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020-1292-60-000
~Jiscoit~sin•Department of Commerce PRIVATE SEWAGE SYSTEM Safety ar~1 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 Danielson, Har Hudson, Town of CST BM Elev: Insp. BM Elev: BM Description: 99.5 i61M ~ TANK INFORMATION n. _, TYPE MANUFACTURER CAPACITY Septic ~.: ate' ~ e Coy /ao0 R t.Jee.(e.~ Z(rr ( 2, ~: ~ g Po ~d~. zs TANK SETBACK INFORMATION TANK TO ~ / i ~ WELL BLDIG. GCJG. Vent to Air Intake ~ ROAD Se~i~ 7 25 ~ ~5 ~, 1 ~gl >z5' 9b~ Z - _ Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Numb TDH Lift Friction Loss System Head Ft Forcemain Leng Dist. to well SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. CfOIX Sanitary Permit No: 515151 0 State Plan ID No: Parcel Tax No: 020-1292-60-000 Section/Town/Range/Map No: 27.29.19.1443 STATION BS HI FS ELEV. Benchmark 5. t~3 14s./3 9 q. 5 Alt. BM 7 /os. ~3 Bldg. Sewer X~ ~ ~~ St/Ht Inlet ~ ~ ~~ St/Ht Outlet ~ ~ 3 5.L +~ 9 Dt Bottom Header/Man. 9. ~~ I 95 • ~~ Dist. Pipe Bot. ystem ~D• b( ~~ ~/Z Final Grade s.~ y9. s3 St Cover 5.3g 4~~ 7~ 1~~lJC, o~~- o B, 94.73 t1_l~~ auk- .~ $,~ = 9~ •~3 BED/TRENCH Width / Length ! No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. ~ Liquid De` DIMENSIONS '3 p t~ 3 t <en.c,~p `' SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: ~ ~ `~ ~ ~ INFORMATION CHAMBER OR ~. ~ i. '- Type Of System ~ G ~ /~ t 5 7 / ~ Z7 , /r "' UNIT Model Number: ` o~Jc o DISTRIBUTION SYSTEM ~ /Ve(Jb. ~'-"~'T'~~ _ A Z~ +• Z~ Header/Manifold ~ / Distribution x Hole Size x Hole Spacing Vent to Air take/" ! i ~~ Pipe(s) h ~ Di \' S i ~ 'Z~ Q D a Length Lengt a pac ng SOIL COVER x Pressure Systems Only xx Mound Or At-Glade SVStems Only ~ ~~ ~ _~v Depth Over Bed/Trench Center b 1 Depth Over Bedrfrench Edges ~ xx Depth of Topsoil xx Seeded/Sodded ~ xx Mulched y es ~ No es [] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / /_ Location: 767 Hill Farm 1Road Hu son, WI 54016 (NW 1/4 NE 1/4 27/T29N R/19_W) Humbird Hills 1stAddi~tioln Lot 17 Parcel No: 27.29.19.1443 1.) Alt BM Description = ~~,1~ G ~ ~.~o~•~.~ 6~„ w'Q~~ Zoo 1 2.) Bldg sewer length = /~ ~ Comm@rCE.Wi.gov Safety and Buildings Division County 1 ~ C ~ ~ 201 W. Washington Ave., P.U. Box 7162 , Q~_ ~ s co n ~ ~ n Madison, W 153707-7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce 5 ~ 5 ~ 5 / Sanitary Permit Application State Transactio~mber In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to [he appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application fornls for st~q,)grl d POWTS are submitted to the Department of Commerce. Personal information you p~ ide may ~~ii ~ n mailing address) Project Address (if diffe ent tha ,! ~ / ~ u oses in accordance with the Privac Law, s. 15.04 I (m), Slats. ~ ~ j / - /'"~ fr ( ~`'~ ~ / ~ L , ~~ yl/ - A lication Information -Please Print All Information /< r; Property Owner's Name ~ 200n ~ t Parcel # d Zv - r Z~ ~- ~6- At~+~ Ahi if SaN sT c Property Owner's Mailing Address . ~ ~ i 1 ING &ZO NING OFFIC Property Location C j y y 3) t l A 2 ~V 1 ~ ~1 ~1 Govt. Lot l City, State Zip Code Phone Number ~~ ~ ~.: /.,~ /., Section 1`4 ~ ~~ ~~~ ~ ~tl ~ e ~~ ~ ` T a~ (circle one) N; R ~~ E or W lI. Type of Building (check all that apply) Lo _ I or 2 Family Dwelling - Number of Be onms -- - Subdivision Name r f ~~ 14~Q..IMB B LIM 1 U ~ ^ Public/Commercial -Describe Use -- -- ^ city of`- ^ State Owned -Describe Use CSM Number ^ Village of {~ ~, ~~ fi Z~ tZ ~~ C~fown ot'__~4-b567y t.. V III. Type of Permit: (Check my one box on line A. Complete line B if applicable) A. ^ New System -replacement System ^ TreatmenUHolding Tank Replacement Only ^ Other Modification to Existing System (explain} B• ^ Permit Renewal ^ Permit Revision ^ Change of Plumber ^ Permit Transfer to New List Previous Permit Number a~n[d ate Issued Z ~ ~ `" Before Expiration Owner T Z g ~ ~ 9 ~ 3 IV. T e of POWTS S stem/Com onent/Device: Check all that a 1 ~~#lon-Pressurized In-Ground ^ Pressurized In-Ground ^ At-Grade ^ Mound > 24 in. ofsuitable soil ^ Mound < 24 in. of suitable so^il ~/I~r ~~~ ^ Holding Tank ^ Other Dispersal Component (explain) _ ^ Pretreatment Device (explain) ~ V. Dis ersal/I'reatment Area Information• Design Flow (gpd) ~ Design Soil Application ate(gpdst) Dispersal Area Required (st) / / Dispersal Area Propo d (st) 1?, System Elevation ' Cj 1 ~6t~ , 6C? t2 y ,ZS Vl. Tank lufo Capacity in Total # of Manufacturer Gallons Gallons Units ~ ~ U ~ 5 .u NewSanks Existing Tanks n I ~ C~~ J ~ C ~ 2 v Y ,°a i~ w V `~ a CK 1 ~ ~ rv ` a o, , ~, v~ Septic or Holding Tank / ~1 e1~ s Dosing Chamber Vli. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) ~>~ '~ ~~ u ber' at a MI'/MPRS Number aa~~~ Business Phone Numb r ~iS~3~L~~G~D . o~~~s Plumber's Address (Street, City, State, Zip Code) r ~ ~ ~ ~ ~ ~ ~ L~~f tl~I ~ ~ ~~ v ~ V11I. Count /De artment Us nl Approved d Permit Fee Date Issued Issuing e t Signature Owner Reaso enial $ ~ ~~ q IX. Conditions o easons for Disapproval 1. Septic tank;.efl7ui~ttt tiller and dispersal cell must aA pg services! maintained SuJ; ~,~ ~Oe~,ce. 1 ,^ to o~... 5~~" ~^J • . ss per management plan provided by plumber. 2 tAN se~7adt rpr~a~rds must. ba ntairMaNt~d t-~' "~"FlT19CRtaL•dtRli1~~111rIISlETTM1e s~•stem and submit to the County only on paper not less than 8 V2 x 11 inches in size SBD-6398 (R. Ol/07) Valid thru 01/09 ~~o ~ ~a /~-.me ~pRK1~ ~q~jY-Q1SO~ . m 1~a1V1ees-~e~ L~lOA Han.b7ab dills Is~pd~ G;~e~se'#~d9o~ r~~~ Qal1 Ruwya~ a~~ ~~} Tp~l~ w) Pu),~ Lek ~~ l~~'~ W ~~ l 0' 3 T~-~c~.e s 3 k~ ~ a 0 c1,nM1~n s ,~~, ~a cl, Tw N ~l, ~x-~'~i "'~ to ~U TUp 0~ CoNCr$1~? S1A1~ Flev.9'g~SU t~COPY MP&S aaa9~y g a11o9 ~eN ~~ Atha ~~. T~ ~ 1 ~ ~1'~~~'~ psi a~~et~ ~~~Y - ~V~~~ Q3 ~! ~~ ~. ~io~ ~a~ /I~--me HNRKt~ ~gN~-21SO~ Trn l~umees~e~ Laca~ion Numb~~ ~~iis is~udA G~~ense'*~ldgof~ e~ Un~'~~ lax7~' (3M112uwlln ac~ ~ 5n~ Tp~ l~ 7 w (ja, t~' 3 T~ucl~er 3k~U a 0 c1~oM~n s ~~~ ~b L~ ~fL! N L~ ~~x-~~-~j la~~ yon ~~r~ ~. Tip o~ CoNC~~~e Slpl, Eley- 94~su C~~, R v -nP~.s aaa9oy ~ a11o9 ~~N~1~ ~~~~ Tp ~C 1 ~ S~'°k~" a S~ ~-~4d ~.l ~.v = ~ ~ o, o a3 ~. ~PAIID Wisconsin Department of Commerce SOIL EVALUATION REPOR Division of Safety and Buildings in accordance with Comm 8.5 Wis Adm. Code 2170 Page 1 of 3 A.C.E. Soil & Site Evaluations County Attach r~mplete site plan on paper not less than 8% x 11 inches in size. Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I D percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. . . 020-1292-60-000 / ~/~3 Please print all information. R iewed y ate Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 7 P O y' Property Owner RECEIVED Property Location Harry Danielson Govt. Lot SW 1/4 NE 1M S 27 T 29 N R 19 W Property Owner's Mailing Address ~~ $ Lot # Block # Subd. Name or CSM# 209 767 Hill Farm Road ~~~ 17 Humbird Hills 1St Addition City State Zip C dde Phone Number g7 ~ City J Village r/ Town Nearest Road CROIX COUNTY Hudson ~ WI G a~d~p1va3~F~~1 Hudson Hill Farm Road _f New Con ion Use: yJ Residential / Number of bedrooms n flow rate _ 4 Code derived desig 600 GPD Replacement ~ Public or commercial -Describe: v ~2t?~,'~ ~a 3~Q ~ / ~~% ial Glacial Outwash Flood plain elevation, if applicable Na General comments and recommendations: Site suitable for replacement conventional POWTS using 0.5 gpd/sq.ft. loading rate. Recommended system elevation =94.75'. $~~ is-t,~n ' ~d syl~~-r--- a Boring # /J Boring > ~ 08„ Pit Ground Surface elev. 99.30 fl. in. J Depth to limiting factor Soil A lication Rate pp Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP Dlft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-13 10yr3/2 none sil 2fsbk dsh as 2fm 0.6 0.8 2 13-20 10yr3/6 none sil 2fsbk dsh cw 1fm 0.6 0.8 3 20-27 10yr4/6 none sl 2msbk mfr cw - 0.6 1.0 4 27-38 10yr4/6 none Ifs Osg ml cw - 0.5 1.0 5 38-68 10yr4/6 none gr s Osg dl gw - 0.7 1.6 6 68-108 10yr5/4 non gr s Osg dl - - 0.5 1.0 H#6 contains 1/8" - 1/2" bands o~ Oyr4/~. oading rate reflects reduced permiability of horizon associated with restrictive Ifs bands. 2 Borin ~ ~ Boring # ~ g ~ 9 Pit Ground'Surf elev. 99.65 ft. Depth to limiting factor >113" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/(t' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-17 10yr3/2 none sil 2fsbk mvfr as 2fm 0.6 0.8 2 17-25 10yr3/6 none scl 2fsbk mfi cs 1fm 0.6 0.8 3 25-33 10yr4/4 none sl 1msbk mvfr cvir 1f 0.6 1.0 4 33-44 7.5yr4/6 none ~ Ifs Osg ml cw - 0.5 1.0 5 44-58 7.5yr4/4 none ~ ' s 2fsbk mfr cw - 0.6 1.0 6 58-113 10yr4/6 none ~ fs Osg ml - - 0.5 1.0 H#6 & 7 contain 1/8" - 1/2" bands of 10yr3/6 4" - 'ante als. Loading rate reflects reduced permiability of horizon associated with restrictive Ifs bands. * Effluent #1 = BODS> 30 <_ 220 mglL a d TSS >30 < 0 mg/L Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signat e: CST Number James K. Thompson 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 7/3/2009 715-248-7767 n Property Owner Harry Danielson Parcel ID # 020-1292-60-000 Page 2 of 3 Boring # ~ Boring J Pit Ground Surface elev. 99.58 ft. Depth to limiting factor > 110" 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 1 0-12 10yr3/2 none sil 2fsbk mvfr as 2fmc 0.6 0.8 2 12-22 10yr4/4 none sl 2msbk mfr cw 1fmc 0.6 1.0 3 22-30 10yr4/4 none Ifs Osg ml cw 1 f 0.5 1.0 4 30-40 75yr4/4 none sl 2fsbk mvfr cw - 0.6 1.0 5 40-46 7.5yr4/6 none Ifs Osg ml gw - 0.5 1.0 6 46-110 10yr5/6 non e s Osg ml - - 0.7 1.6 l 7/T' ~/ ^ ~ Boring '~~~'~ I y~ Boring # Pit Ground Surface elev ft. Depth to limiting factor in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots PD in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 ^ Boring # .-1 Boring _( Pit Ground Surface elev. ft. Depth to limiting factor in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Stnucture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 "Eff#2 * Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS <30 mg/Land 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.o7/o0) A.C.E. SoN & Site Evaluations ~, \ `~~ ~` \~~ \.~ ~;~'iszi' /.2.'x 9~' d~;sFc~sK/Ce/% 5 w. fa-cL e /u~' = ~~ ~o j Exs~ ~ ?,~~~9I _uP ~ r ' ¢~ ,Ade~~oF'cuf1F~,:9G.fG3' ~ y~.49~ ~~ i ~ i i ~ /~i ` ~~~ E~(is6^~ ~a+-fie.. ~ bedi'ao~ ~~ /~ ~~ /•~e s, de nee ~ ~' 1 h b \~~ sC9~ ~ ~ ~~~~ ~~ tt%~~nl-ai•m NCO t~ 1 bZ- i i i i i t ~/ 1~/ / • E~CjS~r~q 9/~de e%~ • Loe~~,~rd/o~o/o. Sic r~ zr7o 7l0 7 fi~"// ~i~ ~a.a! 0 //k ds~, ~/. ..ss~rG Scu1~rlErS,~ ,Scc, 2 7 T. ,L9?., .Q /4G T. a~' yKdso-~, 5f. erexC'a , ~+.~~ ~c% '` 020 -/292 - Go -cam ~- ~jcs~i~ we// 0 Soil Absorption System dross Section 1~(~.~~ e q.~ S'tt Final Grade Leaching ---- Chamber ~ w_ Soil Absorption System Plan View U ~ ~._ ft i ~~5~ ft Trench 2 rTrpnch :t Leaching C4~amber Sgecitications y Manufacturer And Mode! _ ~~~n~1~5~J ~4~ ~~ EtSA Rating v(~ sq ft per chamber Soil Application Rate e~ gpd/sq ft ~@ U~ gpd Design Flow ~ ~ ~ Soil Application Rate ~ ~.~~~' ElSA = ~t~~'Chambers 3 rows of ~ ~' chambers each. ~- '? ~ ft System Elevation -- - Leaching Trench 1 Chambers '' _ ~~ Vent Or Observation Pipe 4" Dia. Header Page _..-,_ of -------- _v . v ' ft ~ ft ft '~"' ~..V 1 1 tf ~7~ Ae. r~ 96i fl~ "~. ,~~~C cif t~cx ~ ' '~' t~ ~ ~ '+. ~'~`,. ~ ~a~ ~~ ~ ~ t ~'" ~ s P ~ POWTS OWNER'S MANUAL. & MANAGEMENT PLAN FILE INFORMATION -'aae - of ._~ Owner SYSTEM SPECIFICATIONS Permit ~ -l~y ~~~ !-Q ~ S ~)~ Septic Tank Capacity 3 __ _ _ -- - - -_J aad ~- al O NA ---- - -- Septic Tank Manufacturer '~~ ^ NA DESItiN PARAMETERS -'--- "t n d• le _..__~ ~ Effluent Filter Manufacturer Number of Bedrooms - -----__--------------~_~~_ p NA ______ _ _ -_ _ C) NA Efrluent Filter Model - --- -- Number of Public Facility Units ~ ^ NA --- __ _ ANA Purrrlr lank CAlrar it.y _ ------ ----- Eatimated flow (averse ~ b ~ - - ai 8 1 _ ----- NA _ _ ----- - gal/dad Purnp lank Manufacturer _.--- Design flow Ipeakl, (Estimated X 1.51 __._ ~ - ----- - NA -- _.._ --- Soil Application Rate - - - ~ ~ - ._-_._ gal/day f urnp Manufacturer _ _ NA -- --- -- Standard Influent/Effluent Oualit ~ gad/day/It' Pump Model V Monthly avers e" ---_.__.__----- ___-.-__ .__ __ NA g Pretreatment lh~it Fats, Oil & Grease IFOGI <30 nrp/1_ O NA Biochemical Ox 17 Sand/Gravel Filter fa heat Filter Yaen Demand (80h,;) <2~u rnp/l 17 N/1 Total Suspended Solids ITSS) 5150 m /(, LI MAr,hmricai A~ratirrrr I I Wr+tland -- "------------ -- g C] Disirrlection C:1 Otl-er; Pretreated Effkrent Quality ---- - -- -- Mrnrthly avers A -__ .. . Biochemical Ox N f )(elver sal r:elila) _ _ _ _. `__ _-- Y41en Demand (80Ds) s30 rng/L ^ NA Total Suspended Solids ITSS- 530 m /~ IA"Irr Ground Ipravity) O In-Ground (pressurized) A [J NA C_i At Grade ^ Mound Fecal Coliform (geometric mean) 510° ctu/100-ni --- --- j Maximum Effluent Particle Size _ f7 Drip-Line O Other: _ _ _._ Ya in dia. Cl NA c)ther '~ other-- ----- -_.- _ ._ - _ ^ NA . --__ --- IJ NA c)thpr- __. _. . ._. __ "Values typical for domestic wastewater and septic tank nllhwnt. ----- - _ ^ NA Other. _ .. -.-_ MAINTENANCE SCHEDULE ^ NA Service Event Inspect condition of tank(s- Service Frequency At least once every: O monthlsl Pump out contents of tank(s) `___.____._-__. .._ _. __ __ __ 1~R, (~1 earls) (Maximum 3 yesre) ^ NA When combined sludge and scum equals one-third 1!',1 of tank volume O NA Inspect dispersal celllsl ~ --`-"------ __ At IAa9t OIICA AVAry; ~ ^ month(s) Clean effluent filter _ ~~- - - ~~ ~l yea-Isl (Maximum 3 ysarsl O NA At least oncA Avery: ^ monthls) Ins act um -- - yeerlal ___ ^ NA p p p, pump controls & alarm .._... ___.--_._--- At least once every; ^monthlsl ----_.______.__ ^yaerls) _ NA Flush laterals and pressure test -- - - - ------ 14t least once Avery: O monthlsl Other: ------_--. ___ - _ ._ _ _ .- _ . ___ -^ yearlsi _ __ NA At least once every: ^monthlsl - Other. _ - _____ ^ yearlsl NA MAINTENANCE INSTRUCTIONS ~ NA Inapectiona of tanks and dispersal cells shall be made by an individual carrying one of fire followin Master Plumber; Master Plumber faestricted lic inspections mu Sewer; I'OWTS ins act g mass or certifications: st include a visual inspection of the te<tk~al to (den P y any miss g oMbroken hardware, identlt measure the volume of combined sludge and scum P g ervickrg l)Perator. Tank and to check for any back up or ponding of effluent on the ground surface, The dispersal cefllsl shall be visually inspected $O check the effluent levels in the observation pipes and to ~~ t racks or leaks, of effluent on the ground surface. The ponding of effluent vn the ground surface ma in immediate notification of the local regulatory authority. V dicate a tailing condition end~qu~sdtl~s When the combined accumulation of sludge and scum in any tank equals one-third IY,1 or more of the tank v contents of the tank shall be removed by a Septa$e Servicing Operator and disposed of in accordance With chapter. NR 113 Wisconsin Administrative Code. olume, the entire All other services, including but not li mrted to the servicl units, and any servicing at Intervals of 512 months, shah be performed ny a car ivied Powrs Mas caee COmpOnenta, pretreatment A service report shall be provided to the local regulatory authority within 10 days of complAtion of arty service event. START UP AND OPERATION Pave of For new construction, prior to use of the POWTS check vsatment tankls) for the presence of painting products or other clMrrAaals that may impede the vsatment process and/or damage the dispersal celllsl. If high concentrations are detected have the contents of the tankls) removed by a septage servicing operator prior to use. • • System start up shell not occur when soil conditions are frozen at the infiltrative surface. ;.e During power outages pump tanks may fill above normN hlghwater levels. When ower is restored the e P xcess wastew ~ wNl atK be discharged to the dispersal ceillsl in one large dose, ovsrbad~ng the ceNlsl and msy resuk in the backup a surface dhcharge of ` effluent. ~1'o avoid this situation have the• contents of the pump tank removed by a Septege Servicing Operator prior to rsstorinp., 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! whhin 16 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prokmg the fife of the POWTS: ~ antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; tat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides;. meat scraps; medications; oN; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: ' • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. M SNM MI~111NNia1~w~ Gill iMf1M~ fMM~I M~iM wNliil 0111 Iriw~~rMw +rwW wM~~Ane /iliili~~1YM iii iris r MrWiMi~if1 Ir`w/i17ai1~M aa..~f1~Mi1i • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the vokf space filled with soil, gravel or another inert solid material CONTINGENCY PLAN It the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ~ ' `, A auhable replacement area has been evaluated and .may be utilized for the location of a replacement soil absorption!,;`' " system. The replaoelnent area should be protected from disturbance and compaction and should not bs.blfr~ged upon by required setbacks from existing and proposed structure. lot lines and wells. Failure to protect the repleoenrsrtt area wiN result in the need for a new soil and site evaluation to estabNsh a suitable replacement area. Replacement systems muM comply with the rules in effect at that time. O A suitable replacement area is not available due to setback and/or soil limitations. Barring advances M POWTS tech~obgy e, hoklkag tank may be installed as a last resort to replace the failed POWTS. ~ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soN and site.,. , 3 evaluation must be perfomned to locate a suitable replacement area. If no replacement area is available a holdktg tank ~ , may be Metalled as s last resort to rep ar the faNed POWTS. ', .. ~ ~, d.:., rQt'(fEl~~~{:. v,.,. O Mound and et-grade soil absorpt t,,be reconstructed in place following removaail~ot~M` bkaKnst at the MfNtrative eurface..Reconatructio ~ ~~~~ must comply with the rules In effect at the ~ ~ ow: ~ ~ ' SEPTIC. PUMP AND OTHER TREATMENT T~1NK8 MAY CONTAIN LETHAL GASSES ANDIOR INSUFFICIENT OXYGEN. DO NOT , . , fiE1TER A SEPTIC, PUMP OR OTHER TREATMEIILT .TIMIK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A' s PERSON FROM THE INTERIOR OF A TANK MA1~Bt~7)~FICULT OR IMPOSSIBLE. , --~-r~ POWTS INSTALLER T'11rt ,If1~1 l1~ ^~ ~r: Ya{' a~;~Y rptj r ~ f '.;'s +iv4iila4~1`5~ ~'k1~ Name ~ ~r,~~ ,~.~*~, ~, Phone - ,• ~.. - ~ .~~,,.i , • ,.~v ~„~ f-,~~, . BEPTAOE SERVICING OPERATOR (PUMPERI ~ ^ ~-•~'~ `~~" Name .,~ .~ ~ ~; k~r+,, p n~. ,~.,„>~- Phone - 4'a <: ;~ FF, i~T:~,` 1!: w , . ~~ f ai ~~.ai .• ., POWTS MAINTAINER ,~ ~ ~ ~ :. Name :~-;j ° '~~11ti,~ r'• Phone ``'',~.f~ ~, `; _ . ~ . LOCAL REGULATORY AUTHORITY ~ttl•~"a~A~~~'!-, i • Name ' ~ C.Xt~) ~,r'a •~,. Phone ~ - ''~ tiara. This document was drafted In ooarapNsnes wkh cheptir Comma ti3.3xlZllbll i Ildlifthl end 83.5411), (2- b 131, WlsconsM AdnaNdsvathre Cods. (TART UP ANC OPERATION Page of For new conatructiort, prior to use of the POWTS oheck Vestment tanklel for the presence of painting products or other that may impede the treatment process and/or damage. the dispersal celllsl. If high concentrations are detected have the oontsnts of the tank(s) removed by a septage servicing operator prlor to use. System start up shall not occur when soil conditions ere frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewster wEl bs,,Y. discharged to the dispersal cellls) in one large dose, overloading the celllsl end may result in the backup or surface discharge of ` effluent. `i'o 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 areq within 16 feat down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the Nfe of tftq ' 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; medicstiona; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. IBANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shell be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • Ail piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. w i~NE MffMil~iWii~~fli Wii tMi111ti YINI~Y w~iN N-tliii kiri 4.irww.-rf~i www wMfiaiAir~t~ AltiMw/iYM qi Vii; » -prWiW/1iM i-iwr~i~iill~d •Mri~iliW(<i • After pumping, all tanks and pits shall be excavated and removed or their covers removed end the void space filled with soil, gravel or another inert solid material :ONTINOENCY PLAN ' If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a coda compliant repiscement system: ~: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorptkm}" ' system. The replacement area should be protected from disturbance and compaction and should not bs.Mfrktged upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement eras vriN result in the need for a new soil end site evaluation to establish a suitable replacement area. Replaoemsnt systems muK comply with the rules in effect at that time. O A suitable replacement area is not available due to setback and/or soil limitations. Barring advances M POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. O The she hasR not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and sits.,; evaluation must be performed to locate a suitable replacement eras. if no replacement area is available a holding tani~ ~ may be installed as a last resort to repl a ths~faUed~POWTS. O Mound and at-grade soil abaorpt) infiltrative surface..Reconetructlor C <WARNINO> > 6EPTIC, PUMP AND 07HER TREATMENT ENTER A SEPTIC, PUMP OR OTHER TREA PERSON FROM THE INTERIOR OF A TANK ~emi,~~:,be reconstructed in place iollowing removal~of~' bkmtat at the s must comply with the rules in effect at the a~~ ' . :~ .. _. BANKS MAY CONTAIN LETHAL DASSES AND/OR INSUFFICIENT OXYGEN. DO NOT , , , MEIyIT.TI~YK UNOER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A ~AA1~.B@~Ci~CULT OR IMPOSSIBLE. , .. ` _ ~ ~~re E ~.~~"ur:~' its:.. , ~,~ } r. . ~; r~~,., o~~~ily,~~;~; ~' ~','~; i~'~ ~1~~'Yt~• . '.. POWTS INSTALLER Nerve nyw ~+ttr _ ~ ~ ,,+.r. 'ev rG Phone - r l~, s " , -,~ ,~~1«~.~~ rl'~~. SEPTAOE SERVICING OPERATOR (PUMPERi •'^ h ~ ~?~~ Name ~~ ~~ -, ~ ~s-f A nn-Q, ,~~:1,~,~z ~~~ Phone - ~ ~ ~ ru~~ f sro >~ >$~ ~, r POWTS MAINTAINER ~~:.• ~~ Name ~. '}f•` ` ~-rf- .'~llt~,.. • ,.; Phone xt°~r.'E' !; .. , LOCAL REGULATORY AUTHORITY -.ll~. ~~~~K--,, ~. ~ Phone ~ _ ~ i"<=,~ 5; ~ ~,. This doc~nnent was drafted in compliance with chapter Comm S3Z2f211b111 Ildl&(f1 end 83.54111, 121 i4 131, Wisconsin AdraNristratiw Cods, ST. CROIX COUNTY 7,ONING Of'FI:CI? CERTIFICATION S`.I'A`.l'EMEN`1' FOR UTILIZATION OF AN EXIS'1'TNG SEPTIC TAIdY. This is to certify that I have .inspected the septic tank presently serving the U~rt,~„ ~~N',~1$~-~ residence located at: ~ W ~ ~ ~~~ Sec. ~~, T 3-~ rI, R~- W~ Town of NiA1~S"/~__ _ St. Croix County, Wisconsin. Upon inspection, I certify that I leave found the tank and baffles to be in good condi.ti and it ap~>ea.rs to be functionin . ~ G9 9 Properly. Last time serviced Did flow back occur from absorption system? Yes line. Approximate volume or length of ti e: Capacity; ___ .~ Construction: Prefab Concrete _ __ Manufacturer (if known) ; _ ~1~lsch Age of Tank (if known): ---~ _ CJo~ ( i f no ski p next '1___ gallons __ minutes Steel Other (Signat e) ---- --- _ --- 'J ~ 1nn 1,~~bI~Q;~j (Name) Please Print (Title) ~~ _ (License Number) `~ ~ 9 (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outletcc~~b'affle) . Name Jl1rY~ pu1h.~Q~i ~ Signature MP/MPRS _ --- -- -- - - ~aa g ~~' S~Tt. C:RO[X Ct3Ui`~TT~F S~~"t'IC TANK MAINTFNAI'~-t'E :d!CF.EIEM~*~`~' ~',,a~a ~?jAJN'~ItSkit~ (',cr'{~i it i~:;~i~i'ION Ft~KM .._~. Mailing Address Pt~per:-f A,dd: ass ~~.~~ar M ~- - --- - - - (Verificatioae required from Planning & Zoning Drpat-h_n.Ct!t for nee+.~ ~;,::stre;ct:oz. } ~°itylaotatG -~~~~ ~~ ____ ~'arcc) }dentif•:,at~7r l'dittalt~er p~ /a~~ _.~j"V -QDD LEC~"-,',, RE°aClR1I='~`~t~l~ P; er ~~c.:t:o;a ~ ~ ~ i., ~ /a ,Sec. a~_, T ~_N R_-.L.W, Toter. ;;f _t~I~SU~' Subdivision _~~~~~ ! I J , Lot ~ ~, "~~~ ~~e;;! St~izey l~a~ i# ,Volume _~_. , 1'ag4 # vlfArtrs~lnty Deed # ,J ,~~~ _ , Vtliiiiale 03' t a Pit - ~~-.---• ~~~ - ~ g' 8 Spec ruse yes a:o i.ot lines identifiable yes no S~STT~~'~1~~T+iA,'~iC~,A~iD Ui~VNER CERTIF[C,~'~'I+C~N !sr~rope=' esge A:.d ;araintenance of your septic systerx~ cavld Tessa{t itt ito prematwe failure to haedk wAstPs. Proper t!+s°iR*.erarwe consists a€pumping out tae septic tank every three years or sooner, if needed, by a licensed pLa~r. ~t yon pu; L„o tl:e syste:r: cr:s at:eei the [unction of the stptic tank as a trsatmeret stags in the waste disposal syctPm C~±v±aer rr:aiatenatiee r~^^•^.s~ 4~iee: are spes;ified in gCOrtun. 83.52{ {)and in t~eaptcr ! 2 - St. Croix Cnteaty i~!nitaery Ordisszaece. a'r'pP"~~ s•~'nsr ag;ecs to submit to St. Croix County Platr~ing & Z,oating Deparhxscnt a certificat,na! f~arna, signed by flee rwraPr and b; a master p{u;r,~ser, jomresyrresn phamtrcr, restricted plumber or a {iccnsed purger verifying that. ({)the on-site w~!ate°7a!'-r siis~sa! syste:u;,S in ptvper operatm~g co~ctditiptl atad/or (2) after in9psction aaxi pining {if neces~y:. t}ts s.~tir tr.nk is less than {/3 fu!? a1'rtudge. f!v'", flee undersigrtsd 'nave read t.1Yt+a ~ etc end agree to neaiastaiss tine private sewegs t{iaposa{ a ~.... ~ attlradards SCt ft;a'tli, lt/~rE 88 aGt ~ t{te i . 4 r~ ~s...w w;La flee ~ Y - ce essd tf~tc Dcpertreacret of Nattmal Resrnsrc~, $tats of W:acorair.. t`srti~~+!eaa stating that yt-ser septic system ~ tned must be co feted and returned to the St, (~„jt, CQ.ra+. P{a;a:.ir- & ~aeairg'{?~artment wii{ait~ 30 days of tine ttere~ j-~ ' {~. ~' ye~tttion lL~tt:. {~C Ilxs ccitii'y ti~at a{{ statements on thm fiotm,IUro fiat to the best of my/our lCnowieclge. liwe am/arp +Lhe p~zr(s; cf the pa~~ u~traibed above, oy virhde pf a v~snr;~nfv rs~sded iaa Regsste: of i'rlecds Oi~ce. _~ ~ ~ , ~ q S ~ TAT'LJP.E Ql~' APPLILAI~1°I'~~) ~ °~ ~t *~ay it~iameatioee that is t±usreprsspndsd array totilil~ iii the saeyitary permit being revoked by the Flanrsing & Zoti~ing Gepattment. •'• Include with this Applataton a rtearded a%a.'i'auty f $'Om fire Register of Deeds tJtTsce and a copy of tite ctrtafted survey snap if referetecxss mad¢ in the war*atalg• decd. ' uoCU."nE!V r 1V 0. "STATE BALL OF WISCO:YSiN I'O!:9'I 1 -- 1982 ! ""' ~F^-E rf.SEr.'e° FaR Rcc.;RO:r:c o.a-.~ WAFTf3A!'d7l• DEED ~~ t. .~i.~s.~~.iav i_ v l: .L~)vc7,•rut- .l~Jc~--- -- _, - ..!~ 9 K~(si5! tK"~ ~F1~1~~ _ _ . _ .. -_-- s; sr. cRO~x co., vv~ Ti-I1S DJP.@d, Sam F . Mi i Ie r , male ht•tween - _ - - ~~ l2ee'd for Record a single man - - --- -- --- - - -- _.......__.._ ....____ -- -- -- ------ . _.... --- - ~~ JAN 6 1994 - -----. _ Grantor. ~ ~t / 2 • 30 P. ~ and...-.-. -.Ha_rr-Y--L.---Danielson.and-_Sharon.-F__---Dah-1-'---as---.-------.- ~I ~/7f Joint 'Tenants t~ ------------ ~ ~ Rt-Kisler of Deeds i~ ~T11:I1GS.°-,'Call, That the said Grantor, for a Valuable co:esidcrati~n.... ~~ --._ , RETURN YO conve,YS co Granuc the following described reni estate in - St. GrUlX ~~A~~~ ~_~ ~!y ~,, ~ _,` Coun+~.~•, State of Wisconsin: 'j ~' v ^ iY ~" ,~ j'w sue. ., Lat ~ , in tY.e 21at ~~ Slumhir3 Hills in the Town of Hudson. ~~~~ . u ~ Tam °arcel Ao- ---------------------------------- ;~ This __.?:S__??9t_.._________ homestead property_ (is) (is not) Together with all and singular the hereditamenta and appurtenances thereunto belonging; And_.____Sam-_F _, Miller _ _ warrants that the tiY.le is good, indefeasible in fee simple and free and clear of encumbrances except ponding easement. as shown on the above mentioned F-lat. ru7d v:ill warrant. and defend the same. Dated this ....- ~~~! --_..-....._. day of .._-__3anu3ry- --- ----- .....__, 7.9,_94... ------..._ (SEAL) _~'C Z.(/~ - ~' ~~rt.~~!~~ .................. (SERE) Sam E. Miller - ---------------- ------------------- -_ ------- - ---------CSEAL) ?UT1<IFirTiCA{{TIOhT 'Cont.. 4~ !~ ~(~~~ Signature(s) ----•/f -- ~---------°----'--f-------------------------- authenticated ;,his __~'~day of . L,it~~'°'.w`3_:____.. 19_~.y_ ~ .% -- -------------- --=-- 5`__ rf___________------ TITLE: MEMBER. STATE BAI2 OF V~ISCONSIN 4Z~-xieS- ------ - ------ ---------- -• -•------...----------------- av!;horiz(+d by .~ 7n(;.p$, Wie. State.) -fH~S 1N~TRU MEN?" WAS OR4FTE~ OY Heywood & Cari, S.C_, by Joi:(n D. Heywood P.O. Box 229. Iludson. Wisconsin 5/+016 f tiignn+vrr.c may h(• auth<lntjrsilr•d nr acknnwledr-ed. Loth RTC IIOt 17000SSar~_) AC'K1K(?S7VLEDLiY~3ENT STATE? OF WISCGNSIN ` ST. GROIX !~ sm. -' -- ------`- --------- ---- - • -------- -County. ------_--Personally elms before me this ._____ _..-__._d<(Y of January _---_ 1g-94 the above named ---__._._Sam__E~_1`Ii11eL_.._._--•--------- ----------------------- to me known to be chc person _....._._._. who executed the foregoing instrument and ack-nowiedge the same. _ ... ca- rr^iv lvota ry Punnc ..."--.. ._..._.. ... ..._ ....Counrt; WI=. .wl>- 1°-ommission is permaaen'. llt not. state eXfl!r~tl~.+: .I1r..~: _. .. .__. .. t~ 7 ~*inm~. .. r•~r.n n. - ,nom .,. .n y , ~ y -:i....,~r t,c v'. n^-.! ..- !. r,n v.~.+ 1: ~t....~ :hrir vi~n:a,... r... W'fiRRA NTY P[?f'T? `IT.I TI; }tAlt f)F w}tif'()ti ~i1N I ~-a--,! }~. .... - - 1-'()R~i iV o. t - t~P2 ~~I ~;..n•.A ar. wic. nv,p ~ ~n .. d ~" d ~~ ~ 3 ~: ~. ~ V n _ O ~ N 'J W N ~ p ~ W W a N CD ~ O O ~~ ~ CNO O O <p O N ~ N 7 ~ N . 'p O ~ N n 2 p ~ ,p ~ as O O C O Oo Oo ~ O N 7 W .~ O O O ~ C V d w ~ '; ~ D a m = ~ : ~ ~ a W ~ W C ll N O ~ *' ~ ~~ O ~ Zl '. (1i Z O a `D ~ C7 ~ cA O c O N O C ~n cn 2 7„ •'•' a c a .. ~ ~ 'O '0 ~ p ~ '. 0 0 0 7 ~, N ~ Q C ~ ~ ~ < C ~~. O c~ ~ fn Ul U1 `J C N .-r O O ~ ~ ~ W ~ .~ v o cn ~ ? 3 6 O ~ ~ N "~° _ D1 '~ O ~ Q ~ O) _ N _ 3 3 n, ~, ~ ~ ` i O- . ! i Z . '~~ D O Z fA Z a i ~ D am I =- v ~ ~ ~ ~ ~ ~ ~ m m ~ N ~ N ~ ro w m ~ c ~ i W ~ a a ~ ~ Z m ~ ~ -~ p` -~ U~ Z m O ~ , ~ n -' ~ A Z O m a 'i ~ o .. ~~ N ~ ~ : ~ ~ ~ a ~ z 3 ~ A ~J O ~ 9 Z m O ~ tll Z O ~ A ~ N O ~ O ~ o ~ O .~ 3 N o m ~ N~ a ~ cQ am ~~ ~. ~ o cco v c m ~ m N m ... n z a p i 'O 7 7 p .. O i ~ i , ~~_ ~ t ~ O d N O F m _ C O O ? N X N O Q ~ W ~ ~a $.~_o Q ~ m ~ m no Q~.~ ~ ~ ~ ~ • ~ o ~ ~ O~ m >j~ 'I i N ~ ~ O n 7 ~ ii O 'I I (D 69 ~ O ~ O O ~ ~- '1 ' 8 9 STC - 104 AS BUILT SANITARY SY R~O ~ ~O OWNER T ~/ ~~`~9s ADDRESS ~j 7 ~U `~ ~~~/ -~ ~ ~,~' /~ SUBDIVISION / CSM# _ ,, ;,rte ~ . c LOT # SECTION~~T~N-R~W, Town of ~~~1 sue/ ST. CROIX COUNTY, WISCONSIN PLAN VIER SHOW EVERYTHING WITHIN 100 .~ J I g~ /7 g T fay ~~ ~~ ~~ Provide setback ~ cn /ele ation inf Provide 2 dimensions to ce er SYSTEM ,.~~. %/" INDICATE NORTH ARROW tion on reverse of this form. of septic tank manhole cover. ~,,~~~ BENCHMARR • ~~~~ ~~ fi ~ ~,~ - ~~ ~~/' ~ ~ ALTERNATE BM: oa ~ s. ~I a~z~~~~~,L~ ~ ~ SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: ~it/~'~~15 Liquid Capacity: Setback from: Well ~js"' House ~C3 Other, Pump: Manufacturer Float seperation Alarm Location Model# Size Gallons/cycle• -:SOIL ABSORPTION SYSTEM Width:_ ~_ Length ,~~ ~ Number of trenches Distance & Direction to nearest prop. line: ,~~' _~~ ~ Setback from: well:, House~~ Other ELEVATIONS Building Sewer , ~ // ST Inlet ; c~7~ ~ ST outlet y~ PC inlet PC bottom Pump Off Header/Manifold Ql..~-~/ Bottom of system ~ ~/ Existing Grade ~-7~ Final grade T .DATE OF INSTALLATION: - JS PLUMBER ON JOB: `/ LICENSE NUMBER: ~~~.5 ~ INSPECTOR• ~,y, 3/93:jt Wiscpnsin Department of Industry, Labor and Human Relations Safety,and Buildings Division GENERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) Permit Holder's Name: ^ City ^ Village aTown of: DANIELSON, HARRY X CST BM Elev.: Insp. BM Elev.: BM Description: UO . L oT Coy-r~~ ~~~ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Dosing ~~~ Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Airlntake ROAD Septic NA Dosing NA Aeration NA Holding PUMP /SIPHON INFORMATION Manufacturer Demand Model Number GPM TDH Lift Lriction System TDH Ft Forcemain Length Dia. Fi Dist. To Well ELEVATION DATA County: ST. CROIX Sanitary Permit No.: State Plan o.: Parcel Tax No.: STATION BS HI FS ELEV. Benchmark ~• 3~ IOS / 00 - d 2G~( 5~--(~ ~3 Bldg. Sewer ,~ Z3 G) ~, ~ (o St/Ht Inlet ~, lS~ ~~, Z St / Ht Outlet ~ , ~~ O Dt Inlet ~- ~ Dt Bottom ~ `~ Header /Man. Dist. Pipe $.g~ ~~ Bot. System ~ . ~ c S Final Grade (~. (~ rj~. 79 /kl~-, t3rVl s z6 po. ~3 door s~`~( /1/I~cvt ~ of ~ r (p~7 d' ~~'• (o l SOIL ABSORPTION SYSTEM BED /TRENCH DIMEN I N Width Length No. Of Trenches PIT DIM N I N No. Of Pits Inside Dia. Liquid Depth SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION TypeO CHAMBER Mode Num er: System: OR UNIT DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length 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 Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson. 27.29.19W, NW, NE, Lot 17, Hill Farm Road ~. d~~ ~ a~ ~~~. ~~~ ~ ~~~~ s Plan revision required? ^ Yes ^ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: .' , ,~ .' ~~G ~~`53~ 00 v-U ~ i©~ s 7~ ~' J J `~ rom REQUESq- vv~ ~~ -, ~.. ~~( e c CO~ eCt: \~ // '' 1 ADDRESS. l h"~y `~- asp e°t a DC;CUMENT No. ~, STATE BAR OF WISCONSIN FORM i -1982 TNIS SAC[ R[Sf RY[D IOR R[CURDINO DATA ~; WARRANTY DEED !i .i3.1i26 __ _ ' _ __~~lt 1(~59vASE.~S3 _ _ REGISTER'S OFFICE ,' Sam E Miller, ~' CROIX CO's ~ This Deed, made between ..... ................. ......... ................ Reed for Record __ a_ single man _ _ _ ~ _ - .....~.......~- ----------------~..............~.....~:~--...... ---~-------- ._... -~ ~-- -- ... --....I JAN 6 1994 _.... -------_ ........................:..................... ....... ........... . ........... Grantor. ~~ 2.30 p', and._..-..-_ Harry L. Danielson and Sharon E. Dahl, as '~ aL (~ ~ M Joint tenants ,~ `[~"•+`~•~ - ---. - -- fts~laaraDseds ........ ............ ............... ......... ....- ....... .. II i' .. - --•------ it ~_ . ............................................................•--•--•---........................., Grantee, i Witnesseth, That the said Grantor, for a valuable consideration__... i R[TU qN TO conve s to Grantee the followin described real estate in St. C[olX-. --.- ~ ~~ County, State of Wisconsin: I ~ F 0. A d.r 2 z y ~4..tls.,,, I "-_-_ - - -__ _ _ Lot 17 in the Plat of Humbird Hills in the Town of Hudson. Tax Parcel No_ ___________________________________ '. l~Y~•~~ ~__-1-=-~-. F~ This _... i s not homestead property. (ie) (is not) Together with all and singular the hereditamenta and appurtenances thereunto belonging; And_._._.Sam E.•-.Miller••-----•-. warrants that the title is good. indefeasible in fee simple and free and clear of encumbrances except ponding easement as shown on the above mentioned Plat. and will warrant and defend the same. - -.. _ _-. Dated this ------ - -------~~~--•-•-•--•- -•--•--.. day of ..- - January _ _- , 19. 94_. '^' ~~.- -ti^~""'r.. ..... ..(SEAL) Sam R. Miller AUTHENTICATION p-1S ,~GLYft, ~r ~~ir~,c, Signature(s) ----- -- -- --•----------• ------------------------------- authenticated ;,his _.y:~da of__ ~,F ~u'"i"""3_....._, 19 i_5'_ '--------- ~-~-- J~ ~~-...-h----~~-~--~-w ~-~ p---------- TITLE: MEMBER STATE BAR OF WISCONSIN 1nthorized by ~ 706.06, Wis. Stets.) 6 THIS INSTRUMENT WAS DRA FTEO BY Heywood & Cari, S.C., by John D. Heywood P.O. Box 229, Hudson, Wisconsin 54016 (SiKnatures may be authenticated or acknowledged. Both are not necessary.) ACHNOWLSDOMSNT STATE OF ZISCONSIN ST. CROIX ~ ss. - •-•----•--••--•----•--•-•----.......County. Personally came before :ne this ________________day of January i~ 94 the above named - -------.Sam..E_..Millet:-------•---------- ----•-•---•----- ------ to me known to be ti:e person ......-....- who ezecuted the foregoing instrument and acknowledge the same. Notary Pi:blic .St. CrolX _ - .-_. -County, Wis. 5fy Commission is permanen`. ([f not, state expiration datee - 19 -1 SONITeRY PERMIT ePPI 1[`OTIIAN ~~L~7R -- -- -- - - -- - - - -- ----- - - -- - -- -- - - - - < In accord with ILHR 83.05, Wis. Adm. Code CouNTY STATE SANIT Y P RM T # -Attach complete plans (to the county copy only) for the system, on .paper not less than Q~a~3~(~ 8r~ x.11 inches in size. ^ Check if revision to previous application -See reverse side for instructions for completing this application. sTATE PLAN I.D. NUMBER I. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION. PROPER OWNER PROPERTY LOCATION ~ t ' (or /4, , N, R /a PROPERTY NER` MAILING ADDRES LOT # BLOCK # CI - , ATE ZIP CODE PHONE NUMBER SUBDIVISIO AME OR CSM NU BER ~ 11. TYPE OF BUILDING: Check one CITY ~ NEAREST ~D ( ) State Owned O VILLAGE ^ Public ~ 1 or 2 Fam. Dwelling-#~ of bedrooms ~ PAR ELTAX NUMBERO / III. BUILDING U$E: (If building type is public, check all that apply) ~~~~ ~~ ^ !~~ 1 ^ Apt/Condo 2 ^ Assembly Hall 6 ^ Medical Facility/Nursing Home 10 ^ Outdoor Recreational Facility 3 ^ Campground 7 ^ Merchandise: Sales/Repairs 11 ^ RestauranUBar/Dining 4 ^ Church/School 8 ^ Mobile Home Park 12 ^ Service Station/Car Wash 5 ^ Hotel/Motel 9 ^ Office/Factory 13 ^ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ~ New 2. ^ Replacement 3. ^ Replacement of 4. ^ Reconnection of 5. ^ Repair of an System System Tank Only Existing System Existing System B) ^ A Sanitary Permit was previously issued. Permit # Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ®Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank 12 ^Seepage Trench 22 ^ In-Ground 42 ^ Pit Privy 13 ^Seepage Pit Pressure 43 ^ Vault Privy 14 ^ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION / C6 ~ 8 T '` Feet Feet VII. TANK CAPACITY in allons Total # of ' N Prefab. Site C l St Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks s Manufacturer ame Concret on- ee glass App Tanks Tanks ~ structed Se tic Tank or Holdin Tank '- Lift Pum TanWSi hon Chamber VIII. RESPONSIBILITY STATEMENT , I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumb r' Nam (Priryt): Plumber's Si atu e: ~S ps) MP/MPRSW No.: Business Phone Number: /.~ P umber's Address (Street, Ci fate, Zip Code): ~ r ,~ i IX. COUNTY/DEPARTMENT USE ONL ^ Disapproved San'tary Permit Fee (Includes Groundwater a e slue Iss ing Agent Signature (No Stamps) Approved ^ Owner Given Initial Surcharge Fee) ~ r ~~~ Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety ~ Buildings Division, Owner, Plumber INSTRUCTIONS , • • 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: {. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where -the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in .line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. Vt. Absorption system information. Provide all information requested in #1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for a// septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VI11. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8%z x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. ~ - SBD-6398 (R.11/88) ~/.~, ~~ syo~~ S.C~J'sC ~~' ~GLJw I~~~~/ ~~ i / _ /o s~fE ~~?~ ~~ ,D~-~ /~~~'s~ ~?s9 ~' ~~, ~Ti' --rte ~~ ~u~ u1cl~ ,, ~ 4, ~~ ~ __~` \ a ~ ~b,,,r ~\/ ~Ce f / 7 J~ PA•G E ~,^ O F Cr~SS _y Fresh Alr Inlets And Obcervallon Pipe 0 ADDrovod Vrrnt Cop Mlnlmum 12` Abor• rn float Grod• 20- 42" AOovo Plp• To float Grad• IAOrsh Hoy Or SynlMfk Cov~rlnq "10. 2" Aggroqat• Over Pip• Olatrlbollon plpe -~ 0 0 0 0 0 G" Aggr~qou 8~noath Plp• - PruPoSe~ t'Inkl 11gr~.~1{ ~`cJr.T ton _ 4" Cap Iron Vonl Pip• T~• Porlwolod Pip• Bpow Capllhq T~rminollnq AI Bolton OI Sy~Um SOIL FILL 2" of A6GR AGATE -~~~ Sec~Ion o~ rl ~en SyS~e~-, OISTFc18U710F.] PIPE ~~EV oFE~T-~ i (o OF 12-zl/2 AGGREGATE .. 1 APPROVED ~~~jFIETIC COVER ~'`"MAT~Rfll~l- OR 9~~ OF STRAW ~~_ OR ('1AiC5N HAy - ~ ~- ~ ` ~ DIS'rRIa~UT101J PIPE TU BF_ AT LEA5T ~~_ IRJtHES BELOW ORIG1RIAt_ GRADE AR)U AT LEA ST 20 (RICHES 6UT 1.10 MORE THA1J 42 IRlCHES BELOW FI(~JAL GRADE MAXIMUM ®~QrH OF ~X~ayAT~m-.o I~~oM al~i~r~+gt 6~Ao~ WILD 6E _~_ IR1cHEs MiK~MV1~ ®EQ1"~i of ~XCA~~TimN ~RoM ~rG~NgL ~~ap€ WILL BE _ZL- INCNES r LIGERISE AJUMgER: ^? DATE: ~~ %~,C/'~~ Wisconsin Department of Industry, L2bor and Human Relations Division of Safetv & Buildings SOIL AND SITE EVALUATION REPORT Page ~ of ~~i uvvv~4 •\~1~~ ~~~ ~~ \ vv.vv, •~v. • ~v.. ,. vv\wv COUNTY Attach complete site plan on paper not less than S 1/2 x 11 inches in size Plan must include but . , not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPE OWNER: PROPERTY LOCATION GOVT. LOT 1!4 1/4,S T ,N,R ,~ (orJ~ PROPERTY NER':S MAILING ADDRESS - LOT # BLOCK # SUBD. AME OR CSM # . ~ ~ CITY, TE ZIP CODE PHONE NUMBER ( ) CITY ^V LAGE ®fOWN NEAR ST ROAD f~/J New Construction Use ~(f Residential / Number of bedrooms _ ___ [ ]Addition to existing building [ ]Replacement [ ]Public or commeraal describe Code derived daily flow ~~ gpd Recommended design loading rate ~_bed, gpd/ft2~~trench, gpd/ft2 Absorption area required .S'X bed, ft2 _7s'o trench, ft2 Maximum design loading rate ~ 7 bed, gpd/ft2~trench, gpd/ft2 Recommended infiltration surface elevation(s) T. S°.~' ft (aS referred to site plan benchmark) Additional design !site considerations ~ '~ C '~ Parent material ~ ~ _ loud plain elevation, if applicable ft S =Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable for s stem f~] S^ U I~ S^ u [X7 S^ U ~ S ^ u ^ S ~ U ^ S L~1 U SOIL DESCRIPTION REPORT Boring # yv;.4::::1:.v: F Vii:: }i•: ;i'.4`>.'+~?~; v'i:::.:i4i::•::•: iii .... ............. Ground elev. /D,~ 3 ft. Depth to limiting factor 9" Boring # t . : .: : : . : . . ,. . . : : : : . .,f..~.:~.::. ~:~ ... :;~~ \tii~\~:•i:•:~i:t~: Ground elev. ~_ ft. Depth to limiting factor ~lD H i Depth Dominant Color Mottles Texture Structure Consistence Boundar Roots GPD/ft or zon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. y Bed Trench Remarks: J 3 ~~ -~ ~ _ _ .r Remarks: CST Name:-Please Print ~;, Phone: ddress: r Signature: Date: CST Number: PROPERTY OWNER ~L SOIL DESCRIPTION REPORT PARCEL I.D. ~ Boring # i~ `~'\ y::::}:: ... v.. titi'i.::% Ground elev. ~ ft. Depth to limiting f9G Boring # ~~s:.:.:::::.:; :: ` j~.~: Ground elev. /~ ft. Depth to limiting factor G Boring # <~ ~5' Ground elev. ft. Depth to limiting factor ~ 8 Boring # h ::.... .:... :4} .... Ground elev. ft. Depth to limiting factor Page of Depth Dominant Color Mottles Texture Structure ~~~~~ ~.~ Roots GPD/ft Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trerxh Remarks: -~ ~ Remarks: ~ s J '_' Remarks: Remarks: SBD-8330(8.05/92) • PROPERTY OWNER~~,Q~~~,~~~l.cJ.~/ SOIL DESCRIPTION REPORT PARCEL LD. # Boring # G:v:: ~4h~~ .v tis'. z £4 ,:. ... v~4~i. •x.:: i.S'v Ground elev. eft. Depth to limiting f~- Boring # `:4a~: ~~~ s .~s.: Ground elev. /~ ft. Depth ro limiting facror > 9G Boring # ~~~. •: -.' 4.4~ `r V ~n~i ~ ': . ' ' x C u • . .:... v Ground elev. Q~; ft. Depth ro limiting factor ~ g Boring # :: : . , : ; : ti x :: : ; ::: ; .: ., F~. '\{ti .fi. t.*' Ground elev. ft. Depth to limiting factor Page of ~ Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourdary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench Remarks: d Remarks: l i Remarks: SBD-8330(8.05/92) Remarks: .4 s®,~,~.~~gs ~~~~ ~.~ _~ 8y --~ !i --~~ ~~ S ~_ /-/U.C2S0iV ~~~wa// ~~ Tiy~/~ -~ o~ ~- ~.~ ..: ~. ~, ~ -~ ~ ~,~ ~- ~~ i ~~ d'~i /V .~m~ /r .~, 6 ~~ 'v~ STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER MAILING ADDRESS _ ,,,g~g ; ~1~, ~~~ PROPERTY ADDRESS ~y/7 ~~~ ~~~ (locatron of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION ~ 1/4, ~1J~' 1/4, Section ~, T~_N-R~_W 'SOWN OF ---,~!'~ ~9aJ ST. CROIX COUNTY, WI SUBDIVISION _ ,~h,~,,,ra ~ ~~~ ~~ LOT NUMBER ~_ CERTTFIIEDSURVEYMAP ,VOLUME ,PAGE ,LOT NUMBER-~ 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. Tl~e property owner agrees to submit to St. Croix 7.onirig a certification form, signed by the owner aid by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. U\'V e, the undersigned Dave read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, I~erein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and resumed to the St. Croix County Zoning Officer within 30 days of the three year expiration date. --~ SIGNED: ? i ,~~ ~ U ~'~ i DATC: __ T~~ / ~~~ St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11 /93 , This application form is to be completed in full and signed by the • owner(s) of the property being developed. Any inadequacies will ~~ only result in delays of tY}e permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. ---------------------- ---------------------------------------------- Owner ofproperty-- ^~.~_ ---__--,_- _ Location or property~_1/4_1/4 , Section ~ , T~~N-R_ /~_W Township~j~G~1 Mailing address ____ Address of site Subdivision name ~ -~ _ Lot no. _~~_ other homes on property? Yes, ~Io Previous owner of property -~~'~ ~ . r ~~-~`' ---- Total size of property ~~/ ~~Pr'S Total size of parcel Date parcel was created Are all corners and lot lines identifiable? ~ Yes No Is this property being developed for (>pec house) ? __-_____Yes ~__No Volume ~`7~I and Page Number ~~3 _ a:.~ recorded with the Register.. of Deeds. --------------------------------------------------------------------- INChUDE WITH THIS 11PPLICA'i'ION TIIE FOLLOWING: A WARRANTY DEED which includes a DOCUML:N`P NUMBER, VOLUMr AND PAGE NUMBER AND TIIE SEAL OF TIIE REGISTEP. OI' DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the decd description references to a Certified Survey Map, th e Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of: the pr.oper.ty described in this informati.or~ form, by virtue of. a warl:anty deed recorded in the office of the County Register of Deeds as Document No. _Jr~`5_a_~_ _ _ and that I (we) presently own the proposed site for the sewage cJisposal system or. I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duJ.y recorded i.n the office of the County Iegister of Deeds as Document No. S.ignat re of Applicant Date of Si. nature Co-Applicant Date of- Signature