HomeMy WebLinkAbout020-1060-10-000,Wisconsin~Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township
Severson, Dennis Hudson, Town of
CST BM Elev: Insp. BM Elev~ BM Description:
't/~.~I 1~'~iH ~ ~fr~ln
TANK INFORMATION
TYPE MANUFACTURER CAPACITY
Septic ` `~ ~ ~ L ~•~
~/ 7 ~D O
Dosing ~eGks 2 6 !
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD
Sreo 2 ~ ` >2~"'` 5' 23
Aeration
Holding
~.
PUMP/SIPHON INFORMATION
Manufacturer Demand
GPM
Model Number
TDH Lift Friction oss System H TDH
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
ELEVATION DATA
county: St. Croix
Sanitary Permit No:
514882 0
State Plan ID No:
Parcel Tax No:
020-1060-10-000
Section/Town/Range/Map No:
22.29.19.2280
STATION BS HI FS ELEV.
Benchmark ~ , ` ~~Z.~6 i 4 B
Alt. BM
2 6~ Cn.cJ ~ 3. ~Y ee
I -i
Bldg. Sewer 6•S ~ {~ l •,Y3
St/Ht Inlet 6,¢~ ~ a • ~
SUHt Outlet
ILI ~~~ ~ !~ ~S, ~3
Dt Inlet
Dt Bottom
Header/Man. •7, '~;!
Dist. Pipe 7,'~~•
7,4?• ~
.~J
Bot. System t.1(
4'. ~~, D~
~y. oS
Final Grade 3~I~t f '~~ S" 2
st ~Gv~r 3.! ~ 9~,Yz
BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 4 U~~
7 z ~~ -- ---
SETBACK
INFORMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING
CHAMBER OR Manufa~;ur .+~
~/r 71 ~~'~~ Q"1"<<(„ yN'
Type Of System: ~
v
Ll'1Vt'g4iM1 +q t 3s O t
' ~ So
r UNIT
Model Number:
DISTRIBUTION SYSTEM
sk
Z Z GMq~~t,~ [~ Y~!
Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
~+
~+` ..--
~
~
L ~ ~ ~^ ~ ~ ~~
Length
Dia ength
Dia
Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over ~f ~
d/T
h C
t
~ /
B
5 Depth Over
d/Trench Ed
B
es ~-` xx Depth of xx Seeded/Sodded
To
il ~--
s xx Mulched
renc
en
er
e
, g
e p
o
Yes ~ No Yes ~ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: dy / ~ 1 /~~ Inspection #2: / /_
Location: 656 Badlands R~~Hudson, WI 54016 (SW 1/4 SE 1/4 22 T29N R19W) NA Lot Parcel No: 22.29.19.2280
~___/ f
1.) Alt BM Description = ~ ~ L~Cr E ` ,~ G+~Kl~ '7 (~i-~ S t (d (,`f
2.) Bldg sewer length = ~~ ` ,
-amount of cover = '~ ~ 7
Plan revision Required? ~ Yes [14 No ~6~2 ~ 0 T 'I,
Use other side for additional information. ~ - ___
Date
SBD-6710 (R.3/97)
e, ~
Cert. No.
Safety and Buildings ion
201 W
W C
G
`
~ ~ .
ashington Ave., . B ~
`G~
iscons~in Madison, WI 53707 - 71 62 Sanitary Permit Number (to be filled in by Co )
Department of Commerce (608) 266-315 511 a $ -7
U L.~
Sanitary Permit Application State Plan I.D. umber
in accord with Comm 83.21, Wis. Adm. Code, personal information you provide
may be used for secondary purposes Privacy Law, s15.04(I)(m tea..
~- Project Address (ifdi(fcrent than mailing addras)
I. Application Information -Please Print All Information
i ~ ~~ ~~~ ~f P
/y
Property Owner's Name
! arccl q Lot # Block ><
F~"
a~Nr<~
/~ t .t2I/ev ~~ M d 20 - lt16c~ -- ~ d - o~
Property Owner's Mailing Address s-(,O~,NG~F
Z
~
~ ~
~ Property Location ~ ~Z~ G
•
~
~~~;
~ ~ fAl
S ~ '
Z
City, State Zip Code
/~
y one Num
be
r Y.,
/., Section
~~ ~! p
v ~
`
7~ _ ~(ov _ u, 7b
/ T Z4 (oirol~ o)
N
R~~
W~
[[. Type of Building (check all that apply) ;
or
Z `i MJ~-p ~
^ I or 2 Family Dwelling -Number of Bedrooms `~`'''~.''~~+**~~`."''' Subdivision Namc CSM Number
^ Public/Commercial -Describe Use
^ State Owned -Describe Use ~ /~ ~- l ^City_^viua`gc (,Township of
l~C.a!
III. Type of Permit: (Check only one box on line A. Co plete line B if applicable)
A.
^ New System
Replacement System
^ TrcatmcnVHolding Tank Replacement Only
^ Other Modification to Existing System
B• ^ Permit Rrnewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Numbcr and Datc Issued
Before Expiration Plumber Owner -~' 1
1~~' ~ `--f v~
[V. T e of POWTS S stem: Check all that a l ~ ` i
Ntm=_Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^
Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Fi{tcr ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^
Recirculating Synthetic Media Filter ^ Leaching Chamber ^ Drip Linc ^ Gravel-less Pipe ( p )
^ Other ex lain
V, Dis ersaUTreatment Area Information:
Design Flow (gpd) Design Soil Application tc(gpdsf)
~~ ~ Dispersal Arca Rcquir (sf)
~ Dispersal Arca Proposed (
~ System Elevation
3~a . y28 . ti Si . ~ ` ~ ~ r ~
VI. Tank Info Capacity in Total Number Manufac[urer Prefab Site Stccl Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing ~ / ~ ~
may
~
~
Tanks
Tanks ,
s VJe
I
Septic or Holding Tank (~p~-)
C7v- D
~t. C
Aerobic Trea[mem Unit
I
~°Tr+~'cr 2 f l
1
t
e L
VII. Responsibility Statement- I, the undersigned, assume responsibility fo inst Ilation of the POWTS shown on the attached plans.
Plum 's Namc (Print) PI bcr's Signature MP/MPRS Number
- Business Phone Number
~,
Plumber' Addrcss (Strut, City, State, Zip Codc)
3 f 2 2~ ~~ ~J~~ ~s~ rs,~ ~ z
VIII. Coun /De artment Use Onl
Approved ^ Disapp ved Sanitary Permit Fec (includes Groundwater Dat Issu Issui Agent Sign rc S
^ Surcharge Fec)
~~ ` lriY-7
5 ~ ~$
Owner a eason r Denial
' IX. Conditions of Approval/Reasons for Disapproval ~ ~ b~
sd-~w~.. an.
SYSTEM OWNER: 3' Ei~~~;
~
1. Septic tank, efftulnt fNter and J
dispersal cetl must all be s rv ces /maintained Q..~j ~ Gp
as per management plan provided by plumber.
2. AA setback requirements must be maintained ) ~
~
~
Gt,~ fro t~t,COc,~
lit~ble ~ / ordirgafces
(bfJ 1 ~ /
Lf 1 P/u
as
at a
~
.
pp
p
w~
•vu•p,~,v v,.,~. t~~ ~~K ~.uunry omyr ror me system oo paper nor teas roan aut s r r inches to siu
ti
SBD-6398 (R. 01/03)
' TIMM EXCAVATING
Route 1 Box 192
WILSON, WISCONSIN 54027
(715) 772-3214
roe ~~~ s9 d S .~-~~L~ SG'~1
SHEET NO. OF
CAICUlATEO BYY ~ -n DATE- ~- Z g~ G~'
CHECKED BY gg~" DATE
ere c , ~~ '- ^~.rf~'
roe ~-~~ `'/ <6 ~.o{/~y S~
TIMM EXCAVATING
Route 1 Box 192
WILSON, WISCONSIN 54027
(71~ 3~ ~,
SHEET NO. OF
~-
CALCULATED BY ~ ~ ~n'H" DATE ~^ Z ~~ ~~
CHECKED BY DATE
/Ol ~ -`aI
SCALE (~
'~
Re'
y
Z
1 dad ~
PRODUCT 205-1 ~ Inc., Groton, Mess. 01471. To Order PHONE TOLL FREE 1-800.225fi380
`~ RECEIVF~g
Wisconsin Department of Com erce IL E ALUATION REPORT
Division of Safety and Buildin In accordan with Comm 85, Wis. Adm. Code
Page 1 of 3
'~ ~ ZOU~
Attach complete site Ian onr not less than 8 % x 1 t ches in size. Plan must County
St. CroiX
Include but not limit to: vertical and hog~~'f~erenc point (BM), direction and
hd BM r erenced to nearest road.
Percent slope
scale dime~Tor~ e ! Parcel LD. 020-1 O6 1 n-nnn
,
~
[)NItyG G ormation
~
-t
~ Revi d by Date
~ ~~
Personal information you provide may be
ed
for second pu (
us Law, s. 15.04 (I) (m))
Property Owner Property Location
Leon Kearns Govt. Lot SW '/a SE '/, s 22 T 9 N R 19 w
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
656 Badlands Road
City State Zip Code Phone ^ C;ty ^ Village ®TOWn Nearest Road
Hudson WT 54016 715-386-3443 Hudson Badlands
^ New Construction Use: ®Residential /Number of Bedrooms~_ Code derived design flow rate 300 GPD
® Replacement ~ Public or Commercial -Describe:
Parent Material Loess over Outwash
General comments and recommendations:
Flood Plain elevation if applicable N/A ft.
1 I Boring # ®pit a Ground Surface Elevation 99.6 ft.
Depth to Limiting factor > 1 OR in.
Soil li ti n Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P D/ft~
in. Munsell u. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 0-12 10YR3/2 - LS 2-f-bk Mfr Gs 2f 0.7 1.6
2A t2-eaFiLL 10YR3/2 - SL 2-m-bk Mfr Ab 1f 0.6 1.0
2g 12~34FILL 10YR3/4 - SL 2-CO-bk Mfr Ab 1f 0.6 1.0
2C 12~aFILL 10YR3/2 7.5YR3/3 c-1-f SL 2-m-bk Mfr Cs 1f 0.6 1.0
3 44-106 10YR5/4 - / S 0-sg ml - - 0.7 1.6
t
~t `~
^ Boring v ~
2 Boring # 0pit Ground Surface Elevation 99.4 ft. Depth to Limiting factor > 1 OR in.
Soil li tion Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P Dlftz
in. M n II . Sz. Con . C for Gr. Sz. Sh. 'Eff#1 'Eff#2
1 0-18 10YR3/2 - LS 1-m-bk Mfr Gs 2f 0.7 1.6
2 18-33 10YR3/1 - SL 2-f-bk Mfr Gs 1f 0.6 1.0
3 33-38 10YR3/3 - S 0-sg MI Gs 1f 0.7 1.6
4 38-105 10YR5/4 - S 0-sg ml - - 0.7 1.6
'redo top
and bolt of e n
01~
~
Z~ ~
' L"ff1UCRt # t = tSVLS > SU ~ LLU mg/L ana t JJ > SU ~ 1 ~U mg/L ' hIIglent rfL = ISVLS ~ ~V mg/L anU 1 JJ ~ ~V mgir.
CST Name (Please Print) Signature CST Number
Mark Iverson o~L 46672
Address Date Evaluation Conducted Telephone Number
P.O. Box 155 Hammond, WI 54015 Mav 27.2008 715-796-5664
Property Owner
Parcel ID# 020-1060-10-000
Page 2 of 3
^ Boring
3 Boring # 0pit Ground Surface Elevation 99.6 ft. Depth to Limiting factor > 1 U8 in.
Soil li ti n R to
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fP
in. Munsell u. Sz. C nt. Color Gr. Sz. Sh. •Eff~k1 "Eff#2
1 0-20 10YR3/2 - SL 2-m-bk Mfr Gs 3f 0.6 1.0
2 20-43 10YR3/1 - SiL 2-m-bk Mfr Gs 1f 0.6 0.8
3 43-53 10YR3/4 - SIL 2-m-bk Mfr Gs - 0.6 0.8
4 53-59 10YR4/4 - SIL 1-m-bk Mfr Cs - 0.4 0.6
5 59-108 10YR5/4 - S 0-sg mi - - 0.7 1.6
I'
~1 1 '
^ Boring ''~
4 Boring # ®pit Ground Surface Elevation ft. Depth to Limiting factor in.
oil i lion Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP
in. Munsell u. Sz. Cont. Color Gr. Sa. h. *EIf#1 •Eff#2
Boring # ^ Boring
®Pit Ground Surface Elevation ft. Depth to Limiting factor in.
it li lion Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft2
in. M n II z. o olor Gr. Sz. Sh. 'EtT#t1 *Eff#2
~` Effluent #1 = BOD;> 30 _<220 mg/L and TSS > 30 <_ l50 mg/L • Effluent #2 = BODS <_ 30 mg/L and TSS <_ 30 mg/L
Leon Kearns
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.
Page 3 of 3
Site Location
r
Y
0 ft. 24 ft. 40 ft. 80 ft.
~^,
-- N
BM# & Descri tion
Elevation =Bench Mark ~, =Boring Location & Elevation
Owner: Leon Kearrns Site Information: Completed By: Mark Iverson, PSS #197
656 Badlands Rd. SW1/4, SE1/4, S22, T29N, R19W 680 Larcom Street
Hudson, WI 54016 Town of Hudson Hammond, WI 54015
St. Croix County 715-796-5664
Phone: 715-386-3443 CST# 46672
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer ~ ~-y 15 ~.¢~/~S~Y1
Mailing Address ~~ `~ ~~~~
Property Address (v~~ ~u,c~[ ~~~ ~c~
(Verification required from Planning & Zoning Department for new construction.)
City/State ~~~=Q ~,~ Parcel Identification Number Q~ V ld ~ -- I~ " ~ °~
LEGAL DESCRIPTION
Property Location ~1~ '/4 , ~ ~ '/4 ,Sec. 2Z , T Z~ N R ~~ W, Town of
Subdivision
Certified Survey Map #
Lot #
Volume ,Page #
Warranty Deed # ~ 7 ~ JP2 ~-- ,Volume ,Page #
Spec house yes no
Lot lines identifiable es 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 §Comm. 83.52(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.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin.
Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning &
Zoning Department within 30 days of the three year expiration date.
Uwe 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, by virtue of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms ~~
i'
SIGNATURE OF APPLICANT(S)
/~~/~
DATE
***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. 08/05)
State Bar of Wisconsin Form 1-2003
WARRANTY DEED
Document Number ~~ Document Name
THIS DEED, made between Leon C. Kearns and Arlette M. Kearns, husband and
wife
("Grantor," whether one or more),
and Dennis F. Severson and Cynthia A. Severson, husband and wife
("Grantee," whether one or more).
Grantor, for a valuable consideration, conveys 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 addendum):
SEE ATTACHED EXHIBIT A
1 llilil lilll I ill Illli lilll IIIII IIII 111111 1111 Ilil
~ 8 4 9 2 2 2
87492
KATHLEEN H, WALSH
REGISTER OF DEEDS
ST. CROIX CO., WI
RECEIVED FOR RECORD
05/16/2008 10:00AM
WARRANTY DEED
EKENPT t
REC FEE: 13.00
TRANS FEE: 315.00
PAGES: 2
Recording Area
Name and Return Address
River Va11ey Abstract &'Pit{e, Inc.
1200 Hosford Street, Suite 201
Hudson, W154016
Fife q 2698694
020-1060-10-000
Parcel Identification Number (PIN)
This is homestead property.
(isl (is not)
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except:
Easements, restrictions and rights-of--way of record, if any.
Dated ~ I ~~ ~ G' J o
r.
*
Signature(s)
authenticated on
*
AUTHENTICATION
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by Wis. Stat. § 706.06}
THIS INSTRUMENT DRAFTED 13Y:
ACKNOWLEDGMENT
STATE OF WISCONSIN )
ss.
St. Croix COUNTY )
i
Personally came before me on ~ ~ < ~ y ZG~)
the above-named Leon C. Kearns and A ette M. Kearns
to me known to be the person(s,~.l~6-~'tetau~~d5>;1~'bforegoing
g ~'r'~-~ ~ ,;
instrument and acknowled a arY,ke~
VV
* ~i Gz1 l/l> i
Attorney Doug Berg Notary Public, State of Wiscon$~n '
1200 Hosford Street, Suite 201 Hudson, WI 54016 My Commission (is permanent} ~~
,-y„•. ve
(Signatures may be authenticated or acknowledged. Both are not necessar~f+~~` Oi~ '~e1~C v~'~
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE t'~BA~,t1^I~ENTIFIED.
WARRANTY DEED rcJ 2003 STATE BAR OF WISCONSIN FORM NO. 1-2003
• Type name below signatures.
1 of 2
(SEAL)
Leon C. Kearns
(SEAL) (SEAL)
* r e M. Kearns
• F•XHIBTT A ~ .
South 180 feet of the West 6 rods of the East 67 rods of the SW 1/4 of SE 1/4 of Section 22, Township 29 North,
Range 19 West, St. Croix County, Wisconsin.
TOGETHER WITH that certain parcel of laad located in the Southwest 1/4 of the Southeast 1/4 of Section 22,
Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin, more fully described as
follows: Commencing at the South 1/4 corner of said Section 22, thence S 89 degrees 57'53"E (assumed bearing on
the South line of the Southeast 1/4 of said Section 22) a distance of 294.92' to the Point of Beginning of the parcel
to be herein described; thence N00 degrees 28'38"W 180,00'; thence S 89 degrees ST53"E 9.65'; thence S 00
degrees 25'22"E 180.00'; thence N 89 degrees ST53"W 9.48' to the Point of Beginning.
LESS AND EXCEPT that certain pazcel of land located in the Southwest 1/4 of the Southeast 1/4 of Section 22,
Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin, more fully described as
follows: Commencing at the South 1/4 corner of said Section 22, thence S 89 degrees ST53"E (assumed beazing on
the South line of the Southeast 1/4 of said Section 22) a distance of 195.92' to the Point of Beginning of the parcel
to be herein described; thence N (?0 degrees 28'38"W 180.00'; thence S 89 degrees ST53"E 9.65'; thence S 00
degrees 25'22"E 180.00'; thence N 89 degrees 57'53"W 9.48' to the Point of Beginning.
TOGETHER WITH an easement for purposes in ingress and egress and for use of water and well rights as set
forth in a certain Warranty Deed dated May 18,1957 and recorded May 20,1957 in Book 339, Page 206, in the
office of the Register of Deeds for St. Croix County, Wisconsin.
2of2