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HomeMy WebLinkAbout020-1342-10-030Wisconsin Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. County: St. Croix Sanitary Permit No: 399569 0 State Plan ID No: Parcel Tax No: 020 - 1342 -10 -030 permit Holder's Name: City Village X Township Kin sborou h Ho es Hudson Townshi 'ST BM El ev: e p Insp. BM Eleccv��: BM Description: 1 00 k SIP SANK INFOR ATION ELEVAT16N DATA ( I° •4 TYPE MANUFACTURER CAPACITY Septic Vent to Air Intake ROAD Dosing ction Loss System Head Aeration --� Length Dosing Holding Bldg. Sewer TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ction Loss System Head 30 + --� Length Dosing Dist. to Well 4. Bldg. Sewer + +/a 10 L Aeration SVHt Inlet 6r V " 0 Holding St/Ht Outlet t L t M ` . 3 1 PUMP /SIPHON INFORMATION Manufa urer Distribution ---- -- Pipes) and GP Model Numb acing TDH L ction Loss System Head TDH Ft For ain Length Di . Dist. to Well 4. SOIL ABSORPTION SYSTEM 15. 13, ( 12 t.)4 DISTRIBUTION SYSTEM - �) Header /Manifold Distribution ---- -- Pipes) x Hole Size eeded /Sodded acing Vent to Air Intake 1 D Dia Length Spacing [k Yes ❑ No r n Yes ❑ No Alt. B .... Length is Bldg. Sewer + +/a 10 L SOIL COVER v 0--ira Cva#ama nniv YY Mmind nr Ot.rrade Svstems Only Depth Over IDepth Over xx Depth of eeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil [k Yes ❑ No r n Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: lAt" (b / VZ— Inspection #2: ­4- Location: 673 Cottage Lane Hudson, W 1 (NW 11/4 NW 1/4 32 T/219-N R19W) Windsor Heights L Parcel No: 32.29.19.1819 1.) Alt BM Description J, 2.) Bldg sewer length = 3`� ► I l3 • D r 1 `{ . 1 ++ - amount of cov isioon R"equir Yes No '2 fqj adi it too-".44 at eZ � /4- Date Insepctor's Signature Cert. No. ,8.3/97) TTI N BS HI FS ELEV. Benchrpprk 1 t Alt. B Bldg. Sewer + +/a 10 L SVHt Inlet 6r V " 0 db• + St/Ht Outlet t L t M ` . 3 1 Dt Inlet Dt Bottom Header /Man. Z•qZ 1Z. i�•'� Dist. Pipe 13. C 9 ?• �•�,• Bot. System t Final rade 1` " (a,� �rw..� -� + J 41D . 8D St C0er ��+ �pq, 62' ; SBD -6398 (R. 07/00) Sanitary Permit Avplir�ahon Safety & Buildings Division ;�,�► In accord with Comm 83.21. Wis. Adm. Code 201 W. Washington Ave. PO Box 7302 seonsin See reverse side for instructions for completing this application Madison. WI 53707 -730.^ Department of Commerce Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(1)(m)J (Submit completed form to county if r state owner Attach com lete plans (to the county copy only) for the system. on paper not less than 8 -1/2 x 1 I inches in size. County State Sanitary Permit Number O Check if revision to previous application State Plan 1. D. Number ti I. Application Information - Please Print all Information Location: Property Owner Name Location y Prr / operty /VLL1 /4/U-4/4. S T RA r! C ( or Property Owners Mailing Address Lot Number Block Number _ City, State Zip Code Phone Nyrstbe Subdivision Name or CSM Number L C� � f �OY �1�1. II Type of Building: (check one) ,' A. CC ❑ City 0 1 or 2 Family Dwelling — No. of Bedrooms: - r, R�CE�v own of ❑ Public /Commercial (describe use): z 1 `� / ❑ State -owned III Type of Permit: (Check only one box on line A. Check b Np lin t app a Nearest Road h A) I. �1 New System 2. ❑Replacement 3. ❑ Repla t of r�iticrrrto ax Number(s) System Tank Onl 2 INS xtstin . B) Permit Num r '3 �f \ Date Issued ❑ A Sanitary Permit was previously issued IV. Type of POWT System: all that apply) - . �ZI Non- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground El Holding Tank 1: ❑ Single Pass ❑ Drip Line ❑ Aerobic Treatment ❑ Recirculating ❑ Other: ❑ At -grade nit V Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. DispersalArea 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required p b Proposed G V . ( Rate (Gals. /day /sq. ft.) Min. /inch) Elevation C 7 VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks �. ,$1 ❑ ❑ ❑ ❑ VII Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (print) Plumber's Signature (norm ): MP/MPRS No. Business Phone Number 711 �--- .,— Plumber's Address (Street, City, State, Zip ode) (6 c x-21' Aj VIII County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Agent Sig iature (No stamps) Approved ❑ Owner Given Initial Adverse Surcharge Fee) t Determination IX. Conditions of Approval /Reasons for Disapproval: ljvp6oV% g — floo O a°n`e " Tl`f'E N"O wlfe 01A fat.. GIs P-�PoA.)sil3c:C,5-,F- W- *Y� a.-. nr rp tAnec r= esF'>� R0xr S- P Ptr z_ l-rw VFAv iAct S v fet.. V-"C-tt, rLZV - u -T W w a_ L- 1^^ L4C, t li A W% g tJ -OT ; SBD -6398 (R. 07/00) e of Survey for KINGSBORO UGH House Address: _ 673 Cottage Lane S ( 1 � — 30' Ni13,00 ME m DRAINAGE ' AND UTILITY EASEMENT S76 "4703 "E,_ 22.56 ______S02 - W \ 61 96.13 v � a _ I I V I 1 1 F 1Y � 1 � I I 1 1 1 I I I � 00 1 I I i 1 I 1 1 I s 4 vacant Z 'I I i 1 I i I I I I I I 1 I I 1 1 I li HOMES G n ! 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M In 3 6 M M p M or N M C^. q In r M a �a)oc r- CI C y Ia N C) cn r- Co d o ° a C7 yr o = a J ti tP Le) qt Cl) N 0 0 0 0 0 0 m r° i!1111w!r!els Department of Commerce a ND SITE EVALUATION Pa e of Division of Safety and Buildings �, l g Bureau of Integrated Services t s. ILHR 83.09, Wis. Adm. Code County Attach complete site plan on paper not less JK 112 x size ` must include, but not limited to: vertical and hod referen di an s r percent slope, scale or dimensions, north and distance to es road. � Parcel I.D. # nd ..- APPLICANT INFORMATION - P/ prinf a '� OIX lion 7 11 � 41 r; Re b y Date Personal information you provide may be used for ' (t ) (m))• Property er Property Location Govt. Lot p 1/4 ,� 1/4,S_3 T ,N,R V(or 1&11 Prope Owner's Mailing Address Lot # Block Subd. 7� or CSM# _, City State Zip Code Phone Number E] qty Village Town Nearest Road / ® New Construction Use: Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 4 1L gpd Recommended design loading rate „_gyb gpd* l trench, gpd/ft Absorption area required bed, ft trench, ft Maximum design loading rate - bed, gpd/H gpd/ft Recommended infiltration surface elevation(s) � ft (as referred to site plan benchmark) Additional design/site considerations Parent material Flood plain elevation, if applicable ft r S = Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system 0 S❑ u ® S❑ u 0 S❑ u I ® S❑ u ❑ S ®u I EIS O u Boring # Ll Ground elev. ft. Depth to limiting factor ?m in. SOIL DESCRIPTION REPORT Horizon Depth in. Dominant Color Munsell Mottles Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD /ft2 Bed , Trench _ e s Remarks:. Boring # Ground s elev. Depth to limiting factor >t�in. Remarks: CST Name (P as rint) igna Telephone No. Address Date CST Number —IT0_1 adzz 4� ZL_ ZIL _t PROPERTY OWNER PARCEL I.D.# Boring # 1 Ground elev. / Depth to limiting factor -95—: Boring # 'El Ground elev. A Depth to limiting factor > �{j_in. Boring # f Ground elev. , ft. Depth to limiting factor - 7>_in. Boring # Ground elev. ft. SOIL DESCRIPTION REPORT Page of < Horizon Depth in. Dominant Color Munsell Mottles Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots 2 Bed , Tre ch M� /i r L INAM =�A �2 ' - / z ! r mm Remarks: i. i =M �M�l!!L�WAMM�ol Remarks: Mai Dominant Color Munsell Mottles Ou. Sz. Cont. Color M� /i r i �M INAM =�A mm r _ Remarks: Depth to L� limiting factor in. Remarks: .g tI •(J 'a Y SBD -8330 (R. 07/96) zf /"I- i� -0-2 0 A14V -IV - y�,,V-,e19td 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 Soli Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- 10567 -P (R.6/99). Table 1: Svstem Desion specifications Sanity Permit Number c i r l SZo Number of Bedrooms Design Flow - Peak Design Flow - Peak pd''' Inspect once every 3 years Estimated Flow - Average (g Septic Tank Capacity (gal) Maximum BOD /L) Soil Absorption Component Size ( ) 220 Type of Wastewater Domestic 150 Table 2! sail Absarotlon Component - 1_imits of Reliable Operation Table 3: Maintenance Schedule Septic Tank Septic Tank Component Soil Absorption Comp2nent Design Flow - Peak r i 5 0 Inspect once every 3 years Maximum Influent Particle Size (in 1/8 Maximum BOD /L) 220 Maximum TSS (mg/L 150 Table 3: Maintenance Schedule Septic Tank Inspect and/or service once eve 3 years Outlet Filter Ins once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years Septic T$nk 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 ofthe septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall j " 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 confrned 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 AbsgMon 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 oomponenrs 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 Saptu 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. A CONTINGENCY PLAN If the POWTS falls and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: P soil absorption A sultable replacement area has been evaluated and may be utilized for the 10000" 01 a s+eptacernen system. The replacement area should be protected from disturbance and compaction and should root be Intt %ed upon by required setbacks from existing and proposed suvcwrr, lot fines and wells Failure to protect the replace area will result in the need for a new soil and site evaluation to establish a sultable replacement area. Replacement systems must comply with the rules in effect at that dme. C] A sultable replacement area Is not available due to setback and /or soil limitations. Sara l adva0t0es In POWTS tech"09y a holding tank may be lrotalled as a last resort to replace the failed POWTS- 0 The site has not been evaluated to identify a suitable replaeattent arcs. Upon failure of the POWTS a soil and site evaluation must be performed to locate a sultablo replacement Yea. if no replacement area is available a holding tank may be Installed as a last resort to replace the failed POWTS. 0 Mound and at-grade soil absorption systems may be reconstructed In place following removal of the biomat at the InflivaUve surface. Rx(onstrumlons of such systems must.comply with the rules in effect at that dme. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHLI TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY EL DIFFICULT OR (Ml'llttrRl f. ADDITIONAL COMMENTS POWTS INSTALLER Name Phone 7i4 -/ _ y SEPTAGE SERVICING OPERATOR PUMPER Name POWTS MAINTAINER Name "NM LOCAL REGULATORY AUTHORITY A�ncy his- - ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer b o r o t-- 1' 9c_ S L L L. Mailing Address �S 7 5 O- 1 C �' S S. Co d n G rcD U e, V ✓V y - T O Property Address .e, I_ C_ (Verification required from Planning Department for new City /State /Z e, ( (C LLlo�t Parcel Identification Number LEGAL DESCRIPTION Property Location A) W %., ✓�'"� v Sec. 3 2- , T_2.9 N -R19 W, Town of Subdivision �^ `� H t \ �^ S �— n 3 Lot # Certified Survey Map # Volume . Page # Warranty Deed # 6 32 4 y 9 Volume �� 3 . Page # 6 Spec house M yes ❑ no Lot lines identifiable Kyes ❑ no SYSTEM CE 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 master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 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 witbin 30 days of the year expiration date. SIGNATURE 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office. <4�� /a SIGNATURE OF APPLICANT DATE * * * * ** 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 Dated this /"7 - day of February 2001 West Lake Bttjlders, Inc. AUTHENTICATION Signature(s) - authenticated this — _- day of , — TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by S 706.06, Wis. Stats.) ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. (� 6 ; X County ) 1 :Personally came before me this I It __ day of Februag 2001 the above named West L"ke Builders, Inc., a Wisconsin Corporation by �' ct;�n' 7EKOFt it's t C S r ryc/�T — to me known to be the person(s) who executed the foregoing instru ent and acknowledged the same. Notary Public, State of Wisconsin My Commission is permanent. (If not, state expiration date: 3 It / - ') THIS INSTRUMENT WAS DRAFTED BY Attorney Kristine Ogland Hadson,W 154016 (Signatures may be authenticated or acknowledged. Both are not necessary.) of persons signing in any capacity must be typed or printed below their signature. STATE BAR OF WISCONSIN WARRANTY DEED FORM No. 2 - 1999 InrorrnatlDn Professionals Company, F a d d L , W11 593Pa(A67 639409 STATE BAR OF WISCONSIN FORM 2-1999 KAT41_.EEN H. WALSH REGISTER OF DEEDS WARRANTY DEED T. C F:OIX CO., t 0 WI Document Number REaIVED FOR RECORD This Deed, made between West Lake Builders, Inc., a Wisconsin Corporation 02- 28-2001 11:45 AM WARRANTY DEED EXEMPT A --- .. -_ - -- __. - -.- ^ -- Grantor, and Kingsb Homes, LLC _ CERT COPY FEE: COPY FEE: TRANSFER FEE: 1438.20 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 Lots 3, 4, 7, 13, 14 and 15, Windsor Heights in the Town of Hudson, St. EAGLE. VALLEY BANK, N.A, Croix County, Wisconsin. Unit Rd 2 1301 COUI88 e d Unit Together With the right of access over Outlot 2, Plat of Windsor Heights in Hudson, the Town of Hudson for the benefit of Lot 14 of said Plat. 020- 1342 -10- 030, 020 - 13 42 -10- 040,020 - 1342.10 -070 020- 1 -10- 130 ,020 -1 130,020 - 1342 -10 -140 Parcel Identification Number (PIN) This is not _ homestead property. O4) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this /"7 - day of February 2001 West Lake Bttjlders, Inc. AUTHENTICATION Signature(s) - authenticated this — _- day of , — TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by S 706.06, Wis. Stats.) ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. (� 6 ; X County ) 1 :Personally came before me this I It __ day of Februag 2001 the above named West L"ke Builders, Inc., a Wisconsin Corporation by �' ct;�n' 7EKOFt it's t C S r ryc/�T — to me known to be the person(s) who executed the foregoing instru ent and acknowledged the same. Notary Public, State of Wisconsin My Commission is permanent. (If not, state expiration date: 3 It / - ') THIS INSTRUMENT WAS DRAFTED BY Attorney Kristine Ogland Hadson,W 154016 (Signatures may be authenticated or acknowledged. Both are not necessary.) of persons signing in any capacity must be typed or printed below their signature. STATE BAR OF WISCONSIN WARRANTY DEED FORM No. 2 - 1999 InrorrnatlDn Professionals Company, F a d d L , W11 Oct -03 -01 10:44A P.02 * * * L7422 nliatto t icights,�MN 5i )1ZU Pio IAN? SURWYOR 51) 681 -1914 FAX: 681 -9488 7• �. -, a • CIVII ENI:INEERS engt >en Bring ' � " �'� LAND * PI nNNERS - • I ANp: ;(;ASE ARf'HITEC7 g 625 Highwrty 10 N.E. Blaine. MN S!a -1.54 * >� 1 (763) 783 -1880 FAX: 783 -1883 Certificate of Survey for KINGS-)BOROUGH HOMES I f o use Address: 673 Cottage Lane pp Zo© /w�CY1� t 7ep Ir fl, pe _ � EL- 4sG, 4 N114 11RAINAU ANp UTILITY EASFk49NT 3TP•Y03'E �� 7Z.!<R KI `h91J � _-- I 7 I I I I f I I f I 7 1 r I r f I 1 r I I 1 1 1 I f I I 1 I I 1 f 1 1 I 1 1 f t 1 I 1 h � ., i 1 l 1 1 1 N � 1 \ �a • t\ a L \ \ \ t \ \ \ , \ i 3 /e ►t�S % 'mac SCALE_ 1" - 30'