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Home My WebLink About020-1230-80-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 399678 0 GENERAL INFORMATION' (ATTACH TO PERMIT) state Plan ID No: Personal information you provide may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township J Parcel Tax No: Edin, Nathan I Hudson Township - 1230 -80 -000 CST BM Elev: Insp. BM Elev: BM Description: ( _ TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark ' 4 lam WQ f Dosing Alt. BM Z-9 I o l -t.�o Aeration Bldg. Sewer !' Z6 q 11 q. 96` Holding St/Ht Inlet S SS 8.6t / St/Ht Outlet TANK SETBACK INFORMATION 7 7" TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pipe �' g b•36 � Holding Bot. System Final Grade jq log Q I � _ I . � r PUMP /SIPHON INFORMATION Man cturer Demand St Cover GPM Model N ber TDH Lift tion Loss System Hea TDH Ft Forcemain Length la. Dist. to well SOIL ABSORPTION SYSTEM PI @CB RENCH Width Length No. Of Trenches T DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 / $ f � L � i Qa SETBACK SYSTEM TO P/L JBLDG WELL LAKE /STREAM LEACHING M 13 =6w_ r - r � �� /L _ INFORMATION CHAMBER OR tF►.�• Type Of System: , / UNIT Model, Number: ` Z-0 Z .e, DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) ^- 3 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 r Yes % No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: —A . Inspection #2: ^- -- Location: 486 Country View Road Hudson, WI 54016 (N 114 SE 1/4 29 T29N R19W) Rossing's Country View Lot Parcel No: 29.29.19.1236 = ro P 1. Alt BM Descri p tion a F9. " 2.) Bldg sewer length = 7J }'t� r. - amount of co J k 71P11L w�t�� toy SAD' Plan revision Required? Yes °° No I Use other side for additional information. iY �9_ 4 �� Da te sepctor's Signature Cert. No. SBD -6710 (R.3/97) Safety and Buildings Division COY 201 W. Washington Ave., P.O. Box 7162 Pisconsin Madison, WI 53707 - 7162 rte Address Departmenf of Commerce �-4 /aL Sanitary Permit Application Sanitary Permit / , Num - b 7 er In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ❑ Check Revision S may be used for secondary purposes Privacy Law, sl5. 1 m I. Application Information - Please Print All Information ^ - State Plan I.D. Number Prope rs N e r „' r' Parcel Number "Note P Pr rty Owner's Mailing Address r" perry Location art a ;. LiJ City, State Zip Code' 1 Phone NVa3PQtiy. -, t Number Block Number J /Su bdivision Name CSM Number II. Type of Building (check all that apply) J ❑City r o Bedrooms Dwelling ' - Number f 1 or 2 Family lhng []villa p� Y ❑ Public /Commercial - Describe Use §dTownship ❑ State Owned Nearest Road M. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) A. 1 ,0 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use System I I Tank Onl I Existing S stem B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) 44 0 Non - Pressurized In- Ground 2111 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland 22 ❑ Pressurized In -Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line 45 ❑ At -Grade 46 ❑ Aerobic Trea nt Unit 49 ❑ Pecirculating 30 Other V. DisversaM eatment Area Information: ' 2 3 x Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./I Elevation VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank Dosing Chamber VII. Responsibility Statement- I, the undersigned, asqmne responsibDity or installation of a POWTS shown on the attached plans. Plum is ame (Print) Plumber's i MP/MPRS Number Business Phone Number Plumber's Address (Street, City, State, Zip Code) Sip VIII. Count /De artment Use Onl Approved El Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Surcharge Fee) ❑ Owner Given Initial Adverse z , ZS� Determination 1X. Conditions of Approval/Reasons for D' approval � tw.Lo.� cllasM. nnn.�� Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 Inches in size SBD -6398 (R. 05101) i I fi , -5 lee- .4z a i l t Nv YY _91d - I Ile I T J J I , , I r , i i �a _ .. PW I I I - ✓ � � ,�.� _ ,fir 9 - -�� _, - I I i Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County , Attach complete site plan on paper not less than 8 1/2 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. Q _ Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). . Z-S Property Owner Property Location Govt. Lot 2) 1/ — 1/4 S T N R E (or� Pr erty wner's Mailing Address Lot # Block Subd Name or CSM# City Stat Zip Code Phone Number ❑ City ❑ Village MT wn Ne est Road l ( ) - New Construction User Residential /Number of bedrooms Cede, de v0d destgo ftow 1 e GPD ❑ Replacement ❑ Public or commercial - Describe: n Parent material Fl ocCPtain ei y e t licable ft. General comments and recommendations: s�� --41 9% 9 t P4 at 3T :, FOX z r Dcl F/ I Boring # ❑ Boring , Pit Ground surface elev. 99, l ft. Depth to ' tih 1fae1grr 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 IV L a.It 9`f 7 o / qf• s� Y Boring # ❑ Boring Pit Ground surface elev. 98.9 ft. Depth to limiting factor > a in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. ont. Color Gr. Sz.. S / h. *Eff#1 *Eff#2 y �f t`J * E ent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L u nt #2 = BOD , < 1 30 mg /L and TS S < 30 mg/L _ CST Na ease Pri ) Signature CST Number Address ate Evaluation Conducted Telephone Number Pelt) SBD -8330 (R07 /00) Property Owner _ Parcel ID # � if ^ R(7 -Al" Page '�20f Boring # ❑ Boring Pit Ground surface elev. ft. Depth to limiting factor 2Z—, in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Pont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 / ? t ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor 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 ❑ Boring # ❑ Boring El Pit Ground surface elev. ft. Depth to limiting factor 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 * Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD5 < 30 mg /L and TSS < 30 mg /L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 - 264 -8777. SBD -8330 (R.07 /00) s; '/ lez;e Al, 6 t1w(ors ` r . 9� 9 t / _ ss - POWTS OWNER'S MANUAL at MANAGEMENT PLAN Page L of FILE INFORM ION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity gal ❑ NA Permit # 39%+b Septic Tank Manufacturer - s ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer 13 NA Number of Bedrooms O NA, Effluent Filter Model _ 13 NA Number of Commercial Units C9 NA Pump Tank Capacity gal �3 NA Estimated flow (average) gal /day Pump Tank Manufacturer ANA Design flow (peak), (Estimated x 1.5) gal /day Pump Manufacturer NA Soil Application Rate gal /day /ft' Pump Model a NA Influent/Effluent Quality Monthly average* Pretreatment Unit ONA Fats, Oil 81 Grease (FOG) 530 mg/L ❑ Sand /Gravel Filter ❑ Peat Filter <220 mg/L ❑ Mechanical Aeration ❑ Wetland Biochemical Oxygen Demand (BODs) ❑Disinfection ❑Other: Total Suspended Solids (TSS) 5150 mg/L Manufacturer Pretreated Effluent Quality ❑ NA Monthly average ** Dispersal Cell(s) Biochemical Oxygen Demand (BODs) :530 mg/L % In- ground (gravity) ❑ In- ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ At -grade ❑ Mound Fecal Coliform (geometric mean) 510' cfu/ l OOMI ❑ Drip -line ❑ Other: Maximum Effluent Particle Size % inch diameter * Values typical for domestic (non - commercial) wastewater and septic tank effluent. * * Values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every _� ❑ months 9 year(s) (Maximum 3 yrs.) Pump out contents of tank(s) When combined sludge and scum equals one -third (Ya) of tank volume Inspect dispersal cell(s) At least once every ❑ months 61 year(s) (Maximum 3 yrs.) Clean effluent filter At least once every Lf ❑ months a year(s) Inspect pump, pump controls ex.alarm At least once every ❑ months ❑ year(s) ISf NA Flush laterals and pressure test At least once every ❑ months ❑ year(s) 0 NA Other At least once every ❑ months ❑ year(s) W NA Other: At least once every ❑ months ❑ year(s) M NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or cerdflcadons: Mast( Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspection must include a visual Inspection of the tank(s) to identify any missing or broken hardware, Identify any cracks or leaks, measure th volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels In the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Ys) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of In accordance with ch. NR 113, Wisconsii Administrative Code. - The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatement components, and any other maintenance or monitoring at intervals of 12 months or less shall be performed by a cerdfled POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemica that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the content of the tanks) removed by 3 sentage servicing operator prior to use. Pip ,2 Qf System sun up shall not occur whtn soil condll.)Qm are (roan at the Inf%VJ0v4 Wrfactt, During power outages pump tanks may All above normal hlghwater levels. When power is restored the exceu waSWwatt:r will t" discharg+td to the dispersal cell(s) In one large close, overloading the cell($) and may result In the backup or surface discharge u effluent. To avold this situation have the contents of the pump tank removed by a Septap Servking Operator •prior to resto . power to the effluent pump or contact a Plumber or POWTS Malnulner to assist In manually operaOng the pump control) w restore normal levels within the pump trnk, Do not drive or park vehicles over unks and dispersal cells, Do not drvt or park ever, or otherwIR dUWrt) or compact, the ire within 15 Net down slope of any mound or at-grade soll absorption artra. Reduction or elimination of the following from the wastewater $trtarn may Improve the performance and prolont the life of trx POWTS; andbiotla; baby wipes; clgaretw butts; condoms; cotton swabs; degreasers; denul floss; diapers; dislnfecunts; fat, foundation drain isump pump) water; Emit and vegtubit peelings; gasoAne; grease) herbleldss; meat scraps; mtcdtcatiuns; oii, painting croducw otsticldes; sanitary nookins: u m pons; and wsw softener brine. AUANDONEMENT When the POWTS fails and /or Is pemianently taken out of sxrvlce the following steps shall be taken to Insure that the system o properly and safely abandoned In compliance wlO ch, Comm 83.33, Wlscoruln AdnnInlstrative Code] • All piping to unks and piu shall be disconnected and the abandoned pipe openings sealed. q The contents of all tanks and plu shall be removed and property disposed of by a Sepuge Servicing Operator. AMer pumping, all tanks and pl shill be excavatkd and removed or their cov removed and the void space filled wi4r soil, gavel or another Inert solid mdterlal. CONTINGENCY PLAN If the POWTS fails anti cannot be repaired the following measures have been, or must be taken, W provide a code compliant replacement system; A sulubie replacement area hats been evaluated and may be utilised for the location of a replacement soli absorption system, The repfacement area should be protkcud horn cilswrbance and compaetlon and should not be infringed upo ; required setbacks from exlsdng and proposed swcwre, lot fines and wells. Failure to protect the replacement area wil; result In the need for a new soli and site evaluation w establish a sulwbltr rt plactawnt area. Replacement systems rnu�; comply with the rules In effect at that time. 0 A sulUDIt replacement area is not available due w sttback and /or soli limitations. Barring advances In POWTS cechnQi a holding tank may be Installed as a last resort to replace the failed POWTS, 0 The site has not been evaluated to Idtntlfy a suitable repixement area, Upon failure of the POWTS a soll and site evaluation must be performed to locate a suluble replacement arts, If no replacement area Is available a holding uns; r bt Insulled as a last resort to replace the failed POWTS, O Mound and it-grade soll absorption sysums may be reconstructed In place following removal of the biomat at the IntjltraUvv surface, Keconsvvcttoiu or such syswrru must comply with the rules In effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES DEATH MAY RESULT', RIKUE OF A PER SON FROM TKE INTERIOR OF A TANK MAY 69 DIFFICULT OR IMPMURi F ADDITIONAL COMMENTS POWTS INSTAL R , POWTS MAINTAIN Name N ame Phone _ — phone SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name Ap Phnne f hon ,S 1113 }2001 08:42 7152173038 BELISLE EXCAVATING I PAGE 01 S T CROIX COUNTY SEPTIC TANK - MAINTENANCE A GREEMENT AND n r AW4 O W NERS - IP CERTIFICATION FORM Owner/Buyer - I a4fim �a �- �� ( n Mailing - Address Property Addro'ss (Verification required from Plannit Department for new construction:' CitylState n Of Nt1d ._._ Farrel .Ide4Uifw4tion Number L E 9A L I M f 1 P Tj Q L t3c&t;ut7 ' /i, !;, -Sec. , T 1� -R�W, TOW-u �3-` tZ'U/�$�l GkS 5 ai✓� bdi�risiort j , Lot # . Ceixifled Su-yay Map # -- ._ -... , Volume -_ - , Page # �— Wairrauq Deid # -_ yy� Z Volume - Page 0 Spec -house 0 yesxno Lot li s i&ati- ftable I;,.( yep D no 9YSIK i MAINUNA.NCE Improper sue and maintcnanceof y- our septic systern -could result in its-prernature failur- to- handle wastea,.P.rnpar maintenance consists of out the septic tank every three years or sooner, if needed by a licensed pumper. What-you-put into the system can afloct 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 ccrtificat form, signed by the owner and by a masterptumber, journeyman plumber, restricted plumber or a licensed Pumper verifyi,ig that (1) the on -site wastewaterdisposal system is itilhWer eperating and/or (2) aftor inspection and pumping (if necesssrY), - the septic tank is less 1/3 fuel of sludge. Uwe, the undersigned have rt44 the Abovt - requirements- and agree -to maintain -the private sewage-disposal system with .the siaadards set forth, herein, as set by the Department of Commerce ansl the Depgrimant-of Natural Resources, State of Wisconsin- Certification stating that your septic system has been maintained roust be completed and returned to the St, Croix County Zoning Office within 30 d s of the three year expiration date. / / NATVRE OF APPLICANT DATE I (we) certify that a statements tan - thi; -fi are true - to - the - best of m (our) lcttowledga, - f - (wG) am - (are) - the owncr(s) of the prnparty iieseribed above, by vir#uc -of a warranty tlee4 fiecttrdcd in Register of Deeds - Office. I 1 SIQNATURZ OF APPLICANT DATE I Any infortrtaiion that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. *• *�" JAWUdt With Ibis applicatlen: a stamped warranty deed from the - Rcgistec of Deeds QM" a copy -0.f -the -ee 14md _surr -cy map if reference -is -made -in -the warranty -deed DOCUMENT NO. � STATE BALI OF WISCONSIN LORI[ i —!M nus aenea aaasaVae FOR aseawlNS DATA WAIIRWY ono VO L 8.35 ?cl195 Y `.. Imo/{. San n S E. Miller, a single sa T Dew, msde d ' .......................... ............. .. • - - -• ........ •- • !i ST. CM ak ........... , ................................... •---- ...... - -••- -- ...-- •.................... -... -•• .. - . - - ........... ", - - - -- - . ... ...... .... .. .• ...... u MAR lam and_.... fiTiomas A....Edin in i f L. Edin husband and -•• d $: /AMA s wife se urvivorship marital property I� -------------- ---------------------------------------------------------------------------------- . - - - -• •- --- --- - -- -•---- •-- - -- --- ------ --- --•--- -- -•---- - ••- - - -- --- --- Grantee, Wit llesseth, That the said Grantor, for a valuable consideration _ ............................................. ..................... ....... . y�Tl` URM TO O RST conveys to Grantee the following described real estate in ..... ............ ... - - - -- r Q � County, State of Wisconsin: v. /! 'i Lot 8, Rossing's Country View Addition in the Town Ta: Parcel No- ----------------------------------- of Hudson. i� i ':'� :_Reserving a nonexclusive easement to use as an access road and for the installation of utilities so located that they will not interfere with the use of the road, the 66' strip of land lying Northerly of the Northwest line of Lot 7 in said Plat. The easement granted hereby shall extend from the town road to a line drawn as an extension of the Southwesterly line of Lot 7 Northerly to the boundary of Lot 9. Provided, however, that the driveway to be installed to the dwelling house to be built on Lot 7 shall be so located that its Westerly line shall be not more than 200 feet from the town road measured along the North line of said Lot 7, AND PROVIDED FURTHER that such easement shall not exist but shall terminate if the driveway from Lot 7 to the town road connects to the road along the Easterly line of said lot. M NS is not $� This _ ____ _ y_ __ _______t- -- - -- homestead property. rr�� (ia sot) F X Together with all and Jn gu lar the hereditaments and appurtenances thereunto belonging; Sam E. Miller, a single man And........... ... --- ------ ----------------------- .------- warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except H dF t4 E and will warrant and defend the same. Dated this ............. G' ... ...... ..... -------- day of .......... - -------------Ma r c h -- 19.8 .. - -• i j - • - - - - -- - - - -- - - - • •- •-- -------- ---•...... (SEAL) -- - (SEAL) i Sam E. Mill ------- .(SEAL) -- - - - - --- --- -- - - -- ------- ---- --- -- --- -----------•- --- ... • • i I AUTHENTICATION ACHNOWLSDOMBNT I� $(a) _____ Sas _E._ Miller. _ _________•____ STATE OF WISCONSIN ------------------ _ .t_ �r;.�• ... -------------------- County. ' autbenti this Ld da of,___..._ - 11AX �l.._.... 19 - , _$9 Personal] came before me this ... .............day of '' Y j 4 . �� -_•--•_ ------- ---- ---- _--- ---•--_.__.. ............ 19-- the shots named v John D. eywood -------------- ------ -' -----•----------------•---------------- •--- •--- •-------- - - - -•- ............... ------------------------------------ - - - - -- ----------- ••- •--- ••--- •-- • - - - -- -- TITLE: MEMBER STATE BAR OF WISCONSIN --------------- •-- ------ •- ..... (If not, ............................................ -- ...... authorised by 1706.06. Wis. 3tata.) t me known to be the person - .--- _ - ---- who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY HEYWOOD, CARI b HURRAY -- --•-- --•- -- -- - - - -- -- ------- ..-- ... - -• • -- ...... �q ' John" D:" deyi�io�d" • • •• ----- • ---- _• .- .- -..... i ----•---------------------------------------- -- - - ----------------------- E -Q�__ Box_ - 229.,__ Hit" oIx,---- Xl ------ 3.4A16t........ Nota -,r Public ----- -------------- - -- ---- --- --------- - --County, Wis. t o - ( 'w 2'S 520 52 \3 4 1 LL N 66 \ J \ 1 F 1 126, 923 SQ. FT. E 3 1 = 3 2.91 ACRES 1 N n of � i + N t-- l0 l0 h R O ti� ` t 1 Z O N F 1 O 0 0 �9 �0 + �3 t i + S89 °15'22" W 212. 22' t 1 I 97,945 SQ. FT. 2.25 ACRES le ' m O A � 9 E In 177,177 SQ. FT. 4.07 ACRES w_ Q M LOT 2 OF CERTIF' o O — IN VOLUME 7, F I 377, 12 " ' I S89 °06 + 51 + �W — CERTIFIED SURVEY MAP IN VOLUME 5, PAGE 1500 PLAT 0 o