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020-1121-00-000
r q-to -Is-6 i'eo Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 572894 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: — 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 Parcel Tax No: Sharleen Johnson Trust Hudson, Town of 020-1121-00-000 Description: Section/Town/Range/Map No: Elev: BM Descri CST BM Elev: Insp.BM e p ;0,6-- /DD.U0 AJE 6024E(2- aF gU4R 17.29.19.527 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic EX, Benchmark Z.110 /t2.90 /00,60 41// 4- /DDS ' 6)E ) Alt. BM Pit-Tea KuFtzair zft, Aeration Bldg.Sewer Holding Stia let q,00 q;,HU St/Ht Outlet 9.z0 g3.10 TANK SETBACK INFORMATION Ais w TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic , , >SD a t /0' 4/49 Dt Bottom TM 7 SPg v/COI t 70 t 7(§-r Header/Man. 49.VU *.4/1) Aeration Dist.Pipe r IO ft.57J Holding Bot.System «.fO 9/•00 a.os q/. 3c Final Grade -r too (e(.So PUMP/SIPHON INFORMATION Manufacturer Demand St Cover %go 17(00 GPM Model Number •� 7.Q0 R.sv P— 1>�o k IK TDH 'Lift Friction Loss System Head TDH Ft A-t- 7.Q - qq.q Forcemain Length Dia. Dist.to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width 'Length 1No.Of Tre ches I PIT DIMENSIONS No.Of Pits Inside Dia. !Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR .Z0VF/L7197-04-- Type Of System: ( ` t / y?S.' ,/ UNIT Model Number: toKlrev 0 ` 7� t 75 AO zz/r064m acne-l4 q DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake t cI Pipe(s) >/S Length_p—Dia y 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 7 Bed/Trench Edges --‘—. ,Z • © Topsoil —_ Yes ] No El Yes * No COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: 9 / /0 / (C' Inspection#2: / / Location: 374 Brookwood Dr. Hudson,WI 54016(NE 1/4 SE 1/4 17 T29N R19W) Trout Brook Woods Lot 24 Parcel No:,17.29.19.527 1.)Alt BM Description= —O*tJGtt CA/Di 0/`A/ OW/ 2.)Bldg sewer length= EIce5rx& ypA Tits#VGH ''fr ,�r/S�Z.TI -amount of cover=Elct Sr2N(, 13' W,Z- ,ii&3-r/b c/ TE— Plan revision Required? Yes No 1 /, `� �S�J 1 Jz14 Use other side for additional information. 7 Date Insepctor's Signature Cert.No. SBD-6710(R.3/97) ���' County 1 L s�04 lz Safety and Buildings Division 5 1 eroi ,§`�l p �1 201 W.Washi tons Ave. P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) T S:':- ps, k�' � ,�,� Ns t'c �V" t` 32 �y+�. A` � !�`�O � �,e�� I) ; 5-12.8 9 (--{ "ZRCIOt• C�� \1,.V j�j,� ��` unitary Permit Application State Transaction NumbfrA N/ In accordangk'rth SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) the p the Department of Safety and Professional Seevies. Personal information you provide may be used for secondary �CL.Ii�1L�' / 1 ,6ro o k_woo ( Dej e- purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. I. Application Information-Please Print All Information Property Owner's Name Parcel# ..------.. „ 0 Property Owner's Mailing Address Property Location .:1) 3 7 V K� /�+!l C{ , D 0� . Gott.Lot C /L City,.tate A Zip Code Phone Number r/,, /., Section g ircle o' -/s .a ) /� • / .rte T �/ N: R/ E 7 II. ype of Building(check all that apply) Lo ' or 2 Family Dwelling-Number of Bedrooms ►k.--. 0' Subdivision Name ✓ Mirr V B �/ �dt � 'n� /cJ � ke," ❑Public/Commercial-Describe Use l \61` ❑City of 1 1V CSMNumber ❑Village of / ❑State Owned-Describe Use ►l/" f �� 2- pis1r;bvtion (.ells w 22 chiherS ems-- ZpM X III.Type of Permit: (Check 1 . .. on lide A. Complete line B if applicable) A. Type New System /pr. • ment System 711 ❑Treatment/Holding Tank Replacement Only Ell Other Modification to Existing System(explain) Z1- 3 ' k g0' // j 217- 'TAP q77 ❑Chan I t:LL ist Pr vi us Perm ISumber• D Issued B. ❑Permit Renewal ❑Permit Revision Change of Plumber ❑Permit Transfer to New cfor ion It I Owner i l'AL //1-fjl/ 1 etit I QV/Lk- T. vpe of POWTS Syste .•Component/Device: (Check all that apply) r s cd WS P :" Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil 1 . :;.,- S •l,er Dispersal Component(explain)_ ❑Pretreatment Device(explain) A V.Dispersa l/Treatment Area Information: �- i3� /J�/e 1" Deign Flowyr Flow( Design Soil Appli tion Rate(gpdsf) Dispersal Area Requ' d(sf) I Dispersal Area oposed(sf) System Elevatio / e;r ' 7 7 gs--.4evr I ?it/ .rfo I'49.0 VI.Tank Info Capacity in Total #of Manufacturer Gallons Gallons Units ) Tom' U NI Ljear &1 1 New Tanks Existing Tanks a. n v u r . Septic or Holding Tank Dom e o /0(7c) J/2(© Lp. jng(f/NX Dosing Chamber i - VII.Responsibility Statem t-I,the undersigned,assu,,r. ponsibility for installation of the POWTS shown on the attached plans. Pl bet's Name(Print)y Plumber's.`r ature MP/MPRS Number Business Phone NFiberrf IL /1 27 r`on �j,�-t6'1,/� Plumber's Address(Street City, 'tate,Zip Codej/� / , VIII. i unty/Department Use Only Permit Fee Date Is ued I Issuing A. S'._,,,-,. e Approved r •t.r,, i .i $ I ! , • i er Given Reason for / /S L. /� 1 / IX.Conditions of Approval/Reasons for Disapproval S STEM OWNER: 1.S iti,,p tank,'effitrt filter and j dispersal cell ql4t het &t_rrladntaned as per management plan provided by plumber. 2.All setback requirements must be maintained as.per applicable codilit: aaces. Attach to complete plans for the system and submit to the County only on paper not less than x inches so size SBD-6398(R. 11/11) Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 3/31/15 Owner:Sharleen Johnson Trust Location: 1/4 1/4 S17 T29N,R19 374 Trout Brook Rd Hudson Manuals Used: In-ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cross Section 4-6. Maintanance and Contingency Plan 7. Filter Specifications Sheet 8. Existing septic tank •• m Signature li License number 26900 PLOT PLAN PROJECT Sharleen Johnson Trust ADDRESS 374 Brookwood Drive Hudson Wi 54016 1/4 1/4S 17 /T 29 N/R 19 W TOWN Hudson COUNTY ST.CROIX SYSTEM ELEVATION 91.0/90.8' 3.8' below grade 3/31/15 BEDROOM 4 DATE CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000/280 LIFT TANK SIZEnone DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 891 # of chambers 44 BENCHMARK V.R.P. Top of walkout slab ASSUME ELEVATION 100' Filter BEAR Filter ❑ BOREHOLE O WELL *H,R.p. Same as Benchmark A Scale = 1 4" = 10' Scale is 1" = 40' All piping shall be SDR 30/34,within 10' unless otherwise of tank,piping shall be Schedule 40. noted Existing 4 10' Well Bedroom House 25' B.M.* ♦ 30' 15' 25' Valve 15' 20' Huffcutt 280 tank 18' X 36' bed 30' Vent 100' B-1 - B-2 50' Vents 20' 25' 20' 2-3' X 88' cells 45' 45' with>3' spacing B-3 6% Slope . 45 Brookwood Drive • Cross Section of Infiltrator Quick 4 Leaching Chamber Typical cross section for 2 of 2 cells Quick 4 Standard Leaching Chamber with 20.0 ft2 of Area per Chamber To be >1' above grade 5.6ft^2 pair of end plates Finish grade elevation Typical Installation 94.8' ap Vent i Grade cDVent ■ 3' 4„ 3' • X30/34 Septic Tank 5' Long 111bh- 5' S' Long 1 Grade at System Elevation 36" Grade at System Elevation Spacing 5' 2-3' X 90' ' Cells Same on other end Observation tubeNent At end of cell B 22 chambers per cell System elevations: A_91 .0' B 90.8' ST. c0aAx 00uNX'e , SEPTIC TANK MAINTENANCE 'dGREFMENT AND QVVNERSH[P CE8IBlCA'D[!N FORM [>vvnor/Boyn — ��__-_ _ ^~= ---_.-- _-_-- ~ _=-` _-'_--_—____ Mailing Address �� ^� �� -- ` �-'�� ,,,42/6/0-eyte � ��. _ _ Property Address (Vord/:ubouroguurdGv'uPlanning& Zoning{�:pmt.ovm ter new cv^`t,u »')-------- ---- -- City/State ---- ___ Puzo�lk1ou����edouI�ozih�r �' /� -__-_--__-_~~-~_°___- _ _ LEGAL DESCRIPTION Property Lo r2�r � ^ . ' A9:57/>------ Sobcivi8i0U A2411-- 5,,,A__ _4_,/,,,J, __ �� �' 7��=�� Lut# �~� . Certified Survey Map #___.__��_____ ` Volume , Page le-- _ __' ���� Warranty U�med # _ � _7 �. Q , \/o[time ~-' # _°�~� ____ ___ Page Spec house yes 0 {"/line: identifiable dr no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its pr.rnature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, it 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 was ie disposal system. Owner maintenance responsibilities are specified in§Comxn. 83.j2(l)and ixChapter 12 St. Croix County Sanitary Ordinance The property owner agrees to submit to St. Croix County Planning &Zon dig Department_a certification form, signed by the owner and by a master plumber,journeyman plumber,restricted plumber or a licensed pumper verifying that(1)the on-site wastewater disposal system is in proper op condition and/or(2) ater mspciion and pumping(if necessary), the septic tank is less dmo 1/3 full of sludge. 1/we,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 Commeicc and the Department of Natural Resources, State.`fYvio"oumio Co,d�cgimzu�d���your uu��sy�o bakonomuiomi�6mus/bxrvmylcm.|voJ,rmue6womSt. LmixCmmy & Zoning Department"vdl�b,JV days oi�the�rouycu/�oop'noioudate. Planning 1/we certify that all stat •icnts on thus form am Cue to the best of toy/our I nowledge; Dwcuot/uz �� uvm�ra) ofUe propo�ydescribed above, 6y • . ^ .v xoauiy deed recorded b�Register ofDxm|x0Uioo. - owner(s) - • ��, __ 3 �,� �)� � ^,^ ^. ANT(S) L}'47E +**Aoyiufoonudondhpio misrepresented may result iu the sanitary permit being uNokod6y the Planning & Zoning Department. *** Include with this application a recorded warranty deed from the Registei of Deeds(Alice and a copy of the certified survey map if reference is made in the wairanty deed. ^ (REV.08/05) • POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner SAO F 1,QQ.c.. I—DIA$h_ Tr/ Tank Manufacturer: mtJc/ ❑ NA Permit# Septic 0 Dose ❑ Holding Volume: /G0-0 (gal) DESIGN PARAMETERS Tank Manufacturer: ❑ NA ' Number of Bedrooms: y ❑ NA Septic ❑ Dose ❑ Holding Volume: 2 e ? (gal) Number of Public Facility Units: ` lA Vertical Distance Tank Bottom(s)to Service Pad:1/ (ft) Estimated(average)Plow: Sid C (gal/day) Horizontal Distance Tank(s)to Service Pad: /" l4- (ft) Specific servicing mechanics must be provided if vertical is>15 feet or Design(peak)Flow=(estimated x 1.5): 6'l7o (gal/day) if horizontal is>150 feet. Specific Instructions to be provided on back. In Situ Soil Application Rate: (gallday/ft2) Effluent Filter Manufacturer:/57e— _/2...._ ❑ NA Standard(Domestic)Influent/Effluent Monthly average Effluent Filter Model: Fats,Oil&Grease (FOG) s30.mg/L Pump Manufacturer: Biochemical Oxygen Demand(BOD5) s220 mg/L ❑ NA , pump Model: Total Suspended Solids(TSS) 5150 mg/L High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer. (BOD5) >220 mg/L Cl Aeration ❑Peat Filter • (TSS) >150 mg/L //// \\\\ ❑Disinfection ❑Wetland Pretreated Effluent Monthly average ❑Sand/Gravel Filter ❑Other: (BODO) 530 mg/L )(1- Soil Absorption System Fecal Coliform(geometric mean) 510'm�L A round(gravity) ❑In-Ground(pressure) ❑ NA At-Grade ❑Mound Maximum Effluent Particle Size 3b in dia. ❑ NA ❑Drip-Line ❑Other: Other: XA Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tanks) Nhen combined sludge and scum equals one-third(35)of tank volume ❑When the high water alarm is activated Inspect condition of tank(s) At least once every: 3 ❑�'month(s) (Maximum 3 years) ❑ NA year(s) Inspect dispersal cell(s) At least once every: 3 months) Maximum 3 years) ❑ NA year(s) At least once every: ("Tonth(s) NA Clean effluent fitter e y f ears) ❑month(s) NA Inspect pump,pump controls&alarm At least once every: ❑year(s) ❑month(s) NA Flush laterals and pressure test At least once every:. ❑year(s) Other: At least once every: ❑month(s) NA ❑year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper). Tank inspections must include a visual inspection of the tank(s)to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The soil absorption system 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 treatment tank equals one-third (1 )or more of the tank volume,the entire contents of the tank shall be removed by a Septage Servicing Operator (pumper)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, pretreatment units. and any servicing at intervals of 5512 months,shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 30 days of completion of any service event. GMW-005(02/05) Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil absorption system. If high concentrations are detected have the contents of the tank(s)removed by a Septage Servicing Operator(pumper)prior to use. , Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will be,discharged to the soil absorption system in one large dose causing an overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator(pumper)prior to restoring power to-the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. 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 treatment tanks and soil absorption system: acids, antibiotics, baby wipes,-cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drain (sump pump)discharge,fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps,medications,oils,painting products,pesticides,sanit, ry napkins,solvents,tampons,'and water softener brine discharge. 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 s. Comm 83.33,Wisconsin Administrative Code: • All piping to tanks,pits and other soil absorption systems 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(pumper). • 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 the rules in need a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply u effect at the time of their permit issuance. A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be *----.—)4. rehabilitated and barring advances in POWTS technology,a holding tank may be installed as a last resort. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biornat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. WARNING TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE. . Pe't ADDITIONAL INSTRUCTIONS: ..L I 5 .. _ -�► S.. ) c_.� I 0 POWTS INSTALLER (� POWTS MAINTAINER. J _ l J Name�N+ j�J.gyp r Nam Ita.„ /�� �/ //// Phone —7),T,..._cil !J/4i Phone ✓�/J ''-`7'U ' y>� . SEPTAGE SERVICING OPERATOR LIMPER) LOCAL REGULATORY AUTHORITY Name - Name 7l ill,7)C__. .... A ' Phone 10,--:„..?/Z.,3/� Phone -7 J,;'- 1 t • This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f)and 83.54(1),(2)&(3),Wisconsin Administrative Code. x�' 4 r-t . i INSTRUCTIONS FiLTER CARTRIDGE . " -- .1.'...v.::-1:=,,,,:::'::v..:-..p- >- k .,.ri Installation STEP 1 Dry fit the filter case onto the end of the outlet pipe to ensure it is ,, "' k w centered under the access opening. If not, then either insert more pipe into the tank through the outlet or solvent weld (glue) additional pipe onto the outlet pipe. STEP 2 While the case is still dry fitted on the outlet pipe, measure the length of 3/4 inch pipe needed to brace the filter to the tank e dowall if not ilizi utilized,he optional supplemental side support. If side support proceed to step four. STEP 3 For installations utilizing the optional supplemental side support: solvent weld the 3/4-inch pipe onto the filter case. If side support method is not , „ utilized, proceed to step four. 5 STEP 4 Solvent weld the filter case onto the outlet pipe. Insert the filter ;�i cartridge into the case, pressing down until the filter locks into the bottom of the case. )„ � STEP 5 If a VRS switch is utilized: insert into the filter and lock by turning :e:n: clockwise 90°. Maintenance 1. The effluent filter should be cleaned every time the septic tank ism _ ` serviced. P 2. Open the outlet access opening to inspect the tank and filter. ' <'� 4� �, 3. Pump the septic tank completely, making sure to remove the sludge ,� N ' layer on the bottom of the tank and not just the scum and effluent. 4. Once the effluent level has been lowered below the invert of the , outlet pipe, firmly pull up on the filter handle to dislodge the „ cartridge from the case. " u.�o .' ors; 5. Slide the cartridge up and out of the case for cleaning. ! { 6. If a VRS switch connected to an alarm is present, the switch 4 r should be removed by turning counterclockwise 90° and cleaned ° 4 w, ; with water only. 7. While holding the cartridge on its side (large flat surface facing ey ki down) over the access opening, rinse off the cartridge with water r ', 4° ,,_ only making sure all septage material is rinsed back into the tank. * '. ,�• 8. If VRS switch is utilized, replace by inserting into filter and f turning clockwise 90°. 9. Insert the filter cartridge back into the case, pressing down until a the filter locks into the bottom of the case. ; ; . „ �.. 10.Replace and secure the access opening on the tank. BEAR ONSITE'FILTER CARTRIDGE-FIVE-YEAR LIMITED WARRANTY - r- d ., -n c .,:,yj?..f ..3'" D ro..Are -,a-,F,.!..=:-: ,. - `-_ , BEAR ONSITE`"Filter Case-Lifetime Limited Warranty ,i r. � I I frl 7 2 a Y Td i .. .. al _ 1( C _ r lit r'. ...f' E . E. ..,i r. Y D 7 't i r..i('d•sates P ^l i p - �' - 5....- J .......14-5tf. - 4,L . & 'o-a "' :§F ,"% � � � w t.' P � �' 1 e o- - r sits it ~ ' h. - ,4 a 're s a e 3 5�`x ^sr r "! g'- c Y r= # '" fir, z .: ` . ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK 'tTh.i.s is to certify that I have inspected the- septic tank present � y:;crving the 1, 1� , , --.� resi ence locate at: %, Section ��_ T7tN --_______• Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced: _ / Z9/ 1)id flow back occur frgm absorption system? Yes L`pf o (If no, skip next line) Approximate volume or length of time: �-�----- gallons _ - - minutes . opacity:/y6-0 construction . Prefab concrete Steel Other Mdnufaeturer: (If known) :Lt yL, y,actzdv✓ tl<�e of Ta If known) ,: �� . c -- X��u Z/ (S ure� /� (Name) Please print — (`I'itle) Z� _ (License Number) �- Dote Corm to be completed by licensed plumber (s. 145. 06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best 4 , my knowledge will conform to the requirements of ILHR 83, Wis. ,C:m. Code (except for inspection opening ver outlet baffle) . F Name 4 �,d Signature P MPRS 2 or 997842 BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI • RECEIVED FOR RECORD State Bar of Wisconsin Form 3-2003 QUITCLAiIYXDEED 06/27/2014 08:00 AM EXEMPT # 16 REC FEE: 30.00 Document Number Document Name PAGES: 2 THIS DEED,made between Christopher G.Johnson and Sharleen . nson, **The above recording information husband and wife verifies that this document has • I _("Grantor,"whether one or more), been electronically recorded and Christopher G.Johnson and Sharleen R.Johnson,co-trustees of the Christopher &returned to the submitter G.Johnson Revocable Trust a/dit dated April 22, 2014 ("Grantee,"whether one or more). Grantor quit claims to Grantee the following described real estate,together with the rents, profits, fixtures and other appurtenant interests, in St.Croix County, State of Wisconsin ("Property") (if more space is needed, please attach Recording Area addendum): Name and Return Address AN UNDIVIDED ONE-HALF INTEREST IN AND TO THE LAWSON,MARSHALL,McDONALD& FOLLOWING-DESCRIBED PROPERTY: OALOWITZ,P.A. 10390 39th Street North SEE ATTACHED EXHIBIT A. Lake Elmo,MN 55042 020-1121-00-000 Parcel Identification Number(PIN) This is homestead property. (is)(is not) Dated April 22, 2014 By (SEAL) t;n —A/ �J 07� (SEAL) • *Christopher G.Johnson - * (SEAL):.. 1_l- 1 CI–�-v~-^-- (SEAL) Sharleen P.Johnson • AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN MINNESOTA ) )ss. authenticated on . Washington COUNTY ) Personally came before me on April 22, 2014 * the above-named Christopher G.Johnson and Sharleen R. TITLE:MEMBER STATE BAR OF WISCONSIN Johnson,husband and wife (If not, to me known to be the person(s) who executed the foregoing authorized by Wis.Stat.§706.06) instrument and acknowledged the same. THIS INSTRUMENT DRAFTED BY: Lawson,Marshall,McDonald&Galowitz,10390 39th St. * Maura A. Severin • NoLLake Elmo,MN 5042 (651)777-6960 Notary Public,State of Wiseonsin Minnesota M. .. +i ::r; : vim's: t 3t• oa0 ) (Signatures may be authenticated or a 7t` d. Boni a�ot`F �c airy.) NOTE: THIS IS A STANDARD FORM. ANYMODIFICATI: S;'1175". HI Fe 1['� !AE 'jTt y ELY IDENTIFIED. QUIT CLAIM DEED 02003 STATE A�u e. ,,. '? ;"ti res a FORl1I NO.3-2003 St. Or iallatefia laaage 1 of 2 • . • • •: • • . • •. • . • . •• . • . •' . • . •• • • • • • - . . - ' - • • : . • •• , • • • EXHIBIT A . . • • • • . tot 24,Trott Brook WOodk Adaition.,Town of Illidson, Si. Croix County, Wisconsin. • • ... . •.• . • , -• .• • .. . • . . • • • . . . • • . . . - • - • . • . . • • . • .< • • • • . . . • • . •• • • • • • • • • • •• • •• . ' • • . . • . •• • •• • • • • • • • . • • :• • • • • ••• • • • • • St. Croix County 997842 Page 2 of 2 Property Owner_ Parcel ID# Page Z of 3 Eli Ong# 2 Boring q te,pit Ground surface elev. l 3 _ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIff in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'Eff#1 •Eff#2 1 o- JO y,2 -- sl a?- .7,.�i (..)- Z�c , 6 /,0 Z- 7-16 611/,y a„,, 5U G/ �J h, �j°O . CCI Boring# ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. I Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *BUM •Eff#2 Boring# ID ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon lepth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. •Eff#1 'Eff#2 •Effluent#1 =BOD5>30<220 ng/L and TSS>30<150 mg/L •Effluent#2=BOD5<30 mg/L.and TSS<30 mg/L 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 608-266-3151 or TTY 608-264-8777. no-8330(R.6o0) V, b"' ` re g'i 7 f )' -, k,) I 3 Wisconsin Department ofCommerre �.r�"'('0;1,�i`'-� SOIL EVAL ORT Page of Division of Safety and Buildings?:° " -'-'3 .c - t 1-∎� `- in accordance with Comm 85,Wis. Adm. Code \, vk°` County � /70%t 1\ Attach complete sire on paper not less than 81/2 x 11 inches in size.Plan must indude,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. D? 0'-// '/- Zrli-bl-IU Please print all information. Reviewed by �Daate /t Personal information you provide may be used for secondary purposes(Privacy Law.s.15.04(1)(m)). �� I `7/�/7O/S Property Owner Property Location Qf CA'(1_3-- 'To 4/2; l 1-,/v/).1.-- Govt.Lot 1/4 1/4 S / 7,z? N R) E(∎r)W Property Owner's Mailing Address Lot# Block# Subd. Name or M# 3 7 y rr=,a�ivc Or, . 2 — 2 rc7<, - /3,-arr4' o ' / / City State Zip Code Phone Number ❑City ,D Vllatown Nearest Road L I kA IVp1 h i ( ) riti.t I..!av,1i3 sJ.c D.-- ❑ New Construction Used 2esidential/Number of bedrooms ' Code derived design flow rate 5 G 0 GPD Replacement ❑ Publi5jor commercial-Describe: ________ - -------.--Parent material eNQ -C/ccet£4./ Flood Plain elevation if applicable fv 1/t' �] ft. General comments 3. t-13e 1 o-,4> I r and recommendations: 0 System Type L 0/f/lJt° I System Elevation 7 1 . 0 9 D. I [I Boring L,/ ` �# ®+ Pit Ground surface elev. 9!' t4 ft. Depth to limiting factor trJ/in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. •Eff#1 •Eff#2 1 0-/D )0 21 5/ 0714y,--, i f C — p.,4 - 4 /r7 Boring# ° Boring �j rii INL Pit Ground surface elev. ft. Depth to limiting factor / i/in. ( Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. •Eff#1 *Eff#2 1 o- .6 / ,/,/z., S1 0'1 1-17 e'r- c;2pt " 4 2- 6- 76 /7,V/‘ S Os?, /7 / A/24), i I - -7 / 4 noy.\C), kr) .0'1. , •Effluent#1 =BCD.>30<220 mg/L and TSS>30<1 if •Effluent#2=BOD,<30 mg/L and TSS<30 mg/L CST Name(Please Print) J' nature_ CST Number Bird Plumbing, Inc. Shaun Bird - 226900 Address - Date Evaluation Conducted Telephone Number 1432 120th St, New Richmond, WI 54417 3 -3/--/ j 715-246-4516 Soil Test Plot Pla jj 3 '-3 rl en Johnson Trust S "Bird Project Name Sha e Address 374 Brookwood Drive /%& Hudson Wi 54016 f M #226900 Lot 24 Subdivision Trout Brookwood Add Da e 3/31/15 1/4 1/4S 17 T 29 N/R19 W Township Hudson 0 Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. top of walkout slab System Elevation 91.0/90.8 *HRpSame as Benchmark A Scale is 1" = 40' unless otherwise noted Existing 4 10' Well Bedroom A41'4.0 House 25' B.M.* 0 30' 15' fa 15' 18' X 36' bed Vent B-1 Ac B-2 4 100' % 4 50' 20' 25' 20' J • • � 45' B ■ 45' 6% Slope . Brookwood Drive V • I- ' �: {r. �` veer�veer am, — -Li - . ti I :. - K/ y t s VV.' . i ILe s kr CYO i 0 � p y O r+Pet a � IA +r - e rR w .. ,. 4., P yr VM 44 �� 1' 1r i .. s - )_ m ,ssm s 7 a' M 27� ' r` ,°a � .04! '00" '.N 0 3` r 0 .• w. T ■ • .90 6 \ ao CO R w L_ g Of i mob' - ...e.. ' : \ / : \ \ § t & 0 j , / 1 $ . . / .+ ƒ i % 2 I 't: ' I . / c 2 2 7 ; 2 » co « 1 } § / § § z / , § .2 N.ji ; 1 a ■1 2 1 o) t ) \ N ID ° 0 aCt/ Ce E )-� . .c E $ 0 Q k � k } 1 , k 0 2 C Pitt ) M k © E % k f c ti / k § 0 2 .2 6 ® tkiti § # ® co co m E E as \ ~ § i c 0 0 0 Z -� 60 : 0 a a a \ R k \ § ' � \ \ : 6o) \ : ] 7 \ § 2 : $ § § = = E I co • % ƒ o J 0 M ■ i % , a e 8 % 11 E 2 I ) E / \ § } � k 8 { 0 c .,— o § / d c c - - a o ° a = > • 0 c ] .k \ $ \ 7 { 3 ± @ § 2 CO R ) $ f & 2 A « 1 E c et ii { a ' E ° ƒ : k f k 3 a. 2 (o $ J Parcel #: 020-1121-00-000 03/15/2006 03:54 PM PAGE 1 OF 1 Alt. Parcel#: 17.29.19.527 020-TOWN OF HUDSON Current XI ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): 0=Current Owner, C=Current Co-Owner O-COUNTRY HOUSE INC COUNTRY HOUSE INC 374 BROOKWOOD DR HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *374 BROOKWOOD DR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.700 Plat: 2553-TROUT BROOK WOODS ADDITION SEC 17& 18 T29N R19W TROUT BROOK WOODS Block/Condo Bldg: LOT 24 ADDITION LOT 24 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 17-29N-19W Notes: Parcel History: Date Doc# Vol/Page Type 05/29/2001 646695 1648/11 WD 07/23/1997 767/521 2005 SUMMARY Bill#: Fair Market Value: Assessed with: 92397 280,600 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.700 79,800 206,400 286,200 NO 05 Totals for 2005: General Property 2.700 79,800 206,400 286,200 Woodland 0.000 0 0 Totals for 2004: General Property 2.700 44,200 201,400 245,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch#: 312 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 AS BUILT SANITARY SYSTEM REPORT cj `� ( OWNER �'`1.t.V'"r Ve`l-z-cSG--"- , TOWNSHIP I 1 Li o s oNJ SEC. I e T 2q N, R./9 W P.O. ADDRESS , ST. CROIX COUNTY, WISCONSIN SUBDIVISION 17(10 UT 8 &oof< CO OppS , LOT L •LOT SIZE PLAN VIEW • Distances &dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM A ` ett\ i A V r 4 ALLO • co00 ,� ;e�,,rtc N. I f uus 1 � SEPTIC TANK(S) f MFGR. f-- [ e CONCRETE STEEL NO. of rings on cover a Depth DRY WELL TRENCHES NO. of width length area BED no. of lines 1 width Jg > length 3(c.'" area depth to top of pipe AGGREGATE W i\S Re r I `/z r, >E'ock f PERK RATE 7 AREA REQUIRED ( I .; AREA AS BUILT (01, Disclaimer: The inspection of this system by St. Croix County does not imply complete compliance with State Administrative Codes. There are other areas that it is not possible to inspect at this point of construction. St. Croix County assumes no liability for system operation. However, if failure is noted the County will make every effort to determine cause of failure. GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. -INSPECTOR y-y�j DATED _ L —1 8 PLUMBER ON JOB C � 2 L LICENSE NUMBER X4/1/ r. 11 REPORT OF INSPECTION--INDIVIDUAL SEWAGE DISPOSAL SYSTEM / Sanitary Permits d 0 State Septic /2:_.,-2/7 7E TOWNSHIP .►_ 4L„,1t. Croix —ounty SE TIC TANK Size ) 0 Q 0 gallons. "lumber of Compartments 1 Distance From: Well 5-CA ft. 12% or greater slope cc, ft. Building ' VI ft. Wetlands 11 f: I;ighwater Ylo, ft. DISPOSAL SYSTEM L-'/Tile Field or Seepage Pit(s) Distance From: Well S( t ft. 12% or greater slope flrk- ft Building 3 / ft. Wetlands FIELD Highwater rl 4 ft. Total length of lines /40c, ft. Number of lines .3 . Length of each line -.?(0, ft. Distance between lines �,> ft. Width of the trench 1R ft. Total absorption area (A8 sq. ft. Depth of rock below tile in. Depth of rock over tile 9 in. Cover over rock: i G ,� Depth of tile below grade iR in. Slope of trench in per 100 ft. Depth to Bedrock Ylk ft. Depth to ground water blot ft. PITS Number of pits . Outside diameter ft. Depth below inlet ft. Gravel around pit : yes no. Total absorption area sq. ft. Square feet of seepage trench bottom area required r • Square feet of seepage - : equired Inspected . Title: Approved , Date 197`. '\\ Rejected , Date 197 . • EH - - WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES . DIVISION OF HEALTH,BUREAU OF ENVIRONMENTAL HEALTH ti . , P.O.BOX 309 MADISON,WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TES S LOCATION: 4'/a,$SA1/4,Section/.,T,iN, R/� (or)Oowns ip or Municipality �jlt-cox/ Lot No. e241 Bloc No. , 7 QK7L A A Wet County �l� `x Subdivision Name Owner's Name: S e#A , r-5.0A/ / , Mailing Address: 311 6-/i-�A X I. A/0)- /1 � j K//�. .�yD/,C TYPE OF OCCUPANCY: Residence & ��NN/o.of Bedrooms - Other EFFLUENT DISPOSAL SYSTEM: NEW /4- ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS ! pZ0" 7) PERCOLATION TESTS / 'f `77/ 9 0lf-7? SOIL MAP SHEET a'fr- SOIL TYPE /l 7G.PRCt F-?5C /O4. Ave_e S SO � S� PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P- / lig" See 4o re 'A4 oZ`f Kcp /0 //2- /%2 //2- 7 P ,Z Sya -5--e-e. arc Ash 02 //YO /0 a2/14 °Z J P Sg", See guest , ,g-41 do '0 .2 x 02/ Z S SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH T,O/BEDROCK IF OBSERVED) B- I 96"� /116A1t 776..' are' i �'7 0 s" "e S' 73 "" 1,5 2_ X gone_ 776" yS," , 3.7 " "2 el S 6 0"" X S B_ 3 96„ kA e 72'6" 3',rs; ,Y" A4ed , 69" ,GS Y 96" � -e 296`, s," 73 / 7" e S, Tits 4.5-. B- 3- Q6`' /doze 7'2('-, %e„ 1-s'� /7,, t-i eI,s -7;s" CGS 6 94" ,lcte_ ?9C" s- rg /9' tied S, 7.2" £5 PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet f suitable area; In sate u per f sq re feet of absorption area needed for building type and occupancy. Cir ' 2,S ''�/ )u.. �,p / .In�d to/c�_ca_�le or distances. Give horizontal and vertical reference points. Ins' ate ••e �".S" ""' 7r / �■II �■ ■ � �� I r_ ++i= ■.■■ IIII s ■ smilimemmorterimmunommomommirms .a m■■s u■.P a.im ■ ■111.■■ IIIIMIIIIIIIIIIMIIIIMIMPIEIIIIIIIIIIPIIIIMIENIPMIIPEIEVMIOIJIIIIIMIII IIIIIIIIIIIIIIIIIIIIIIIWAIIIIIIIIIMIIIIIIIIIMIIMIIIIIIIIIIIIIIIIIIHII 111111111111111111DIEllillti D Iiiiii11111111111111111111111111111111111111111111111 ■�I �IIIElri"'i iii" iii lllkiii iil IIIIIIMII IIIllIllIl lI ll t11111111111111M0111111111111111111Eraill1111111111111111111111111111111111111111111111 111111111111111116N1121111111111111111111111111111 1111111111111111111111111111111 ■11 it r�11r� ■ ■11!>r 1 IIIIIIIIIIIIIIIIIIIIIIIIIIIII ■ 111111111111» 1111» ■ ■1111111 ■11111111111 sa9,,, y V 3 % 'S I,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and location of test holes are correct to the best of my knowledge an/ belie . /0 'Name rint L2!tt�4 S /I k r S ' • Certification No. 5--C--/S-7, (print) / �/�� Address /1l� A 2Ic,.e( I97i1, ,4he, 0.4 L//1S. 5-14" Name of installer if known ) ' ' L / , CST Signature - - • ( ,•� OPY A—LOCAL AUTHORITY 0 or pr.B6 7 I;�;1a State and County State Permit # l%- Permit Application County Permit # _?e) for Private Domestic Sewage Systems County ��f- *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Addre s: 31/ G / Ad, 5A ek Al "sjek..5.0"/ itiOi-#.A S__ _ ,JoAt Gt.)ItS. XV0/6 B. LOCATION: A/� Y. Se '/4, Section /8, T.Z9 N, R/F D (or) Lot# City Subdivision Name, / nearest road, lake or landmark Blk# Village � gr 00/( woods Township Al /sac/ C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family )( Duplex No. of Bedrooms .-3 No. of Persons /7/ D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder YES •NO # of Bathrooms 3 Automatic Washer X. YES NO Other (specify) E. SEPTIC TANK CAPACITY /ODO Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation X, Addition Replacement_ Prefab Concrete *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) Total Absorb Area (F, /5'sq. ft. New K Addition Replacement *Fill System Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length 361 Width _/Qt Depth 4'6" Tile Depth 3(0" No. of Lines 3 Seepage Pit: Inside diameter v Liquid Depth Tile Size /" Percent slope of land 3-S°?, Al or-I-4 Distance from critical slope SO WOGS /r be /i 4 4'Pe4 0 S";‘,5,6".• I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the C-4 ified Soil ilterAk NAME ,/' c vir P-AT /1 - 4. C.S.T. # and other information obtained from .5044 errmer/builder . Plumber's Sig ire L L _�.�...: MP/MP W /�l7 Phone #376— 2_$7S 0 Plumber's Address ._ A ,�, I .c�'�c-.o PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). , /o Sc, /42— SO' u0b� P s'* off � \, Pt edf W L -"hip R S �. ea 7°• I 3 Do Not Write in Sp. e el - FOR DEPARTMENT USE ONLY Date of Application n6 1 Fes Paid: State /0.60 C3u t n� Date ��rJ° 7 Permit Issued/ e' stt�ee/el- date) 9 JO 2 Issuing Agent Name ,,._d..��� , e _�Lr.G�►.lr i+ �_� Inspection Yes /1No Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISOIV,'WI 53701 L 2. state (pink copy) 4. plumber (canary copy) Revised Date 6/1/76