HomeMy WebLinkAbout020-1395-69-000 Wisconsin Department of Carnmerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No: 420693 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:
Tvent, Eric & Kari I Hudson Township 020 - 1395 -69 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
10a .0 1 1 �Q D44ryv 4 km4t— OvP.Y 25.29.19.2463
TANK INFORMATION ELEVATIONDAT
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic d D ,l Benchm rk / �
Dosing �[ � Alt. BM
Aeration Bldg. Sewer L � D r
Holding- St/Ht Inlet 7
S `�3 1 3- �Z
St/Ht Outlet
TANK SETBACK INFORMATION p
TANK TO P/L WELL qG. Vent to Air Intake ROAD Dt Inlet /
Septic .� Dt Bo ttom
e
Dosing Header / Man.
Aeration Dist. Pipe bf o C ? V q q L f
Holding Bot. System q,3?j Ct
D.
PUMP /SIPHON INFORMATION Final Grade
S3 N"445
Manufacturer Demand St Cover _ Z � - ` O q �_
Model Number !
TDH Lift Fri s System Head TDH Ft
Forcemain Length Dia."
SOIL ABSORPTION SYSTEM I ( C
BED/TRENCH Width } Length r No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 2 ��
SETBACK SYSTEM TO P/L& JBLDG IWELL LAKE /STREAM EACHING Manufactul:8
INFORMATION HAMBER O 1�►-f ?�
Type Of System: O r 0 s � �� / UNIT Model Number:
RIK RIBUTION SYSTEM
Heade /Manifold Distribution h i x
Hole Size x Hole Spacing ent t Air Intake N�
L R e ngth , Dia L ngth / Dia / Spa �� 7D
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only INeff 94-L ed jNo
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
BedlTrench Center Bedlrrench Edges Topsoil Yes No Yes
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: /l�� Inspection #2:
Location: 728 Regal Ridge Hudson, WI 54016 (NW 1/ J SW 1/4 25 T R19 Scenic Hills Lot 69 Parcel No: 25.29.19.2463
1.) Alt BM Description
2.) Bldg sewer length = � � dS/ T} , 1� F CiLf �giGQy`/ A4- — �Ccl�•� ¢PcQQ�/
- amount of cover = / ( I I C� ?1 10-0 Li
Plan revision Required? /es [ 'j No
Use other side for additional information.
SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No.
Safety and Buildings Division County
N vi 201 W. Washington Ave., P.O. Box 7082
sevnsi►n Madison, WI 53707 - 7082' Site Address
De artment of Commerce
Sanitary Permit Application Sanitary Permit Number
In accord with Comm 83.21, Wis. Adm. C nformation you provide ❑Check if Revision I ld O & 9 3
may be used for secondary cur poses I'rivac
I. Application Information - Please Print All Inf rmation State Plan I.D. Number / n
Property Owner's Na me FEB 11 2003 _ Parcel Number '"�
a -
Property Owner's Wailing Address ZONING OFFICE Property Location r31,)
�b �ti ; T N, R
City, giate Zip Code Phone Number Lot Number Block Number
i
Subdivision Name CSM Number
S
II. Type of Building (Check all that apply.) v� ❑City
I or 2 Family Dwelling - Number of Bedrooms ❑ Village
❑ Public /Commercial - Describe Use Vk
❑ State Owned Nearest Roast
IN
III. Type of Permit: (Check only one box on line A. Numbering is for internal use.) (Complete line B, if applicable.)
A. 1 New 3 ❑ Replacement of 6 ❑ Addition to
System 2 ❑Replacement System Tank Only Existing System For County use
B • ❑Check if Sanitary Permit Previously Issued Permit Number Date Issued
IV. Type of POWT System: (Check all that apply. Numbering is for internal use.) S,td , Ej j-A r4izoL
44,4 Non - Pressurized In- Ground 21 ❑ Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland
22 ❑ Pressurized In Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line
45 ❑ At -Grade 46 ❑Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑Other
V. Dispersal/Treat ent 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 Existing
Tanks Tanks
Septic or Holding Tank _ s
Dosing Chamber
VII. Respopsibility Statement- I, the undersigned assume responsibility for installation of the POWTS shown on the attached plans.
Plum is a e (Print Plum is Si nat e �� MP /MPRS Number Business Phone Number
r
- 7 K�_ /�( -
Plumber's Addre ss (trees, City, State, Zip Code)
VIII. ount /De artment Use Onl
Disapproved Date Issued uing A nt Signature Stamps
Y )
Gi l Ad Sanitar Permit Fee includes Ground ter
Approved Owner Given Initiaverse / 6�
Determination Surcharge Fee) a s S /oZ Q G�-
IX. Conditions of Approval /Reasons for Disapproval _
_S -P,»,
en
tach omp ere plans (to the out y o ly� system o paper not less thin 81/2 x 11 inches (n siz
SBD -6398 (R. 05101)
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vyg rosin Department of Commerce SOIL EVALUATION REPORT Page I of
' Division of Safely and Buildings
in accordance with Comm 85, Wes Adm. Code County
Attach complete site plan on paper not less than 8112 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal re1erenKe4xnint.(1BM), direction and Parcel I.D. C,
percent slope, scale or dimensions, north arrow�,rrd loc;atign po distance to nearest road- 2� r 13 - to - I
Pimm print alyin"it/on. eviewed b Date
Personal information you provide may be used f6rsecdndsq pu�Ot 3 Pr -1-Y 04 (1) (m))-.
Property Owner V (': rty Location
. '� f y , Lot Nw 1/4 a 114 S Z s T- 9 N R y E (or)
Property Owner's Mailing Address r �R �� ' L # Block # Subd. Name or CSM#
Cv LO
City States Zp Code Phone Fi ,C, . K`. City ❑ Village Town Nearest Road
® New Construction Use: ® Residential / Number of ` � K Code derived design flaw rate 1 O O GPD
❑ Replacement Q Public or commercial - Describe: C . - -: " ''t'' q� q o
Parent material Oct +L- JGt-8 (�. ` t ? Flood Plain elevation if gpfic�able 9 ft
General comments S S f c rrt e. l c J 0.f . b n - 90.30 o 11-
and recommendations: e,� 0. : d v� — 9/ 3 D !� c'GcG�m
all
i`/t cam ah 5 s �eu� ern �, s dy Ckti�
❑ Boring /I� C6 /Jrt�ira
a Boring #
+p Pit Ground surface elev. R Depth to limiting factor (l in.
Sort Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'EN#2
b -lip ID r - 5 SI'I 2 r a mfr c
2- r � 1 3 l 2 rr h rr c S 2 3
3 2 -►►$ l� r `tl1.0 rn5 05 rn
Boring # . ❑ n g
® Pit Ground surface eiev. '7G AO ft. Depth to limiting facto In. Rat
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2
.. I . I 2 k rr, �' ` S 2- _ 3
_tt s ds rn l
6
' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) ignature CST Number
Z53.3Cn
Address Date Evaluation Conducted Telephone Number
2113 `6d S-, e 'fOZS� �—� - 715 - 2K7 -Y�
Property Owner 4 r ke_ l f Parcel ID # Page Z of 3
a Boring # ❑ Boring
® Pit Ground surface slev. ft Depth to limiting factor 1 l �o in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIfE
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. - 01#1 -Eff#2
o -g to ir 242 LS c I�� - 1 ` -Z
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in. Appl ication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2
❑ w ..
a Boring # Bo Ground surface elev. - ft. Depth to limiting factor in.
❑ Pit Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDlfF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - Eff#1 'Eff#2
' Effluent #1 = BOD, > 30 S 220 mg& and TSS >30 150 mg/L ` Effluent #2 = BOD < 30 mglL 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 60 8-266 -3151 or TTY 608- 2648777.
SBD -8330 (ROlPoO)
PAGE 3 OF.
NAME A y , LOT# (o �{ LEGAL DESCRIPTIONNW '16w'/. SA4T24 N,R )Q E (or)l�
SCALE: 1 "= y 0
BM 1 ELEVATION /Qd. o
BM I DESCRIPTION /o P o rr D, D c
BM 2 ELEVATION 91 . Zs -
Sec . 1
BM 2 DESCRIPTION da� '' y p,'p X
SYSTEM ELEVATION I Z , 3 d — - {-
ALTERNATE ELEVATION Q/ • 30
CONTOUR ELEVATION 9G• so q 7.so 9X •So
I j
� d -2
13 .3
1
SIGNATURE eO G
PAGE 3 OF 3
NAME 14 y - K e-� L LOT# (o q LEGAL DESCRIPTIONNW ' /45cu`Aa S ,19T24,N,R )Q E
SCALE:
BM I ELEVATION /old• o
BM 1 DESCRIPTION 4o q o z tram 4,; _
BM 2 ELEVATION q.
BM 2 DESCRIPTION oj? o f 1 0.'a - e x
SYSTEM ELEVATION
ALTERNATE ELEVATION
CONTOUR ELEVATION 9G. so , q 7,so , 9Tl •S'o
d -2
G. r
d ,
0
Co ✓�i4
a`
� 5
�/ iG r fij
1
SIGNATURE �O
ST. CROIX COUNTY
SEPTIC TANK MAINTANANCE AGREEMENT
AND
OWNERSHIP CERTIFICATE FORM
OwnerBuyer -�'I C1 1�1 Ivf-t
Mailing Address j 61 NV'% >
Property Address
(Verification requiraid from Planning ment for new construction)
City/State L (Q �i 1 W L Parcel Identification Number
LEGAL DESCRIPTION
Property Location NW V,, VW 'h Sec, Z T 2�` N -R r W� Town of }U �
Subdivision ��L -YI C,' \- 1 (`J Lot#
Certified Survey Map# , Volume Page
_Wananh' Deed# � � , Volume �l_ Page
Spec house yes __.� Lot lines identifiable _y es no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result its premature failure to handle wastes.
Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed
pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste
disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the
owner and by a masterplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-
site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary),
the septic tank is less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with
the standards set forth, herein, as set by th Department of Commerce and use 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. roix Coq oning Office within 10 days of the three year expiration date.
SI NATURE OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge I (we) am
(are) the wner(s) of the property described above, by virtue of a warranty deed recorded in Register of
Deeds ffice.
I a -�o -03
"SI GNATURE OF APPL! ANT DATE
000000 Any information that is misrepresented may result in the sanitary permit being revoked by the Zoning Department—••
•• Include with this APPlication a stamped warranty deed Itom the Register of Deeds office
a copy of the ceninad survey map if reference is trade in the warranty dad.
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page Lof
FILE INFORMATION SYSTEM SPECIFICATION
Owner Septic Tank Capacity al ❑ NA
Permit # _Septic Tank Manufacturer ❑ NA
Effluent Filter Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Model ❑ NA
Number of bedrooms ❑ NA Pump Tank Cap acity al 4YNA
Number of Commercial Unit NA Pump Tank Manufacturer 1 NA
Estimated flow (average) gal/day Pump Manufacturer L'NA
Design flow (peak), Estimated x 1.5) gal/dax Pump Model ANA
Soil Application Rate gal/day/ft' Pretreated Unit
I nfluent /Effluent Quality Monthly Average* n Sand /Gravel filter ❑ Peat filter
Fats, Oils & Grease (FOG) 530 mg/L n Mechanical Aeration ❑ Wetland
Biochemical Oxygen Demand (BODs) <220 mg /L ❑ Disinfection ❑ Other:
Total Suspended Solids (TSS) <150 m L Manufacturer
Monthly Average ** Dispersal Cell(s)
Pretreated Effluent Quality XNA <30 mg/L XIn- ground (gravity) ❑ In- ground (pressurized)
Biochemical Oxygen Demand (BODs) ❑ At -grade ❑Mound
Total Suspended Solids (TSS) <30 mg/L ❑ Drip ❑ Other:
Fecal Coliform (geometric mean) <10 cfu /100mL
Maximum Effluent Particle Size '/ inch diameter * Values typical for domestic (non - commercial)
wastewater and septic tank effluent.
** Values typical for pretreated wastewater.
MAINTENANCE SCHEDULE
Service Event Service Frequenc
Inspect condition of tanks At least once every ❑ months ❑ ears (Maximum 3 rs)
Pump out contents of tanks When combined sludge and scum equals one th '/3 of tank volume
Inspect dispersal cells At least once every ❑months ears (Maximum 3 rs
Clean effluent filter S -ta7E�1� At least once every ❑ months a� ear(s
ns ect um um controls & alarm At least once ever a months earls -'NA
blush laterals and pressure test At least once every ❑ months ❑ ear(s) j�KNA
Other: At least once every ❑ months ❑ ear(s) ,ANA
Other: At least once every ❑ months ❑ ears 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 tank(s) 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 ('/3) 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 ch. NR 113,
Wisconsin Administrative Code.
The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatment components, and any other
maintenance or monitoring at intervals of 12 months or less 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.
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other
chemicals that my impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have
the contents of the tanks(s) removed by a septage servicing operator prior to use.
Owner: ,i, e Pagq_--20f
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal high water levels. When power is restored the excess wastewater
will be discharged to the dispersal 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 soft absorption are.
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.
ABANDONEMENT
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 ch. 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
re7 1ament system:
A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed
upon by required setbacks from-existing and proposed structure, lot lines and wells. Failure to protect the
replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area.
Replacement systems must comply with 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.
g, e site has not been evaluated to identify a suitable replacement area. Upon failur of PO7a� S a soil and site
r va at st pe ed loc a suitab la cement If no re �ent a and
tank may be installed as a ast resort to the fai PO S.
❑ 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 the time.
<<WARNING>>
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASES 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 INSTALLJgR POWTS MAINTAINER
Name Z/ Name
Phone -
Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name
Phone Name '
Phone
J 2 13 2 P 3 0 6 706444
State Bar of Wisconsin Form 2 - 1982 KATHLEEN H. MALSH
REGISTER OF DEEDS
WARRANTY DEED ST. CROIX CO., XI
DOCUMENT NO. RECEIVED FOR RECORD
020 1395 69 000
Parcelldcntification Number (PIN) 02/06/2003 08:30AM
EXEMPT #
Carriage Homes XXI, Inc. a Minnesota corporation conveys and REC FEE: 13.00
warrants to Eric Tvedt and Kari Tvedt the following described real estate in TRANS FEE: 024S. '7o
St. Croix County, State of Wisconsin: COPY FEE: CERT COPY FEE:
PAGES: 2
SEE ATTACHED EXHIBIT A
This is not homestead property.
Exception to warranties: any easements or restrictions of
record if any. THIS SPACE RESERVED FOR RECORDING DATA
Dated this 30th day of January, 2003 Name and Return Address:
Land Title, Inc.
1900 Silver Lake Rd Suite 200
New Brighton, MN 55112
Carriage mes XXI, Inc. ,p
QQ /!��� /� /• (SEAL) (SEAL)
* Kellei St Martin, Vice President
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF MINNESOTA
) SS.
WASHINGTON COUNTY.
authenticated this 30th day of January, 2003 Personally came before me this 30th day of January, 2003,
the above named Kellei St Martin, VicePresident of Carriage
Homes XXI, Inc. a Minnesota corporation to me (mown to be
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, Arty, 1900 Silver Lake Rd #200, New
Brighton MN 55112
Notary Public, Washington County, Minnesota
(Signatures may be authenticated or acknowledged. Both are My Commission Expires:
not necessary.)
p.aNVNn �
'Names of persons signing in any capacity should be typed or printed below their signatures. ANN ETT D. THEIS
NOTARY PUBLIC - MINNESOTA
{ ' _ M ,mm Expires Jan. 31, 2005
v✓wa.v„tinnnn�r+w.nr� *
ci
120,091 SO FT W
2.757 ACRES N W
ci
ww E 639.26' N 1
175.00
F
68 o
)8,886 SC FT 3 69
1270 ACRES 90 SO Fr
2.073 ACRES
= 991.9 1
f....... ..............
100.13' — — —� — — —
S86°58'14 "E 336.83
- Regal Ridge -
N86°58'14'W 336.83'
.99' a
95,918 SO FT
22M ACRES