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HomeMy WebLinkAbout040-1279-50-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 579002 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. z ZZ f Permit Holder's Name: City Village Township Parcel Tax No: Dan & Lynette Nack TOWN OF TROY 040-1279-50-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: S tK6 ;e, 114) Z 75P G 1lfE 17.28.19.1567 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 4~ p Dosing _ Alt. BM Aeration G~ Bldg. Sewer YA149 Z.67 Holding SUHt Inlet g32.( s 6j S f4 y7 TANK SETBACK INFORMATION St/Ht Outlet 9 yZ 9Z~0• TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet / Y~ q3Y 9S v Y Septic , t Dt Bottom 10 cot 13f. fr Dosing Header/Man. f;K I >~v~ 4 3.t1 ~f 3~. Aeration Dist. Pipe 703Y.9s 3.10 Holding Bot. System 17T•f~ ; 36 1~ Final Grade 1 7 ZA/ PUMP/SIPHON INFORMATION 9/.' : Z•5- > '1S Manufacturer Demand St Cover -ICI 2- GPM N& s-F µ EC / Z Z • T I D. v7 Model Number t TDH Lift Friction Loss System Head TDH Ft Forcemain Lengtt, Dia.Z ~r Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS p -7-- t SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR T Type Of SOtuem / ! , )'10'), ' ! Cie, UNIT Model Number: L~_u DISTRIBUTION SYSTEM Header/Manifold Distribution UI x Hole Size ix Hole Spacing Vent to Air Intake 9 , t' n Pipe(s) y p 9 % S~ 2`r y Len th_~ Dia_ Length Dia Z S acin SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth of xx Seeded/Sodded xx Mulched Depth Over / Depth Over Fpsoil Bed/Trench Center C Bed/Trench Edges Yes 0 No Yes No COMMENTS: (Include code discrepenci persons present, etc.) Inspection #1: (prow) Inspection #2: 9_lb~lr Location: l~ GHt3EGr V~' ~~•t' D•T J 489 OMAHA RD 1.) Alt BM Description = ~_tJl~`:~ &40 ' 2.) Bldg sewer length= $D,~ et uM~ ~AISuQ& PROPER GovEQ a 5. Gi(L N41•SS144LE,rTF - amount of cover (cSfiw~aftd~y, PEA 12. 3f)~!(~. ~ ~ c~' aF Cov~. I~ 1 / 3 - 5~ of Y ft'.Fl• 30 -3y wrua-4) S.-T Plan revision Required? Yes [al No Q Use other side for additional information. IL-~ ~ / / SBD-6710 (R.3/97) ~ Date "Insepctor's Signature f Cert. No. bvK)r1A1& Fo(L 2E1~irro,v cK~N& /N TA~I/~ ~IL/ _I P &JW sna "OV- ,t ~14 lvE I)v s 17 ,t f Ic''L~ 3 1=~ Y J b 40 -Tor, r. LIT, :C-Ico p,y IVED Ma Cd ty I l us rvices Division C d d ashington Ave P g, N 2 3 1 a P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) q O'\ CROM COUNTY Madison, 1 53707-7162 ''N111TV DRUM 012h 9 Sanitary Permit Application State Transaction Number) V In accordance with SPS 38311(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit rJ~ bGC, is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address (if different than mailing address) ses in accordance with the Privacy law, s. 15.04(1 m), Stats. 1. Application Information -Please PrintAU Information irtlgT 0AP-11 R Kb Property Owner's e Parcel # DA1~ NAM, 046- IZ79- SD-cam Property Owner's Mailing Address Property Location / 57 9 O AINVk N Govt. Lot City, State Zip Code Phone Number E / t v ~/1 Section 1 ~ (circle one) T Ze N R)q Eore IL Type of Building (check all that apply) JL4 Lot C.I or 2 Family Dwelling - Number of Bedrooms Subdivision Name ❑ Pubiie/Comrnercial - Describe Use ( 01 1~ ( o (Block # tLc t3W / rrll- ❑State Owned - Describe Use h oo J(1 I Q b [I City of i i O u n f~ ! CSM Number ❑ Village of X / V C. CaTown of I-RO III. rmit: heck on one box on line A. Complete tie B if applicable) A. N in ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner N. Type of POWTS System/Component/Device: Check all that ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade Mound > 24 in. of suitable soil ound < of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ V. Dis rsabT'reatment Area Information: Design Flow (gpd) Design Soil Application Dispersal Area Required 00 Dispersal Area Pr sed (sf) System Elevation ~O~1D Rate(gpdst) I o , '60 7, 5 C /Z a o (oD4 0 9.32 ' VI. Tank Info Capar4ty in Gall Existing Total # Of Tacks Gallons Units Manufacturer d New Tanks / d A a, v~ is, C7 tl, Septic or Holding Tank I ZSr-> Dosing Chamber M VIL Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. PIsFN~e (Prin tier's umber Business Phone Number .:A/ ~Y- ZZ32 y2 7 ~s ~3ys~ Plumber's Address (Street, City, State, Zip Code) Coun apartment Use Only Approved ❑ v P empit Fee o~ Date ued Issuing Agent Sign r Givat for Denial $ ~ DL Conditiq Reasons for Disapproval Septic tank, affluent fllter and wQ~ dispersal cell must be_serviced. /maintained as per management plan provided by plumber. ~j~ Z All setback requirements must be maintaine$$ peC app A ns a r tba systeact eas tbsu :1aches size anP cr✓+'s~vSIID-6398 (R03/14) a~C e VVakl/~d (-1 'ej f 1l 6 Land USe perm. AxE~T DIVISION OF INDUSTRY SERVICES yti/ ro 10541 N RANCH ROAD o HAYWARD WI 54843 Contact Through Relay http://dsps.wi.gov/programs/industry-services www.wisconsin.gov ssrorScott Walker, Governor Dave Ross, Secretary June 17, 2015 CUST ID No. 223242 ATTN. POWTS Inspector JEFFERY V FOX ZONING OFFICE JEFF FOX CONTRACTING & SEPTIC INC ST CROIX COUNTY SPIA PO BOX 565 1101 CARMICHAEL RD DRESSER WI 54009 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 06/17/2017 Identification Numbers Transaction ID No. 2560221 SITE: Site ID No. 813798 Dan Nack Please refer to both identification numbers, 489 Omaha Rd above, in all correspondence with the agency. Town of Troy St Croix County NE 1/4, NE 1/4, S17, T28N, RI 9W FOR: Object Type: POWTS Component Manual Regulated Object ID No.: 1540930 Maintenance required; 600 GPD Flow rate; 42 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01/01, R. 10/12), Pressure Distribution Component Manual - Ver. 2.0, SBD-10706-P (N.01/01, R. 10/12), SSWMP Pub. 9.6; Effluent Filter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation; operation or maintenance of the POWTS. JEFFERY V FOX Page 2 6/17/2015 Sincerely, Fee Required $ 250.00 This Amount Will Be Invoiced. When You Receive That Invoice, Carl J Lippert Please Include a Copy With Your Wastewater Specialist, Division of Industry Services Payment Submittal. (715)634-5035, M-f 7AM - 12PM WiSMART code: 7633 carl.lippert@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm JEFFERY V FOX Page 2 6/17/2015 Sincerely,/ Fee Required $ 250.00 !O This Amount Will Be Invoiced. When You Receive That Invoice, Carl J Lippert Please Include a Copy With Your Wastewater Specialist, Division of Industry Services Payment Submittal. (715)6--14-5035, M-f 7AM - 12PM WiSMART code: 7633 carl.lippert@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Dan Nack Owner's Name: Dan Nack Owner's Address: 489 Omaha Road Hudson W154016 Legal Description: NE-NE-sec17-T28N-R19W Township: Troy County: ST Croix Subdivision Name: Eagle Bluff Lot Number: 35 Block Number: Parcel I.D. Number: 040-1279-50-0000 Plan Transaction No.: CONDITIOWIM .LY APB OXI .U Page 1 Index and title DEPT OF } F:-TY ATK Page 2 Data entry PROFESSION4L. SER' ! -S Page 3 Mound drawings Page 4 Lateral and dose tank DIVISION OF INDUSTRY SC:.RV CES Page 5 System maintenance specifications Page 6 Management and contingency pla Page 7 Pump curve and specifications Page 8 Plot Plan SEE CO , ESpONDENCE Page 9 Soil Evaluation Designer. Jeff Fox License Number. 223242 Date: 06/05/15 Phone Number: 715-755-2461 Signatur , v. 0 000, Designed Pursuant to the Mound Component Manual for POWTS Version 2.0 SBD-10691-P (N. 01/01, R. 11/12), and both SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST-SAS (01/81) and Pressure Distribution Component Manual Ver. 2.0 SBD-10706-P (N. 01/01, R. 10/12) Version 7.0 (R. 11/12) Page 1 of 9 Mound and Pressure Distribution Component Design Design Worksheet Site Information (R or C) It Residential or Commercial Design Note: Sand fill (D) calculations assume a 400.00 Estimated Wastewater Flow (gpd) Table 383-44-3 in-situ soil treatment for 1.50 Peaking Factor (e.g. 1.5 = 150%) fecal coliform of - 36 inches. 600.00 Design Flow (gpd) 4:00 Site Slope 931.501 Contour Line Elevation (ft) 42.001 Depth to Limiting Factor (in) 0.50 In-situ Soil Application Rate (gpd/fe) Distribution Cell Information 75.00 Dispersal Cell Length Along Contour (ft) = 8.00 Cell Width (ft) ~a__-.T 1.00 Dispersal Cell Design Loading Rate (gpd/ft) ~A1 Influent Wastewater Quality (1 or 2) Are the laterals the highest point in the distribution i Y Pressure Disribution Information network? Enter Y or N (C or E) E Center or End Manifold 4.00 Lateral Spacing (ft) If N above, enter the elevation ft) 2 Number of Laterals of the highest point. 0.156 Orifice Diameter (in) 2.50 Estimated Orifice Spacing (ft) = 10.00 fe/orifice 20 Forcemain Diameter (in) 0 Forcemain Length (ft) Does the forcemain drain back?_ Pump Tan k Elevation (ft) Enter Y or N 4.55 System Head (ft) x 1.3 9.79 Forcemain Drainback (gal) 11.83 Vertical Lift (ft) 67.32 5x Void Volume (gal) 1.33 Friction Loss (ft) 77.11 Minimum Dose Volume (gal) 0.00 In-line Filter Loss (ft) 32.31 System Demand (gpm) 17.72 Total Dynamic Head (ft) Lateral Diameter Selection Manifold Diameter Selection in. dia. options choice in. dia. options choice 0.75 m~ 1.25 x 1 1.00 1.50 x x 1.25 2.00 Iy 1.50 x x 3.00 2.00 x 3.00 x y - Gallonslinch Calculator (optional) Treatment Tank Information 1250.00 Total Tank Capacity (gal) 1250.00 Septic Tank Capacity (gal) 48.00 Total Working Liquid Depth (in) Wieser Manufacturer 26.04 gal/in (enter result in cell B49) Dose Tank Information Effluent Filter Information 750.00 Dose Tank Capacity (gal) folock Filter Manufacturer 18.12 Dose Tank Volume (gal/in) Lff~ 525 Filter Model Number W Iser ~ ]Manufacturer Project: Dan Nack Page 2 of 9 Mound Plan and Cross Section Views T 1/10 B J Observation Pipe p A W B L Mound Component Dimensions Down slop a toe extension made. A 8.00 ft E 9.84 in H 1.00 It K 7.36 ft B 75.00 ft F 9.50 in I 8.00 It L 89.71 ft D 6.00 in G 0.50 ft J 4.80 ft W 20.80 It 600.00 (ft) Dispersal Cell Area 1200.00 (ftz) Basal Area Available 8.00 (gpd/ft) Linear Loading Rate 7.50 (ft) 1/10 B Obs. Pipe Placement Mound Cross Section View Aggregate Dispersal Area Finished Grade 933.79 (ft) H ,r,r.,rrrr rrrrr,ffs G I F Dispersal Celt 932.50 (ft) Lateral Invert 932.00 (ft)--P- Dispersal Cell Elevation 931.50 (ft) Contour Elevation 4.0 % Site Slope Geotextile Fabric Cover Shading Key s- Dispersal Cell See lateral details on 0 Topsoil Cap = 1.5 ft Page 4 for number, size, 2 ,r,.r... Subsoil Cap 0 0 l o and spacing of laterals. ASTM C33 Sand t0 / T Laterals are equally ° typical Lateral F spaced from the Tilled Layer C.8 Uri distribution cell's © Aggregate o © centerline in the A distribution call (AxB). Project: Dan Nack Page 3 of 9 End Connection Lateral Layout Diagram Laterals centere over the rnensron ♦=Turn-upvWbellvetva, oraleanoutplug P <I AU laterals are Wentical Ir x-y~ Roles drilled on the bottom of the lateral y equaliq spaced Force main connection via tee of cross to manifold at anti point. Laterals Morcemain Sch 40 PVC per SRS Table 384.30-6 Number of Laterals 2 Orifice Diameter 0.156 in Lateral Diameter 1.50 in Orifice Spacing (X) 2.53 ft Lateral Length (P) 73.37 ft Orifices per Lateral 30 Lateral Spacing (S) 4.00 ft Orifice Density 10.00 fe/orifice Lateral Flow Rate 16.16 gpm Manifold Length 4.00 ft System Flow Rate 32.31 gpm Manifold Diameter 1.50 in Total Dynamic Head 17.72 ft Forcemain Velocity 3.30 ft/sec Dose Tank Information Locking cover with warning label and locking device and sealed watertight Electrical as per NEC 300 and SPS 316.300 WAC Disconnect 4 in. min. Tank component is properly vented E- Alternate outlet location Forcemain diameter Weiser Manufacturer_ 2 in. Capacityl 750.00 Gallons Volume 16.12 gal/inch A Weep hole or anti- Dimension Inches Gallons B siphon device A 31.74 511.69 B 2.00 32.24 C P~p off elewatiort (ft) C 4.78 77.11 920.67 D _8.00= 128.96 D Total 46.53 750.00 ♦Dose tank elevation (ft) Bedding under tank. 920.00 Alarm Manuafacuurer S_J_Electro - ! Note: Switches containing mercury Alarm Model Number ~ 101 'HW - may not be used in Pump Manufacturer Zoeller this system. Pump Model Number. B,RN 152 Pump Must Deliver 32.31 gpm at . 17.72 ft TDH Project: Dan Nack Page 4 of 9 Mound System Maintenance and Operation Specifications Service Provider's Name Jeff Fox Phone 717-755-2461 Phone 715-386-468Q POWTS Regulator's Name ST Croix_ System Flow and Load Parameters Design Flow - Peak 600 gpd Maximum Influent Particle Size 1/8 in Estimated Flow - Average 400 gpd Maximum BOD5 220 mg/L Septic Tank Capacity 1250 gal Maximum TSS 150 mg/L Soil Absorption Component Size 600 fe Maximum FOG 30 mg/L Type of Wastewater Domestic Maximum Fecal Coliform >10E4 cfu/100 mL Service Frequency Septic and Pump Tank Inspect and/or service once eve 3 ears Effluent Filter Should inspect and clean at least once eve 3 ears Pump and Controls Test once eve 3 ears Alarm Should test month) Pressure System Laterals should be flushed and pressure tested eve 1.5 ears Mound Inspect for ponding and seepage once ever wears Miscellaneous Construction and Materials Standards 1. Observation pipes are slotted and materials conform to Table SPS 384.30-1, have a watertight cap, and are secured in as shown in the mound component manual. 2. Dispersal cell aggregate conforms to SPS 384.30 (6)(i), Wis. Adm. Code. 3. All gravity and pressure piping materials conform to the requirements in SPS 384, Wis. Adm. Code. 4. Tillage of the basal area is accomplished with a mold board or chisel plow. 5. The mound structure and other disturbed areas will be seeded and mulched to prevent soil erosion and help reduce frost penetration. Lateral Tum-up Detail Finished Grade ' ' ' ' ' Threaded Cleanout 6-8" Diameter Lawn Plug or Ball Valve Sprinkler Valve Box Distribution ~y Long Sweep 90 or Two 45 Degree Bends Same Diameter as Lateral Project: Dan Nack Page 5 of 9 Mound System Management Plan Pursuant to SIRS 383.54, Wis. Adm. Code General This system shall be operated in accordance with SPS 382-84 Wis. Adm. Code, and shall maintained in accordance with its' component manuals [SOD-10691-P (N.01/01, R. 11/12), SSWMP Publication 9.6 (01/81), and Pressure Distribution Component Manual Ver. 2.0 SBD- 10706-P (N. 01/01, R. 10112)) and local or state rules pertaining to system maintenance and maintenance reporting. No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with SPS 383. 33, Wis. Adm. Code when the tanks are no longer used as POWTS components. Septic or pump 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 84nches in diameter shah be secured by an effective locking device to prevent accidental or unauthorized entry Into a tank or component. Septic Tank The septic tank shall be maintained by an Individual certified to service septic tanks under s. 281.48, Slats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code. The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by Inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should 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 filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent fiber alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of sludge and scum 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 a triennial 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. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such products are used they shah be approved for septic tank use by the Department of Commerce. Pump Tank The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary. Mound and Pressure Distribution System No trees or shrubs should be planted on the mound. Plantings may be made around the mound's perimeter, and the mound shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic (other than for vegetative maintenance) on the mound is not recommended since soil compaction may hinder aeration of the infiltrative surface within the mound and snow compaction in the winter will promote frost penetration, Cold weather installations (October-February) dictate that the mound be heavily mulched as protection from freezing. Influent quality into the mound system may not exceed 220 mg/L BOD6, 150 mg/L TSS, and 30 mg/L FOG for septic tank effluent or 30 mg/L BODS, 30 mglL TSS,10 mg/L FOG, and 104 cfu/100 mL for highly treated effluent. Influent flow may not exceed maximum design flow specified in the permit for this installation. The pressure distribution system Is provided with a flushing point at the end of each lateral, and it is recommended that each lateral be flushed of accumulated solids at least once every 18 months. When a pressure test is performed it should be compared to the initial test when the system was installed to determine If orifice clogging has occurred and if orifice cleaning is required to maintain equal distribution within the dispersal ceh. Observation pipes within the dispersal cell shah be checked for effluent ponding. Ponding levels shah be reported to the owner, and any levels above 6 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component(s) shall be immediately repaired or replaced with a component of the same or equal performance. If the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or replaced in its' present location by increasing basal area if toe leakage occurs or by removing biologically dogged absorption and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. See Page 5 of this plan for the name and telephone number of your local POWTS regulator and service provider. Pretreatmerrt Units The information and schedule of mananagement and maintenance for prebeatrrrent devices such as aerobic treatment units or disinfection units are attached as separate documents and are considered part of the overall management plan for this system. t"A OW • ll~i pot MOM EMLM AND PUMP oms t , t5t ~2 i53 O'- Own Fad VMS ,A j r 40 ~ i 6 20 lIEI ~ ~ - . G~ti31tt3 ° raw t~gt ttt ar°'d°r ~ i II+ s cotaL~~ - s s~ a wi.. s 4 sTP Mrwi t i >z w~• l w t maor 1 2. gnaw NOOSE mw 4 5 Ica c3 JOA 55D ,f .44 P~ f-I ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer Dan and Lynette Nack Mailing Address 1013 Cardinal Circle, Hudson, WI 54016 Property Addre s 489 Omaha Road, Hudson, WI 54016 51 (Verification required from Planning & Zoning Department for new construction.) City/State Hudson , W l Parcel Identification Number 040- LEGAL DESCRIPTION ~D 1 Property Location ~ 1/4 , ~V G '/4 , Sec. J1, T J,~> N R ` W, Town of IL Subdivision Plat: E Me ~ LV F F- , Lot # 35 Certified Survey Map # , Volume , Page # Warranty Deed # (before 2007)Volume , Page # Spec house ❑yes[3no Lot lines identifiable ❑yesE] no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning 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 operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/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 Safety And Professional Services 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 Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue o warranty deed recorded in Register of Deeds Office. of bedr oms 4 06/22/15 SIGNA OF APPLICANT(S) DATE jNu; ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) "A 8 . 1% AC4 dr 1.4 70 ACRES t • 64,045 S.E. t4 r 411: i~Jt{ go pi w 1 ~ .o C ya a - 9. 20- ---T 4s1~ C8 ' 'C67 14.14' , t 1.251 w 3 38 33 030 ACRE w ev 34 4,888 S.F. 37 r 1 t'? t i t t.*~ -a t Is rn --z 'd~ 35 36 /1.01 Sf 3 AC f 46,29 d tq 41.000 5•72 ACRES x289 S.F. t . 11 SF. m AN 1 ~9 t + 13 Od-, S 179.81 r 176.700 13 of X84. ' 3 '7 O TLOT 5 10.538 ACMES 489,904 S.F. L 1i SOUTH LINE OF THE NE 1 J4 OF THE NE 114 n 1&214&1 UNRA T`T"p L ND T ~ EASE! ST ONE HUNDREDTH OF A FOOT AND ALL AM.11LAR SAS AID! COA#{JTEp TO THE VALUES SHOW. 1 COUNTY, AND TONNSH I P LAWS r RULES AND 5 TO PARCEL. ETC.). BEFORE PURCHASING OR ZONING OFFICE AND THE APPROPR I ATE TOWN BOARD Tyre am no objections to this plat with tespec Secs. 2315.1 S, 236.16, 236.20 and 236.21 (1)'m We !:fate SHERIFF'S DEED ON FORECLOSURE -44 S7- P152014 WHEREAS, pursuant to a Judgment of Foreclosure and Sale rendered in vc the Circuit Court of St. Croix County, Wisconsin, on June 3, 2014, in an action r'pi" .S between: BMO Harris Bank, N.A. as successor to M&I Marshall & Ilsley Bank, Plaintiff, and Thomas A. Stewart and Gail A. Stewart, Defendants, as Case No. 14-CV-158, and, after due advertisement, the subject premises hereinafter described were sold on September 9, 2014, to Lynette A. Nack, for the sum of $51,000.00; and WHEREAS, the said Lynette A. Nack is now entitled to a conveyance RETURN TO: according to law, ILA& Tax Key No. 040-1279-50-000 NOW, THEREFORE, the undersigned, in consideration of the payment of $51,000.00, conveys to Lynette A. Nack, the following tract of land in St. Croix County, Wisconsin: Lot 35, Plat of Eagle Bluff, in the Town of Troy, St. Croix County, Wisconsin. DATED this day of d 12014. John hilts Sheri A of St. Croix County State of Wisconsin ) ss. St. Croix County r ) On this l r da of, y kn4ba~ 2014, before me came John A. Shilts, known to be the individual and officer described in, and who e ecuted, the above conveyance, and acknowledged that he executed the same as such Sheriff, for the uses and purposes therein set forth. Notary Public, St roix County THIS INSTRUMENT DRAFTED BY: State of Wisconsin ~y Linnea A. DeBraal My Commission: a f d gry"MaftE3~ xowy PUNW 0*ft0fW1qWWin St. Croix County 1005129 Page 2 of 2 ©lain's Drawing Room, LLC 201 5 i y.3 I I I I _v spay ~_ay z~° rn W l rn rn ZO o ~ f ~ ~ _ aco m Ili ~o I m m , Q~ , C E rn m a< L E~ I rn TM > > 10 L I O rn_ II i f I m LJJ it OrnO I- ( - ~ I I !I fI I ~I o D ~ Nib o0 ° o --n~ o ° oz cn o ~z I I I ~ I I I U ~ I I 0 - z ~ ; ~ d5 a~noenc.~rca: ~ s` 5`6 lain's Drawing Room.,,.. 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I I N I ~m 1 J I zl I J// I I I Z ~1 00 i 7a -TI F_U 0 0 Z Z U) 0 n _ 0 Z A ~ "o d5 ~ 2fjloencE roa: A 4 `s lain's Drawing Room LL. PAn & LY/IETTE RACK HART A 19 ~O 489 OMAHA ROAR HUD/0/1, WI 54016 c p low l Wisconsin yepartment of Commerce SOIL EVALUATION REPORT Page of 3 Divia-ion of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code ST• L° lZ 0 `X Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, 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. a5r- SD , Please print all infonnation. viewed Date ---L Perso information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).~ T Property Owner r Property Location CU~`T1N ~b12 /Por2~noN Gey6Ut f-IF 1/4 1V 1/4 S T Z~ N R E(or Owners Mailing Address Lot # Block # Subd. Name or Z;SW 1 vg oo r°r8 Z0EaKi S 1mloFT ME: , S U "ns )'3 0 3 S - hF?PvG La '8L,VFf city State Zip Code Phone Number ❑ City ❑ Village ® Town . Nearest Road 13L.P~lYj r Nj 554Y9 ( 6I) -15-7 --1566 zol OMB R lzr0 © New Construction Use: E Residential / Number of bedrooms Code derived design flow rate b 0 GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material L0 S 0 V FVZ_ elevation if applicable N ft. General comments and recommendations. P~( S k,~ , ~LgT~ $ V , BLS W b 7 S , o t= RECEIVED Boring # ❑ Boring 7 1) U 1 y .S/ g Ground surface elev. O•,~ ~T_ C, 01 SZ Cl3 fL, ~te,~imiting f~~r in. Pit Soil Application Rate Horizon Depth Dominant Color Redox Description ,-;Texture tructur sistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color / ' Q. :Sala. 'Eff#1 'Eff#2 o- t $ ti p`1P- It Z - St 0_L13 - s t.3 Z 1~- 10 li 31Z si) ZvdS6k • tw - • s 3 36-~.~ 1o`-tR Y~6 si I 1~°-S~k eS - • 2- -3 4$=6~ ~•SyR31y - 1 s 0S 9 e - .o .O F 71 Boring # ❑ Boring ® Pit Ground surface elev. C1 3 ft. Depth to limiting factor u S in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munseil Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 o-1:Z l0wa_ 31 Z si l Z:`Fsb`rt wi r- e , S Z-- IZ- `?2 316 - s i ! Z»~S~k w)'~•' ~ 3)- S ~.SyQ31y - - S 1 1 ~sbk m~ ~S - • ~ -b S~ u3 -6b .S `t.2 3 /5! , O hi , m v fi., S) w n.H t unrtyA6 .O In rh t,fl_1 s ~L.~o eo>,r~,,.,• s w~-l~-~y c-~-l i-~v s 1 • 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) gnatu _ 3 1 S - CST Number ncaL!:~2~ I - 1. 00 ~ as 220254 Art ur L.-Wegerer Address E e g e r Date Telephone Number er Soil Testing Design Service 421 N. Main St. River Falls, WI 54022 l ~ _ S -O 715-425-0165 MM" ' t Property Owner a"11) t-W*,L -bN Parcel ID # PE)QbJti1(:; Page' of Z Boring # ❑ Boring Fil ❑ Pit Ground surface elev. X132 • ft. Depth to limiting factor 4 Z In. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 ~ 0 -1 Z 10`1.2 3!Z - gl ~ Z~sbk vn~ Z°„t,~ . S Z L'Z-Z9 tO`2R 3!6 - si l 3 ~sbk A SNn CS - •S 3 ~lZ ~-tlz y/b C3 6t r s h es - - -2- 0 3 y BIZ-yg t~~trzy/ flF-~Syrz S!8 si I rn, A Z~ - .p •O s ' -b~ ! o ~c~~~6 l s o S9 -v ..0. S t?t12 Ly <2gML?Q,vr S ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor In. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 F-1 Boring # ❑ Boring El pit Ground surface elev. ft. Depth to limiting factor In. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 ' Effluent #1 = BOD6 > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD6 < 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. SBD4330 (86(00) r • Property Owner CJQI~IJ Colt- Parcel ID # pEh-~pl NG; Page Z of Boring # ❑ Boring ® Pit Ground surface elev. ~13Z • ft. Depth to limiting factor 4 Z in. Soil Application Rate Horizon . Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 o-1Z IiJ`1.2 3/z - si i Z'Fsbk w)~F►- - , s Z 12-z9 ioLilz 3/6 - sit 3~sbk r~ sl, CS - ~S 3 2-9-qZ 2 VJb - S,1 es bk ,h es - - z . 3 1F~Sy2 S 48 -6:S IQ~ 1~7L~C~b i s 0 SC5 S iz Ly C-r pr^A> S Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor In. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 Effluent #1 = BODE > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BODa < 30 mg/L and TSS c 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. 580.8330 (RAW) ' of PLAN Page f 3 Scale P=q,) ' U,~-r 3b Liz, T- 3s -OtIN Ik, J b~S1ti~~Z aiZ t~ C,~a s~ 0004L I-,$ -715-425-0165 220.254 o0_31S- 3S CST Signature Date Telephone No. CST No. Job NO.