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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. Q 0 '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 F food Q(mn lJ'%�4 Mt C� ,�� r,,� � - .Ff -%- ALq A&tl 6c h,,krA14 -%w! � lnq.Agl- - S ski otih N--� t�vut .his(, MA1,4 ln- Soi w.4&w ( IOJT� V cV1,- rl 2. U� ! 3o uor SBD -6398 (R. 07/00) f 6 A - 1 ` ld� J7-, f3 1 i aa X � I a r2 kf� w�u 3 X n b'` ; cs •� t l � F� ya b 1 ®( � �J 93 7 5 17`a Sc P�- �K 1L � � �or tIK 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 .�� I n t -� A L G Gary L. Steel 5 -18 -2001 r 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 � 67 1 5) 7 y�80 3 f 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 i r 1 23 N •47' • 0 w — - :i 0 - 6#,.26 44,00', 00 !4! •26 " S �0� 6 � � 23 W A ~ z a se.0o a ��r4 • /V 40 S7'33"E i •� 71(1 (> b 20 letie1 . hJ �.'�O � I •� N i' f } 1• O � Noo II' 45 "E i l r W 383.85 '. Z • i '160,00' O ! 1 g0 pp N A 2a ° 19 loi M 100.95' 160.00' to I j Ofl M o � -1 f Z 260.951-, I 0 Q 3 3 0 �iy i so s a N ° 0 4'37 "E zss.0 30.00' } � I 39.00' DRAINAGE o EASEMENT 109.00' 32. � I YI � $0 Z