HomeMy WebLinkAbout020-1395-14-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division ----I{
INSPECTION REPORT Sanitary Permit No:
GENERAL INFORMATION (ATTACH TO PERMIT) 561069 0
State Plan ID No:
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 Parcel Tax No 1
Johnson, Thomas P. & Jodi Hammerstad Hudson, Town of 020-1395-14-000
CST BM Elev: Insp. BM Elev: BM Description: f~ Section/Town/Range/Map No.
/0 i C, p~ 25.29.19.2408
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic (r - Benchmark Z-77 1071,
Ing IN 2 Alt. BM
,4 A
Ae ti Bldg. Sewer
Hol St/Ht Inlet
St/Ht utlet
TANK SETBACK INFORMATION
TANK TO P L WELL BLDG. Ve t to Air In k ROAD Dt
Septic
ls^4 . °n' Nett b, ZD
sing ea an. 110~ 1105 0'./
Aeratio Dist e 6rfs
1 '7-Z 3
Holdin ot. Sy`ste p e
N `7 7o 17
PUMP/SIPHON INFORMATION Final Grade V[ p~,t~~--vw_t- -14 S~ Z. (~/5 / D p 3
Manufacturer Demand St Cover p Q I + z
GPM (~I Gt 1 +T c
Model Number
1 tl k - 1 'NI. 6
TDH Lift Friction Los System Head TDH Ft
Forcemain Length Dia. Dist. to well
SOIL ABSORPTION SYSTEM t k, J - > ►ti. GPl1rtJ~a c~G.
BED/TRENCH Width Len ( No. Of Tren es PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS r1 /
SETBACK SYSTEM TO P/L BLDG WEL LAKE/STREAM (!U C NG Manufac rer: INFORMATION BER Type Of System:
6 NIT Model Number:
IBUTION SYSTEM / ,}t f C~ icy` f
eader/ anifold 31D,51 Distribution f Ix Hole Size x Hole Spacing nt t Air Intake' e
Pipe(s) I
Length Dia Length J Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench center i, ( Bed/Trench Edges Topsoil E] Yes [ No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: /
Location: 815 Prairie Meadows Dr Hudson, WI 54016 (NW 1/4 N 1/4 25 T29N R19W) Scenic Hills Lot 14 Parcel No: 25.29.19.2408
1.) Alt BM Description ~y~00~ ljyl`
2.) Bldg sewer length
- amount of cover
Plan revision Required? 7 Yes No 1
Use other side for additional information.
- C ___Z_ re ert.
Date InsepctoIs-, natu C.
No.
SBD-6710 (R.3/97)
~~-'a;~;e ■ S9il eJa-lu.a~on /o:t
iKeade+e9S ♦ ~X~S~+ng eleda
CCn round cc"1,~~ Cr,/e;
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~ G a, -fin /~]-n.%Ea•r' G~ lr..rr, r/F
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~rr,ar County
?`f Safety and Buildings Division St. Croix
e 1-d 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.)
P Madison, WI 53707-7162
V ermit Application State Transaction Number
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the app gate governmental unit Na
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned S ale submitted to project Address (if different than mailing address)
the Department of Safety and Professional Services. Personal information you provide may be ndary
s in accordance with the Privacy Law, s. 15.04 1 m Stats. ` Same
1. A lication Information - Please Print All Information
Property Owner's Name 013 Parcel #
Sr
Tom & Jodi Johnson cRO~ 020-1395-14-000
Property Owner's Mailing Address /Itn, Property Location
815 Prairie Meadow Dr. Govt. Lot _
City, state Zip Code Phone Number NW ''/s, _NW_'/., section 25
(circle one)
Hudson, WI 54016 715 xxx-xxxx T 29 N; R 19 E or W
IL ype of Building (check all that apply) ~~1 S j Lot #
1 or 2 Family Dwelling - Number of Bedrooms 4 14 Subdivision Name
Block # Scenic Hills
❑ Public/Commercial'- Describe Use _ Na
❑ City of
❑ State Owned - Describe Use CSM Number Q Vill e of
Na own of Hudson
III. Type of Permit: (Check o y-og. !!!,A. Complete line B if applicable)
A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
B• ❑ Permit Renewal El Permit Revision ❑ Change of Plumber 11 Permit Transfer to New List Previous Permit Number and Date Issued
404963 issued 3/25/2002 r/
Before Expiration Owner
IV. T of POWTS System/Componeat/Device: (Check all that apply)
LKNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dispersal/Treatment Area Information: 42 Infiltrator "Q-4 Plus" Standard chambers & 4 endca s, existing Zabel A-100 effluent filter
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (st) Dispersal Area Pro posed (sf) System Elevation
600 Gpd 0.70 Gpd/Sq. Ft. 857.15 sq. ft. 860.40 Sq. Ft. 95.25
VI. Took Info Capacity in Total # of Manufacturer
Gallons Gallons Units $ o I;
New Tanks Existing Tanks a 0, 1
~U ~ ~ ~ wC7 a
Septic or Holding Tank Na 1,250 1,250 1 Wieser Concrete X
Dosing chamber Na a
VII. Responsibility Statement- I, the ndersigned, ssume responsibility for installation of the POWTS shown on the attached plan&
Plumber's Name (Print) Plumber's S' ature / MP/MPRS Number Business Phone Number
James K. Thom son ! s MFRS 30021 715 248-7767
Plumber's Address (Street, City, State, Zip
.OK
340 Paulson Lake Lane, Osceola, WI 54020
VII oun epartment Use Only
~
Approved ❑ Disapproved $Permit Fee Date Issued ssuing Agent ign e 6V
❑ Owner Given Reason for Denial `((7 ~ 34 3 _ r:
IX. Conditions of Approval/Reasons for Disapproval 3 / I42t~n
SYSTEM OWNER: 1 V s 2~12C~U1~~
1. Septic tank, effluent filter and
dispersal cell must beAtrjv /maintained
as per management plan provided by plumber.,
2. All setback requirements must be maintained UU
ZIS per applicable A W~ijlfR6plans for the systeand sabn~it to the County orwly on paper not s than ~nsh s
SBD-6398 R.11/11
Conventional POWTS Index & Tilte Sheet
Project Name: Johnson 4 bedroom Replacement Conventional POWTS
i
Owners Name: Tom & Jodi Johnson
Owner's adress: 815 Prairie Meadow Dr., Hudson, WI 54016
Site address: Same
Project Location:
Subdivision: Lot 14, Plat of Scenic Hills
Legal Description: NWi/4 NWi/4, Sec. 25, T.29N., R. 19W., Tn. of Hudson, St. Croat Co., WI.
Parcel ID 020-1395-14-000
Page 1 Index and Title Sheet
Page 2 Site Plan
Page 3 Dispersal Cell Sizing Calcualtions
Page 4 System Cross Section
Page 5 System Management Plan
Page 6 Septic Tank Maintenance Agreement
Page 7 Certification for Utilization of existing septic tank
Page 8 Parcel map
Page 9 Waranty Deed
Attachments: Soil Evaluaiton Report
Mater Plumber Restricted Service: James K. Thompson, Dept. of Comm. Credential #30021
Signature: Date:
Page 1 Of 9
Design pursuant to In-Ground Soil Absorption Component Manual for POWTS, version 2.0 SBD-10705-P (N.01101)
~Seil aa.lua~ion/oi,t
1'Yteczde~..s • ~,rs~inc~ eleda~'m-,
nclef ro"nd 467146
t~ b7727
/ocQ ~-or~~ ep/~raX,
are in ~ndx-d ~v~' 82n~rrz / g ~SoF J~~ sun
/'eFer`ence~~loosQS on/y. \
• , ~ ffKalso-n, ~J/• 5`/0/6
o • O Lot/'/, F/~~ o,F' Scen~~,~/,C;
o ,
toe-/. 020 - /3RS-if/-cry
S~, c~ CU
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n fC: 'o dvo!' prop cud dw",Oo
100
T o~ S.
i ' EX;Sfi'o:'S~lSc~F bt
n1r~.. ha/e CalQ•% Efe%= 9193, ' ~ ncAn ~.cbpc{ by %~~f~!/d~'on
v~d;verS.vn Jo~de. Ce!/
110E 5 l ode. -UVO (k) • ~ar~~'a~ s of 6wo (2-) trU(4S
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~ q5 at a `X 9S!'"J/lSS16,114 dui'
h\ s,~~ce elect' = 9S.loo'±
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JOHNSQN DISPERSAL CELL SIZING CALCULATIONS
1. (4 bedroomsx 100 gallons estimated flowx 1.5 design factor) = 600.00 Gpd design flow
2. Infiltrative capacity of native soil = 0.7 gpd/sq fft.
3. Absorption area required: 857.15gq. ft.
4. Absorption area as proposed: 860.40 W. ft. (42 chambers total)
Infiltrator "Quick 4 Plus" = 20.00 sq.ft. EISA per chamber, Infiltrator "Quick 4 Plus" end cap = 5.10 sq.ft. EISA
857.15 sq. ft. - (4 endcaps)(5.10) = 836.75 sq. ft.
836.75 sq. 8./20.00 = 41.84 chambers required
Number of trenches: 2 Aa, 21 chambers per trench
Trench width: 2.83'
Trench length: 86.00'
Trench spacing: 9.00' on center
Total system area w/ 9' center spacing: 12.00'x 86.00'
Pg. 3 of 9
Soil Absorption System Cross Section
9 9.
9.soft
4" Schedule 40 Final Grade
PVC Vent Pipe
With Vent Cap 6,2sft
Leaching - ►
Chamber GAS ~5 ft
F- System Elevation
z.93 ft Sy.ft
Soil Absorption System Plan View
ft
.Z, 83 ft {
1
ft Vent Or Observation Pie Leaching Trench 1
P Chambers
111 4" Dia.
Trench 2 Header
Leaching Chamber Specifications
Manufacturer And Model c/ arc 41z-S
EISA Rating ~o o sq ft per chamber Soil Application Rate O.7 gpd/sq ft
gpd Design Flow 0.7 Soil Application Rate •i EISA Chambers
2 rows of chambers each.
Page 7 of /
2324
Wisconsin SOIL EVALUATION REPORT Department of Comrnel~t~~ Page 1 of 3
Division of Safety and Build A.C.E. Soil & Site Evaluations
in accordance with Comm 85, Wis. Adm. Code
Aitach complete s on than 8'%x 11 inches in size. Plan must County
include, but not limfffooo and horizontal reference point (BM), direction and ~~c~i St. Croix
percent slope, scale or dimemsions, north arrow, and location and distance to rrea t road. amel I.D.
Please print all informat9on. 20-1395-14-000
Personal irdormation ~y 73 Revi d By Date/
you provide maybe used for secondary purposes (Privacy law, s.150(1) (m)). ZO1 3
Property Owner Prope wtion
Tom Johnson & Jodi Hammerstad Govt. Lot'*v NW 1/4 NW 1/4 S 25 T 29 N R 19 W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
815 Prairie Meadows Dr. 14 Na Plat Of Scenic Hills
City State Zip Code Phone Number City J Village a Town Nearest Road
Hudson WI 54016 715-)=-xxxx Hudson Prairie Meadows Dr.
J New Construction Use: r, Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD
iel Replacement -J Public or commercial - Describe:
Parent material Glacial Outwash Flood plain elevation, if applicable Na
General comments
and recommendations: Site suitable for conventional POWTS._disp I cell with 0.7 gpd/sq.ft./day loading rate. Proposed
infiltrative surface elevation to be =-25'.
i 7 I Boring # J Boring
I . I I✓ Pit Ground Surface elev. 99.42 ft. Depth to limiting factor >102" in. Sod Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/W
in. Munsed Qu. Sz. Cont. Color Gr. Sz. Sh. 'E 1 ff#2
1 0-7 1Oyr3/2 none sil fill na na na 2vf,f 0.0 0.0
2 7-42 10yr5/6 none strat. s Ogg ml cw lvf 0.7 1.6
3 42-102 1Oyr5/6 none strat. s Osg dl - - 0.7 1.6
Ho ns #3 contains 10yrW2 OM sill inclusions. Inclusions are 1/2"- "thick, discontinuous & irregularly- shaped, oriented both horizontally
vertically, comprising 5 -10°k of horizon with redox. concentrations at outer edges due to tension saturation.
a Boring # _I Boring
y Pit Ground Surface elev. 100.78 ft. Depth to limiting factor >96' in. Sod Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P
in. Mursoll Qu. Sz. Cont. Color Gr. Sz. Sh. -Eff#1 'E
1 0-15 1Oyr3/2 none sil/sl fil na na na 11fm na na
2 15-29 1Oyr4/3 none sl 2f&msbk mvfr cs 2fm 0.6 1.0
3 29-42 1Oyr4/4 none sicl 1fsbk mfr cw 1fm 0.2 0.3
4 42-56 7.5yr4/6 none Is Osg ml cw 1vf,1f 0.7 1.6
5 56-96 1Oyr5/6 none trat s&g Osg ml - - 0.7 1.6
' Effluent #1 = BOD? 30 c 220 mg& ad TSS 1-30 1 mg/L ' Effluent #2 = BOD S30 mg/L and TSS S30 mg/L
CST Name (Please Print) natu C T Number
James K. Thompson q - 3602
Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number
340 Paulson Lake Lane, Osceola, WI 54020 5/8/2013 715-248-7767
Property Owner Tom Johnson & Jodi Hammerstad Parcel ID # 020-1395-14-000 Page 2 of 3
a Boring # - I Boring
ie Pit Ground Surface elev. 96.23 ft. Depth to limiting factor >107" in. Soil Applatlon Rate
Horizon Depth Dorninant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Mursell Qu. Sz. Cord. Color Gr. Sz. Sh. *Eff#1 `Eff#2
1 0-25 1 Oyr2/1 none I 2fgr mvfr Cw Alm 0.6 0.8
2 25-39 10yr3/6 none cosl 1msbk mvfr 9w 1vf,1f 0.4 0.7
3 39.47 1 Oyr414 none Cost 1 msbk mfr 9w - 0.4 0.7
4 47-60 7.5yr4/4 f2f7.5yr5/8 COW lmsbk mfi aw - 0.2 0.3
5 60-77 1Oyr4/6 none 'ement.l Osg mvfr cw - 0.4 0.7
6 77-107 1Oyr4/6 none strat.s Osg dl - - 0.5 1.0
Horizon #16 contains 1/8" -1" bands of 10yr4/4 Ifs at approx. 3" - V intervals. Loading rate reflects reduced permiabilty of horizon associated with
banding,
Boring # Boring
F-1_J 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/r
in. Munsell Qu. St. Cord. Color Gr. Sz. Sh. *Eff#1 *Eff#2
❑ Boring # -j 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
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS -S.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.
SBD-8330 (R 07/00) A.C.E. SOO & Site EVeluaWM
• ~/'7"0.j/'ie ~ J~6i/QJa.ICt~Y~On /Oit
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Q(6. ~l r T p o ~ s, Z~ 81 -Xis6,~ o!'s pwsa..F W1,6o be
fia/e Ca/e% Ele%= 99.93, ' ' 0 U
I nCannCc,bW by 'n5fk!/dbcn
Oled;vers,brn dCY(de. @e//
no-.2.: ✓l.0 Slope- -dVoc.4LOt. . eor73.~6s w6w,o ez-) tr~ cAs
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Conventional Septic System Management Plan
Pursuant to SPS 383.54, Wis. Adm. Code
General
The conventional septic system shall be operated in accordance with SPS 382-384 Wis. Adm. Code, and shall be maintained
in accordance with component manual SBD-10705-P (N.01/01). All local and/or state rules pertaining to system
maintenance and maintenance reporting shall be complied with. Questions on the operation or maintenance of the system
should be directed to the installing plumber, Jim Thompson at (715) 248-7767 or the St. Croix County Zoning Department at
(715) 3864680.
Septic Tank
Septic tank servicing mechanics comply with SPS 383.54(l)(e). Septic tank to be located within 150' of service pad, with
bottom of tank to be 515' below service pad elevation. The operating condition of the septic tank and outlet filter shall be
assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in
the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR
113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are
not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be
needed to maintain less than 1/3 scum and sludge accumulation in the tank. 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. Septic tank manholes 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 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank.
No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank
abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS
component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If
such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings
Division.
Soil Absorption Cell
Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should
be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for
vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface
within and above the system and will promote frost penetration during cold weather months. Cold weather installations
(October-March) dictate that the system be heavily mulched for frost protection.
Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L, TSS, and 30 mg/L FOG. Influent flow may not
exceed maximum design flow specified in the permit for the installation.
Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the
owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring.
Effluent flow shall be alternated between dispersal cells on a two-year schedule by use of diversion valve. Effluent to
be diverted from new cell to old Drainfield at 2 year anniversary of new system installation. Old drainfield to be utilized for
a 1 year period. Effluent dispersal to be alternated between systems on a three year rotating basis thereafter.
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. Excessive ponding within the dispersal cell will be eliminated by installing a new soil
absorption cell to bring the system into proper operating condition.
Pg. 5 of 9
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the following residence:
(Street address) 815 Prairie Meadow Dr., Hudson, W154016 located
at: NW '/a, NW '/a, Section 25 , Town 29 N, Range 19 W,
Town of Hudson , St. Croix County Wisconsin.
Upon inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of SPS. 384.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service 5/08/13
Did flow back occur from absorption system? Yes X No
(if no, skip next line.)
Approximate volume or length of time: Unknown gallons unknown minutes
Tank Capacity: 1,250 gallons
Construction: Prefab Concrete X Steel Other
Manufacturer (if known): Wieser Concrete
A Tank (if known): 11 years, installed 8/23/02
ermit ber (if known) 404963
James K. Thompson
icensed Plumber Signature) (Print Name)
Mater Plumber Restricted Service MPRS 30021
(Title) (License Number) MP/MPRS
May 8, 2013
(Date)
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev. 2/2012
X0 79
r
~2V DRAINAGE H.W.L= 553. si
EASEMENT
drat ` \ C~ ~
13
8
/ 129,119 SO FT
m 2.964 ACRES
00,
4.c
l
14
1
t' 189,551 SOFT
4.351 ACRES
V d
.41
25
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ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer Tom & Jodi Johnson
Mailing Address 815 Prairie )Meadow Dr., Hudson, WI. 54016
Property Address Same
(Verification required from Planning & Zoning Department for new construction.)
City/State Parcel Identification Number 020-1395-14-000
LEGAL DESCRIPTION
Property Location NW NW /4 , Sec. 25 , T 29 N R 19 W, Town of Hudson
'/4 , '
Subdivision Plat: Scenic Hills , Lot # 14
Certified Survey Map # Na Volume , Page #
Warranty Deed # 42 j 7 0 6 ,S (before 2007)Volume 1Y 77 , Page .
Spec house Ayes r, ►o Lot lines identifiable OyesQno
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 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 4
SIG 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. 04/12)
U 18??P 4 0 8 l\
STATE BAR OF WISCONSIN FORM I- 1998 6 7 _71120 6 5
KATHLE8111 H. WALSH
Document Number W TY DEED REGI. CROIX COD,YI
020-1070-10-000 RECEIVED FOR RECORD
Parcel identification urnber (PIN) 04-24-2602 8:30 AN
THIS DEED, made between Carriage Homes Inc., a Minnesota WARRANTY DEED
corporation, Grantor, and Thomas P. Johnson and Jodi V. Hammerstad, EXEMPT #
Grantee. as joint tenants REC FEE: 11.60
Grantor, for a valuable consideration, conveys to Grantee the following TRANS FEE t 239.70
described real estate in St. Croix County, State of Wisconsin (the COPY FEE:
CERT COPY FEE s
"property-): PAGES : 1
Lot 14, Scenic Hills, St. Croix County, Wisconsin
Recording Area
This is not homestead property. Name and Retum Address:
,
=1 it Inc. Ea Q /c ✓4/ry
Together with all appurtenant rights, title and interests. Lake Rd #200 `
Grantor warrants that the title to the Property is 8ood, indefeasible in N nab on, MN 55112
fee simple and free and clear of encumbrances except
Dated this 19th day of April, 2002.
Ca3fiage Ho YM, Inc.
/ (SEAL) (SEAL)
• Dwight S. Harvey, Presi t '
(SEAL) (SEAL)
e s
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF MINNESOTA
SS.
WASHINGTON COUNTY.
authenticated this 18th day of April, 2002 Personally came before me this 18th day of April, 2002,
the above named Dwight S. Harvey, the President of Carriage
Homes XXI, Inc., a Minnesota corporation to me known to be
s the person(s) who executed the foregoing instrument and
acknowledge the same.
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by § 706.06, Wis. Stats.)
THIS INSTRUMENT WAS DRAFTED BY
Gregory A. Booth, Atty, 1900 Silver Lake Rd #200, New
Brighton, MN 55112 r
Notary Public, State of Minnesota
(Signatures may be authenticated or acknowledged. Both are My commission is permanent. (If not, state expiration date:
not necessary.) ■ •
-Names of persons signing in any capacity must be typed or printed below then
NOTARY PUB'IC-MINNESOTA
signature. -'sr
My Comm. Expires Jan. 37, 2006
■
.onsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
, trand Bunding Divisiov,
INSPECTION REPORT Sanitary Permit No: 404963 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
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 Parcel Tax No:
Landmark, Inc. Hudson Township 020-1395-14-000
CST BM Elev: Insp. BM Elev: BM Description: vw ~L
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM V
Aeration Bldg. Sewer
. Sy c!~_ ~-L
Holding St/Ht Inlet
~2 9 7-6~
TANK SETBACK INFORMATION St/Ht Outlet
QI 9~- b
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
jff,~ Dt Bottom
Septic 7 -7 5-/
Dosing Header/Man.
Aeration Dist. Pipe
Holding Bot. System l r s ; 7
z9 ~
PUMP/SIPHON INFORMATION Final GradeL`
Manufacturer Demand St C , P7 l bd ' t/
Model Nu bar
TDH Lift Friction Los System Head TDH Ft
For amain Le Dia. Dist. to well
SOIL ABSORPTION SYSTEM /
BED/TRENCH Width .3 f - Length / No. Of Trenches PIT DIJN RNSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS t
SETBACK SYSTEM TO P/L\tV BLDG WELL LAKE/STREAM LEACHING an turer:
INFORMATION CHAMBER OR Cl~e>t~`
Typ f System: UNIT Model Number: (c2 ii
DISTRIBUTION SYSTEM 3S2a s¢y. ~3--
Header/Manifold Distribution fI Q~ x Hole Size x Hole Spacing V nt to Air Intake
P (s)
Length Dia Length Dia t n
SOIL COVER x Pressure Systems Only 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 W1 No 1 Yes j] No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: l~/ Qy Inspection #2: L13
Location: 815 Prairie Meadows Dr Hudson, WI 54016 (NW 1/4 NW 114,25 T29N R19W) Scenic Hills Lot 14 Parcel No: 25.29.19.2408 01
1.) Alt BM Description =511 at #r') s/~( I v t Awm4t&~ add V-4i S '
2.) Bldg sewer length = N e>z-d flu Sow s-~1 6tl~4 (fir/ , , /1 le// yt o
- amount of cover = r / Q U
d&fAA-)
Plan revision Required? s No
Use other side for additions information.
- - -
Date insepctor's Si a ure Cert. No.
SBD-6710 (R.3/97)
,
Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162 G>rd ,2
Ifisconsin Madison, WI 53707 - 7162 Site Address
9, 15-
Department of Commerce
Sanitary Permit Application Sanitary Permit Number ~~55 ~j
in accord with Comm 83.21, Wis. Adm. Code, personal informatio e k if Revision~v ~ ` 6
may be used for secondary purposes Pnvac . k4
1. Application Information - Please Print All Informa on Krww State Plan I.D. Number /1-4
Property Owner's Name r, 'S LUTJI- Parcel Number a S l • Zxlp a
Aa-.v
Property Owner's Mailing Address NING UFFI Property Location
73 /~.S dL / ' A ; S T g N, R
City, State Zip Code Phone Number Lot Number ` Block Number
Subdivision Name CSM Number
1,0 Z e,111 r 1-1116-
H. Type of Building (check all that apply) ❑City
❑ 1 or 2 Family Dwelling - Number of Bedrooms ❑Village
❑ Public/Commercial -Describe Use ownsbip kd a~'~~
❑ State Owned _ 3 X q q / Nearest Road
M. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete hne B if applicable)
A' 1 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use
stem Tank Only Existing stem
Permit Number Date Issued
B. ❑ Check if Sanitary Permit Previously Issued
IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use)
440-Non -Pressurized In Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wedand
22 ❑ Pressurized In-Ground 410 Holding Tank 48 ❑ Single Pass 510 Drip Line
45 ❑ At-Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other
V. DispersaMeatment Area Information:
Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade
Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Tanks Concrete Constructed Glass
New Usting
Tanks Tanks
Septic or Holding Tank -
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume responsibility f on of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's Signature /MPRS Number Business Phone Number
Plumber's Address (Street, City, State, Zip Code)
tl 5e -z9]2,0-- .9-0 r✓ ~Z (T.14
VIII. oust /De artment Use Only 2-pproved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issu Is. nt Signature (No Stamps)
Surcharge Fee)
❑ Owner Given Initial Adverse YI-7103
19~9
Determination IX. Conditions of Approval/Reasons for Disapproval Stj .
Cs T s1 wf - s
L
z d
complete Plasm (to th County ody for the em on paper not less than Sla x 11 inches In size
t,(Ja4t Ld c, l)15/13
SBD-6~ 6"8 (R. 05101)
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23~q~b~,s
FROM Sckumaker Pl-umbinq FAX NO. : 7153863121 Aug. 21 2002 01:37PM P2
s~~ ,ate
PA~ 4hkItil
Wsmnsin D2 wvftnt of Co-Meroo SOIL EVALUATION REPORT rw i Qf -
Diviston of 84100ty Ond guild'"" ~ eoaorfUr w WM Comm rig, Wo, Aam- Code Coitnb mos Atsral+ erxnpraue Nr plan on paper not lase than S 1!2 X 11'n~ m). Qtrwon artdt pry~rosl
1.D. r7 Z D - / 3 ~S - Qj~
Includ0. tit not Wall lot wwlmr and h0ftw ol Pr An (B ~
porcer# dope. SAW& or dfrr"doww, hoAh a"WO- and WOOD". end dlemnac ncer~t road. Mrld ~Am
Preasd print all Irrformewill. 11 7 0
be used for owrdmy purpoW p"ay Low, e, 15.04 p) (r"R•
Parsd+atietnrrr~ouanYa+pr ~ rtiy Laoetian
praperlY Owner G tat fV ~~df` 1/d S T ~q N R I q E
Lot 0 Block * Name or IN~ t Is
Property pwnera Address t 1
t e ape Villap M Ton Nesraot Puma
ri
• t
r Qode deNred 136810 ttoer MUD O OPD
RL New Consauafon We:R tlel / Nunlti Dea
❑ Repldoerfikr+t ❑ public upfrc or appunx:tr"tta - Darenwt -40
~Sh p{ood Plain elevation It appllcRNe
Parent material /~C/ ~ ~G • ~'6
ftnerai oamrrretrta Sr' v' _ r✓.
and renymmendslions, /
scring ti to arninno !scot
SAl1 IiCilfon m
t artless der. R Depth in.
on Texhxt. Strudwi Consistence Scundary Realer OPD/Itr
NoA2on D'Ptt1 t7a*„nan! CQtor gadox Okscxlpd
in- wir"ll ou. Sa. ConL Color Gr. S7- Sh.
2 -(p~S r rr'-jg _ ' -
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pit Grwnd suttees rlev. R. Depth to Mn►rtMO ta3orrn. qp Rats
(p~cn Caplh CFo insrd Color Raadx 5aorfiPdom Tecturs Structure Consislanee Boundary Ric
in. Mun9g1 Qu• Ste. CONC. COT" Qr, BE. $h. 'EM VIM
1 J
045 5- rni
• Effluent #1 x SOD, > 30,c 220 r-KYL end T86 530 a 159 M9& ' Effluent ft = SOD,:! 30 mylL and TSS ~ 30 mt>n-
(Please F'n re GST Nuff*W
pate 6+t,tuati0'1 Conrsuctea Tolep one Nucrdw
padre'
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Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162 s
Madison. WI 53707 - 7162 Site Address
i~SCt~!"1sin b3 ~5 ta (E D
De artment of Commerce 3 2) z- Z Sanitary Permit Number
Sanitary Permit it App 'cation
In accord with comm 83.21. Wis. Adm. Code, personal information you provide ❑ D=k if Revision
~ I-A Used for Privac Isw, i15. 1 m Staff Pan I.D. Number
1. Application Information - Please Print All Information
G ~,vGD Parcelr z s. a9. ( .2
Property Owner's Name ` G
C 0-13S-
a, ` R Property Location
Property owaer'a Mailing Address `1 Y .c..!/ MAR 1 ~ ~ X02 i ' yi ''f • S -~?S T a N. R
7 L` U! Lot Number Block Number
city, state Zip Code PS~ X00 lGE /
ZpNiNC' Subdivision Name CSM Number
b*e~i~A+'d /U
o~ ~v 5 ~ eats. Dcicy
H. Type of Building {check an that apply)
it, or 2 Family Dwelling - Number of Bedrooms ❑Village
❑ Public(Comnsere"d - Describe Use
Nearest Road
❑ State Owned f l
M. Type of Permit. (Check only one box oa line A (numbering scheme for internal IM). Complete line B if appti ble)
F or Cunty im
A. 1 New 2 13 Replacement SyTsw=3 acement of 6 ❑ Addison to
stem BCheck if Sanitary Permit Pteviwit Number
IV. Type W Permit: (Cheek all that app1y)(numbering scheme is for internal me) -f-- I itOLD-1- IT- 50 ❑ Constructed Wetland
44~Non-Preasurixed in-Ground 21❑ Mound 47 ❑ Sand Filter
22 ❑ Pressurized in-Ground 410 Holding Tank 48 ❑ Single Pass 51 0 Drip Lint 46 ❑ Aerobic tst Unit 49 ❑ Recircula M111
30 ❑ Other
45 ❑ AL-Grade ~
V. D t Area Infornmtiomt percolation Rate System Flev ohs Fitnl Grade
Dhpe Soil Application Blevation
Design Plow { Required 5Rate(Gals./Days/Sq.Ft.) (Min.linch)
propor
l
Prefab Site Steel -Fiber Plastic
VI. Tank Into Capacity in Total Humber Manufacturer Concrete Constructed Glass
Gallana Gallons of Tanks
New F~~f
Tanks Tusks
septic er lHokft Tadt x / Q l e S B r'
1?osioy chamber
assume rMes saibWty for a of the POWTS shown on the attached pianS.
VIj, otrsiblli Statement- I, the tmderdgrtid Number Business Peoix Number
31111111111 p>uahber's Name (Print) Plumber's
Plumber's Address (Street. City. State, Zip Code)
/pe artment Use Only Dau Issued Issuing Agent Signature (No Stamps)
SanitaryPermit Fee "Includes Grouhhdwater
,Approved C1 Disapproved Sure Fee) eD
❑ owner Given Initial Adverse ~ C 2f 3 p ` ' J,Qn
Deternninati G~C~ on c~G~O~-6~S
JX. Conditions of provaneasons fisaooval C&t~ ~ u.a
~;~,~s cep- 4' 0 ~s~tidQ..e
trot ka teas IN x ly iocea in she
Pasch Piet, Xas (to tfuh Counq ea11) to the sr:tem an Ma'
~ ~ C'mt~~a,w, ~.~!~%G,~"~ PA^- rer.~t,N.R..~aQ•~l-l~ts
S&7398 (R. 05101 "
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Vdsconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code County
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must 1-• C rot')(
Include, but not limited to: vertical and horizontal (BM), direction and Parcel I.D.
distance to nearest road.
percent slope, scale or dimensions, north a on
Please print 1n>1pi77n8ifQ R iswed by Date
FemwW information you provide may be fQr, Law,1,15.04 0) (m))..
Properly Owner Property location
`Govt Lot N 1/4 m 1/4 S 25 T 29 N R i E (od
Property Owner's Mailirw Address s? it # Bbdc # Subd. Name or CSW
City state Zip Code POW _ ❑.city ❑ Village Town Nearest Road
t 1 l w« cr 111 D FEZ a ^ It i R~
® New Construction Use: ® Residential / Number of bedrooms 3 _ Code derived design flow rate ~~d ~lo O O GPD
❑ Replacement Q Public or commercial - Describe:
Parent material Ov f L tcLs Flood Plain elevation if applicable 9 Z _S R
General comments r y S k w%_ e, l e- L) o, • b n - c)-1,040
and recommendations: (,.4,
Boring # n Boring
a I3 Pit Ground surfaceelev. 99.4D ft Depth to limiting tailor 100 in.
Sod Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPQW
in. Munsefl Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 U- 10 ~jr 2 LIS m an c 5, ivy 1 2
2 -Ibo 101le-4111, rnS s 1 -1 1. Z
~.a
4- Cl
28• a~ G. a
Boring # . ❑ Boring
® Pit Ground surface elev. ft. Depth to limiting factor in.
Sol Application Rata
Horizon Depth Dominant Cob Redox Description Texture Structure Consistence Boundary Roots GPOW
in. Munsell Qu. Si Cont Color Gr. Sz. Sh. 'Eff#1 •Ef w2
I 0-1L tb Z - S n1 ~r c v _ -1 ► . Z
m S - - -7 Z
Z 12 _i tt 1 cJig
' Effluent #1 = BCD,-- 30:5 220 mg& and TSS >30:5 150 mg/L ' Effluent #2 = BOD < 30 mg& and TSS < 30 mg/L
CST Name (Please Pratt) S' are CST Number
e.r' z5 33p
Address Date Evaluation Conducted Telephone Number
-Z 11 5 4 Sd er t~- / DZS - j - o -7 lS- 2y 7 -y 00
Property Owner 4r k~ l Parcel ID # Page Z of _
Boring # ❑ Boring
❑ Pit Ground surface elev. 9q - Oft Depth to lb tg *W ) in. Soil Application Rate
Horizon Depth Dominant Colo Redox Description Texture Stricture Consistence Boundary Roots GPDfit:
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. -8W 'Eff#2
p-14 l 2
Z 14-IIO mS m I - ~ : "1 I . Z
33,E bg.~
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil ication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDff
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'EfM "Etf#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 GPDftf
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. `Eff#1 '0#2
" Effluent #1 BODS > 30 < 220 rig1L and TSS >30:5 150 mglL ' Effluent #2 = BOD5 < 30 mglL and TSS 30 mgfL
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.
S$D68330 (R07/00)
I
PAGE 3 OF
NAME ►4 Y` K e- f LOT# LEGAL DESCRIPTION, /cal '/e,lWY4,S z5T Zq N R I,( E (or&
SCALE: 1"= yd
BM I ELEVATION lDO.O
l
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BM 1 DESCRIPTION 4612 o (Z yc. Q /Le- V +
l BM 2 ELEVATION 9 7• Sl 5 cc • Z5
l BM 2 DESCRIPTION to e o I z ~yc- TPe
SYSTEM ELEVATION q 7• 00
ALTERNATE ELEVATION 9 & ' O 6
CONTOUR ELEVATION 17P. So 9 9 5 0
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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 (POWTS) 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-
9 0567-P (R.6/99).
Table 1: System Desi n Specifications
Sanita Permit Number b
Number of Bedrooms
Design Flow - Peak pd)
Estimated Flow - Average (gpd)
6D
Septic Tank Capaci (gal)
4
Soil Absa tion Component Size ftz) Z_
Type of Wastewater Domestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Abso tion Component
Design Flow - Peak (gpd) I - --j
Maximum Influent Particle Size (in 1/8
Maximum BOD m /L) 220
Maximum TSS m /i. 150
Table 3: Maintenance Schedule
Septic Tank Inspect and/or service once eve 3 years
Outlet Filter Inspect once a year and clean at least once eve 3 ears
Soil Abso tion Component Inspect once eve 3 ears
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 sep ' and outlet filter shall be assessed at least
once every 3 years by inspection. The outlet fil r shall be cleaned as necessary to ensure
proper operation. The filter cartridge shou not be removed unless provisions are ma a to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
Absorption Component
Management Plan for a Septic Tank and Soil
filter to equipped with an alarm, the filter shall bs serviced if the alarm is activated continuously.
Intermittent filter alarms may lndi=te surge flows or an impending continuous alarm. The
septic tank shall have Its contents removed when the volume of scum and sludge 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 an assesecnent, maintenance personnel shall advise the owner of when the next service
needs to be performed to maintain leas than maximum scum and sludge accumulation in the
tank.
Manhole risers, access risers and covers should be Inspected for wetter tightness and
soundness. Acct openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, detective, or subject to failure must
be replaced. , Exposed access openings greater than 8-inches In diameter shall be secured by
an effective Iockin or unauthorized entry into the tank.
9 device to prevent accidental o
No one should enter a septic or other treatment or holding tank for
any reason without being in full eompilenoe with OSHA standards for
en" a esesnllned specs. The a mosphwo within the septic cw other
tr~aaffinnt of holding tank may 6ont8in lerahal gases, and moue of a
psi m ftm tho IntWor of the tank may bt dfiftuN or Impossible.
w
Tank abandonment shall be In accordance with Comm 83.33, Na. Adm. Code when the
tank Is no longer used as a POWTS component.
ll Abag+,,,, ion Corngga g
The soil abswption component serving this structure Is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2,
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation, Good water
conservation predicts by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption components operation must be assessed by Inspection at least
ones every three years. The Inspection shall Include recording the levels of ponding, if any, In
the observation pipes, and a visual Inspection for any evidence of surface seepage or discharge
from the oomponent. On steeply sloping sites, arem of erosion should be Identified and
reported to the owns, for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard,
Traffic around or over the soil absorption oomponent should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure Is usually temporary, but Is difficult or
Impossible to repair until weather conditions improve. In general, soli compaction over this
component will reduce diffusion of oxygen Into the soil and dispersal cell, which may lead to
more Intense, and earlier, organic clogging of the soil.
2
Management Plan for a Septic Tank and Soil Absorption Component
Plantings of doep-rooted trees and shrubs directly over of within ton fest of the component
should be avoided since root intrusion into the component may obstruct wastewater flow.
Contingency Plan
In the event of system failure, a new system could be Installed in an alternate area. With the
Installation of a dlvsrter valve, the existing system could also be reused after a period of three to
four years.
It Is the property to maintain the aI ate free from
responsibility tea area any planting of
truss, shrubs, etc, In case of failure of the original system, the alternate area will be needed. If
any trees, shrubs, etc. have been planted on the alternate area, they will have to be removed at
property owners expense.
If alternate area is destroyed, there are other alternative systems that can be used, in which,
could result In added expense to the property owner,
Any tank abandonment shall be done in accordance with Wisc. Code 83,33, Any questions
regarding this code, please contact your local Zoning Office or contact the installing plumber.
, o aN ice fl ~c„e„ ~'1 t S ~3 $ - 4 tp 4
C~ v,,r~~ o..~'a.'~L ~ \.'U~ M ~ ~ N t Z i S~ ~ ~ ~a► ~ S .Z
ST' C ROIX C:OUN IN
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address
Property Address r
(Verification required from Planning Department for new construction)
City/State ~ SarJ,Zj de 4e4Parce1 Identification Number
LF,GAL DESCRIPTION
Property Locatioa~ 11.,,FYA) t/., Sec. 'ISS, T•f _N-RLY-W, Town of Ai e Z wo--Vr 4,
Subdivision. Lot #
Certified Surrey Map # Volume . Page #
Warranty Deed # ~ ~94- . Volume . Page #
Spec house' yes ❑ no Lot lines ideadfiableo yes Cl no
SYSTEM MAII~IT'ENAI~ICE
. brptoper use and maintenance of yow septic:ystera eouId result in its prima =failure to handle wutes. Proper
consists of pumping out die septic tank every throe yens or tooter. if needed by a Iicea=sed pamper. What you put into the system .
can affect tie function of tare septic tank as a trrainment stage in the waste disposal system.
The prvpctty owner :.genes to submit to St. CMMZoning Dcpnt=nt: omttficatsaafotm. sigmed by the OW= and by a
mastarplmuber.lovmeyman Plumber; restrietod ptumber or a liceasod pumper verifying that (1) the on-site wastewatcrdisposal systam
is in proper operating condition and/or (2) after iaspoctioa tad pumping (if necessary), the septic tank is less than 1/3 fitll of sludge.
Ilwe, the aadersigmed have read the above roquirements 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 his been maintained meat be completed and returned to the St Cram County Zoning Office within 30
days a three year expiration, date.
g DATE
OWNER CERTIFICAT)<ON
I (we) certify tha statements on this form are true to the best of my (our) knowledge. I (we) am (amt;) the owaa(s) of
the property . by virtue of a warranty deed recorded in Register of D?oe& Office.
f` ! ~L
SI TURE OF APPLICANT DATE
***000 Any informatioa that is mis-rept+eseatcd may rmdt is the unitary permit being revoked by the Zoning Department.
Indude with this application: a stamped warranty deed firom the Register of Deeds office
a COPY of the ceztified sti vey nup if reference is trade in the warranty decd
;
DOCUMENT NO. WARRANTY DEND
~I BTATB OF WISCO CONDISINN- -FORM 0
Ll i1
j I TMIL 8►AC1 RLBLRVLD FOR RLCORDINO DATA j
I.
RICHARD N. PEARSON and JEAN M. II
i
THIS lIVDEN'I'URE, Made b
PEARSON, husband and wife,
'I
grantor. S.. of....st:.. Croix ..................................................County, Wisconsin,
CARRIAGE HOMES XXI, INC., a
hgeb conveys and warrants to........._........_
Minnesota corporation.!
. _.....................................fautee of II
.............................................................Mi ~X
'as6ing£on County, or the sum of ~i.
i .t~
prl~_Qglr., and noj] 00 01.00) and other good and valuable RETURN TO
CS211S1~JC~7.SZr}
...............................................................j;
the following tract of land in....G...CQ1x ...............................................County,
Wisconsin : A1.1..Of the...N..9r.k.hW.~S.t..Q4iart e.r....! Nti~';; ~nd_.-(lor ~h- ~Ialf (N~) of the Southwest
Quarter (sA) of section Twenty-Five (25) , Township 'lwenty-Nine (29) North, Range
Nineteen (19) West, St. Croix County, Wisconsin, except Lot One of Certified Survey
map filed June 29, 1994, recorded in Volume 10, Page 2782, St. Croix County Register
of Deeds, as Document No. 518444.
i
In Witness Whereof the said grantor... their........... hand 5... and seals.... this
S ha.v..e . hereunto set
day of... ~ay A. D., UC. ZU.1
(SEAL)
BIGWW AND SEALED IN PRESENCE OF
.......................(SEAL)
M.:.~O1V .
................................V (SEAL)
State of , Z 7 a „F ( 7 A. D., ]X ....2.4,0
119-M-Corporation Minnesota Uniform Conveyancing Blanks (1978) Miller/Davis Co. ° St. Paul, MN 651-642.1988
STATE OF MINNESOTA ss. Affidavit Regarding Corporation
COUNTY OF and being first duly sworn, on oath says(s) that:
1. (They are) ( - -he is) the and the
respectively, of
a corporation, the corporation
_ - -
named as -
in the document dated and filed for record as Document No. (or in Book of - - - - - - - _
) in the Office of the (County Recorder) (1UPiVXX40(K 4
of St. Croix County, .Minnesota.
2. Said corporation's principal place of business is at - -
and said corporation's previous principal place(s) of business during the past ten years (has) (have) been at:
3. There have been no:
a. Bankruptcy or dissolution proceedings involving said corporation during the time said corporation has had
any interest in the premises described in the above document ("Premises");
b. Unsatisfied judgments of record against said corporation nor any actions pending in any courts which
affect the Premises;
c. Tax liens filed against said corporation; except as herein stated:
i
4. Any bankruptcy or dissolution proceedings of record against corporations with the same or similar names,
during the time period in which the above named corporation had any interest in the Premises, are not against
the above named corporation.
5. Any judgments or tax liens of record against corporations with the same or similar names are not against the
above named corporation.
6. There has been no labor or materials furnished to the Premises for which payment has not been made.
7. There are no unrecorded contracts, leases, easements or other agreements or interests relating to the Premises
except as stated herein:
8. There are no persons in possession of any portion of the Premises other than pursuant to a recorded document
except as stated herein:
i -
9. There are no encroachments or boundary line questions affecting the Premises for which Affiant(s)
(has) (have) knowledge.
Affiant(s) know(s) the matters herein stated are true and make(s) this Affidavit for the purpose of inducing the
passing of title to the Premises.
z H ,yes. ` ~ _
6" d sworn to before me this
Subscri
day of G_.`~ - _ 9 .2001
WARRANTY DEED
w DOCUMENT NO.
)`t: ~cg+. ~pD STATE OF WISCONSIN-FORM 9
ri
TNIi {PACE RESERVED FOR RECORDING DAYA
THIS INDENTURE, Made b ;RICHARD N. PEARSON and JEAN M. 1i
PEARSON, husband and ife,
grantors.. of..__St...Croix ........................................................County, Wisconsin, i
.AGE
h4;reby convecys and warFants to..__CARRIAGE HOMES XXI , INC. , a
Minn Bsota orporation,
..................................-----raiitee...._. of
.
WasFi ng~on
County, mor the sum of! I
pry _PQLlar,--and-.no1100 1 :00)...and_ other_•.good.... and. valuable RETURN 70
G.S21Al-dir.4.. ign.................................................................
jL
the following tract of land in..... 5t_..... C Q1?( ................................................County,
Wisconsin: .AU_Q.f...thy...N9. .G.hY? S ..Q41 .tte.r__(~~4y!;;j nd---~]orth-.Half ON ) of the Southwest
Quarter (SW%) of Section Twenty-Five (25), Township Twenty-Nine (29) North, Range
Nineteen (19) West, St. Croix County, Wisconsin, except Lot One of Certified Survey
Map filed June 29, 1994, recorded in Volume 10, Page 2782, St. Croix County Register
of Deeds, as Document No. 518444.
In Witness Whereof the said grantor. s.. haY.e...... hereunto set:......_. thei....._....r hands... and seals.... this
day of... May....................................... A. D X~L..2QQl
(SEAL)
SIGX D AND SEALED IN PRESENCE OF
. .......................(SEAL)
_ _
~ (SEAL.)
t i01V
(SEAL)
Minnesota
4b oak:~,
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I-- DRAINAGE H.W.L- 953.
EASEMENT s~
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