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HomeMy WebLinkAbout020-1395-53-000WisconsimDepartment of Commerce PRIVATE SEWAGE SYSTEM °Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). Permit Holder's Name: City Village X Township Kell ,Jason Hudson, Town of CST BM Elev: Insp. BM Elev: BM Description: TANK 1NFORMATION TYPE MANUFACTURER rA`f', " .~ CAPACITY Septic r ~ ` ~ -, •~^~ ~-, I ~,. ~ ~ . F,~ Aeration ; Holding TANK SETBACK INFORMATION TANK TO P/L !'~;,. . WELL BLDG. Vent to Air Intake ROAD Septic ':,~r` ~ °i ' ~ , r 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 DATA County. St. CroIX Sanitary Permit No: ~ 506339 State Plan ID No: Parcel Tax No: 020-1395-53-000 Sectionlfown/Range/Map No: 25.29.19.2447 STATION BS HI FS ELEV. Benchmark _ Alt. BM Bldg. Sewer y ~. ` ~; SUHt Inlet - SUHt Outlet 5 ~~ G ~ . b I Dt Inlet Dt Bottom Header/Man. ~ ~~ A ~ • ~~ 1 Dist. Pipe `7 • ~~. ~c. ,~.~ " 9t~. i/. Bot. System i 0 . ~ 1j,. ~, ~. qt.3 ,t Final Grade _ - ~ _ ( Q f St Cover ~ ~ ~ ~~ ~ O~ .,` BED/TRENCH Width ~ Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS '- ` - SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer;.. -~ ~: , ~ , _ C { ~ e ~" ' INFORMATION CHAMBER OR :. . - ~i ~. , Type Of System: 9- r ,A. ~ ,. ..,/' If ~ ~ y , ~. ~ ~ ~.+ ` UNIT Model Number: ; ~ ,q.~ r~ u,.Y.... 01 e.:.. ~.~ DISTRIBUTION SYSTEM '" ~••. ~t',~,, .... ; :•• _- Header/Manifold ~ e Distribution x Hole S' x Hole Spacing pipe(s) Length ~ = Dia `i' Length Dia Spacing ~ ' SOIL COVER Y Pressure Systems Onty YY Mnund Or At-Grade Systems OnIV c' :,. :~ / ~, -.J • r ~ -- "Z. Ven~t~q A_ir Intake -,~.• ~_ " ~..; 'G'_~. ~.. ~ . 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 discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: ! / Location: 757 Regal Road Hudson, WI 54016 (SE 1!4 NW 1/4 25 T29N R19W) Scenic Hills Lot 53 Parcel No: 25.29.19.2447 1.) Alt BM Description = ~ ` '- ' ~ '' `~ 2.) Bldg sewer length = - amount of cover = , . ~ ._ _~- F Plan revision Required? j] Yes [; No / _ __ __ . ,. -_ __.-__- ~s:~' ~ I f~ l --~ Use other side for additional information. " ~ ,.- _ L__ _ _ SBD-6710 (R.3/97) Date Insepctor's SF)tJrlature ~ - Cert. No. Safety and Buildings Division 201 W W hi P O County C~~ ` ~ ~ . as ngton Ave., . . Box 7162 ~seons~n Madison, 707 - 7162 Sanitary Permit Number (to be filled in by Co ) Department of Commerce (60 -31 5a~ 33 Sanitary Permit Applica State Plan LD. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you c ~~ may be used for secondary purposes Privacy Law, s 15.04(I)(m) Project Address (if different than mailing address) L A li i I ~~? ~~ ~~G pp cat on nformation- Please Print All In rmati~ECE1VED IBC G Property Owner's Name ~ ~ ~l Parcel # t # ~ Block # - ~~N 0 8 2008 _ ~ ~y - - o~ Property Owner's Mailing Addr Property Location l Z~~~ //~ ~/ ST.CROIX000NTY f Y ~' Z / Ci ry , tate S Zi ., : J., Section 1 , o J ~ ~ , ~ r- tti-~-o~~l (~/ ~ ~~' /~U ~,~j 7~~°f '~ ~f l " f`7(~ ~7 circle one) T Z ~ N R ~~ $ W II. Type of Building (check all that apply) ; or ~ S bdi i i N M C I or 2 Family Dwelling - Number of Bedrooms O ~ 14 u v s on Number S amc / ^ Public/Commercial -Describe Use JC / ~~~ L ~~ ~iC~ ^ State Owned -Describe Use x ity_^Villagc Township o(~ 1 [II. Type of Permit: (Check only one box on line A. Complete li e B if applicable) A. Ne- System ^ Replacement Sys[cm ^ TrcatmcnVHolding Tank Replacement Only ^ Other Modification to Existing System B• ^ Permit Renewal Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Datc Issued Before Expiration a, 5 'l 1 es Plumber Owner ;/~~ ~ 3~ 1 ~5 D ,7 Y IV. T e of POW'TS S stem: Check all that a 1 ^ Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constnxtcd Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ Drip Linc ^ Gravel-less Pipe ^ Oth la V. Dis enallTreatment Area Information: t' y~,~..~ ~ Design Flow (gpd) ~ Design Soil Application Ratc(gpdsf) Dispersal Arca Required Dispersal Arca Proposed (sf) System Elevatio~ T3 ~dr VI. Tank Info Capacity in Total Number Manufac[urer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank / ' ~ / /)` ( Auobic Treatment Unit ` L~ G C~ T posing Chamber VII. Responsibility $tatement- 1, the undersigned, assume responslbllity for installation of the POWTS shown on the attached plans. Plu bcr's Namc (Print Plum is Signature MP/MPRS Number Business Phone Number ~~ 1 ~~~ ~- z ~ ~ Z ~ z~~ Plum 's Address (Street, City, State, Zip Codc 2 ~. ~e ~ ~ 1~. ~~ y~~ z7 VIII. Coun /De artment Use Onl Approvod ^ tsapprov Sanitary Permit Fce (includes Groundwater Dat Iss cd Issuin gent Signa (Tlo S ps) ter Given Reason nial Surcharge Fcc) ~ g b ' IX. Conditions of ApprovaUReasons for Disapproval `3~ ~~~ ~ ~ ~r~ ~ SYSTEM OWNER: ' ~ • , 1. Septic tank, effluent finer and f o~ ~ r dispersal cell must all be st~vtces /maintained as per management plan provided by phtmber. 2. ~samack r aquiremettfa mast be ~ ~ ( ~ a ~ ~ , 1 ~ ~v ~ ~ ~''~ ' ~ eak / ordirtirrces. ~- t ,vt 6 IZ ~. j naucn comptese puns lro me Lounry Doty) for the system on paper not Its~than 8112 x 1 I inches in siu 3J y SBD-6398 (R. 01/03) ' ~ TIMM EXCAVATING Route 1 Box 192 WILSON, WISCONSIN 54027 (715) 772-3214 MPRS zZ65~ roe ~~ G~`~1 ~ t° ~ r SHEET NO. ~ OF CALCUlATEO BY • '' ~ ~ ` DATE m ~ <~ CHECKED BY DATE SCALE ~ a ~~, PRODUCi205-1(A~/lnc., Groton, Mess.01471. To Order PHONE TOLL FREE 1-800-2254180 JOB ~.1 ~5~~ I~+GI ~V TIMM EXCAVATING SHEET NO. Of Route 1 Box 192 0 WILSON, WISCONSIN 54027 CALCULATED BY ~~~~ DATE ~~ 7° (715) 772.3214 MPRS ~ CHECKED BY DATE zz~5~1 ' SCALE ~ " ~ i . ,~:,,,! i. .. ..... ..... .... ': ! _.. .. ._.... ....................:.........................~ ..... ~............. 9 ~" ~ , ... .....:..... :... ~ ': ~', a....... '~ <, i ~~ s . M1 PRODUCT 205-1 ~ Inc, Groton,Mass.01471. TO Order PHONE TOLL FFEE I-BOp-225E,7B0 .~ ' ~~SCOnsin VALUATION REPORT #263s ~ Department of Commerce ~~~~~~~ witn Comm a5, Wis. Adm. Code Page 1 of 3 Division of Safety and BujldingSt ~~ Certified Soil Testing, LLC Attach complete site of less than 8'/~ x 11 inches in size. Plan must County ~ 5e~ GeO.,e include, but not limit .vertical and I reference point (BM), direction and ' D Parcel I arrow, and location and distance to nearest road. percent slope, scale or dimen . . 020-1 95-5 -000 Please print all information. Revie d By Date Personal information you provide ma es (Pri cy Law, s. 15.04 (1) (m)). ~~ ~y ~7 Property Owner Property Location Kelly, Jason & Kimberley Govt. Lot SE1/4, 1/4, S25, T29N, R19W Property Owner's Mailing Address j~Q Lot # Block #. Subd. Name r CSM;ti 757 Regal Ridge Trail 53 Senic Hills City St a ZiISCo~pl umber ^ City , ^~ Village~^' Town Nearest Road Hudson ,I Sp Regal Ridge Trail © New Construction Use: ®Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD ^ Replacement ^ Public or commercial -Describe: Parent material loess over sandy/loamy outwash Flood plain elevation, if applicable NA ft. General comments install "cgpyentional",in-ground trench system w/ system elevations 5.5' below surface contours @ 0.7 and recommendations: gpd/sq ft loading ---'~' Boring # ^ Boring ^ Pit Ground surface elev. 92.5 ft. Depth to limiting factor > 120 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure ,' Consistence Boundary Roots GP D/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 1 0-6 7.5YR 2.5/1 - sil 2 m gr mvfr cs if/m .6 .8 2 6-12 7.SYR 3/3 - sil 1 m sbk mvfr gs lm/c .4 .6 3 12-32 7.5YR 3/4 sicl 1 m sbk mvfr cs im .2 .3 4 32-36 7.5YR 4/4 Is 0 sg ml gs im .7 1.6 5 36-54 7.SYR 4/4 ~ - s 0 sg ml cs - .7 1.6 6 54-120 10YR 4/6 - s 0 sg ml - - .7 1.6 H 6 grades to lOYR 6/4 5 @ 120" w/ one small inclusion of sl noted at 60-64" 2 ^ Boring Boring # © Pit Ground surface elev. 97.9 ft. Depth to limiting factor > 120 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure ' Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gc Sz. Sh. `Eff#t 'Eff#2 1 0-16 7.5YR 4/4 - sil fill 0 0 2 16-21 7.5YR 2.5/1 - sil 2 m gr mvfr cs if/m .6 .8 3 21-27 7.5YR 3/3 - sil 1 m sbk mvfr cs lm .4 .6 4 27-48 7.5YR 3/4 - sicl 1 m sbk mvfr gs im .2 .3 5 48-55 7.5YR 4/4 - ~~ sl 1 m sbk mvfr cs - .4 .7 6 55-80 7.5YR 4/4 - ~W s 0 sg ml gs - .7 1.6 7 80-120 10YR 4/6,6/4 s 0 sg ml - - .7 1.6 * Effluent #1 = BODS> 30 < 220 mg/Land TSS .30 < 150 /L * Effluent #2 = BODS < 30 mg/Land TSS < 30 mg/L CST Name (Please Print) Sign to CST Number Henry F. Grote 222774 Address Certified Soil Testing, LLC Date Evaluation Conducted Telephone Number E. 4366 353rd Ave. Menomonie, WI 54751 10/25/2007 715-233-0398 SBD-8330 (R07/00) Property Owner Kelly, Jason & Kimberley Parcel ID # 020-1395-53-000 Page 2 of 3 s 3 ~ Boring Boring # pit Ground surface elev. 96.9 ft. Depth to limiting factor. > 20 in. ~~_ Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consiste undan} Ro,~ts, GPD/ft' in. ' .Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ~- °•.,~,,,, `Eff#1 `Eff#2 1 0-8 7.5YR 2.5/1 - sil 2 m gr mvfr ~c~''^~ ~• .~,,],rn/c .6 .8 2 8-13 7.5YR 3/3 - sil 1 m sbk mvfr gs lm .4 .6 3 13-24 7.5YR 3/4 - ~ sil 1 m sbk mvfr gs im .4 .6 4 24-29 7.5YR 4/4 -~ l} sl 1 m sbk mvfr cs lm .4 .7 5 29-40 7.5YR 4/4 ~ Is 0 sg ml gs - .7 1.6 6 40-64 7.5YR 4/4 - s 0 sg ml cs i - ~ .7 1.6 7 64-120 lOYR 4/6,4/4 - s 0 sg ml - - .7 1.6 Effluent #1 = BODS> 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. SBD-8330 (R.07/00) Certified SOiI T25ting, LLC Property Owner Kelly, Jason & Kimberley Parcel ID # 020-1395-53-000 Page 2 of 3 3 ~ Boring Boring # Pit Ground surface elev. 96.9 ft. Depth to limiting factor . > 20 in. ~ Soil A li R ti ---- --- pp ca on ate Horizon Depth Dominant Color Redox Description Texture Structure Consiste` undar}tk Ro~fs~ GPD/ft' i ' _ n. Mansell '~~> Qu. Sz. Cont. Color Gr. Sz. Sh. `" -) `Eff#1 `Eff#z 1 0-8 7.5YR 2.5/1 - sil 2 m gr mvfr ~~'c~"°-°-- .;,gym/c .6 .8 ~~ 2 8-13 7.5YR 3/3 - sil 1 m sbk mvfr gs lm .4 _ _ .6 3 13-24 7.SYR 3/4 - ~ sil 1 m sbk mvfr gs lm .4 .6 4 24-29 7.5YR 4/4 -~ ~ sI 1 m sbk mvfr cs 1m ,4 .7 5 29-40 7.5YR 4/4 Is 0 sg ml gs - 7 1 6 ~ . . 6 40-64 7.5YR 4/4 - s 0 sg ml cs - .7 1.6 7 64-120 lOYR 4/6,4/4 - s 0 sg ml - - ~ .7 1.6 `Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mg/L 'Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L SBD-8330 (R.07/00) 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. Certified Soil TeSling, LLC Y ~~ •. P } 1- .~ ~, ~ o ~ ~ P 0. k ~ j g~ ~ ~ '' ~ ~ J (~ r~ ~ `~ J s .I J C'~ 0 ~ O in ~- ~ ~~/ ~- -~ d ~ a J ~.( d ,_ ,n -t' ~ ~ _ ~ s fl ~j ,y p c/~ s d ~' \~ d f _ d 1 0 1 `^ M ,^V l ~~, ~~ ~' ~ .~ s ~ Sp I ~ ~ ~ ^~ I III D 9 S ; C o ~ ~ ~ ^ O ~ e~ 6` 1 Q \ ~ ~ ~ ` ~ \~ { g d® ~ v ~+ ~ w \ C -- v ~ d I r °r~~ ~+~i~ -~~ d N o~ ~ ~ o 6 Y ~ ~ {n ~ ~ s ~ o ~ ~ o `l A~ tl' ,~ r `.t r/1~ d '~ ...rJ J .~ -~, pS J o O -` A 3 -'' , d ~ ~~ 0 0 oS ~ d s ~~ d ~ r„ ~ ~ o e ~, Z Safety and Buildings Division County ~ ` ~ ~ 201 W. Washington Ave., P.O. Box 7162 ~ ~seons~n Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 266 51 CQ 3~ Sanitary Permit Application State Plan I.D. Numbcr ~ In accord with Comm 83.21, Wis. Adm. Code, personal information rovide may be used for secondary purposes Privacy Law, s 15.04(I)(m) Project Address (if different than mailing address) [. Application Information -Please Print All Information RECEIVED 7~ T ~ ~ a ~ Property Owner's Name Parcel it Lot 5 ~ lock p ~ SEP 2 4 2007 0 _ 13 g _ Property Owner's Mailing Addres Property Location ~/ Z 7 ~Ia ~ `~ ~ ST. CROIXCOUNTY /~ ,,/, r ~ /t/L~'/ Section Z ~j ~ Y ., ., - Ciry, State Zip Code ()/ j , { /~f ~ ~2/ _ ~'fOj,.r / 7 (circle T Z ~ N; R l~ ~or II. Type of Building (c eck all that apply) ~ ~ tMa fSk ~ ~ ~V i i CSMN b S bdi N I or 2 Family Dwelling -Number of Bedrooms v s ame um cr u on CC ~ ^ PublidCommercial -Describe Use J Lf [ ^ State Owned -Describe Use ZZ. ^Ciry_^Villagc Township of_(~ ~s~ [[l. Type of Permit: (Check only one bo line A. Complete line B if applicable) i A' New S tem ys ^ Replacement System ^ TrcatmendHolding Tank Replacement Only ^ Other Modification to Existing System B• ^ Permit Renewal ^ Permit Revision ^ nge of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumb Owner ('~ ~( IV. T e of POWTS S stem: Check all that a 1 Ks. Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ ound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank _.~ P filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ D ip'Linc ravel-less Pipe ^ Other (explain) V. Dis ersalll'reatment Area Information: ?~" Design Ftow (gpd) ~ Design Soil Application Rate pdsf) Qpersal Arca Rcquir sf) ~ Dispersal Arca Proposed (sf) System Elevation ~ bean a ~ ~5~ 8 Y t VI. Tank Info Capacity in Total Nu ' er Manufactur Prcfa Site Steel Fiber Plastic Gallons Gallons of nits Concrete Constructed Glass New Tanks Existing Tanks ~ t~ s Septic or Holding Tank l2~/ ~~ ~ > ~ t ~~ ~ titer s u Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- 1, the undersi d, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Namc (Print) Plumber's ignaturc MP/MPRS Number Business Phone Number 1 rev ~mn-- ZzI( J~~ '7/~ -77L~3~7~ Plumber's dress (Street, City, State, Zip Codc) ~ 2 ~ ~ ~ '1 ~ v z-t VIII. Coun /De artment Use Onl Approved isapproved Sanitary Permit Fcc (includes Groundwater Datc Issued Issui Agent S gn rc (1`1 tamps) Surcharge Fec) , )~/t ()6 ~(/ G 'G a7 f ~-/ iven Reason for Denial 7 ' [X. Conditions of ApprovaVReasons for Disapproval 3~ , 4 ~~ ~ ll 1 t //~~ M~,~ ~b ~ t A. 14at 4 4 O S}~ 2vM.- I S ~ 1 \Vj ' 1. Septic tank, effluent filter and fie, ~. dispersal cell must all be servtoes !maintained as pef mana ement lan rovided b l mb ~ ~ '~ g p p y p er. ~~~ u ~ ~ub~.,. 2 ~AN setback r,aq~emertts must be rnatintairted y) ~~~4.w1~ ~ par apptipble code ~ ordirtnces. , Attach compkte plans (to the County only) for the system oo paper not teas than gIR x 11 inches in size C~ SBD-6398 (R. 01/03) ' ~ TIMM EXCAVATING Route 1 Box 192 WILSON, WISCONSIN 54027 (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN JOB """S p'~ ~C-~. ~ I l,~ SHEET NO. OF CALCULATED BY ~ DATE ~~ CHECKED BY DATE i SCALE ~ t ~' `l y ~a~ ~~ 'RODU0T 20S1'~ Inc.,'Groton,Mass.Otd71. TO Order PHONE TOLL EREE I-800225-6380 TIMM EXCAVATING Route 1 Box 192 WILSON, WISCONSIN 54027 (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN .~ sue„ h!a, ! I ~~ JOB SHEET NO. Of CALCULATED BY ~ DATE ~~ ~ ~ _ O CHECKED BY DATE ~ ~~ ~ SCALE ~' YV `J , fqq. .... 5 I,, ~.. ~~i ~flODUCT 205-1 ~ Inc.;Groton,Mass. 01471. TO0rtler PHONE TOLL FREE I-800-215.6380 r Wir;~Onsin D~artmerrt of Commerce - ' ' Division bf Safety and BuiMings SOIL EVALUATION REPORT Page ! of m aoooraance wrm ~ormn ~, vws. rwm. woe st i i Pl 11 i h 81/2 - ~n~ 5 f. c ro ~' ze. an mu es n s x nc Attach complete site plan on paper not less than include, but not Ignited to: vertical and horizontal reference , deection and Paroei LD. ~ ' - 3 ~ S - ~ percent slope, scale or dimensions, north arrow, and b nearest road. ~ 024 5 3 Please prliit aN f n. ~ ~ ,Y `~~ by Date Personal information you provide may be used for rh~y , n11acY Law, s. t5.d¢ (~) (m)).. GG[/1~-- I 2 6 4 . Property Owner - ~ ~-~ ~ ` ~~ Prope' Location ~'w ~ ~ JUI~ ~~ Govt:t F 1/4~c,v1/4 S Z~'T Z ~(N R /~' E(or)~ Property Owners Maikng Address ._..' g r (,qp Lot # ,, -Block # Subd. Name or CSM!/ ~X City State Tap Code ~ ~ FFl~. ` -~ dy ^ Ydlage (~ Town Nearest Road ski: I l w«.~r ~ ~ . ~'S'o ~Z ( ~- .., j ~ ~ s -~,~ ~~ ® New Construction Use: ® Rol / Number of bedrooms __ `L_ Cade derived design flow rate DSO ~(e O a GPD ^ Replacement ^ PubHc or commercial -. Describe: Parent material OU fcaJC~-S (~. Flood Plain elevatior- if appfir~le l~1 Z . c~ ft. General comments S ~ S ~ yrt, e.. (C V0. f .b /~ -- ~~U • o and recommendations: ~ ~~ ~ (.e, J a, {-, o ,.~, _ . loi ° Boring # ^ Boring Ground surface elev. ~ft Depth to limiting factor ~ ~ $ in. Pit ~3' Sal ' n Rate H~¢on De th Dominant Cobr Redox Description Texture Stricture Consistence Boundary Roots GP D/fP p , in. Munseil Qu. Sz. Corrt. Color Gr. Sz Sh. 'Effl~1 'Etf#2 I o-lz to Iz - sil ZrnG.bk rY,~ c Iv ~ . 5 •8 Z ! 2 -2(c 1 ~y - Sic 2rnS 1C r rr~r/ G 5 _ . ~ • ~P 3 2(e ii$ y _ ! I( m S (~ rr 1 _ • 1 l . 2 Q p ~ ~ ~~ 5 `G~ ~ ~ ~ v ~` h r.2a>2 ~- c~ r Z Boring # ^ ~~ ®Pit Ground surface elev.l~ Z. ~ o ft. Depth to {'ariitmg factor I I In. ~ ~ Horizon Depth Dom~rant Cob Redox Description Texture Strudun: Consistence Boundary Rans GP DIf~ in. Munsefl Qu. Sz. Cont. dolor Gr. Sz. Sh. 'Efr#'1 *Eff#2 ~ b-ly t~ ~ )2. -~ ~ ~ ,11 2mabk . mfr ~ I v~ . S . ~ 2 ly-)lo. . ~ r `III! - Sid 2m5bk ~ {•n~r GS - .'-(' _~ 3 Ile-ll~S 10 y)(p `_ . r»S D ~ mI - J .~ I_.2 t+ .l $4 ' EiNuerrt #1 = BOD > 30 < 220 mc/L and TSS >30 < 1 50 moll. * Effluent #2 = BOD. < 30 rrglL and TSS < 30 mglL CST Name (Please .Print) S' nature CST Number - ~r--• 25 330~j A,~~ Date Evaluation Concluded Telephone Number 211' ~sb~ ~ ~ Sdmer~~.l~l ~IO25 (9-/--O/ 11 -2L{~-~Ob$ Property Owner IQ,.r k~ ~ ~ Parcel ID # _- Z Page z of _~ Boring # ^ BOA 3 ®Pit Ground sur!'aceelev. /UZ•Z~ ft Depth to limiting tailor 11(~ in. Soil I'~cation Rate Horzon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f~ in. Munseil Qu. Sz. Cont Color Gr. Sz Sh: "Eff#1 'Eff#Z ~ o- ID 2 -- .i 2r~.bk Gs .._ ~~~' . ~ • S Z -I~+ 1 ~r`II`I '~i 2rnsbk -~n~r G _ ~ ~ a Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. ~~ ication ~~ on ri H th De Dominant Color Redox Description Texture Struchme Consistence Boundary Roots GP Dlft° o z p in. Munsell _ Qu. Sz. Cont Cobr Gr. Sz Sh. 'Eff#1 'Eff#2 a Boring # ^ Bonng ^ Pit Ground surface elev. eft .Depth to limiting factor in. Sal lication Rate Horizon th De Dominant Cobr Redox Description TBxWre Struc~tn'e Consistence Boundary Roots GP D/ff? p in. Munseil Qu. Sz. Coat Cobr Gr. Sz. Sh. 'Eff#1 'Eff#2 ' Effluent #1 = BODS > 30 < 220 mglL and TSS >30 <_ 150 mglL ' Effluent #2 =GODS < 30 rrglt. and. TSS' 30 mglL 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 (8.07/00) r Property Owner ~.Y' k< < ~ Parcel ID # Page Z of _~ Boring # ^ Boring 3 ^ Pit Ground surFace elev. ~UZ•Z~ ft Depth to limiting factor Il (~ in. Soil I"ication Rate Horizon Depth Dominant Color Redox Description Texture $bvcture Consistence Boundary Roots GPD/fr? in. Munsell Qu. Sz. Cont Cobr Gr. Sz Sh: "Efl#1 `Eff#2 S o- z Ib _ ~i 2 rrwbk ~ s : (v~ , 5 - • S Z - ICI 1 qtr `I I ~-I .c~ Zm s bk vn~r __ ~ -- ~ . CP -~ oo'- 2 CP. Y`' y'' v ^ Boring # ^ Boring ^ pit Ground surface elev. ft. Depth to limiting factor in. Sod. lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consisterwe Boundary Roots GPD/f~ in. Munsell Qu. Sz. Cont Color Gr. Sz Sh. "Eff#1 "Eff#2 Bgnng # ^ Bonng ^ Pit Ground sucFace elev. ft. .Depth to limiting factor in. Sal icatbn Rate Horizon Depth Dominant Cob Redox Description _ Texture Structrue Consistence Boundary Roots GP D/f~ in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. `Eff#t 'Eff#2 ` Effluent #'1 =- RODS > 30 < 220 mgJl and TSS >30 _< 150 mg/l ' Efl1ueM #2 = BODs < 30 mgll-and. TSS < 30 mgll- 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 60&264-8777. SHD-8330 (R07/0o) PAGE ~ OF~_ NAME -~ Y` K -e- ~ L LOT#,S 3 LEGAL DESCRIPTION S E'/<AI~'/4 S ~,s T z.~t N R [4 E (or) SCALE: 1"= yU , BM I ELEVATION /U U ~ G 1 BM 1 DESCRIPTION •Fo (~ o -~ Z '~ ~ ~ c, p, '/~_ - + BM 2 ELEVATION ~ g • ~ ~ I ~ eC Z S BM 2 DESCRIPTION -~ p a -~ Z '' Dv c_ ~•' Pc SYSTEM ELEVATION /~ y ' y ALTERNATE ELEVATION (O ~• y CONTOUR ELEV. ~ ,` ~ t~ ,. .. a ~r ~r ~, 2~ br~~ ~ ~~ ~6d~c~ $mt Q,,hZ S~,y..~e--~-v~-v, Lv'r ~~ 6-e~a ~ k 3 A 3~ 1, 3~,A 10p2. x .N ~ X 6 ~`, • 12X ~ I ~®1¢.0 lE i x o \ ` X • / ~X 10 2.5 r1 ~ . • ~ I/ X ~ 97t. , ~ 1.9 ` X .7 AC 1 1C1,Q.Ea) 995.9 r, _~. ~ ~/~~~ ~ A56. / ~ ~(i) X7 ,,~~ 105 6 //, [~.~ ~~/ ~{'' 1054.2 , V X __ ~~ t % /,~'~. SCENIC HILLS f.O rATE'Q !N TflE Ni1I/J O£ 1'LIE :4"111/4, ;YF!/4 r1£ 1"ffE .4': M":Ij"J. SE1/J OF' TIIE :Y M'!j'J, f'AH7' OP' 7'HE SNI/4 OF TIfF .4`II L; J, f'.1RT OF THE ,5'Nr;'J L't TIIE' SIIf/4 dX'p l;4 THL+' NB!/J' OF THE' S'111/J. 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CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIl' CERTIFICATION FORM Cc~CI'/1 Mailing Address `1 y g ~LtiUlf~1 '~}v~-~e Property Address ~~5~ (Verification require from Planning Wing Department for new construction.) Y City/State ~ ~ ~ ~ Parcel Identification Number ~ ~ " ) ~? ~~ " ~7 ~ -UD p LEGAL DESCRIPTION Property Location S l/ '/4 , ~~'/4 , Sec. 2 r7 , T ~_N R~W, Town of ~Sc7yJ ~° 1 Subdivision a C C,e-~u.t. ~~ ,Lot # ~. Certified Survey Map # Volume ,Page # Warranty Deed # ~~ ~08~(~ ,Volume ,Page # Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (i) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtutel)of a warranty deed recorded in Register of Deeds Office. Number of bedrooms / SIGNATURE OF PLICANT(S) DATE .~--~ ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) 8 1 6 8 4 5 STATE BAR OF WISCONSIN FORM 1 - 1998 WARRANTY DEED Document Number This Deed, made between Jeffrey J. Van Hammond and Rachelle Van Hammond. husband and wife ,Grantor, and Jason D. Keily and Kimberiv S. Kelly. husband and wife, Grantee. Grantor, for a valuable consideration conveys to Grantee the following described real estate in St. Croix County State of Wisconsin (the "Property"): KATHLEEN H. tfALSH REGISTER OF DEEDS ST. CROIX CO., MI RECEIVED F'OR RECORD AL/20/2000 e1:41t1P11 MARRANTY DEED EXERT tt RfiC IFfifi : 11. A0 TRANS fiEE: ~2A. IBA COPY FEfi : CC FEE: PAGES: 1 Recording Area RE'rl?RIv '1'O: Burnt Title 75~U France Ave. S. First Flc>or Edina. ~}N 55435 AT"fN: }'ost Ciosing Cemral // 020-1395-53-000 Parcel Identification Number (PIN) This ~~ homestead property. (is) (is not) Lot 53, Plat of Scenic Hills in the Town of Hudson, St. Croix County, Wisconsin Together with all appurtenant rights, title and interests. Grantor warrants that the title to the Properties good, indefeasible in simple fee and free and clear of encumbrances except Dated this 4th day of January, 2006. (SEAL) (SEAL) J. Van Hammond Rac .Van Hammond (SEAL) AUTHENTICATION Signature(s) authenticated this day of , TITLE: MEMBER STATE BAR OF W ISCONSIN (If not, authorized by §706.06, Wis. Stats) THIS INSTRUMENT WAS DRAFTED BY Coldwell Banker Burnet/Robert Nicholson 1301 Coulee Road Hudson, WI 54016 5-54398 (Signatures may be authenticated or acknowledged. Bath are not necessary.) Names of persons sianino in any capacity must be typed t WARRANTY DEED (SEAL) ACKNOWLEDGMENT State of Wisconsin, Ar~za~ ~~ ,WU~~~, ~~~ ss. St. Croix County ~(/~,u Personally came before me this 4th day of January. 2006 the above named Jeffre J. Van Mammond an a Ile R. Van Hammond to Public, State o Wisconsin Z My commission is permanent. (If not, state expiration date: /~yDOFER7Y M~I~f# ~a OOtiiNTY Ilrtyt~all9~ tt-tf-loos: STATE BAR OF WISCONSIN FORM No. 1 -1998 Wisconsin Legai Blank Co, Inc. Milwaukee, Wis. . a r System Management 'vanagement of [his system is critical. As a condition of approval of these plans this system management section must be -:~ ~eµ ed ~~ ith the owner, and the owner must be provided with a complete set of plans including this management section. if problems ~e.e{op with the adsorption system or any other system components, the installing plumber, Timm Excavating, 715-772-3214, or the St. ~rotx County Zoning Office, 715-386-4680, should be contacted for assistance. General Proper functioning of an on-site disposal system, "septic system," is significantly dependent on the volume of water which flows ;nto the system and the level of contaminanu in that volume. The lower the volume of water and the lower the level of contaminants, the ~crter and longer the system will function. Typical system components include a septic tank or compartment to settle out solids and contain greases and oils, a filter on the outlet of the septic tank to retain small particles of the same density as water, a pump tank or :ompartment to allow a dose to be accumulated, a pump and controls, and finally some type of soil adsorption cell to recycle the water n a manner to protect ground water quality and public health. I f the septic tank is installed prior to sheet-rock and/or painting, pump the septic tank before normal use begins to ensure adherence to contaminant load design criteria. Install water-saving appliances whenever and wherever possible. Repair even small water leaks as soon as possible. Lever pour grease or oil down any drain or stool. Garbage disposals are not recommended; if you must have one, use it sparingly. do paper products other than tissue should go into the system. - ~o chemicals should go into the system. ~ ~ ord surge flows of wa[er, try to spread laundry throughout the week. Maintenance The septic tank must be inspected every three years by a properly licensed person. necessary, the septic tank must be pumped to remove solids and scum; pumping is required if the combined scum and solids volume equals one third of the tank volume. ~~ nen the septic tank is pumped, any solids in the bottom of the pump tank must be pumped, and the filter must be back-washed into the septic tank to remove accumulated material. - Periodic observation pipe inspections should be made by the homeowner to examine the state of the in-situ soil adsorption cell. Quarterly inspections are recommended; a licensed plumber should be notified if effluent is consistently ponded in the adsorption cell If this system contains specific treatment components other than those mentioned here, maintenance requirements will accompam them specifrcations. The pumping components for this system include an alarm which must be installed and remain on a separate circuit from the pump r the alarm is activated, minimize water use and notify a licensed plumber for service as soon as possible. The system allows resen e :apacit} to accumulate some necessary flow until normal service can be restored; this volume is minimal, and no more than one or ~~~o dais should pass before any necessary repairs can be made. - ~ ~ old compaction such as vehicle traffic within I S' down-slope of the adsorption system. ~~otd disturbing the system itself such that might encourage erosion or disturb the required seeding of the system. Pantcularly avoid winter traffic such as sliding or snowmobiling which might compact snow and lead to increased frost depth. ~) Surface drainage must be diverted around the system; avoid landscape changes which might send surface run-off into the system area. Contingency Plan ti~astewater moniroring of volume and quality is not a normal requirement for low effluent strength systems; such moni[orin~ ~:a, become necessary if problems develop. Any necessary monitoring shall be done in accord with the requirements of Comm 83 ~d Pumping and hauling of wastewater may be necessary while analysis and repairs are implemented. Additional testing, desionin~, and or tnstallauon of additional treatment components or conversion to a holding tank may be necessary. ~ ~ V Page 8 of 8