HomeMy WebLinkAbout020-1178-10-000 Wisconsin Oepartment of Commerce PRIVATE SEWAGE SYSTEM county:
Safety and dings Division INSPECTION REPORT St. Croix
Wi
GENERAL INFORMATION (ATTACH TO PERMIT) San38r3895 it N o.:
Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)).
Pe i Hold is Name: ❑ City n Village Town o : State Plan ID No.:
><nd Hudson ownship - —
CST SM Elev.:• / Insp. BM Elev.: BM Description: Parcel Tax No.:
C 1 ; �i✓ 020 - 1178 -10 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic � lnll • W • P �Z� Benchmark . Z� o - L /� • O
Dosing Alt. BM Z -3S' ol, o�
Aeration Bldg. Sewer 7-3 Y 96.91 r
Holding St/ Ht Inlet �• t {3 96 • Si
TANK SETBACK INFORMATION St/ Ht Outlet Go 96.65 /
TANK TO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
/ �- f
Septic NA Dt Bottom
� '--'
Dosing A Header/Man. q� • ll /
E D Aeration A Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
over
Manu cturer De nd
Model Nu er G M
TDH ction System TDH Ft
Forcemain Length Dia. H Dist. To well
SOIL AB RPTION SYSTEM
D ENC width , Lengtt, ,� N .O Trenches PIT No. Of Pits Inside Dia. Liquid Depth
4!'
1 N 3 DIM N I
LEACHING f e � fturer
SETBACK SYSTEM TO P / BLDG WELL LAKE / STREAM CHAMBER INFORM ATION TyPe um er:
System: OR UNIT a
DISTRIBUTIO SY TEM
Header / any Distribution Pipe(s) x Hole Size x Hole Spacing Vent TO Air Intake
.t, `
Length =' Dia a Spa
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 C] No
n pection Inspection #2: �,--/—
Ldc f194M 1TfarYbYl�,�%6,° u SheR�R` j7j 4 T29N R19W) - 2829191120 Cedar Hills Estates
-Lot 20
1.) Alt BM Description ='('op �
2.) Bldg sewer length= \ �, O
- amount of cover = 34 it +.
3) �� �- -cam �•
tag eve - c- 7
Plan revision required? [:]I Yes P( of (" `�P FEH
Use other side for additional information. b �L�
SBD -6710 (R.3/97)
Date Inspectors Signature Cert No.
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'1 "Y kotoe- 16W 93 C / 5
s Sanitary Permit Application Safety & Buildings Division
In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave.
See reverse side for instructions for completing this application PO Box 7302
oSCOnSin Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302
��partment of Commerce ltd f t
(Submit completed o county if not
[Privacy Law, s. 15.04(1)(m)] state owned.)
Attach complete plans (to the county copy only) for the system, on paper s than 8 -1/2 x 11 inches in size.
Cou� t� C � � State Sin to Pe rrjUtNumber ❑Check if revisiotYfa previous ap¢ll� State Plan /VIA, mber
( 5
I. Application Information - Please Print all Information i �.' cation:
Property Owner Name i C, erty Location
1/4 /U6/4,S PTa (orL
Property Owner's Mailin dress n Qt 4umber Block Number
57,
City, State Zip Code Phond Nurrtber� division Name or CSM Number
II. Type of Building: (check one) ❑ City
PC I or 2 Family Dwelling - No. of Bedrooms : _ - y — e x ;tfjt/J,6, ❑ Village
❑ Public /Commercial (describe use):_ #� O of
❑ State - Owned YU.D� i
(� ' L _
Nearest Road
�,��UeAt- ,2 IT2r Parce TaxNumbe s _ -
DO o0
III. Type of Permit: (Check only one box on line A. Check box on line B if ap plicable) A 1 9 . PIq J °l . J J X p
A) 1. ANew 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to
System System Tank Only Existing System
� B)
1:1 Permit Number Date Issued
A Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
k Non- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
i01411e"e- ka
V. Dispersal/Treatment Area Information: // C2 34`x f
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 1. Final Grade
Required Proposed Rate (Gals. /day /ss. ft� (Min. /inch) Elevation
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks
iabo Ja 6 0 =� °
❑ ❑ ❑ ❑ ❑
VIII. Responsibility Statement
1, the undersigned, assume responsibility for installation of the POWTS showW the attached plans.
Plumber's Name (print) Plumber ignature n p P PRS No. Business Phone Number
Plumber's Address (Street, City, Sta , Zip Code)
1X9 /� - U GUS 5 6 a
IX. County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing t ig ature (No stamps)
# Approved ❑ Owner Given Initial Adverse Surcharge Fee)
Determination
X. Conditions of Approval /Reasons for Disapproval:
IOWA Vvdsaw - - 2:onin
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SBD -6398 (R. 07/00)
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Wisconsin De .partment of Commerce SOIL EVALUATION REPORT Page 1_ of 3
� Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County St. Croix
Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 020 - 1178 -10 -000
Please print all information. R A eviewed by D ate
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). J �(
Property Owner Property Location
Camero Hanes, Inc Govt. Lot NW 1/4 NE 1/4 S 2 8 T 2 9 N R 19 xE (or) W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
box 164 20 na Cedar Hills
City State Zip Code Phone Number ❑ City ❑ Village (RTown N
Lino Lakes 55014 (612) 803 -7058 Hudson Z111
Q New Construction Use: ® Residential /Number of bedroo4 de derived design flow rate e il rate G D
❑ Replacement ❑ Public or commercial - Describe: ` "`
Parent material nu 1 Gh Flood Plain elevation if applicable -ft.
General comments
and recommendations: c SS l,Ra
trenches starting @ el. 95.80', spaced to code 4.0a-,' a3e,. 'may
® BoringA__�
Boring # Ej pit Ground surface elev. 9 9 . 8 0 ft. Depth to limiting factor + 9 6 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff #2
1 0 -7 1 mfr gw 2m .5 .8
2 7 -22 7.5 r4 4 none sl 2msbk mvf
3 22=94 7.5yr4 6 none ms Osg ml na na .7 .1 .2
2—] Boring # � Boring
F
pit Ground surface elev. 99 • 5 0 ft. Depth to limiting factor + 9 6 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft=
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
1 0 -9 10 r4/ none L 2msbk mfr QW _1M
2 9 -24 7.5 r4 4 none sl 2m mfr CjW if
3 24-96 7.5yr4 6 n ms oscf ml na na 7
Nit•
I i i I T
' Effluent #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg /L ent #2 = BOD 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature CST Number
Gary L. Steel 02298
Address Date Evaluation Conducted Telephone Number
1554 200th. Ave., New Richmond, WI. 54017 5 -18 -2001 715 - 246 -6200
y
Camer n Pa
Property Owner O H omes, IriC. P arcel 02o- 117fi_ -nnn e 2 of 3 9
5-1 Boring # ®Boring 9 8 + 9 0
❑ Pit Ground surface elev. _ • 6 0 ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2
1 0 -9 10yr4/2 none L 2msbk mfr qW 1m R
2 9 -24 7.5yr4 4 none Sl 2ms k mfr gw if
3 24 -9 7.5yr4 6 none ms Osq m
F4 Boring # X Boring —
❑ Pit Ground surface elev. 9 7 . 5 0 ft. Depth to limiting factor + 9 0 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fF
in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff #1 `Eff#2
1 0 -9 10yr4/3 none S1 2mcir mvfr gw if .5 .9
2 9 -20 7.5yr4/4 none sl
3 20 -90 7.5yr4/6 none MS Osq m .7 1.2
Boring # Boring
El Pit Ground surface elev. ft. Depth to limiting factor in.
Soil A
�pplication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2
` Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 mg/L ` Effluent #2 = BOD < 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.6 /00)
r
• STEEL'S SOIL SERVICE
Gary L. Steel Cameron Hanes, Inc. 1554 200th Ave.
CSTM2298 Nw4NE4 s28- T29 -R19w New Richmond, WI 54017
MPRSW -3254 town of Hudson (715) 246 -6200
lot #20 -Cear Hills Estates
N
1 =40'
BM.= top of 1" pvc pipe @ el. 100.00'
Alt. BM.= top of 1" pvc pipe @ el. 98.40'
)N .��
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Gary L. Steel
5 -18 -2001
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INDkJSTRY,, KC I uw ,uIL WM NUb AN 6AI-tl Y & 8UILUINI:
LABOR AND PERCOLATION TESTS (115) �� s ; ft P.O. BOX 7
HUMAN RELATIONS 9(
(ILHR 83.09(1) & Chapter 145) Ko�* (, ,,,/( MADISON, WI 537(
LOCATION: SECTTUIT. TOWNSHIP /Mk11ii4FPtsf�1 -Y: LOT NO.: BLK. NO.: SUBDIVISION N �q� E:
Nw t4 r- V4 28 /Tz9 N /Ri91q(or
a z6 - C 4AR T,u<.. ZS
COUNTY: ER'S NAME: AI L I NZ F A 7 5 1 51�= ,
ST�>QU I SdLL L M
USE
N D p P O DATES OBSERVATIONS MADE
Residence / New A N TE TS:
!Jt ❑Replace � /p / 9?6
!/ 47 7 Md 20,
AILS Uk C� OC1 C �,,;Ip - ►av,? kN��LT
RATING: S- Site suitable for system U- Site unsuitable for system
ON INITI�NAL: MOUVD: QU IN -GRO NcD -IN -FILL HOLD AN�K: RECOMMENDED SYSTEM: (opt onal)
II� S S U ( K_1 ] S J ❑ U ❑ u ❑ J !L►J Y �o ^, t/ d N T /G ti.�1 L \
If Percolation Tests are NOT required DESIG RATE: If an
under s. I LHR 83.0915)1b1, indicate: I y portion of the tested area is in the
�-A+� ` Floodplain, indicate Floodplain elevation;
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION - T R UN WATER•INCHES HARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTHC O OBSERVED H TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B 7 Q 1 7 �f). 33 21 S / �� h BRN I Ca r Al �
x 67 B e
B• X5.33 v/,3a /3 "$c«s iS��QtiL /� "�ee.,�c�lGri S "e ,-N iI�S
B-
B - 4 W: / p-2. 3 4
9 -s ' o '7 "kzcTs /o "ge, sc 34'9eU n s 61 Q c ;l C, P
B.
N PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES
NUMBER ltpYES AFTERSW LLING INTERVAL -MIN, RATE MINUTES
PER IOD PER INCH
P. d fJcNIE ? Z 1 <
P- 2 d.9U No b > >2 ? < -4— P 3 13 d osig /0 (s
P-
P
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hors
znntAl And vortical AIPVAtinn rafarane nn:nte anal .1-- t1.A1r 1,j n .... +k. _1_. _,._ c�,..... _�
Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In- Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWTS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
10567-P (R.6/99).
Table 1: System Design Specifications
Sanitary Permit Number 3 S 3& '�—
Number of Bedrooms V
Design Flow - Peak (gpd) 0 C7
Estimated Flow - Average (gpd) 60
Septic Tank Capacity (gal) O
Soil Absorption Component Size (W) ,5 — - % /+— C g
Type of Wastewater Domestic 17.
1p—d W �L
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow - Peak (gpd)
Maximum Influent Particle Size (in) 1/8
Maximum BOD (mg /L) 220
Maximum TSS (mg /L) 150
Table 3: Maintenance Schedule
Septic Tank Inspect and /or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the septic tank and outlet filter shall be assessed at least
once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure
proper operation. The filter cartridge should not be removed unless provisions are made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
Management Plan for a Septic Tank and Soil Absorption Component
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, defective, or subject to failure must
be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
Management Plan for a Septic Tank and Soil Absorption Component
Plantings of deep - rooted trees and shrubs directly over or within ten feet of the
component should be avoided since root intrusion into the component may obstruct wastewater
flow.
s
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer C O to L / ti 6
Mailing Address 90 / o? 1 C� 0
Property
O a Address L S S L� <-3=- P rtY '�
(Verification required from Planning Department for new construction)
City/State Vb9 05 Parcel Identification Number
LEGAL DESCRIPTION
Property Location N 611 V4, N � Y4, Sec. Z . T L2,N -R-.LLW, Town of
Subdivision ° �-� l LAS . Lot #
Certified Survey Map # , Volume . .Page #
Warranty Deed # q y 3 , Volume f . Page # S 7
Spec house ❑ yes�Kno Lot lines identifiable yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
mastorplumber, journeyman plumber, restrictedplumber or a licensed pumper verifying that (1) the on-site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of 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 Zoning Office within 30
day of
ear a on date.
,sj`I /O
SIGNA 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 owner(s) of
the prope cribed a by virtue of a warranty deed recorded in Register of Deeds Office.
c/lr
8I A OF APPLICANT DATE
*s « * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department."""
«« Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
1630
V "
' VUL . PAGE J "17 644396
STATE BAR OF WISCONSIN FORM 2 . 1999 KATHLEEN H. WALSH
Document Number WARRANTY DEED REGISTER OF DEEDS
ST. CROIX CO., WI
This Deed, made betweenW Development, LLC RECEIVED FOR RECORD
05 -02 -2001 12:30 PM
V WARRANTY DEED
Grantor, and Courtney A. Lind and Diane R. Lind, husband and wife EXEMPT M
CENT COPT FEE:
COPY FEE:
TRANSFER FEE: 149.70
RECORDING FEE: 10.00
PAGES: 1
Grantee.
Grantor, for a valuable consideration, conveys to Grantee the
following described real estate in St. Croix County,
State of Wisconsin (if more space is needed, please attach addendum):
Recording Area
Name and Return Address
Lot 20, Cedar Hills Estates in the Town of Hudson, St. Croix County, EAGLE VALLEY BANK, N.A.
Wisconsin.
1301 Coulee Rd Unit 2
Hudson, 1 54016
020-1 175.10
Parcel Identification Number (FIN)
This Is not homestead property.
0t) (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this ASIA day of April 2001
Wi6con Development, LLC
• AUTHENTICATION • ACKNOWLEDGMENT
Signaturc(s) STATE OF WISCONSIN )
'/
)Ss.
St . eve County ) LL
authenticated this day of m 2 irk day of
Personally came bcl'orc e this
April 2001 _ the above named
Wiscon-Developement, LLC by
• Wayne J. Johnson President
TITLE: MEMBER STATE BAR OF WISCONSNP A. CA me kn t c be tl c r(' who executed the foregoing
(If not, a, 4, r %) PubtT'— t d o he same.
authorized by § 706.06, Wis. Stats.) WjSCO
State of k
THIS INSTRUMENT WAS DRAFTED BY
Attorney Kristin" O land Notary Public, State of W sconsi
u son, 1 54016 My Commission is permanent. (If not. state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.) Nta. "L 6 , $eo1 .)
• Names of persons signing in any capacity must be typed or printed below their signature. Ierormetion Protemonais eompu+y. Fond a L.0- Wt
9008562021
WARRANTY DEED STATE BAR OF WISCONSIN
FORM No. 2.1999
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