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HomeMy WebLinkAbout020-1388-02-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENEPtAL 1NFORMATION (ATTACH TO PERMIT) Personal intonnation you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township LaCasse Develo ment Hudson Townshi CST BM Elev: ( Insp. BM Elev: I BM Description: ... ~.. aT~ . O QO - C~ IM ~' ~--~ TANK INFORMATION ~~ TYPE MANUFACTURER CAPACITY Septic st, ~ $ef- ~ 2 Qp Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic 5, z r ~ ~ t Dosing Aeration Holding PUMP/SIPHON INFORMATION Nu Head Ft ELEVATION DATA county: St. Croix Sanitary Permit No: 399408 State Plan ID No: Parcel Tax No: 020-1388-02-000 STATION BS HI FS ELEV. Benchmark ~.2•S to 5 t Q0.0 Alt. BM , Bldg. Sewer ~ , °t~ • 3~ SUHt Inlet ~ ~C~(o t ~Sr 1`~ SUHt Outlet ~ ~ tv r q~{.~ Dt Inlet Dt Bottom Header/Man. Dist. Pipe ~. Ot ~ 39 Bot. System ~ ZS-' 93 •o' , 53~ -3 Final Grade ~. ~. St Cover SOIL RPTION SYSTEM f~t~a~.~ ~D NCH Width Length No. Of Trenches PIT DIME ~.t q? ~,~' + SETBACK SYSTEM TO P/L BLDG WELL LAI INFORMATION Type Of System: ~ / ~~ 1 J~ DISTRIBUTION SYSTEM )IMENSIONS No. Of Pits Inside Dia. E/STREAM LEACHING Manutactu CHAMBER OR die c~ _~ UNIT Modgl Nur Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake W Length~~! Dia Pipes} Lengt Dia Spacing SOIL COVER v Proecnro Cvs4ame Anly YY Mnund Or Ot-Grade SVStBmS Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ~~ Yes ~ No ~ Yes [] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~/~J~_ Inspection #2: Location: 958 Sadies Lane Hudson, WI 54016 (SE 1/4 NE 1/4 14 T29N R19VV) Field Haven Lot 2 Parcel No: 14.29.19.2376 1.) Alt BM Description T~ ~10-i,~,,,n~~`btn G~uu~-rel~~~ 2'1rtsS) ~ , _(~n ,n~ ` f~ ~~ 2.) Bldg sewer length = ~~-' ~ ~ 5~~ ~ '~'° .~..S~Y S r~L.- ~~~ ~ W, - amount of cover - `~Z '~+ , ~ w~st,~1w• O - ~ ~ ~ • 2(.~.art) ~~~ S ~~at1,.2. ~4 ~ t~ fit'/~•-, Cam) ~~ ~,~- c~•s~~-~ ~ ~~ e. d~~. . Plan revision Required? ~ Yes No O Use other side for additional informat on. g' SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No. ~,~ i~~ 3 Sa 201 W. ty and Buildings Division ashington Ave., P.O. Box 7162 C C~~/ ~ / ` in Madison, WI 53707 - 7162 i Site Address ~eons ' J , ~tA~E E l ~ ~~ ` Department of Commerce ~ ' ` ~ -- ~ ~~' Permit Number - , -l- - Sanitary Permit Applies ' ,,! ~ 3 ~q `{~8 ,~ In accord with Comm 83.21, Wis. Adm. Code, personal inf ~ you p ovid~ ' ^ Check if Revision tna be used for seco ses ]?rivac Law 1 m I. Application Information -Please Print All Information O? ~ ~Q `;. ,.. State Ptah I.D. Number Property Owner's Name 7 atcel Number / . 29 , ~ 3~(0 Property Owner's Mailing Address g~~ '. Property Location ,.,,~ `~ ~ li NE,,~; S TZ N, R & City, State Zip Code bqr;,~ ' `' ~/ Lot Num2ber Block Number Subdivision Name CSM Number Ocity Type of Building (check au that apply) ~ ~or 2 Family Dwelling -Number of Bedrooms _-, ^Village ^ public/Cotnmercial -Describe Use 'Township Q " ~ Nearest Road ^ Stau ~ a- ~ _o ~i,< _boz 5~~ III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) A For County use 1 New 2 ^ Replacement System 3 ^ Replacement of 6 ^ Addition to S stem Tank Onl F,zis ' sum Permit Number Dau Issued B. ^ Check if Sanitary Permit Previously Issued IV. Type of Permit: (Check all that apply)(nttmbering scheme is for internal use) y ~ y„"\ 44~Non -Pressurized In-Ground 21^ Mound 47 ^ Sand Filur 50 ^ Constructed Wetland ~A ~ ~ ~ ^ pre~ud In-Ground 41 ^ Holding Tank 48 ^ S'mgle Pass 51 ^ Drip Line ~ 45 ^ At-Grads 46 ^ Aerobic Treatment Unit 49 ^ Recirculating 30 ^ Other V. D' etsal/Treatment Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Ra Sysem Elevatio Final Grade Elevation Req~red proposed Rate(Gals.lDays/Sq.Ft.) (Min./Inch) Do Soo s' ( ~ ~ ~ q yso ~ VI. Tank Info Capacity ~ Total Number Gallons Gallons of Tanks Manufacturer Prefab Siu Steel Fiber Plastic Concreu Consttucted Glass New Facisting Tanks Tanks k di T H o .__ an ol ng Septic or Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for ' lion of the POWTS shown on the attached plans. PI is ~e riot Plumber' Signs /MFRS Number Business Phone Number ~~ll~ a~o3.~ ~ rs - ~~g ~ ~ Plumbelr's Address (Street, City, S u, Zip ) ~~ VIII. Cotmt /De artment Use Onl Sanitary Permit Fee (includes Groundwaur Dau Issued Issuing gent Signature (No Stamps) '~, Approved ^ Disapproved Surcharge Fee) 00 ^ Owner Given Initial Adverse ~fJ+ ~f~ "'"- ~~ ~' C~ ""- ~ ~ Deurmination _ IX. Conditions of Ap roval/Reasons for D' ppSoval I ~/` D~ s-g ~11~.2, /s ~ ~ _ ~ ~~ Sat, ~ sys+tt,~,. ~t-~~ tom.. ~~ ~~ ~,+ , S ~. ~, f-4tach complete pleas ( e ~Coaaty only! ror the system ogrppper nw .~ w.~. a..~ .. -- SBD-b398 (R. 05!01) ~i- ~_ ~ Sao N~ ~ " ~~ ~ ~~ 9 yso ~ ~~~~ ~d~ I -ado T~~~D ~~ ,~o ~~_ ~_ ~ Na ~"~~ a - >s ~- T,~-~- ~~ a "P~-~- i/ dh~ _ / ~ / bo T~ ~ i o f~~/QO 2~' ~~ Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT Page ~ of 3 in accoroance w+m c:omm ua, vvis. ram. woe •-~ Pl t i i 1 11 i h - County ~Q an mus n s ze. nc es /2 x Attach complete site plan on paper not less than 8 inGude, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. R ~~ by Date Personal irMormation you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). .Z / Z Properly Owner Property Location Govt. Lot S t 1/4 N C 1/4 S I B T 2 cj N R J g E (or Properly Owner's Mailing Address Lot # Block # Subd. Name or CSM# C ~ Z ~ I n City State Zip Phone Number [j City ^ Village ®Town Nearest Road 4-I- c~Sis 1~ ~ ( ) -~~tOS ® New Construction Use: ~ Residential / Number of bedrooms 3 ' `~ Code derived design flow rate ` /S~ ~~ ~ O" • GPD ^ Replacement ^ Public or commercial -Describe: 1 Parent material O y'fw a 5 In Flood Plain elevation if applicable i ~~~- ~` ~ ft. ~ .--rte- --T--r-- Generalcanments Sy5-~ewt GJev- 9y SU ! ~ ~+' ~~: i 'f ~. and recommendations: ~q./f.. P I c ~'• °I 2• vD ~.._ ; .B OT i llG ~ ~ J ?~, wr.~S C'o b b~(`~ f •. -~o~~ z.cn ..3 ~q{~' ' ~a~r? 1 :~ „n~~ ST CR~:~ -, [] Boring ~ Boring # ~ ~ ~' ®. Pit Ground surface.elev. ~. 3 d ft. Depth to limiting factor ~ ~ y ir~~ ' ' `~ Soil C~cation Rate Horizon De th Dominant Color Redox Description Texture Structure Consistence Boundary F~o7sts- ~~~"~ GP D/fi? p in. MunseN Qu. Sz. Cont Color Gr. Sz. Sh. *Eff#1 •Eff#2 Z 13-21 1 r y ~y -- r~ c 5 - 5' ~. ,•,.. i ~~ _ "33•x/ fo`t-!: Boring # ~ Boring [~ pit Ground surface elev. q ~• '~D ft. Depth to limiting factor ~ ~ in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fg in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 I a-~ I z12 --- 5;1 2 c l ~.~' . 8 Z iz-36 lU~r `_' ~ ~~ * Effluent #1 = 80D5 > 30 < 220 mglL and TSS >30 a 150 mg/L * Effluent #2 = t3oD5 < 3U mg/~ anq i ss < 3u ~u CST Name (Please Print) ignature CST Nurrrber ~l~l tam ~ h/ ~nri ~;Pr / 2 ~ 3 309 Address Date Evaluation Conducted Telephone Number ,2U3 8~~ ~~ om r^ P-~ lLlt 5~~2~ •3-~-0~ 7I~~Z~f7~-~fGY~FC-- ~~ Property Owner LG rA 55 a Parcel ID # Page ~ of Boring # ^ Boring ~ Pit Ground surface elev. 9 ~• O ft. Depth M limiting factor I Z I in. iii ication Rate `Horizon ~ Depth Dominant Color Redox Description Texture Structure Consistertoe Bourxiary Roots GP D/fg in. Munsefl Qu. Sz. Copt. Cobr Gr. Sz. Sh. •Eff#1 'Eff#2 I - ~ t ~ 212 --- 5 i I 2 k -f,- CS Iv-~ • 5 • ~ 0 6 ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Gcation Rate Horizon Depth Dominant Cobr Redox Description Texture Structure Consistence BourKlary Roots GPI in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Etf#1 *Eil#2 ^ Boring Boring # . ^ Pit Ground surface elev. R Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence 'Boundary Roots GP DYf'f in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. 'EtT#'1 'Eti#2 'Effluent #1 =GODS > 30 _< 220 mglL and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mglL and TSS <_ 30 mg1L The Department of Commerce is an equal opportunity service provider and employer, If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3251 or TTY 608-264-8777. SBD-8330 (8.07/00) ~s PAGE .3 OF ,3 NAME L~ ~G SS e LOT# 2 LEGAL DESCRIPTION S E ~/,RUC ~/< S /Y T Z Q'N R /9 E (or) 6NJ SCALE: 1"= yd _ _ BM I ELEVATION /G~ • d ~ BM I DESCRIPTION ~P o-~ /O~Sa va.~c ~osf• uY~YaJ _" + ~. BM 2 ELEVATION 9S. $~ /~f I BM 2 DESCRIPTION.~~ 3/~(~ ('o.~pe~ ~.'Qe w/F~`, SYSTEM ELEVATION ~`~' S~ ALTERNATE ELEVATION `T Z • ~ D CONTOUR ELEVATION 9~.oy 3 `lS.od 2 ~L•4,vq` ~k SkaP~ 1 r• % 1 ~x; 1, ~ l 3 -8- of s Y F 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 Number of Bedrooms Design Flow -Peak (gpd) O Estimated Flow -Average (gpd) Septic Tank Capacity (gal) Soil Absorption Component Size (ftZ) ~- .-- Type of Wastewater Domestic 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 BODS (mg/L) 220 Maximum TSS (mg/L) 150 :arXte+~ 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 nd outlet filter shall be assessed at least once every 3 years by inspection. The outlet felt shall be cleaned as necessary to ensure pro er o er .The filter cartridge sho 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 y ,~ 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 113 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 r~ .. A Management Plan for a Septic Tank and Soil Absorption Component Plantings of deep-rooted trees aid shrubs d+rectlY ovef or within ten feet of the component should be avoided since root intrusion into the component may obstruct wastewater flow. av` So~- •~~j. ~'-~' QE .~v~ . ~ i ~~ ~~~ ~~ ~~~ ~C-a- c~~s~ a~ ~- ~ 9y.~ ~ o-~ G~~s) 3g~"y~go S'1' CItUIX COUN'1'1' SLI''1'lC 'l'AtJIC MA1N'1'LNANCL AGItIlI?ML~N`1' ANn UWNI?RSllll' CI?It'1'II~ICA'1'lON l~O1tM Owner/Bllycr ~Q C ~ ~~.~_n~--~ j.~~-?-#~,~.~-~Iz-- Moiling Address ~ ~,~'~'~~ ~_~ '~~~ ,~`_ 1'rol)arly Address (Verification required lion- Planning Ucparlmcnl fi-r new ants( City/Stole ~~~~` I'urccl )clcnlilic;tlic-n 1Jun11-cr LrGAL I)I!;SCIZII''1'ION ozo- X38'8' --pz-o~ ~~ 2Q, ~ g , Z 3 ~~ Property Location _SL% '/,, ~ -/,, ,~cc, ly , 'I' ZgtJ-1t~W, '1'owl~ c~f_/~-~t=~.~.,.,,~ Subdivision Certified Survey Map # Z• ~ 3 3 a~.woJ Lot i1 ~_. Wnrruuty llced tl' ~ 7l ~~ ~~ , Vc~lun;c -~t~~--~___, 1'oGc tf Spec house ^ yes la do Lc-l lines idatlilinl-Ie l=) yes ~o SYS1'I!:M MA1N'1'I~NANCI!; Improper use and maiulenanccof yuu- septic syslenr could result in its prcmatu-e l'ailurc to handle wastes.l'ropermahrleuance consists of purnptug out the septic tank every three years or sooner, if needed by a licensed pungrer. What you put into lire system can atT'ect the fiutctian of the septic leak as a trcalnrcnt sla{tc in tlrc waste disposal system. The properly owner agrees to submit Iu St. Croix Zoning lleparlnrent a catilication form, signed by rho owner and by a maslerpluurber, journeyman plumber, restricted plun;l-cr or a licensed pumper vet ifying that (!) the on-silo waslewaterdisposal system is iu proper operating condition and/or (2) alter inspection and purnphrg (if necessary), the septic lank is less then I/3 full of sludge. 1/we, the underslgncd have read the above rcgrrircnrcnls and agree to maintain the private sewage disposal system will the standards set forth, herein, as set by the Department of Cununcrce and the Ucparlnrcut of Natural Resources, Stale of Wiscoasln. Certification slating that your septic s stem has been nraintaincd roust be cony-Ic1ed and tclurnccl to the St. Croix County Zoning Office w)lhin 30 da re duce car pirallon date. SIGNA'IURL~ O A I ICAN'1' ~ / 2~~ ~ DA'I'Lr oWNrlt cclt~rn~JCA'rlo I (we) certify the all slatcnrcnls on Ibis lurnr arc Iruc to the best of my (our) knowledge. I (wc) ant (ate) the owner(s) of llre etly described a ve, by virhre of a warranty decd recorded in (register of Deeds Ollice. SI NATURL~ Of 1' ICAN1' -~-L-~-=-J DATL~ ****** Any information Thal is nris-represented pray result in the sanitary pcrnril being revoked by the Zoahrg DeparUnent. ****** ** Include with lhls appllcallon: a slaorped wauauly decd from Ilre Register of Uccds ofiicc a copy of the ceililicd survey map if reference !s made lu the warrartly deed Yap 1612PAf,r4~.4 ' ' I STATE BAR OF WISCONSIN FORb12 - 1999 Document Number WARRANTY DEED This Deed, made between John W. Moravec and Mary A_ Moravec, husband and wife, Grantor, and LaCasse Development, lnc. __ _ __!_-_ _. - --- Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix_ County, State of Wisconsin (if more space is needed, please attach addendum): EI/2 of SE114 of NEl!4 of Section 14-29-19, St. Croix County, Wisconsin can ~.9s4 I;A'THLCEN H. WALSH kEGI57ER OF DEEDS S7. CROIX CO., WI kECEIVED fOk RECORD 04-03-2001 2:30 RN WAkRRNTY DEED EXE?IPT N ' CERT COPY FEE: CORY FEE: TRAkSfER fEE: 924.00 RECORDING fEE: 10.00 PAGES: - 1 Recording Area Name and Return Address The RiverBank 880 Sixth Street North Hudson, WI 54016 020-1020.70-000 _...____.__ Parcel ldentlfication Number {PIN) This is ,_ homestead property. Gs) I~a10Q Exceptions to warranties: Easements, restrictions and rights-of--way of record, if any. Dated this ~p `_ day of March - __ _, 2001 AUTHENTICATION authenticated this day of __ ______.___. __ _ . _____. • J n W. Moravec .~ ~ Mary A. D ravec _._..__.. ~. - ACKNOWLEDGMENT STATE OF WISCONSIN j } Ss. St. Craix _ _ _ County } Personally came before me this ~ZJ~_ day of March _ 2001 _ the above named -` John W. Moravec and Mary A. Moravec, husband and wife, _ _ TITLE: MEMBER STATE l3AR OF WISCONSIN t~~r1 (ltno[, ___ __ -_--- ,r~iltt sudtorized by § 706AG, Wis. Slats.) .~ .: ,~~ ~~~_ THIS INSTRUMENT WAS DRAFTED 6Y _ ! _ Attorney Kristine Ogland __._ ___ s!L ~SIDU Hudson, W[ 54016 ': fly (Signatures may he authenticated or acknowledged. Both are not necessary.~,r'_ ' Names of persans slenin~ in any capacity must be typed or printed below their stgftYi),ytttr,, STATE BAR OF WISCd WARRANTY DEED FORS1 No.:- t')99 be the person(s) who executed the foregoing 3o~rtowledged the same. ~ - Yubll~. St: ':' of Wisconsin n rnl sior, i~pcnnanent. (If not, state expiration date: - Information arolessanals GPmpany, Fond Ou Lac. 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