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HomeMy WebLinkAbout020-1447-19-000~ o M ~ b a ti Q O O N ~ N ~ ~ I ~ I c ~ I c 3 ~ ~'I ~ v I ~ rn ~ ~' o ~ v Z ~ ~~z ~ y ! am , o z v c d Z ~ O V) H r ~ C ~ ~ E N ~ C L ai U N ~ C ~ L O U C lC Z J ~ r d N LL L _ d Y ~ CO O. {Q p H d ~ o U ~ ~ o o a ~ ~ ~ ~ N aaa R ~o d v ~ o v~ _ V3 J V N O ~ ~ `" N ~ o ~ ~ - 'a y 'o d c a °' ~ H c ~ ~ _~ ~ 3 i o c° ~' c I Y ~ Fed o N ~ 7 N M ~ ~l ~' ~ 2 ( D ~ OD ~ O ~ :: V ~ ~ ~ ~ = E E '~ a ' ~ a m d ~` • '~l ~ m ; ~ c I c :: ~ r r A Ua~ lov~v 3 0 ~ ~ N C O O C 3 a v~ 0 0 a~ r~ o ~- ~° _o v°~ a 3~ ~ ~ c ~- N m E N O N y Z ~a _ ~ o o ~~ > °' a Q ~ a a 0 U .a N a c ~ _~ a ~ a v L V/ N m ~ a~ a. ~ O Z •3 a m ~ m Q Z in c c ~ ~ C~ ~ ~ O N N z ~ a Wisconsin Department of Commerce j Safety and Building Division ~ PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)l. Permit Holder's Name: City Village X Township Bast, Kernon Hudson Townshi CST BM Elev: Yl ~~ Y ~ Insp.) /B~M~EIev~ 4V "`~ BM Descrjption~ ~~ (111""~~CC~r//`` TANK INFORMATION h'S ' 3 ~ ,~. iZ ` w"ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic ~ ~ ~~ Dosing v2 rte Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic B b d ~ ~, Z Z ~ Dosing 0'Y" ~ I Aeration Holding PUMP/SIPHON INFORMATION Manufacture Demand M Model Number TDH (Lift (Friction Loss ~IHead ITDH Ft to SOIL ABSORPTION SYSTEM 1,S BED/TRENCH Width ~ ~ Length r No. OfT~hes DIMENSIONS [!V SETBACK SYSTEM TO P/L BLDG WELL INFORMATION T e Of System: DISTRIBUTION SYSTEM County: St. CroiX Sanitary Permit No: 463152 0 State Plan ID No: /n /Y`/ ~1. Parcel Tax No: ~ to ~ Sectionlfown/Range/Map No: 15.29.19. STATION BS HI FS ELEV. Benchmark ,~ /~„ / Lw` ,' ~ ~/ ~~ Alt. BM .~s" ~~ BIB. Se~e~ g _ `Y'om ~ ~..f~ ~ ~ / t'o .. SUHtlnlet ~Y~c .7J ~~ ~~ S Ht Outlet Dt Inlet .~-- Dt Bottom ~- Header/Man. ~ . q~1-~ Dist. Pip ~_ ~~ ~Cf.'3 S Bot. System S 7~ g ~ 3 Final Grade _d St Co ved ,„I~ ~~- ~~~~ ~ - 7 ei-~ PIT DIMENSIONS No. Of Pits Inside Dia. LAKE/STREAM EACHING CHAMBER O M UNI Model Nur tl.~.s'' ~ /111 ~f Bader anifold Distributio „` x Hole Size x Hole Spacing Vent to Ai Intake Pipe(s) U Length Dia Length Dia Spacing SOIL COVER x Pressure Svstems Oniv xx Mound Or At-Grade Svstems Only Depth Over ~ ~ Depth Over ' xx Depth of ' xx Seeded/Sodded xx'Mulched Bed/Trench Center i / ~,^, Bedl1 rench Edges Topsoil ~ Yes [~ No ~ Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~ ~ /~/~ Inspection #2: / / Location: 681 Pine Timber /L,ane H~/uds~, WI 54016 (NW 1/4 SW 1/4 15 T29N ,R~1/9W)C~odyo'te~Ridge Lot 19 J~c(,~ f rc I o•r .29 1 _„/~ 1.) Alt BM Description = `'~ru~' - i 4 ~--~ / v~~/~.~. ~ G~~~ g I d 0 ~ g ~- 2.) Bldg sewer length = Z2~ / ~ ~ ~~r~~. n ~~ Z/~~ ~j'' ~'~i C~.Q-) (~~ y4~~Cl~ -amount of cover = ~.` ~ '" ~' > ~g ~'~k~ a UV ~2~ ~~ l~" 1^~~-,~o~ eQ..s~-~~~d apt-e~.°`~ -- ___- Plan revision Required? ~ es ~ No ~ ~ ~ 7t J ~ /, Use other side for additional information. ' ~ IV ~~~~~~..- ~` Date Insepctor's Sig ature Cert. No. SBD-6710'(R.3/97) ~ e I ~~ ~ ~~~ C' ~~ /~ 1,z~~LCl'~ ff ~ -~ r ~ ~~ ~ _ ~ ,~~ -~ ®~ ,I zL „~ IJ""+~ .. ~~ (~ ~~ y-~ ~ • Q7 ~ ~~ ~ l~'~' ^'~ ~`' ~~ „-- t ~~ Safety and Buildin t io 201 W. Washington Ave. -, I the-- t ~ r ~/L~~"~' Madison, WI 537 - 7 l s Numbu (to be filled in by Co.) er mit nitary P ~ ~seon ( I ~ / / 7 t0 ~ l~ Department of Commerce Sanitary Permit Applic tion ~~ , state Plan I.D. Number , `'q"' Q~ ~_ f nal inf anon ou provide C d Ad i e, perso o m. s. In accord with Comm 83.21, W may be used for secondary purposes Privacy Law I S•U4(~ f t~ ~ (~ Protect Address (if dill t than mailing address) r (. Application Information -Please Print All Information ST. CROI ~ ~ / _ ~ ~ ~ f Uui~..,, L l.~ Property Owner's Name ICE Parcel # Lot # Block # 1 Property Owner's Mailing Address ~ Property Enters ~ ~ / Y p . ~ y., ~i"''Y., Section St ate City, o de Zip C Phone Number i l '' I, ~~11 A,~, l~^~L~ ~ // t ~ < ~~(t~ / / ~i ,~/i! - t7 ~' W // e~9rieJ rc /~ T~N; R Eo W~ II. Type of Building (check all that apply) ~ j Subdivision Name SIv) N i tuber ~I or 2 Family Dwelling -Number of Bodrooms ^ public/Commercial -Describe Use / - ,, 7 ~~ G~'~'%%>~~ ~ ~ttY_ ill e ~T wnship of J ^ State Owried -Describe Use III. Type of Permit: (Check only one boz on line A. Complete line B ifapplicable) - ~ Q O A' New System ^ Replacement System ^ TreatmenUHolding Tank Replacement Only ^ Other Modification to Existing System B. ^ Permit Renewal Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Ownel____~ IV. T of POWTS S stem: Check all that a 1 - Pass Sand Filter ^ l ^ Si d ^ ng e e At-Gra Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ M d < 24 in. of sus it Constiucted Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Rtcirculating Synthetic Media Filter Leaching Chem ^ 'p Line ^ Gra -les Pipe Other a lain) V. Dis rsaVTreatment Area Information: Requi (s Di Proposed (sf) System Elevation / Design Flow (gpd) Design Soil Application Ra gpdsf) Dispersa ~ 7~~ 3 ~ `~ VI. Tank Info Capacity in Gallons Total Gallons Number of Units Manufacturer Prefab Concrete Site Constructed Steel Fiber Glass Plastic New Existing Tanks Tanks Septic or Holding Tank ~ ,,,r '~ ~~~`, Aerobic Treatnxnt Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assuuie responsibility for i , Ilation of the POWYS shown oo the attached pleas. Plu 's Na (Print) Plum Signa P PRS Number Business Phone Number PIu is Add s (Street, Ci te, Zip Code) ~^ ~+~,~ V .~ ~.J ~W VII Coun /De artment Use Onl Sanitary Permit Fee (includes Groundwater Date Is ued Is 'ng Agent ignatu (No mps) Approved ^ Disapproved Surcharge Fee) ~ 07J ~' / ^ Owner Given Reason for Denial J t/ ' IX. Conditions of Approval/Reasons for Disapproval L ~ ~ /~ G1iL~ 7" ,~~ ~- d~~c 11/z/~ s~. Sy-~-~ -~"~e~-- '~`~ '/z ~/~ ~ - -... i... N..w 112 ~ 11 i.u•hes in siu nrncn eomp~e~e palm tw .a a.wwq ....y, ..........~...... _.. ,._, v SBD-6398 (R. 01/03) ~~- ~C3~-Q ~ ~~- ~~ ~~ ~ _~~ ~ ~ 1 G.~ - l 9 /~,3s T L~ %y f ~ ~ ® ~~ -a = ~° ;:r- ~.. .. ~-y ~~Vaa~~s~ nv~ol 3~~ d o ~, f I c d o ~ r. ~ ~ o ! ~2~~ .~o'~c C' 4 ~ 1 I ~ •• ~ i ~ 3 ~ r: i ~ ~ ~ o ~ ;.• ~ O ~ ~ ~ ~ z ~ rn v c cn • ~ ~ ~' °-'~ 3 N ~ ~ ~ ~ a iv --i 1 N ~ N~ ~ fD N .. N (p (O CO N 7~ ~ ~~ " Q. _ ~ ! 1 ~ c ~ > > A~ O C ~ ~ ~ !r ~ cn ZD ~ a m e~ m co D N a -~ C o W ~~~ N ~~ o Z oom' c7rcn ~ N ~ ~ ~ ~ O O O o C ~ 0 tO ~ ~ 3 N cn N ~ o I a Q ~ v o 0 = ao~' ~ o,A rnl _ ~ ~ „ a ~ 3 m ~ m N .. ? Q. rt Z •• , O 7 O 3i ~ ~ ~ ~ m ' ~ ~ I CD ~ ~ O N o m p c I . ~ C ~ N I w v~ a s I ~ Z ~ ~ N ~ ~ I N~ ~ ~ -I N ° -°'o N 3~ I A z N d ~~ ~ a p ~ ~ N .. I o ~ I o > _ Z -1 cn m W ~ ~ ~ a ~ 3 ~ Z M ' n ~ T o ~ ~ ~ N < < < < Z I ~ ~ ~ I Q N p~j d I ~, $ ~ a I ~ ~. v w c I ~~ ~• o a a 01 N .'S ~ I ~ N ~. o ~ ~ a I $ ~ ~ I °~ ~ ~ N ~ 0 N ~ ~ ~ A p O ti ~ I W C b ~ ~ N '~ O ~ .~~. ~ :~ ~ aC w I c ~ ti °o°o ° ~ ~ y . ti Wisconsin Department of Commerce (~,~~v v ALUATION REPORT Division of Safety and Buildings ~n~Z`ordance with m ,Wis. Adm. Code 1475 Page t of 3 Steel's Soil Service, Inc. 1 ~~~ Attach complete site plan on paper less than 8% x '~ i1~h s¢e. P County St. Croix - indude, but not limited to: vervcal a horiz n~rende point (B ~~irectio Parcel I D percent slope, scale or dimemsions, rth a and locati nce ton F~C~ . . Pending Please prin all ira~pp~F -~ ~ i Dat ~ rposes (Pmacy Law, s. 15.04 (1) (m)). Persons information you provide may be u for ev e ~ J ~ Z~ Property Owner Property Location McCabe Homes Inc. Govt. Lot na SE 1/4 SE 1/4 S 15 T 29 N R t9 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# ~ 935 Osprey Blvd 19 na Coyote ~ / City State Zip Code Phone Number ~ City _~ Village ~ Town Nearest Road Bayport ~ MN 55003 651-351-1018 Hudson Pine Timber Ln t~ New Construction Use: Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD ,_( Replacement ~ Public or commercial - Describe:na Parent material outwash Flood plain elevation, if applicable na General comments and recommendations: Conventional system, system elevation 96.OOft .Trenches spaced and depth to code 3.OOft below grade. Boring # J Boring Pit Ground Surface elev. 99.00 ft. Depth to limiting factor 120 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP Dlft= in. Munsell Qu. Sz. Cont. Cdor Gr. Sz. Sh. *Eff#1 'Eff#2 1 0-7 10yr3/1 none sil 2msbk mfr cs 1c .6 .8 2 7-20 10yr4/4 none sicl 2msbk mfr gw 1 c .4 .6 3 20-27 7.5yr4/4 none sl 2msbk mfr cs 1f .6 1.0 4 27-120 7.5yr4/6 none cos osg ml na na .7 1.6 0 0 Ce ~•.eed `' ~ 3~ Boring # Boring ~f Pit Ground Surface elev. 99.00 ft. Depth to limiting factor 120 in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ftZ in. Murrsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *EffiY2 1 0-12 10yr3/2 none sl 2msbk mfr cs 1c .6 1.0 2 12-120 7.5yr4/6 none cos osg ml na na .7 1.6 * Effluent #1 = BODS> 30 <_ 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signatur _. CST Number David J. Steel - - G~ 248956 Address Steel's Soil Service, Inc. Date Evaluation Conducted Telephone Number 994 200th St., Baldwin, WI 54002 8/1 715-684-5680 ~~ Property Owner McCabe Homes Inc. Parcel ID # Pending Page 2 of 3 Boring # .J Boring Pit Ground Surface elev. 90.35 ft. Depth to limiting factor 120 in. Sod Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots PD *Eff#1 *Eff#2 1 0-7 10yr3/1 none sil 2msbk mfr cs 1c .6 .8 2 7-20 10yr4/4 none sicl 2msbk dfr cs 1f .4 .6 3 20-27 7.5yr4/4 none sl 2msbk dfr gw na .6 1.0 4 27-120 7.5yr4/4 none cos osg ml na na .7 1.6 ^ Boring # J Boring ft. Depth to limiting factor in. Soil A _J Pit Ground Surface elev. ppligtion Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots P *Eff#1 *Eff#2 ^ Boring # J Boring ~J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon th De Dominant Color Redox Description Texture Structure Consistence Boundary Roots P p in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 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. David J. Steel CST-POWTSM Lic. #248956 W~S~ ~~~ ~p(~~ ~,~ Y`,`-` ,' C' v. L STEEL'S SOIL SERVICE INC. 3 of 3 McCabe Homes Inc. 994 200th St. SE1/4,SE1/4,S15,T29N,R19W Baldwin, W154002 Town of Hudson, St. Croix Co. Bus.(715) 684-5680 Coyote Ridge, Lot 19 Fax.(715) 684-3449 Legend N / 1" = 40' l~ ~ --Benchmark Ele. 100.00 ft / Top of 3/4" pvc pipe (~~/// • Alt Benchmark Ele. 100.35 ft To /4" we pipe ^ =Borings ~1 Boring Elevations B 1 = 99.00 ft B2 = 99.00 ft B3 = 96.35 ft B4 = 0.00 ft ~~~~ .5~~ ~~ ~~ ~' G r~-~ r ~' c~ as ~a `?= 5 ~-~~ ~'G~. ~ 5 ~~ ~~ ~~ ~cr ./' //- Z -~ ~f ~~~ m; ~ ~ ~! ^ i % '~ _ ~ tD ~d ~ J ; ;~ N r ~S~ '~1 O ~ ~ ~:.~ J c ~ ~~' ' q ~ $ ^ C `-; if ` N ~ C ~ ' 3 i r ~ ~ ri ~4 i j ~` ~ ...+~--- a i ! ~ ~ r~ ~-._ i ~ f ~~ O i ~ r ~ _ 1 ~ ! 1 J r a /ji, ~ ! . ®~ ~~ ; ~ ~~isF~AS '• ~ { ~ ~ soon er ~ !1 ? J! ~ ~! r ~ ~ r i r~ ~ i i 1 ` , ~ O •' O C ~'~~ rrW i~ r 1 1 ~ ~ m 'Ji r ~ ~ 1 t ~ ; ~ i a 3~JYt~jNliO ~ ' ~ ~ - r j 1 i m U6; ~ ~ ': r r - • ~ •j_ 1 - '• iill~~/ t ~i ~ ~ ~ ' it No21ga4w~?.33.9G ! ~ ~~~~ ~~`*..,.. ~ `-. 1 ~ ~ :t ~ ~ ~ ~.~ r ~ ~ ~ ~ ~- '~'`, r '+. i •~, i •--. r ~ '-•.~.... i ~ ~ ~ ~ r r ® aDw~ j 1 ~- ac a t F- a ~ F 1 n ~, _ m RECEIVED QCT ~~ t 1.004 201 W. W hinge -, y ~ ~ isconsin Ma ' , De artment of Commerce (~8) 261546 Sanitary Permit Application [n accord 'th Comm 83.21, Wis. Adm. Code, personal information you pr be used for secondary ptuppses Privacy Law, s 15.04(1 xm) I. Application Informati -Please Print All I~tformation Property Owner's Name _ , Address ~~~ 31 S2 Project Adddress (if different than mailing address) ~ 60 ~ i ~~ Parcel ~ Lot k Block # Property'L.ocation~ City, State - O Zip Code Phone Number ~ ~ ~'' ~~~ Section -~- S 7 ~ 7~ - ~ ~/ ~ircle9ue~ T 1~1. N; R Jf~o(~YJ Type of Building (check aU that apply) a4~~_ v ~1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name M Nttmbu ^ Public/Cotnmercial - Dtxcnbe Use ^ State Qwoed -Describe Use ^City ^V it ge ownship of III, Type of Permit: (Check only one box oo line A. om to line B if applicable) ~ ~ A' New Systun ^ Replacement System Tteatmen (ding Tank Replacement Only ^ Other odification to Existin tem List vin Permit ued 6. ^ Permit Renewal ^ Petmit Revision ^ Change of Permit Transfer to New Before Expiration Plumber er IV. T of POW'I'S S stem: Check all that 1 ,3 Non -Pressurized !n-Ground ^ Mound > 24 in. f suitable soil ^ ound < 24 in. of s ' ble soil ^ At-Grade ^ Single Pass Sand Filter Constructed Wetland ^ Pressurized In-Ground Holding Tank ^ Peat Filter ^ Aerobic eatment Uait ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Fiher hing hamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) V. Dis ersal/TreatmentAres Information: Design Flow (gpd) Design Soil Application Ra gpdsf) Dispersal Area Required (sf) Dispersal Area Propo S to evasion / • S7 g g~.9 _ __ gt:,as r-3 = 9Sas VI. Task Info Capacity in T I Number Manufacturer f~ Prefab Steel Fiber Pla ' Gallons Gal ns of Units W 1~~~~_~/ U~_ ~ "" Concrete Consducted ass New Existiag Tanks Tanks Septic or Holding Tank ~ / ~- Aerobic Treatment Unit Dosing Chamber ~- VII. Responsibility Statement- I, the unde gned, assume responsibility for Installation of the POWTS shows on the attached plans. PI 's Name (Print) Plum s S' afore MP PRS Number Business Phone Number ~o3.S 7 7is - ~~ -~~~ Plumber's Address (Street, City, State, Zi Code) II. Cozen /De artment Use Onl ~ Approved ^ Di roved Sanitary Permit Foe (includes Groundwater Date Issued lssui g Agent Signature (No Stamps) Surcharge Fee) ~ 2~ _ ~ ^ caner Give Denial O ~r ~D ~ IX. Co~$~i~Bllf~l easons for Disapproval 1 Septic tank, effluent filter and 'S~ ~~~ `uS ~ ~ dispersal cell must all ~e serviced /maintained -F+e,N, ~~, /r' B3 '~ ~¢- ~- as per management plan provided by plumber. 5~~~, ~~~_ ~U~ ~ ~~ '~' 2. All setback requirements must be maintained ~~ ~ ~~,,~,.,~ri as per applicable code/ordinances. fY~o~ `"-- "",,~{- 1 ,1,('~` 1 ~;., L \ ~~ `i 0 ~. ~, ~ ~ ~_ i~ ~ ~ ~~ 1~. 0~. yl ~ ~ ~ ~ ~~ ~~ ~ ~I 0 ' L ~, ~, ~I ~ ~ ~ ~~ ~ ~~ ~i ~ ~ ~~~i ~ ~ s~ ~ ~ a a ~ ~ ~ ~ ~ ~ ~ ~ ~~ ~~ ~ ~ ,~ ~. o ~ ~- ~~ ,~ ~~~ ~~~ J y ~ ~ .O n ti COPY } L ~~ \\ `/ O ~ ~ ~~ --~ ~ ~ °° r ~ ~~ -~ << ~ ~ ~~° ~~ ~ ~ ~ o ~'L ~ ` ,n ` ~ ~. t~ ~~ It ~ ~ `~, ~ ~ ~ ~~ ~ s~ 0 ~ ~ ~ ~ ~ ° ~ ~ ~ ~ ~ i ~ ~ M ~ ~ ~ a ~ ^y^' 1 r~ M V ~- ,c ,~ ~~ ~ ~~ ,\ ( .~` _ ~ t~ ~n a REC~ti~~~;~ .. , w~aaonsin Conrrrerne ~ ,~ SOiL EVALUATION REPORT Dlvisiar- of Safetyand ~- r ,~ „ ., A ~ i ~ 3 - ~ ~ «~ „c,oe,wmr a.omm oa. ,rns..~n...cgs ~xr s T: G R O /)C._. an a ,r2x„ h~ ~ alas Plan trot ~ ova tl ~ . but ~ ~_, tom. , at,a ~ to. ~`r ~C l0 ~U ~ . ,~ andtaroad. Please ~3nt a!1 lrtfiamaifon. ~ ~° Mr«~a+~lyd.asearor.aowbsnai~rc~w.also4t~ft~?- ~VW af- s£ SEGT• l PcopeAy/tar •~r-- 1C~/P/VDi(J ~-/'~}$1 Prr~pertylocation !~/~~ a Go~f.Ld /V~11 U4`s~,r4 ~~-r~ T'~~ N t2 ~` i~(o~}w Pm~pefty Owna<'s Maeng A+ddr+ess tat ~ 8bdc ~ Sibd Name or CSl~tlr EN N Code Phone Number' h~UDSo ~ w/. S yat to '11 S ~ 3 8!Q •'1'17 ^ ~Y ^ Y~Mage (,~ Town Nearest Road ff vOSo•J ~~x~~ ~~ n ~~ a ~c u5~.1~ Rsaidend~ r Nurrb~ of bedrooms 3 ' Code derived design tfoar rake y..SQ - oz~ cPD ©~ ^ PrrbNc a oomtneniai • oemaibe: Parent mkt _ S•Cl~ivn7y 0 U 7?.J~4-Sfl.~ mood t~atn e~,abfe ~/ t~ taeneral oormrerrts ~' "'z~l- T~-ST~O i S s v t r~q-~ %E~"o ie ~I•~/ i%vyieov,~~ ~oaU~r~ow~ Sys fem... - T3rnDi•~Fv.F~7Z 1 Ir~ • > q~ t=a qq ~ c~oina aurae erenr. . ~. ~ A *~ - ~'• Sal, Rafe Morison Oeplh Qarrrinant tisdort 4esafiptlom Texture 8tru~rse Corawatenoe Bat~ary /mots in. Mwaat Ou. Sz. Coat Cabr cr: Sz Sh. 'f~ '~ l o- bYR 3~ ---~ SL ~fsb~ ~ S w 3f- . 9 a • --- s o i ~-- Zs ~}- qs `~ s ~fY•'f ~v. sb • `~ ~~• ~ ^ ~ rV earirr$ ~ pb crourd surface etev. ~ ~ R .. DepU~ b. 7 ~ ~- Sol Reis ttorixon t Dorr~,oant R,edox Desaip~ian T,e~txe sAurhne Cane eamdery Roos ln. Munseif tlu. Sz. Coat. Cotor cr. St. Sh. 'QN~'I 'EfffR2 ~ - ~ ~o !/R 3l SL ifs s cv •3 . s • 9 l • zo ~ sYr2 ~ .ea 5~ / Gr ~ - . ~ ~fi i 61~ ~ 5 O, r z ~G/6~gRfr~=WVy•7V ~fdv ~.~~d ~~7.7 ~.7V'~, •7 V ~ J~m~. ~F+.w•wwMG=~w ~W .W S t ,~ ,~.,, , CiJ~ ~ws•~+o. q Oete Ewon Corrdrxled Tdr+phone. Number r ,r~._:_~.., . ors Private Sewage Consultants 2812 10th Ave. Spring Valley, WI 54767 '~ ~5fi ~o~s ~ ~~ ~ ~iN •s t~i2 TdT,9•G °tc ~~ ~ ZO . l02."7. Zo • D~a Zo • ioz•~ . yp • aa~ " ~ ya Tom- ~;~~ ~, ~'~Rtia,v T3,4-s ~ Z 3 ~ > to # Ga ~ ~ ~ p~ ~ O O 3 # `Pit cad su~oe efe~. ~b ' 3Z ~, ~ r fear ' ~~ ~_ Norm Depth Domaiant Redox Description Texbxe Structure Co-ce Boundary Roots saa OP Rate DVR in. Munsed Qu. Sz Conk Odor Cx. Sz Sh. •E1t#1 'Etflf2 2 ~ L ~ l..Z, l ~~ a ~~~ i uti ~ - . Z , 3 a7f- 9rs• ZSi A~- `Z6.2 ^ pr- s elev. tt_ ,., ~;..,, ~,... ~---.~ u# ° ~, Horizon Depth Opninant Redox Description TexWre Structure ~ -_ Boundary Roots Sod Rate GPO~tIt h Noosed tlu. Sz Coat. Color Gr. Sz Sh. 'Eil#t 'Eil~2 ^ p;+ Ground surface elev. R Dedh m 1'rr~no factor in # O Horiaort Depth Dominant Coto Reriaa Oesaiption _ in. OAarseN Qu Sz Corti. Color - - Sod u-e Shuctrue Came Boundary Roots t ' Gr. Sa Sh. +~I E]Auerrt >N = BODs' ~ `- ~0 ~-1~nd ?SS'30 ~ ~~`0 ~ • Effluent t12 = BOps < 30 trrgll. and TSS < 30 ~ The Department of Commerce is an equ~l opportunity service provider and employer. If you aced assistance to access services or need material in an alternate' format, please r•,ontsct flu departrrrctrt at 608-266-3151 or TTY 608-2(rt-g777. moot I. ~j o ~c ~! v`3 1` n ~- o ~ ~ 4 ~ ~ ~4 ~ \n ?o ~~, N 0 ~° ~ ~ ~- N % ,. -~ ~ ~. 0 0 c' _ ~ s N d ~ o d ~_ N -a ~~ w ~ ~ - ~ -.--:. W c~_ ~~~ a ~ ~ ~~~ ~ ~. NC~ ~~ ~~ ~~ ~ ~. ~~ ~ `o -~. ~s- m r 0 ~POWTS OWNER'S MANUA4 & MANAGEMENT PLAN Page ~ of 2 FILE INFORMATION Owner Permit # 3 / Jr- Z DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units ~, , ^ NA Estimated flow (average) Q al/day Design flow (peakl, (Estimated x 1.5) 0O gal/day Soil Application Rate ~ al/day/ftZ Standard Influent/Effluent Quality Monthly average* Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODE) 5220 mg/L ^ NA Total Suspended Solids (TSSI 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BOD61 530 mg/L Total Suspended Solids (TSSI 530 mg/L ^ NA Fecal Coliform (geometric mean) 5104 cfu/100m1 Maximum Effluent Particle Size Y8 in dia. ^ NA Other ^ NA *Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity SQ al ^ NA Septic Tank Manufacturer ~ ^ NA Effluent Filter Manufacturer ^ NA Effluent Filter Model ~ ~ © ^ NA Pump Tank Capacity a1 A Pump Tank Manufacturer A Pump Manufacturer NA Pump Model ~ C~+NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: ~ NA Dispersal Cell(sl ~In-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ^ month(s) (Maximum 3 years) earls) ^ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Y31 of tank volume ^ NA Inspect dispersal ceII1s) At least once every: ^ month(s) (Maximum 3 years) Ct~,year(s) ^ NA Clean effluent filter At least once every: O month(s) year(s) ^ NA Inspect pump, pump controls & alarm At least once every: ^ month(s) ^ year(s) ^ NA Flush laterals and pressure test At least once every: O ear( 1(s) Y ^ NA Other: At least once eve ry~ ^ month(s) ^ year(s) ^ NA Other: ^ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. 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 to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) 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 tank equals one-third (Y31 or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator 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 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. 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 or other chemicals that may impede the treatment process and/or damage the dispersal ceI11s1. If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the celllsl and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. 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 POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. 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 chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings seated. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • 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 in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ^ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ~~ T alua ' a o mg tank be ' e ai a ~R~i-ri18 Tf>~ ~D1~ A/ ~NS"T7Z(I~Dn! ^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name Phone 5^ _ POWTS MAINT ER Name Phone SEPTAGE SERVICING OPERATOR MPER) LOCAL REGULATORY AUTHORITY .Name `~~ Phone Name S ~. ( dU 2011(l~Cl Phone ~/S- 3g(~_ (0 (~ This document was drafted in compliance with chapter Comm 83.22(2)Ib)11)(d)&(f) and 83.54(1-, 121 & 131, Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer ,~'!~iP,rl~o/~ -' Mailing Address Property Address ~~ (Verification required from Flanning Deparnnent for new City/State ~fi/-~~ Parcel Identification Number LEGAL DESCRIPTION Property Location /~(.~ I/,, ~ U~ ~/,, Sec. ~ T(,~N-R~W, Town of Subdivision Co ~a~ ~~~ Lot # / 9' Certified Survey Map # ~ Volume ~ ;gage # Warranty Deed # ~.~CS ~ ~y~ Volume ~y~ 7_, Page # f ~Q Spec house ^ yes~no Lot Imes identifiablyyes ^ no SYSTEM MAINTENANCE Improper use and mraintenanceof your septic system could result is its premature failure to handle wastes. Proper maietesrance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you pet into the system can affect the function of the septic tank as a tneatmsrn stage is the waste disposal system. T~ PI'oP~Y-aa+~' agrees to submit to St Croix Zoning Department a certification form, signed by the owner and by a masterPlvmber,loP1~~, nstrictedp2umber or a Iicxnsed puaopcr verifying that (Z} the on site v~rastewaterdisposal system is in proper operating couditioa and/or (2) after inspection and pumping (if necessary), the septic tank is less than l/3 full of sledge. Uwe, the eadersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, heicin, as set by the Department of Commerce and the Deparhneat of Natural Resout+ces, State of Wises. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the throe year exp' 'on date. IG ATURE APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above y virtue of a warranty deed recorded in Register of Deeds O#I'ice. ~bi~3i~ IGNATURE OF LICANT DATE **"*** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ****** *'r Include with this application: a stamped warranty deed from the Register of Deeds offcce a copy of the certified survey map if reference is made in the warranty deed ~- Document Number VZ~g~ ~P• Igo STATE BAR OF WISCONSIN FORM 2- 2000 WARRANTY DEED THIS DEED, made between Kemon J. Bast, a married person, Grantor, and Kernon J. Bast and Donalda J. Speer-Bast, husband and wife, as Survivorship Marital Property, Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin: SEE ATTACHED EXHIBIT A Recording Area ?509#+0 KATHLEEN Ii'. itALSI3 REGISTER OF DEEDS ST, CROIX CO. , MII RECEIVED FOR RECORD 0i/07/2004 12;35PM fiARRANTY DEED EXEl1PT # 8M REC FEE: 13.00 'GRANS FEE: COPY FEE: CC FEE: PAGES: 2 Name and Return Address: Edina Realty Title, Inc. 400 S. Z"a St. -Suite 115 Exceptions to warranties: Hudson, WI 54016 Easements, restrictions and rights-of--way of record, if any. 412540 20-1027-40-000 & 30-000 &20-00 Parcel Identification Number (PIN) This is no homestead property. Dated this 6th day of January, 2004. * etnon J. Bast A UTH E NT ICATIQNa,(~1(~l'n gC1 Signature(s) Gh ~U~~~C 0 ~- authenticated this 6th day of Ja~~g TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 70b.06, Wis. Stats.) TH15 INS'!'KUMEN7 WAS DRAFTED $Y Edina Realty Title -Doug Berg 400 South Second Street #11 S, Hudson, VJI 54016 (Signatures may be authenticated or acknowledged. Both are not necessary.) 'Names of persons signing in any capacity must b<: typed or printed below their signature ACKNOWLEDGMENT STATE OF WISCONSIN ) ST. CROIX COUNTY. ) ss. Personally came before me this January 6, 2004 the above named Kernon J. Bast, a married person to me known to be the person(s) who executed the foregoing instrument and acknowled )the same. ~ ~ , __,__ tI.JC~ i(~~ i/ V *Cheri Brown Notary Public, State of Wisconsin My commission is permanent. (If not, state expiration date: 3/11/2007 ~~ WARRANt'Y DEED STATE BAR OF WCSCONSC.N FORM \0.2-2000 i' ~ zys~P ~z~ EXHIBIT A The NE '/, of the SE %, and the NW '/, of the SE %,, all in Section 15, Township 29 North, Range 13 West, St. Croix County, Wisconsin, EXCEPT a parcel described as: Beginning at the E '/. corner of said Section 15; thence South 00 degrees 47 minutes 33 seconds East, along the east line of the SE '/, of said Section, 407.27 feet; thence South 89 degrees 08 minutes 15 seconds West 535.46 feet; thence South 14 degrees 10 minutes 34 seconds West 93.31 feet to a point on a 80.00 radius curve, concave southwesterly, whose central angle measures 25 degrees 34 minutes 33 seconds, whose chord bears North 54 degrees 32 minutes 33.5 seconds West and measures 35.41 feet; thence northwesterly along the arc of said curve, 35.71 feet; thence North 14 degrees 10 minutes 34 seconds East 76.12 feet; thence North O1 degrees 07 minutes 26 seconds West 400.07 feet to the monumented south line of Certified Survey Map recorded in Volume t, page 21? at the St. Croix County Register of Deeds Office; thence North 88 degrees 51 minutes ] 3 seconds East, along said south line, 570.78 feet to the point of beginning. 9~5~ ; w d n Q • `. ®~ ~S ip (O~ ~i ~ i • .• .~ ~ w ~~ • • 2 ~ • ~,• ~•• ~~ ~, v D ~! 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