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Wisconsin Department of Commerce pRiVATE SEWAGE SYSTEM
Safety and Buildings Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)).
Permit Holder's Name: I ^ City ^ Village, ^ T,~wn of_,
CST BM ~ eve: ,at I Insp. i M~EIevO.:I I BM De ~. ~Q SIO~tY I
TANK INFORMATION
TYPE MANUFACTURER CAPACITY
Septic (~ ,~S ~ a'~-0
Aeration
Holding
TANK SETBACK INFORMA
TANK TO P/ L WELL BLDG. vent to
Air Intake ROAD
Septic -~c,J ~~ ~ ~ S~ r r .----. NA
-~ ` ~ S•'U ~ NA
Aeration NA
Holding
PUMP /SIPHON INFORMATION
Manufac er Demand
Model Number GPM
TDH Lift Lriction SYS TDH Ft
F emain Length Dia. Fi Dist. To well
County
St. Croix
Sanitar~~r~jt No.:
State Plan ID No.:
Parcel Tax No
020-1060-20-100
ATION DATA ~ ~ 2 9 ' ~ 9 J ZZg ~
STATION BS HI FS ELEV.
Benchmark ~ , ~ I o I .'~ (b'O. c~
Alt. BM ~ A
Bldg. Sewer ~ ~.
St/Ht Inlet lo• 9 r~r
H
t
t
Outl e
St /
D. z~ r
/. S /
~
~
~ ~
~
,Q ~ \
l'~tTBAfitG171 ~ ~/-Co ( 2 ~ / ~
Header /Man. l D• ~ Qo. ~ ~
Dist. Pipe l l • ev '
9p. ~~
Bot. System ~Z r3 6 8 `? • `~~
Final Grade ~(o S~ ~ , (D'
St cover
SOIL ABSORPTION SYSTEM ~ 1 \ ~ fJa „_ L„ ~ n b _ ~ ~_.,, ~
T ENC Width r Leng No f Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIME ~ ~ }~ DIMEN 1 N
SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING Manufac,ty rer^ ~_n ~
~
~ td-
~
SETBACK -,
l
`~'
'
INFORMATION TypeO
~
~~~
6
r i
~ ~' S
~ CHAMBER
OR UNIT Mo a Num er:
{
~:
System:
~ , ,
3 ~ -
- ~,
DISTRIBUTION SYSTEM ~
Header /Manifold ~~ Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length ~Q~ Dia. ~~' Lengt Dia. paring ~. r
SOIL COVER x Pressure Systems Onty xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1• d`l/ I°I/ ~Insuection #2• ~-
Location: 654 Badlands Road, Hudson, WI 54016 (SW 1/4 SE 1/4 22 T29N R19W) - 222919228E -Lot 1
1.) Alt BM Description = N//~
2.) Bldg sewer length =
-amount of cover =
~) o I, sir„ ~ %,,, p ~ ~ ~ z. "°~ ~~.~...~-~•.~~ ~ ~ ~~ ~ S _ (~ ~.,~ ~».~.+~.,) ,~, .u ~ ~o..~~.
Pian revlslon required? Yes ^ No
Use other side for addition 'nf5rrpati
SBD-6710 (R.3/97) X99 ~ ~ ~j~~,.~ Date Inspector's Signature Cert. No.
lY 1o,7•rs~ws ~~~ ~
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
Sanitary Permit Application Safety & Buildings Division
In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave.
~~ See reverse side for instructions for completing this application PO Box 7302
~'*~~'~~'*~
~
t)epsrtment of Commerce Personal information you provide may be used for secondary purposes Madison, WI 53707-7302
(Submit completed form to county if not
(Privacy Law, s. 15.04(1)(m)j.r__ ~ ,-, 4~ state owned.
Attach tom lete lens to the coon co oni for the to ~o a er ofless 8 -1/2 x 11 inches in size.
Coon State Sani P it Number ^ Chec ~~reigsion to p¢vious appltbcation;l State Plan 1. D. Number
~ '~" : d~
I. A lication Information -Please Print all Information ~`._':' ~~ ~ ocation:
Owner Name ~ ~
... ..J: perry Location
~ C ~ r~ ~QQO
' ~ ~ '~ ~ • - l/4 Jt 1/4, S T ,N R/t~ o
Property Owner's Mailin Address ~.~ (;~(~! *
~T t Number Block Number
City, State Zip Code P ,` or CSM Number
Subdivision Name
~
~y
II. Type of Building: (check one)
1 or 2 Famil
Dwellin
- No
of Bedrooms :~ ^ City
^ Village
y
g
. n
of
~ Tow
PublidCommercial(describe use):_ '
n
// !
I
^ State-Owned l~L(ASD/i
t Ro d
GF~
i -
~ / ~g
~ ~ ~S fL Par~ejTaxl~lu bens)
.
k
o
III. T e of Permit: on nc,' on line A. Check box online 13 if a cable . ^?5~ . ~ . 2ZFs
A) 1. ^ New 2. Replacement 3. ^ Replacement of 4. S. 6. ^ Addition to
S stem S stem Tank Onl Existin S stem
B) Permit Number Date Issued .
^ A Sani Permit was reviousl issued
IV. Type of POWT System: (Check all that apply)
~ ^ Mound ^ Sand Filter ^ Constructed Wetland
Eldon-pressurized In-ground (~) i N ~ ~; c
j
^ Pressurized In-ground ^ Holdin Tank ^ Single Pass ^ Drip Line
C » ~tp"i ~l S, ~~
^ At- de
) ^ Aerobia reatment Unit ^ Recirculatin ^ Other:
V. Dis ersal/Treatment Area Information:
1. Design Flow (gpd) 2. Di Area . Dispe I Ares
Rmnirert ~ roposed~3~-~' 4. Soil Application
~,,, ft
Rate (GalsJda 5. Percolation Rate
(Minlinch 6. System Elevation 7. Final Grade
Elevation
y
VII. Tank rapacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing Crete strutted
Tanks Tanks
~"
5 ff,,
Q~ ,~ ^ ^ ^
tc_
~ U S
VIII. Responsibility Statement
I the undersi ed, assume res nsibili for installation of the POWTS shown on the attached tans.
Plumbers Name (print) Plumbers Signature (no stamps): MP/MPRS No. Business Phone Number
' ~
~u,
a
Plumbers Address (Sheet, City, State, Zip Cod
f _ ~ ~ ~
IX. County/Depa tment Use Only
^ Disapproved Sanitary Pemrit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps)
(Approved ^ Owner Given Initial Adverse age Fce)
Determination o~s. ~ q ' ! ~ - Zee
X. Conditions of Approval /Reasons for Disapproval:
aE l~o~ay.-v/~.m-.,L.e.K~ ,~ s r~1'-~ na shy ~ c-°dZe- t~s~re-".`ev~S -, t /
.
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To ~ P~ ~,~~ ~ ~, a ~ ~~ Ai" N,W ConNe(C. o~ 12cc.~ ~I~V-99,~$
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3
Division of Safety and Buildings in accord with Comm 83.05, W is. Adm. Code
A.C.E. Soil & Site Evaluations
Attach complete site plan on paper not less than 8%: x 11 inches in size. Plan must County
inGude, but not limited to: vertical and horizo n ~ (tdirection and St. Croix
percent slope, scale or dimensions, north e~ ~n stance to nearest road. parcel I.D.#
APPLICANT INFORMATION ~ ase pi~ all i-~foi+lma~ion. vie ~ B1060-20-e100 ID#22•Date9 228E
Personal information you provide may u r secr>ps (Priv~r~w, s. 15.04 (1) (m)). ~ _ ~ ~ y TAI A ~ 14 - /~ - ~r7
Property Owner o ~- rroperty I_ocauon
Paul A. & Donna M. Blod Q(f ( Q g Z~da 1,I r. Govt. Lot SW 1/4 SE 1/4 S 22 T 29 N,R 19 W
Property Owner's Mailing Address ST CROIx "_' Lot# Biock# Subd. Name or CSM#
654 Badlands Road o~ CouNTY "/ 1 CSM Vol. 10, Pg. 2871
City S o e um er ~ City ~ Village Town Nearest Road
Hudson WI - '08~ Hudson ~ Badlands Road
^ New Construction Use: ~ Resr er of bedrooms 3 ^Addition to existing building
Replacement ~ Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate 0 bed, gpd/ft2 .7 trench, gpd/ft~
Absorption area required bed, ftz 643 trench, ftz Maximum design loading rate 0 bed, gpolftZ .7 trench, gpd/ftz
Recommended infiltration surface elevation(s) 91.50. ft (as referred to site plan benchmark)
Additional design I site considerations ~'~ trenches using high capacity infiltrators.
Parent material Glacial outwash Flood lain elevation, 'rf a livable na ft
S=Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fil{ Holding Tank
U=Unsuitable for system ®S ^ u I ^ S ^ u ~ S ^ U ®S ^ u ^ S ®u ^ S ® u
Soring#
1
Ground
elev
DG L.`SI k
Depth to
limiting
factor
>114"
2
Ground
elev
96.76 ft
Depth to
limiting
factor
~~~u•
Depth Dominant Color Mottles Structure
i
t
C
da
B
Roots GPDff~
Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. en
ons
s oun
ry Bed ~, Trench
1 0-21 10yr2/1 None sl 2fsbk mvfr cs 2f - 0.5
2 21-32 10yr3/3 None sl 2msbk mfr cs if - 0.5
3 32-43 10yr4/4 None sl 2msbk mfr cs - - ~ 0.5
4 43-62 10yr4/6 None Is Osg ml cs - - 0.7
5 62-114 10yr6/6 None s Osg ml - ~ - - ~ 0.7
Q.Sa ~ 89•`f~~
Remarks:
1 0-14 10yr2/1 None sl 2fsbk mvfr cs 2f - ~ 0.5
2 14-23 10yr3/3 None sl 2msbk mfr cs if - 0.5
3 23-34 10yr4/4 None sl 2msbk mfr cs - - 0.5
4 34-41 10yr4/6 None is Osg ml cs - - 0.7
5 41-118 10yr5l6 None s Osg ml - - - 0.7
b;.t2 y1,/Z B~t.YS ~
~5~~7'Z/12 . ~Z
Remarks:
CST Name (Please Print) Signatur • Telephone No.
James K. Thompson ~' 715-248-7767
Address A.C.E. Soil & Site Evaluations Date CST Number Ref #
340 Paulson Lake Lane, Osceola, WI 54020 8/2/00 3602 1275
_ PROPERTY OWNER: Paul A. & Donna M. Blodgett
PARCEL LD # 020-1060-20.100 ID#22 29 19 228E
3
Ground
elev
96.15 ft
Depth to
limiting
factor
>112"
SOIL DESCRIPTION REPORT
~2~s Page 2 of 3
A C F Cnil Rr Site F.vAlu 'ons
Depth Dominant Color Mottles Structure i
t d
B Roots GPDlft2
Horizon in Munsell Qu. Sz. Cont. Color Texture ~ ~ ~ ence
ns
s oun
a
ry Bed ~ Tre ch
1 0-14 10yr2l1 None sl 2fsbk ds cs 2f,lmc - 0.
2 14-20 10yr3/3 None sl 2msbk ds cs 2frn,lc - 0.
3 20-29 10yr4/4 None sl 2msbk dsh cs lfinc - 0.
4 29-45 10yr4/6 None Is Osg dl cs 1 fin - ~ 0.7
5 45-112 10yr5l6 None s Osg dl - - - ~ 0.7
.B q(8o ~ ^~.`I( I~.
Ground
elev
Kemancs:
Depth to
limiting
factor
Ground
elev
Depth to
limiting
factor
Ground
elev
Depth to
limiting
factor
. Gtr
.~ (lo S/aA2.
nnay be O co,~,pon~
not d ~ Stovt,/!~ d u,~r ~ ~i
a' Bc~'-ioF~,cl~
le = ic+o ,
~rd.ele/: ode.r-bu~/d~~q Sewer= Q9./o
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Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In-Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWYS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In-Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
Table 1: Svstem Design Specifications
.Sanitary Permit Number q
Number of Bedrooms 3
Design Flow -Peak (gpd) '1'J
Estimated Flow -Average (gpd)
Septic Tank Capacity (gal)
Soil Absorption Component Size (ftZ) 3~s Z- i ~i~~+ u-
Type of Wastewater Domestic
Table 2: Soil Absorption Component -Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow -Peak (gpd) p'oU 3 ~" 'i ~c~.u9
Maximum Influent Particle Size (in) 1/8
Maximum BODS (mg/L) 220
Maximum TSS (mg/L) 150
Tab le 3: Maintenance 5cnedu~e
Septic Tank Inspect and/or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the 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
the completion of service. Any opening deemed unsound, detective, or subject to tailure must
be replaced. Exposed access openings greater than 8-inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
ST CROIX COUNTY
Owner/Buyer
Mailing Address
Property Address
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
~~ (Verification required from Planning Department for new
City/State J.L~~~/~ ~~ parcel Identification Number ~d - ilk ~~rJ ..ti~l~ -/LYE
LEGAL DESCRIPTION
Property Location ~ %,, ~~ %,, SeC, ~, T~,,~N-RAW, Town of ~r~.scah~
Subdivision
Lot #
Certiflied Survey Map # .7:~~~~ Volume tC1 ,Page # ~~7./
Warranty Deed # ~~? ~"54,2h Volume //U f ,Page # ~~%
Spec house O yes ~no
Lot lines identifiable O yes O no
n.
SYSTEM NLAn~TENANCE
Improper use sad 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.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
masterplumber, journeymanplumber, reatrictedplumber or slicensedpumper verifying that (1) the on-site wastewaterdisposalsyslem
is in proper operating condition and/or (2) afEer inspection and pumping (if necessary), the septic tank is less thin 1/3;tirU of sludge.
,~.+~.
Uwe, the undersigned have read the above.regwromentssnd agree to maintain the private sewage disposal aystew wiW rise standards
set forth, herein, as set by the Department ofCommerce and We Department of Natural Resources, State of Wiscoasia: 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 , ye expiration date.
~SIQNAT[JRE O AP CANT
D
OWNER CER ~~ATION
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 prop described above, by virtue of a warranty deed recorded in Register of Deeds Office.
,,,
. ,« _ ~ / .
~SIC3NATURB F PLICANT DA
****** Any information that is mis-representtidmay result in the sanitary permit being revoked by the Zoning Department. ****•*
** Include with this application: stamaed warranty deed from the Register of Deeds office ~`
a copy of the certified survey map if reference is made in the warranty deed
WARRANTY DEED
DOCUl~2iT D10.
525425
T616 Deed made betweea DAVID D. ALWIlV, Grantor, and
PAUL ALLEN BLODGETT and D0~1NA M. BLODGETT, husband
and wife as survivorship marital property, Grantees,
Witaes~seth, That the said Grantor conveys to Grantees the
following described neat estate in St. Croix county, state of
Wisconsin:
SEE ATTACHED "E7[HD~IT A"
This is not t~omesiead property.
sl. fO.I.r wae~ad far aayeua~ case
v~~.1i~1~~ ~~ }',
s;~, ;.
Road fbr ~Moad
,1 A N ~ 4 1995
~ s:oo P.M.
R^^` :ttr ai Deeds
Together with all and singular the hereditaments and apD' thereunto belonging:
Anti David D. Alwin warrants that the title is good, indefeasible in fee simple and free and clear
of encumbrances, and will warrant and defend same.
Dated this 20th day of January, 1995.
~'
.~ /
J /
TRANs~o David D.
EFL
STATE OF WISCONSIN
ST. CRO1X COUNTY
R
v ~'~`~
@~`~ ''
~ ~.•r-
i ~.~ ~.
Personally came before me this 20th day of January, 1995, the above named David D. Alwin,
to me known to be the person who taecutcd the foregoing instrument and acknowledged the same.
Notary Public, State of Wisconsin
My Commisssoa (expires): D f•c ~. /99C
-r
THIS INSTRUMENT DRAF1'FD BY:
Robert W. Mudge, Attorney
MUDGE, PORTER, LUNDEEN dt SEGUIN, S.C.
110 Second Ste, P.O. Box 802
Hudson, Wisconsin 54016
RETURN TO:
Rabert W. Mudge, Atty.
Post Office Box 802
Hudson, Wisconsin 54016
\•
v~tl ~.1(~~~~,. JFi
N~'iAII1B~ AM
Alvin to Blodgett
Put of the Southwest 1/4 of the Southeast 1/4 and the Southeast 1/4 of the
Southwest 1/4 of Section 22, Township 29 North, Range 19 West, Town of
Hudson, St. Croix County, Wisconsin, morn specifically described as: Lot 1 of
Certified Survcy Map crcorded January 14, 1945, in yar. 10. Pa¢e 2871, as
Document No. 325288 in the Office of t,'ie Register of Doeds for St. Croix
County, Wisconsin.
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Part of the Southwest 1/h1of29hNoSththRange119 WestthTownuofeHudson4 St .tCroixuCounty,
1/4 of Section 22, 'towns p
Wisconsin.
pIndicates 1" x ?.A" iron pipe weighing 1.13 lbs./lin. ft. set.
CURVE OATH: CHORD BEAR. - N / 7. 4l' 40"E, CNORO D/ST. - 160.45 , ARC DIST.-163.17;
QWner'S Address: RAD/ US- 237.00', CENT. ANGLE - 36 • 22.' 40", lST TAN. BEAR. ' N00' Z9' 40"W ,
654 Badlands Road 2ND TAN. BEAR. - N 33.3 3' 00"E
Hudson, WI 5A016
UNPLA TTED LANDS
N 89 • 50' 4 6 "E 4 9 /. 34'
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CERTIFIED SURVEY MAP
DERYL AND LORRAINE AL.tlIN
~~
LOT ~
3.5'0/ ACRES
15P, 49! SOFT.
3.448 ACRES EXC. ROAD R.O.W.
150, 1.85 SQ.FT:
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S B9. 50' 46"W 300.00' N 89.37'53
UNPLATTED LANDS
This instrument ]rafted by Laurence W. Murphy
Dated: November 16, 1994
°y'`°` nRevised this 19th d~`of December, 1994."
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S 89.57'S3'E 2602.92- ~ S LINE SEI/4
BA_OLANOS RD. M
S l/4 CDR. SEC. 22, T29N, R 19 W, SE CO R. SE C. 22, T29N,
/p. K. NAIL fOUNDI (~/UPLATTED R I9 W, (COUNTY
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LANDS ~.~~~CON h~~''~.
~'' ALL BEARINGS REF. TO THE SOUTH LINED
'~'''~5,j~'" THE SOUTHEAST l/4 OF SfC.22, T29N,
RI9W,ASSUMED 589.57'33"E
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Laurence W. Murphy
Registered Land Surveyor