oZ `~ G/-Q'G~ z~S" 3 3G ~/
S ~C~t SOIL DESCRIPTION REPORT
PROPERTY OWNER
PARCEL I.D.#
Boring #
3
Ground
elev.
9~ft.
Depth to
limiting
factor
~ in.
Boring #
1
Ground
elev.
~~ eft.
Depth to
limiting
f~p~ r
``~~ in.
Boring #
S
Ground
elev.
g~. ?oft.
Depth to
limiting
factor
~in.
Boring #
Ground
elev.
ft.
Page ~' ~,~
Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench
o- ~ 3 ~ ~~ i I may - ~5 I ~-h . z ; .
Remarks:
b -~ /~ ~- (~ 1 tc~ C ~ I l/T C~
Z ~- y ~;I 1 I ~ ~`~ - .2;.3
3 z~ ~I ID ~ 1 t.o - mS s ran i is -' . ~ ~ . g
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots GPD/ft~
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench
a ~ L~ r3 3 S' lm ~ ~ v-~ - Z~ - 3
2 -ZS y ~~t ~ si I ~ k LS -- . 2 ~ - 3
3 ~- y ~ - s ~s ml c~ - ,~ ,
a3.~ ;
~Z ~$ ,
Remarks:
Depth to
limiting
factor
in.
Remarks:
SBD-8330 (R.9/98)
~.
._~
PAGE~OF~
NAME ~~ V "4' LOT# ~9d LEGAL DESCRIPTIONS '/45~'/4,S1 `l TZa ,N,R 19 E (or~
SCALE: I"= ~U~
/BM 1 ELEVATION ~ ~ • ~ ~ ,
BM 1 DESCRIPTIONf~Po-~Z"~dG p,'p~±l, ,,~v
/BM 2 ELEVATION /OU • ~
BM 2 DESCRIPTION fpQ a ~ 7 "OVA A' c.. aThw/f"~«~
-`TT ~
SYSTEM ELEVATION yppcr q~J.7~ Lows.(' 42.7n
v/Pt r ~ o w+ r-
ALTERNATE ELEVATION //Q!•7U yU7y
CONTOUR ELEVATIONTG~~'
G.(
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer
J 1~t ~<~--Sc~ , w ~ 5216) Co
Mailing Address ~Q`~ ~~-
Property Address
(Verification required from Planning Department for new
City/State ~-1 1 ~N~ 1.~~- Parcel Identification Number ~~. O " I ~`7 to -try 0 -- 00 O
PronertY Location ~ fns !/., S ~ '/., Sec. ~, T~N-R~W, Town of T~`~~ ~~.•
~'.
Subdivision ~
Lot # .~~.
~_..,.;~; ,, r ,.. e.. ~ ~ ,Volume .Page #
Warranty Deed # ~Jd~J~,~ ,Volume ~ Page #
Spec house ^ yes no Lot lines identifiable ^ yes ^ 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.
ent a certification form, signed by the owner and by a
The property owner agrees to submit to St. Croix Zoning Departmv that (1) the on-site wastewaterdisposal system
mastCrplumber, joumeymanplumber, restrictedplumberora licensedpumper erify+ing
is in proper operating condition andlor (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 Commerce 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 Zoning Office wrthrn 30
days of three year expiration date.
~~ / ~.
SIGMA OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge.
the prope described above, by virtue of a warranty deed recorded in Register of Deeds Office.
IGNA F PLICANT
I (we) am (are) the owner(s) of
1 ~1
DATE
An information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ******
««**** y
** 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
c
` ~.
~li,~.~ '
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 95` -"
Number of Bedrooms
Design Flow -Peak (gpd) Q
Estimated Flow -Average (gpd) cr0
Septic Tank Capacity (gal) $'
Soil Absorption Component Size (ftz) 8 ~!/ TS O/~ f/ T.f'~9
Type of Wastewater Domestic
Table 2: Soil Absorption Component -Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow -Peak (gpd) z _ aS ~,.s
Maximum Influent Particle Size (in) 1/8
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 k and outlet filter shall be assessed at least
once every 3 years by inspection. Th outlet filf shall be cleaned as necessary to ensure
pro er o eration. The filter cartridge shou not be removed unless provisions are made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
e~,s
~~
•• ~ ~ 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 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
W .•
• - ~ Management Plan for a 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.
s,~, ~ ova - w~ n
I
P I ~""„`~"~ ' ~ • ~ ~ i rte. ~ ~~t,~PEIU S •, ~ i S- - ~-?.(o - g~~-2
S~ ~~ ~ ~ ~,v/N4 D~~C~ ~..(~-'- 386 - Te6u.
3
' a `t~.jL.~_v ~~PASEIJ~r~
'" ~ STATE BAR OF WISCONSIN FORM 2 - 1998
WARRANTY DEED
Dxument Number
This Deed, made between
RICHARD O STOUT and JANET P STOUT,
__hu_sband_and wife, ___ _ _
- ~ ~ -_- -- ---- -, Grantor.
and t;uFrnRV c EMERSON and LISA M EMERSON, -
husband and wi , ,_
-------~_---_ Grantee.
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
-' described real estate fn r+t _~`t~pjx County, Slate of Wisconsin:
Lot 60, Plat of Sweet Grass Farm, Town of
Hudson, St. Croix County, Wisconsin.
65032'3
I:ATHLEEN H. WALSH
kFGISTEk OF DEEDS
kECEIVED FOR RECORD
G7-G6-2001 8:25 AM
MARRANTY DEED
EXEMPT k
CERT COPY FEE:
COCY fEE:
TRANSFER FEE: 163.50
RECORDING FEE: 14.00
F'A6ES: 1
Name and Return Address
F N ~ - a~ ~Q S~I-t.
020-1376-60-000
Parcel Identification Number (PINT
This 1S riOthornestead property
(is) (is not}
Exceptions towarrant;es: easements, restrictions, rights-of-way and covenants
of record.
Dated this 2q ~ n day of June i, 2001
~e-~^~'~-Ol y1 a (SEAL) ~ ~`-Q~' ~ /ty''~ --_ - (SEAL)
Richard 0. Stout Janet P. Stout
AUTHENTICATION
Signature(s)
authenticated this day of
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not me known to
authorized by §706.06, Wis. Stats.) instrument a
THIS INSTRUMENT WAS DRAFTED BY
Janet P. Stout
1353 Awatukee Tr. ____
Hudson, WI 54016 Notary bhc,
My c missi
(Signatures may be authenticated or acknowledged. Both are not
necessary.)
' Nantes of persons signing m any capncliy must be typed or primed below rhea signature.
STATE BAR OF WISCONSIN
WARRANTY DEED FORM No. 2 - 1998
(SEAL)
(SEAL)
ACKNOWLEDGMENT
State of Wisconsin,
St. Croix County ss.
Personally wme before me [his 2~y f ~ day of
June ~, the above named
Richard O. Stout and Janet_
-_ - P Gtnnt
_ to
the foregoing
J. BAST.
State o W cousin
is r anent. Qf not. state expira o ere:
Ot __. ~~ )
W ~scons~n Legal Blank Co.. mc.
Mawaukee. Wis.
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