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Home My WebLink About020-1409-04-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION r t (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 'ermit Holder's Name: City Village X Township Bast, Kernon Hudson Townshi :ST BM Elev: Insp. BM Elev: BM Description: , /_ ~ ~ Q ~ . j) / 0 ~ ~ D ^ -~ i S ~ ~ 6ZS~ ~-- W ~.~,-rc-6 ic:T_ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic i ~ l,~-~h~ J a 5ZJ Dosing . A -/~u Aeration Holding __ TANK SETBACK INFORMATION TANK TO ~y '1 ~ WELL BLDG tta.2 Vent to Air Intake ROAD Septic { > ~ { - Dosing Aeration ldi H ng o PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Nu ber TDH L' riction Loss System Head TD Ft Forcemain Length Dia. SOIL ABSORPTION SYSTEM ELEVATION DATA County: $t. CroiX Sanitary Permit No: 420664 0 State Plan ID No: Parcel Tax No: 020-1409-04-000 SectionlTownlRangelMap No: 24.29.19.2562 STATION BS HI FS ELEV. Benchmark y-3~' /o roo~a Alt. BM S ~ . Ov~ ~D~, 33 Bldg. Sewer ~ / ~ ~ , SUHt Inlet ~ B A 9 $• s3 0 SUHt Ou#let p .lcf~ o !v~ Zt q~ , t'1 Dt Inlet ~ - Dt Bottom Header/M~rtf ~r ~ p,S,~ ~3,8~ Dist. Pipe r~.•L f ~ ~ ~ f Bot. System I~ Z ~3'1 ~ 2. ~ ) Final Grade o ~7-d8 BED/TRENCH Width ) Length No. Of Trenches PIT SIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ ~ f `~/ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM EACHIN Manuf e • ~ r ~ ~ INFORMATION O HA E ~ Typo Of Syste`~~ (:mot ~' 5-b/_ / 1 f~ / ~ ~ / ~ N T Model Number: DISTRIBUTION SYSTEM IC.~ rlin.~, L,11.~5 l•..~1 an„ v,L." Header/Manifold 1 t ~ Length~_ Dia_ Distribution Pipe(s) f /7 ~ Length~~ Dia Spacing x Hole Size ~ x Hole Spacing ' ~ ~ / ~ ~ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Onlv T I~~ Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center ~'I" Bed/Trench Edges Topsoil ~~ Yes No ~ Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: S/o2t' ~ Inspection #2: / / Location: 824 Hidden Lake Rd~nHtu``dson, WI 54016 (S 1/2 SE 1/4 24 T29N R19W) Boundary Ridg Lot 4 Parcel No: 24.29.19.2562 1.) Alt BM Description = 'sue W~~.. ~~ -~~~ liL~f~acd ~ 5 ~~~ 2.) Bldg sewer length = , ~.~ - /-__L.1 S,a, Q,~C .~ ~~'~•>~Y~~~. ~.~~~~~%dW - amount of cover - ~ c- / (S~ 6 17~.~7~r'W~""/~.`rQY~Q.u.Z~,~Qr yhS /~Q~ d /off 0' _- ~" J r- Plan revision Required? Yes ~~_ No I ~ ~~Z( ~~ ~ ~~~ ~ ~ i Use other side for additional information. ~____ ~ _________ SBD-6710 (R.3/97) Date Insepcto s Signature Cert. No. n ~ Vent to Air Intake ,r _ ~ ~wS Sanitary Permit Application Safety & Buildings Division ~ 201 W. Washington Ave. ~~/~ In accord with Comm 83.21, Wis. Adm. Code PO Box 7302 ~~. See reverse side for instructions for completing this application Madison, WI 53707-7302 l~r+ `V~~~, ~~ Personal information you provide may be used for secondary purposes Submit tom leted form to coup t]epertment of=Commerce (privacy ( p ty if not state owned. . Attach tom lete lans to the coon co onl f th of les than 8-1/2 x I 1 inches in size. ~~h, ` State S itary~Permi N r Check if revision to previous appli ~on State Plan L D. Number I. A lication~formation -Please 'nt ail Infor ation 4 Location: Property weer Name Property Location ` ST. CROIX COUNTY E.~-r1~r1 s-~ ZONING OFFICE .JG1/45E1/4,SZ T.Z.9,N, W property Owners Mailing Address Lot Number Block Number 7 ~ ~ d~ Sul ision Name or CSM Number City, State Zip Code Phone Number rc~~~ c.~ /. 5 O/ ~ S 386 7775 aptyci!, ~o~F ~o~cnolr ~~ of r~ II. Type of Building: (check one) ~~ ~~ ~ ^ village l~l or 2 Family Dwelling - No. of Bedrooms :~ ~ fai~L'own of ^ Public/Commercial (describe use):_ ~q(S~fy~ ^ State-Owned N t Road 2 U/ t ~ .,~a-r.~_ /~=dden t.~Xe mad Parcel Tax Number(s)~~_ „ ~ ~ III. T e of Pe mit: Check onl one box online A. Check box on line B if a licable 5 6. ^ Addition to A) 1. ew 2. ^ Replacement 3. ^ Replacement of 4. Existin S stem S stem S stem Tank Onl Date Issued i B) Permit Number nO~/ 3~ ~3 [1~Sani Permit was reviousl issued as tv IV. Type of POWT System: (Check all that apply) ^ Sand Filter ^ Constructed Wetland fd'~Ion-pressurized In-ground ^ Mound ^ Pressurized In-ground ^ Holding Tank ^ Single Pass ^ Drip Line ^ At- de ^ Aerobic Treatment Unit ^ Recirculatin ^ Other: ~ V. Dis ersal/Treatment Area Information: ~andav (; l~^ e/s E.t.~-A. o,-t,ErenclcS ab3' 8G. 1 Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. stem Elevation Elevation rode Required Proposed Rate (GalsJday/sq. RJ (Minlinch} ~4 9,Z.o t93o` 9S, o~ 96. soy Gc~ ~S . s ~~o.&~ b, 0.7 n VII. Tank Capaci in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing Crete strutted Tanks Tanks ^ ^ ^ ^ .~ y, p --- DSO ~ l.Jr CSC CcsrlC. ^ ^ ^ ^ ^ VIII. Responsibility Statement I, the uadersi .ed, sssume res rsil;ili for ir+.stallation~of the POWTS shown on the attached lans. Business P,".ore Number Plumber's Name (print) ~ Plumbels iture¢t:/ ps). MP/MPRS No. ~ "`?2-503 7/~-, ~~-869 Plum is Address (Stree/t, _Cit~y, State, Zip Code) n_ IX. C unty/Department Use my ^ Disapproved Sanitary Pemrit F (Includes Groundwater D sued Issuing Ag t Signature s ps) Approved ^ Owner Given Initial Adverse Surcharge Fce) ~~. ~ ~ ~ Q 3 T ~ Determination - n X. Conditions of App ~~al /~k~ sons for Disapproval: ~ ~~ y(~~-~ ~,~Q 1 ~~,~,tii-ta-(/ ~ ~' Clh~-~,p~c..tt.'~- a -7 A ~~'~~~ ~ B~cc ~ ~ /1,~irit~ rr ~` G?~h~ G~I~l;c~4 ~'1~rn,t~ -- ark, cam. ~~~ ~~ ~, ~.~ s~ ~~ e~ ~ s- ~ pcJ ~ ~' j S~ J"" /~• ~ • /~-~d /o~oo. ~~ ' 9s[.o' 9G o' ,Sca/E : / 5~0 ~ d oandr~r ~-d~e, IE.P~, .'2a.I ~~ .83 Wc~~- ~y`Qu A y8 0 .3Gf~?(' iao. o u 1 v~ 3 ~~ a~ ~aa t ~Yo ~~---- - ~' d a r o~ ~.~ o ~~ Q~ dr~ve~ h ~ a a F .~ ~i ~~~~ ~o~ d r .~ ~~ ~ga-nc.L. l'y~al'K ~ T P of ~•~; s kcd ~ ~ ^ P.opo.sed /, zsa go.P. s~pt-c. ~.C w/ dab/Q ,4-/~ eF~/uenE ~,•/~erct~ out/¢t- COPY P~. 3 0{~ ~ 50,/ 05se~/a~G~ ~- ~ ' 9~ o' 9~ o' /o ~ v, ~'/af a ~' ~ ocL~d/'~. ,P-die. ~ a /E . P~. ~ 2a. I ~.~ ^83 ~~C~'~ee. ele%' 9s~~0~ Wc~d ~/'Qu A 98 ~ .~~~~/' /a~.o'contoK!' u s ~~ s ~~ ~., ~ ~ ~ d~~ve~.~aQ. ~~---- - ~ M ~ ~ T ~ ~' . _~ d a r F c `0 ~ ~ Q` ~ ~~~ -Pow d /Fr ~ ~ ~~ l3a.nc.1~ ~1:: Top ~'~'~~ skcd =s 6i G . Prcposect /, Aso 9o.P. S~ob-~ b~..,,t' w/ gable ,¢-/~ ~6f'/uent ~,•/~e.-cad out/et. p~. 3 oF~ ~~ #/~2/ Wisconsin Deq{artment of Commerce PRIVATE SEWAGE SYSTEM Safety and Buittting Div*sion • INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes iPrivacv Law, s.15.04 (1)(m)1• Permit Holder's Name: Bast, Kerngn City Village x Township Hudson Townshi CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM ELEVATION DAT county: St. Croix Sanitary Permit No: 420664 0 State Plan ID No: Parcel Tax No: 020-1409-04-000 Section/Town/Range/Map No: 24.29.19.2562 STATION BS HI FS ELEV. Benchmark Alt. BM Bldg. Sewer SUHt Inlet St/Ht Outlet Dt Inlet Dt Bottom Header/Man. Dist. Pipe Bot. System Final Grade St Cover BED/TRENCH DIMENSIONS Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR Manufacturer: Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Onlv xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched BedlTrench Center Bed/Trench Edges Topsoil Yes No ~ Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / /_ Location: 824 Hidden Lake Rd Hudson, WI 54016 (S 1/2 SE 1/4 2 T29N R19W) Boundary $id a Lot 4 Parcel No: 24.2/~ .1 2 1.) Alt BM Description = ~-~ ~~~~1 '- S/7/ 6 3 2.) Bldg sewer length = - amount of cover = Plan revision Required? [] Yes ~ No Use other side for additional information. SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No. 1621 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety anti Buildings in accordance with Comm ti5, Wis. Adm. Cade A.C.E. Soil & Site Evaluations County Attach complete site plan on paper not less than 8'r~ x 11 inches in size. Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and parcel I.D. percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. 020- 09-04-000 Please print all information. R g Date Personal information you provide may 15.04 (1) (m)). C~~ ~ 0'3 Property Owner Property Location Kernon Bast Govt. Lot SE 1/4 SE 1/4 S 24 T 29 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 948 LaBarge Road 4 Plat Of Boundry Ridge City State ip C ZON E ~ City ~ f Vllage 1/ Town Nearest Road Hudson ~ WI - - Hudson 824 Hidden Lake Rd. /_f New Construction Use: IJ/ Residential /Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement J Public or commercial -Describe: Parent material Glacial outwash Flood plain elevation, if applicable na General comments and recommendations: Install two trenches at elevations 92.00' & 93.00' using 281eaching chambers. Boring # J Boring >93" i ~/ Pit Ground Surtace elev. 96.30 ft . Depth to limiting factor n. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/k' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-10 10yr32 none sl fill na na na na na na 2 10-17 10yr3/3 none sl 2fsbk mfr cs 2fmc 0.5 0.9 3 17-28 10yr4l6 none sicl 1 msbk mfr cw 2fm,1 c 0.2 0.3 4 28-3 7.5yr4/6 none sl 2msbk mfr Lwv 1fm 0.5 0.9 5 32-48 7.5yr4/6 none rls & co 0 sg ml cs 1fm 0.7 1.2 6 48-9 10yr5/6~r none s & gr 0 sg ml - - 0.7 1.2 AA/ ~ ~~ . <• H#5 & 6 contain approx. 20% coarse fragments l 2 Boring # J Boring Pit Ground Surtace elev. 97.39 ft. Depth to limiting factor ~ 108•• in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GP *Eff#1 D/ftx *Efi#2 1 0-10 10yr4/6 none sl fill na na na na na na 2 10-17 10yr32 none sil 2fsbk mfr cs 2fmc 0.5 0.8 3 17-23 10yr4/4 none sl 2fsbk mfr cvv 2fm,1 c 0.5 0.9 4 23-36 10yr4/6 none rls & co 0 sg ml cw 1fm 0.7 1.2 5 36-78 10yr5/6 none s & gr 0 sg ml gs 1fm 0.7 1.2 6 78-108 h 10yr6/6 none s & gr 0 sg ml - - 0.7 1.2 ~ ~ ~ H#3 contains approx. 30% coarse fragments. H# 4 & 5 contain approx. 15% coarse fragments. Ll4" ~~ --~--_' - - - /-~~ ffluent #1 = OD y> 30 < 22p mg/L and TSS >30 150 mg/ * nt #2 = BOD <30 mglL and TSS <~30 mg/L CST Name (Please Print) Signat e: CST Number James K. Thompson ~--- 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane. Osceola, WI 540 4/92003 715-248-7767 Property Owner Keeton Bast Parcel ID # 020-1409-04-000 Page 2 of 3 ^ Boring # --~ Boring Q¢ {• '~ /G2/ dJ Pit Ground Surface elev. 93.78 ft. Depth to limiting factor >92" in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots 'Eff#1 *Eff#2 1 0-ti 10yr3/2 none sl ftll na na na na na na 2 6-19 10yt3/3 none sl 2fsbk mfr cs 2fmc 0.5 0.9 3 19-27 10yr4/6 none sicl 1 msbk mfr cw 2fm,1 c 0.2 0.3 4 27-38 7.5yr4/6 none sl 2msbk mfr cw 1fm 0.5 0.9 5 38-76 7.5yr4/ti none Is & gr 0 sg ml cs 1fm 0.7 1,2 6 76-92 10yr5/6 none s & gr 0 sg ml - - 0.7 1.2 -~0~/ ~Gr H#5~ /~ll.!' soar ^ Boring # ~ Boring U Pit Ground Surtace elev. ft. Depth to limiting factor in. Soil Application Raie Horizon th De Dominant Color Redox Description Texture Structure Consistence Boundary Roots !ft2 p in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 ^ Boring # J Boring _f Pit Ground Surtace elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 `Effluent #1 = BOD ~• 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. 4~0' 940' Sca/e : / `: 5/D ~ az s /o ~ v, ~'/af o -~ - , ~~-- a ow~d~y ,P,-d~~. ~ ~ '~ ~0 ~ ~' d ,, i v ~` ~ ~ ~', ow ~ Q t 1 '~ ~. v~ '1 ,~ V ~ d~~ve __ ~ ~ T h ^ _ d a ~ ,c ~~~ ,Pow d ~ r;rt ~ 8.2 5~ ga.nc.L~rv\v*~'~ Topof'~•~iskcd -1 w ^ P~. 3 0~'3 ~~ ~ /Gzl ~`f (..4..~dtp [,~,~.k~ Sanitary Permit Application Safety & Buildings Division 1~~ i A W ' • ' ~~ In accord w-ith Comm 83.21, W'is. Adm. Code ngton ve. . 201 ash PO Box 7302 iseonsin See reverse side for instructions f'or completing this application WI 53707-7302 Madison Department of Commerce Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(I)(m)] . (Submit completed form to counn if not state owned. ) At[ach com lete lans (to the county co only) for the s stem, on a er not less than 8-I/2 x I I inches in size. County 5~'. ~-troi Stat e if r yysi~ t p~ev application ~ G (o State Plan I. D. Number 1. A lication Information -Please Print all Information Location: Property Owner Name L_ ~ Property Location ~n » ~- Property Owner's Mailing Address Cft~ )IX COUN i Y S? Lot Number Block Number ~f! ~ ~r. • . C'Jii~G OFFICE ~/ Gn, Stale Zip Code Phone Number Subdivision Name or CSM Number I1 Tvpe of Building: (check one) as pvi s ~~ ~ ~wt5• ~ City O VjJl r~ or 2 Family Dwelling - No. of Bedrooms: age p Public/Commercial (describe use): frown of f!SOr1 ~ ~ Stale-owned ee.p III Type of Permit: (Check only one box on line A. Check box on line B if applicable) ~Z,1 Neareu a..,a A) 1. t!3"New System 2. ^ Replacement 3. ^ Replacement of 4. ^ Addition to Parcel Tax Number(s) 2~lPZ m ( `fD ' ~~-v S stem Tank Onl ~ Existin S stem . 9 C . o20 -~ $) Permit Number Date Issued ^ A Sanita ~ Permit was reviousl issued IV. Type of POWT System: (Check all that apply) li~n-pressurized In-ground ^ Mound ^ Sand Filter ^ Constructed Wetland ^ Pressurized In-ground ^ Holding Tank ^ Single Pass ^ Drip Line ^ .At-grade ^ Aerobic Treatment Unit ^ Recirculatin ~ ^ Other: ~ d;s sa.4. cel s a.~ 3' 'i9S~'O' V Dis ersal/Treatment Area Information:, 3Eo.-dafd ~~b•di• 3/./ Ez /'Q~~ = 870.80 f• E.z.~A• 1 Design Flow (gpd) 2. DispersalArea 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elev ton 7 Final Grade Required Proposed Rate (Gals./day/sq. ft.) (Min./inch) Elevation ~~ 8s~~s~{ 87D. ~O . -t. 0.7 Yl~• 95~GO' 9~so~,98.~s~ VI Tank Capacity to Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing Crete structed Tanks Tanks ~ ~' ~, z~ -- , 2 a~o l se. C J~ l r~ ^ ^ ^ ^ , e u an~_ . L- /~~ n ^ ^ ^ ^ D VII Responsibility Statement 1, the undersi ned, assume res onsibilit for installation of [he POWTS shown on [he attached lans. Plumber's Name (print) Plumber's Si nature (no tamps)• MP/MPRS No. Business Phone Number Plumber's Address (Street, City, State, Zip ode) b O •D 6 ~ p RJ DSO ,1~ L(~ ~O /,~o VIII County/Department Use Only O Disapprgved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) Approved ^ Owner Given Initial Adverse Surcharge F e) Determination ,~ 225' .3(t 2~3 IX~(ndit(gn~~AppQOVaasot)s for Disa p oval:~~~, n ~~ ~C~ ~~~ n , ~. ~~p ~.7tj ~.il ~XM1 S , r ~`~ SBD-6398 (R. 07/00) ~ Soi/Ob~-/Hc+~~m , i46 ~ ~a~i+.~ed ~i'oP s~ soak: ~ : S/o' I~ /o~ y Olaf ~ ~' ~3s,ncl, Mari!' To,o ~`Xi`SEce/ R"o(~osc.al ~ ~ ~ a~ o , ah o v a ~ 3 a 83 ~ ~~~ ~oa a/ b~ ^ L ~ ~ $2 P~oposcd ~,~ aaP. ~ s(~o~it~a.rit' k3/&~bc1 at out/ctf 1 .iopo~~" st~c./~o:pc. ~kv.-s5 5:~, = ? ,~kb soak = / = 5/0' ,~aw~d~y ,P,-~. s~ .~ s~s~ .1~~~ = . ~n G~-1pG~ MA~1C ~ /oA o'r ~y. F1-oposcd ~u,Q,t~ ~ ~ 63 • o~ ah o v a ~ b~ ^ f~cb..~ (gaffe' ~oa a/ L ~ v _ w w ~ >az P~opoud ~,~ ~~P 0 S4o~:c~a.~K w/ 8abc1 at out/eU 1~.• o"po~l~" f Mlach cornptelo site plan on ~ rr not less than 0 1/7 x 11 inches In size. plan must County 5T' CR Ol ~- n. n . Include, hul not thnlled Io: ve-Iical and horizontal reference point IBM), direction and d percent slope, Scale or dimensions, north arrow, and location and distance Io nearest road. Parcel I.U. ~2Q ~ ~~~ 7 . /O . ~~ Please nrln(all Inforn,allon. R v wed by Uale he±rsonai Inrormallon yorr provide may he used for seconder rlr oses rrivac l.Aw, s. 15.0 1 m ~~' 3 ~ t ZRJD3 r n r 1 r O( )). V properly Owner erl Location ~t ~/ KE~NoN 13i4yT ,' DjNAc~A So~~ G NDoI 5~ ,14.7Pi ,l4 S Z! T ~9 N R ~9 Property Owner's Mailing Address ~ ~0-1 W ii 9y 8 ~~- /3.9-RG-~ jz~ . JUL 2 2 2002 ~ I # Block !! Subd. Name or.66h1# City Stale Zip C e Pho ~~~ ~ COUNTY City ^ Village ~ Town Nearest Road - ` ffvvsol~ ivi. 5yo~~ ~ ,~vflsaN ~ ~AO~~~~s ~~I. New ConslrucHon Use: ~ Residential / Nurnbe- of bedrooms _,3 _ y Code derived design Dow vale yS(rj - ~p lSd GPU (_) Replacement [] Public or commercial -Describe: -'arent maleriai /QT'S f /rj~f~' ,Si9~Q,/ Flood Plain elevation ll applicable it! n. Genera~commenls fIU7~Gcl~-S~ and recommendations: • ' /} ~P~th T~ST~o •SU~•7i9-/3 !~ ~Dl~' ~9 ~~ vEti T O~v h-~- /,v ,Po uiuD T~OGv TS Bming # [~~ Roring Q (g Pit Ground surface elev." ~~ h. ner,u, t.. n...ut.... r,•..r... ~ ~~ r.. ~d( ~~ T ; o~ ~P~'~o~ . 3 5 ~~+,es '" MA-~ a~2 ~lq.T l~~,vy)i N~- +Msconslrl be~rarlment of Commerce SOIL EVALUATION REPORT 3 Ilvlsion of Safely and Buildings - ~ Page / of __._ in accordance with Comm 85, Wis. Adm. Code Horizon bepll/ Uomin l l C . v .... son Appncallon Rate M an o or M ll Redox bescrlpiion Texture Slrrtclure Consistence Boundary Roots GPDIfI'. / . ~' ~8 unse ~°Yi2 ~J'3 Qu. Sz. Cont. Color - L Gr. Sz. Sh. /5~S h~ ~wt~~ kJ 3~,,, 'Eft#i ~ 'Eft#2 , ~ ~~ 'sD ~~ sL ~ f ~ f~` as , ~ . ~ ~fl/ . f-'-l r ~ _ U Boring # iJ °~rrr,9 ~ > htl Ground surface elev. ~ ' ~~ n. hpnlh In tlmllinn hrl.,r ~ 3 t.. 1 io-izon Ueplh UomUrant C l v - Son Appli cation Rate In or o M ll Redox Uescrlplion Texture Structure Consistence Boundary Roots ~p pplr l . o •/D unse /oY~ 3/ Qu. Sz. Cont. Color G Gr. Sz. Sh. SbK f~ w 'Elfq, . y •Eff#2 , ~. ~~ is YR Y --- S . Q S ~ ~S -- .~ / Z Z Eliluen l il, = pnh ~ in ~ ~~n ...,.,t _~ ~..,, _ CS, Name (Please Print Stgnalure ~o,gERT- ~!/6Ric~T ~~ address Date Evaluation Cc ht 8 Asaociales ~~- Q •Z Private Sewage onau 655 O`Neil Rd. Hudson, Wis. 540,8 < 30 mg/l. and tSS < 30 mg/l. CST Number ~243~5 ~is• 38~ •g/85 ~oy-~y • ~ . ,sP~~• ~3~sr ~ ~~ 5 3 K /3~sT hrorierf pwrrer ago . ~o~y .io ~ ~~ Z 3 y Eloring • Parcel Id N Page ~ o, (t 3 oring !! u y~ ~ hq Ground surface elev ! ~' ~~ ft U lh I O , ~~ , . . ep o mlling factor 1(r, 1IorlZOn Ueplh I Uorninanl Color Redox bescripllrm Texture Slruclure . Consistence Bounds ry Roots Soh ~~~ R81e pd n. Munsell qu. Sz. Cont. Color Gr. Sz. Sh. 'E1filG m E1M2 2 •~ goy s~ ~ R ,~ ~~ w ~r~ . y Eloring if t~t Roring tJ hit Ground s(alace elev. - n. Ueulh to Ilmilinn (arlnr rti ~ ~ ~, I .~ Horizon Ueplh t)orni l C l Rele Soil ~ In nan o or Mu tl Redox Uescriplion Texture Slnrclure Conslstence Boundary Roots GP 0/11 . nse qu. Sz. Cont. Color Gr. Sz. Sh. •Effgt Effl12 Boring !! ~ Boring r„r Ground surlace elev. fr. hnnlh r., a...trr.... r....r..- ._ 1lorizon beplh hominanl C l Soil ~pPIlCalion Rate 1rr o or Munsen Redox bescripNon Toxlute Slruclure Consistence Bounds Roots G U/11 . qv. Sz. Cont. Color Gr. Sz. Sh. E1isr1 'Efti12 N Emuen11J1 = 90b, > 30 < 220 mglL and TSS >30 < 150 mgt • Eflluenl M2 = BOb' < 30 mg/~ and TSS < 30 mglL 'l he bepartmenf of Cornmerce is an ehoal npporlunily service provider qnd employer. If you need assistance fo access services or need material in an t+lternale format, please contact fire department al G08-2G6-3151 or 7TY G08-26A-8777. snn_ R) In (R Fm0) :' Sri; M~#~ TDB ~~ ~ ~. aT 3 ~ S ~`-c~2. ~ % ~- C roa- D ~ylp ~ LD T ~- • ~~ DoT y o`~y u~~ Ulbricht & Associates Private Sewage Consultants R55 O'Neil Rd. W~~dson, this. 54016 133 y5' -~ Wpb ~° ° ~ u~,~dR ~ SCR ~~ ~~~ ~RN~ ~~ 3 ~~" q$.~S .~ . ~, . ...._. ~~n a ~~ I~ ~~. ~z ~, .~ 0 ~2 ~~ 7'D~ ~~ ~ . Sf-~ ~~~ ~~S .~ J- .~ _~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of ~- FILE INFORMATION Owner ~./t}6+~ ,'4g i Permh ~ 20 6 6 ~k GESIGN PARAME'(ERS Number of Bedrooms ^ NA Number of Public Facility Units l~J'NA Estimated flow (average) T~ al/da Design flow (peak), (Estimated x 1.5) 60i7 al/day Soil Application Rate p • ~ al/da /ft~ Standard Influent/Effluent Quality Monthly average* Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (RODS) 5220 mg/L ^ NA Total Suspended Solids ITSSI 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (RODS) 530 mg/L Total Suspended Solids (TSS) 530 mg/L ^ NA Fecal Coliform (geometric mean) <_10' cfu/100m1 Maximum Effluent Particle Size YB in dia. ^ NA Other: ^ NA "Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity 2,0'0 al O NA Septic Tank Manufacturer (~ S ^ NA Effluent Fiher Manufacturer ~iqg ~.L ^ NA Effluent Fiher Model ~ o~ ^ NA Pump Tank Capacity al ~WA Pump Tank Manufacturer ~NA Pump Manufacturer l~lA Pump Model ~ CIA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: DNA Dispersal Cell(s) ~In-Ground (gravity) ^ At-Grade - ^ Drip-Line '. ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA MN/1~ ~ G~~/VrVG ~7Vf7GVVLG Service Event Service Frequency Inspect condition of tankls) At least once every: ^ month(s) (Maximum 3 years) ~ ear(s) ^ NA Pump out contents of tanklsl When combined sludge and scum equals one-third IY31 of tank volume ^ NA Inspect dispersal cell(s) At least once every: ^ monthls) (Maximum 3 years) 3 ~ year(s) ^ NA : A l ~ ' Z ®y (sl ^ NA Clean effluent filter east once every t I, earl 1 ^ month(s) ~NA Ins ct um pum controls & alarm pe p p, p At least once every: ^ year(s) ~ ^ month(s) ANA Flush laterals and pressure test At least once every: ^ yearls- Other: At least once every: ^monthls) ^yearls) ®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 tankls) 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 IY31 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 pressut~zed 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 PON~JTS check treatment tankls) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal celllsl. If high concentrations are detected have the contents of the tankls) 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 cell(s) 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 sealed. • 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 replac as been evaluated and may be utilized for the location of a replacement soil absorption system. The I ment area hould be protected from disturbance and compaction and should not. be infringed upon by required setbacks from existing and proposed structure, lot lines and wells ai ure to protect the replacement are~ill result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comp y witTi-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. ^ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a hoking tank may be installed as a last resort to replace the failed POWTS. ^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the 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 rn~ (MLQaN6L Phone ~ ~ _ - ~ ,z POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) ULATORY AUTHORITY Name Phone LOCAL REG Name 1 IK ~"C1f ~oN/IU Phone (~ . 3~ - ~(o~ This document was drafted in compliance with chapter Comm 83.221211b11111d1&lfl and 83.54111, l21 & (31, wsconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer IC¢~i'~o~ ~ - ,~aSt~ Mailing Address g~~ ~ ~~ge.. {~f~~- ~t,~.y~SdY7-a t,~~• Sf~OJ(p Property Address ~o~ ~~ `~ %~ ~ ~ ' (Verification required from Planning Department for new City/State ff4-~S~'"~ ~~ Parcel Identification Number ono -,~,s1~9- 8 5~-~ ~ 2 s 62~ LEGAL DESCRIPTION Property Location SF '/., SE '/., Sec. ~ T ~9 N-R~_W, Town of ~u-~sv--+ Subdivision ~u.r, alr-v ~.'d9e. .Lot # ~. Certified Survey Map # ~ ,Volume ~ Page # Warranty Deed # ~"g ~ Volume ~ ~~ y .Page # ~ ~ ~ ~., 1` ~ f3S. 02 e,~,o Spec house ^ yes Pfno ,~,,,-,,.. t lines identifiable E-I"yes ^ no ~e<~ar ~, SYSTEM MAINTENANCE 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeymanplumber, restrictedplumber or alicensed pumper verifying that (1) the on-site wastewaterdisposal 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 t septic system has been mam ed must be completed and returned to the St. Croix County Zoning Office within 30 day the year expiration a~. ~-' OF AP L CANT DATE ER CERTIFICATION e) certify that all statemen on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of p described abov virtu arranty deed recorded in Register of Deeds Office. ` / ~ ~3, .TUBE OF LICANT DATE v s***** ** ** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed I STATE HA1t OF ~SCONSIN FOAM'1 -'Et100 WAitRANT`Y DEED Document Number This Deed, made between David A. Larson and Lee Ann Larson husband and wife Grantor, andKarnon J. t3ast,andDonalda J. Seer-Bast. husband Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (the "Property") (if more space is needed, please attach addendum): That Part of E'tiSE;a Sec/ 24-T29N-19W described as follows: Lot 3 of Certified Survey flap recorded in Vol. 11 of Certified Survey Mapa, page 3151 as Doc. No. 5d8751. E. 7 8 to to 1 KATHLEEN H. 1iALSH REGISTER OF PEEUS ST. GRUIX CU., MI RECEIVED FUR RECORD 05-03-2002 8:25 Afl i,aaai~~TV gEi:c cXF1w~'T s REC FEE: 11.00 TRANS FEE: 131'L.50 COPY FEE: CERT COPY FEE: PAGES: 1 Recording Area Name and Retum Address ~F~~- 020-1069-10-100 Parcel Identification Number (Pith Together with all appurtenant rights, title and interests. This is homestead property. (is) (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except Roadways, Easements, and Restrictions of Record. Dated this let day of tHay _ , 2002 AUTHENTICATION Signature(s) TITLE: MEMBER STATE BAR OF WIC (lf not, authorized by §706.06, Wis. Stets.) THtS INSTRUMENT WAS DRAFTED BY Michael H Forecki Attorney 3 David A~Larson `~7 C-~~'' ! ~~ l i.~r' • as Ann Larson ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. ~ St Croix County. ) Personally came before me this 1st day of igay 2002 the above named David A Larson and Lae Ann Larson to me known to be the person s who executed the fore o' rg inst ent I knowledged the same. •~ No Public, State of Wisconsin My Commission is permanent. (If not, state expiration date: Si natures ma be authentica[ea or a.canowtea ea. nom arc rn,r ncwsa, - --- -- 'Names of persons signing in eny capacity must be typed or printed below their signature. WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 1-2000 homey Michael H Forecki 1830 Brackett Ave, Eau Claire W[ 54701.4627 T6046612.ZFX Phone: (715) 835-3029 Fax: (JI S) 835131 12 Michael H. Forecki Proeucea wiN LpFarm"' M RE FormaNel. LLC 1aa25 FiRa~n Mis Road CIMOn Township, Mirhpan 49035, (aW1383;a1f05 ~l J \ ~ ~\ \ .. , ,\ ~~ \ ,~o \ • \ ,Q \ '~ \ \~ ;, ` \ ~ \ \\ \ , \ ~ \ \ dOo "u ~ \ ~D~ o o u \ ~,~ \ \ . /~ / ~ /'/, /~ / ,. /" ~ /~/' ~ ~ / -___------------------------- ~ ~ c a ~ __ ~ i ~" ~ ~~ ~__-- ~3 TO 7'~iE R-Q'~~ r- - -moo /~~ _~. ~. i --+~. ~. 218 ACRES '~ . ~ .. SEE NOTE ~ • ~ ~ 94.812 SO. FT. .......... , I, BEHCFMiAlIFi1C • • SEE NOTE A : ' ~ `-~r ~ ~ • SPECIAI. DEEP CASING ~~WELL REaIARE~AEM ~ ~ . MINN4JM BUILDLtdO LOT 2 ~~ ELEVATION ~ 1061.,0 203 ACRES 88,2&i SQ FT. SEE NOTE A SPECIAL. DE1:P CASINO ~] / ~ WELL REOUL4iEMENT. ~ V i ~ ~a °_ a l~_ ~ ~_~ -__ ~ _ ..,. '~ ~ ~~ / ,~ . • /. - ----- -- -- i ~~ ''~' % ~ ~ ~ -.. • / / '~;. i ,< .._ ~ ~ i LOT 3 , : ; ~ ~- o / ~ ; . 202 ACHES • 88`127 so. Fr. ~ ~ ~-!`'~ -;-- ; ~ , l SEE NOTE A : ~ ~ ~ ~ . SPECUIL DEEP CASN(i ~ ~ ~ . ~ 1 WELL REOUIREF~ENL ~ ~ / i I ~ / , ~ ~ seera~rl7w 364.7Y ~ DoT a ~ ~ S ~ -.. ~ zo1 ACRES ~ '~ ~ O ~ 87s44 Sa Fr. ~ ; Q ~~ / ` ~ SPECIAL CEP CAStsK3 •~~ ~ .,~ ' ~~ .. ` SOLRH LINE OF TFIE SPECIAL DEEP ~ ~` ~O ~ CASING WELL FILM L3EPKi THE SOUTH LJI~ OF THE NE1/4 OFTHE SE1N ~4T18'W ~,~ ~ ,~, ~ \ ~ a~ •, ~ ~