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HomeMy WebLinkAbout020-1448-34-000 Wisconsin Department of CcrPierce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division • INSPECTION REPORT Sanitary Permit No: 463223 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 Parcel Tax No: West Lake Builders Hudson Township 020- J yet, 3 ow CST BM Elev: Insp. BM Elev: BM Description'.(, Section/Town/Range/Map No: JQ~, fl►~1 1 ~,~o ( P; 32.29.19. TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic - Benchmark 81115 A/16 /M W /6n Alt. BM C L_ 3 Aeration Bldg. Sewer , /J 3.3 Holding SUHt Inlet TANK SETBACK INFORMATION St/Ht Outlet 5 Me - 61l TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 7 25` -756 -7~5o 7 5o Dt Bottom Dosing Header/Man. 2'. ZS Aeration Dist. Pipe 4 , 0e4 ,/0 Z • / /0.,5 /or --j Holding Bot. System PUMP/SIPHON INFORMATION Final.G~rade Manufacturer DeP and St Cover N13,14 Model Numb TDH ift Friction Loss System He T Ft OLL Forcemai Dist. to Well i SOIL ABSORPTION SYSTEM J y G'~F f . ' 1~.(0 I • 75 BEDITRENCH Width Length I No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS °d (3 SETBACK SYSTEM TO lAJ P/L BLDG 1 rWELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: ! r 4L UNIT Model Number: 7 7~ S J ; DISTRIBUTION SYSTEM ZI CC, (.73 !af-~~ Header/Manifold Distributio Ix Hole Size Vent to IntaJc~ L / Pipe(s) ` 'd P ~--r o Length 15 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 4. Bed/Trench Edges Topsoil as No No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 649 Cobblestone Court Hudson, WI 54016 (NE 1/4 SW 1/4 32 T29N R19W) Windsor Heights 1st Add. Lot 34 Parcel No: 32.29.19. 1.) Alt BM Description = ;~i `'oJ?~~ ~~A"^S ~a 2.) Bldg sewer length = 76 - amount of cover = f- fv,,,,~OJ-~.. ~.j Z -T I Plan revision Required? Yes XNo ~ 24 Use other side for additional information. D ll~~.J Date Insepctor's Sign re Cert. No. SBD-6710 (R.3/97) '~C o a~ o ~ y oN a o Cc 00 -60 , O N O ~ ` L O V N a A En m m it ~ v I N O II L N m y N a Z cmi Q p 6 C'. r- 'a E O N N O O Q C co CL .Q Z y rn E O _ V N N W d m m H Z N I O Z d c of v o m a> Z ~ ~ -o ~ i II N H r I I CY 4) ~_v~V N U • N ki a m Q 12 *1O v Q cD Z S Z O N _ w jLo m m m = c N - ~ d I Qtr a N y m V N H m v 0 d E > E > M r H H H a <°n (L CL (L N i ~i 4i o r 7 O N 10 en~V !.-2CDN W } 1 ^V D M N Z `'C 0 0 0 0 O N N N LO E p to f~ j fD m O a Z Z U 'C W Lm N r r C d Q N (n m o N H C N i H C D E 4 to N~ a C = O O O O I p N N_ N N Q D1 C 12 m m c- v O Lo r U Cl) N J N C'j (D N C C a. -p N 00 Cl) (n r r O >m m whoi O N 2 > IT O Z N > > 2 • E V m m a 0 oc a m CL C ° 'c c ~1 A UIL OaU Safety and Buildings Divisio County 201 W. Washingtsan Ave., P.O. 130 r7 1 AA vsconsin Madison, WI 53707 -7M Sanitary Permit Number (to be filled in by Co.) Department of Commerce 3 Sanitary Permit Appl' ation state Plan I. Number In accord with Comm 83.21, Wis. Adm. Ccrde, personal nfor:ttation you provide 101A may be used for secondary purposes Privacy L 05.104(1)(my Project Address (if different than mailing address) _A~.-~ 6)x4 1. Application Information -Please Print All Information 1p~9 ~,~j~j~ ot~ Ur='=; r•; 7 Property Owner's Na /me Parcel N of # Block N Zllt d Property Owner's M ailing Address roperty L ion~~IL 10"o X d G2 City, State Zip Code ~ Phone Number (:circle o e) T ,2 Cl N; P, or II. Type of Building (check all that apply) (/p Subdivision Name CSM Number Aj or 2 Family Dwelling -Number of Bedrooms OYI N•rswie 9 t-.,~~ ~s`ar•1s ❑ Public/Commercial -Describe Use El State Owned - Describe Use rs) r CV X f 3 X 12 City_❑Viltage LTownship of ~>rp,c/ f _S 3 III. Type of Permit: (Check only one box on fine A. Complete line B if applicable) P4New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System I FB ❑ Permit Renewal I C 'Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: (Check all that apply) Non -Pressurized In-Ground ❑ Mound 24 in. of suitable soil ❑ Mound [ 24 in. of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ onstructed Wetland ❑ Pressurized In-Ground UJI Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter f ❑ Recirculating Synthetic Media Filter yc~-Leac tang Chamber Q_Drip Line Gravel-less Vie ❑ Other (explain) V. Dispersal/Treatment Area Information 3 f G! 4A.5 _ h Y_ Design Flow (gpd) Design Soil Application Rkle(gpdsf is Area Required (sf) rDispersal Area Proposed (sf) System Elevation f I ~ VI. Tank Info Capacity in Total V' Number T- Manufacturer Prefab Site el Fiber Plast' Gallons Gallons of Units Concrete i Constructed I G ass New Existing Tanks Tanks I Septic or Holding Tank Aerobic. Treatment Unix llosing Chamber ,,j ~y try, r ry, I VII. Responsibility Statement- 1, the undersigned, assume responsibility for ' 4 ,illation of the POWTS shown on the attached plans. T. Plumber's Na me (Print) Plumber's Si gnarure/ 4 M MPRS Number Business Phone Number Plumber's Addre ss (Street, City, State, Zip Code) _ VIII. ount /Department Use Only pproved [I Disapproved Sanitary Permit Fee (includes Groundwater i Date Issued suing Agen Signature (N ps) ` tjA Surcharge Fee) /f~~ h GCS I 2 Owner Given Reason for Denial IX. Conditions of Approval/Reasons ` for Disapproval ` .SYSTEM OWNER, 1 septic tank, effiuen filter and , - dispersal cell must all be serviced Pm intainedit~ D as per management lan provided by plu r 03 CA "j,") nVA4,-t Le q-1 AIT setback requirements must be maintained as per a plicable code/ordinances " i G ~ tC4 S rx4-h !l 6 M,* (-C_ h etmt ans (to the County only) fo a system on paper not less than 8112 x 11 inches in t~✓Q/~-~ ~V®r 'Ilk 1 lvx Q 04~J ~C o v ~ C>q O T h :A- t VIP 3r r. 1 a ~a sue, I \ S O X , I`~f~' i h aye J, r a ate, 3 176' ~y r __"711 - y 25 ` r~ENT ?IPE 12" IN ABOVE GRADE 6 FRESH AIR INTAKE JUNCTIcs BOX APPROVED FINicHEw GRAr)r 'KITH CONDL'I'T `A.VHOLL COvER 4" Cl RISER W/ PADLOCK $ WARNING AB£L ~91' 171• Cie 1F" X. 'L+6 i WA.,.RJ.vr!?' SEALS 61 GAS. TIGHT AP~tOYr~ A SEAL F+~JtOY~D JOINT $ 3 S WITH 8 iA ! AppROVID PIPS o S11L 10 ON f 3' ,ONTO ;0?4 L ( C SOLID. SOIL PUMP OFF ELEV. Aim rxTT D I s umrx 'TED C~ILy F TANK MANUFACT'JIER HAS APPROVAL Sit APPROVED BEDDING mER TANK OONCRETE PAD SZPTIC i DOSE 'ANN MA-N'JFACTJR£R: i c~ e~, P~,sMB l~ OSES PER JAY: GAL a r 45w Y v1~a E I N,c LuD!,NG 1L.~Rri DOSE Dc~ CAL. FLOWBACY.: i. .T?.._... GAL. hiAN'JFACTURER; CAI~AC.2E5: A MODEL NJMBER:=- SWITCH TYPE: r MANUFAMIRER ; MODEL NUMBER: C INCHES : GAL. SWx;`CH TYPE: EQuiRED Dl-sc RG£ R.AT © y~ D Z iN~'HE`v' s , UAL. -P-ll PJMP 6 AI ARM k~RiIVG AS r£R YLHe't 26.23 ~.'AC ERT+CAL %rzRrNCE 8E, rrET ~"INIMUM NETWORK SUPPLY pgr OFF AND D1511"A? StJ a I ON PIPE l.2 .Eka iT/IOo FFR:CT:ON FACra. ET s BEET TOTAL DYNAMIC MEAD F "'ERNAL DIMI::~'SIO;vS CF rG~M~ , , , . E TM WIDTH ---til T.T a/ . ~iCI'Ne;. N'MELR a - 'ATr f MGOULDS PUMPS Submersible Effluent Pump 3871 EP04 EP05 APPLICATIONS • Fully submerged in high ■ EP05 Impeller: Thermoplas- ■ Bearings: Upper and lower Specifically designed for the grade turbine oil for tic enclosed design for heavy duty ball bearing following uses: lubrication and efficient improved performance, construction. • Effluent systems heat transfer. ■ Casing and Base: Rugged • Homes Available for automatic and thermoplastic design provides AGENCY LISTING • Farms manual operation. Auto- superior strength and corrosion • Heavy duty sump matic models include resistance. Gnadian5tandardsAssodadon • Water transfer Mechanical Float Switch ■ Motor Housing: Cast iron (CSA listed model numbers end • Dewatering assembled and preset at the for efficient heat transfer, in "F" or "C".) factory. strength, and durability. SPECIFICATIONS ■ Motor Cover: Thermoplastic Goulds Pumps is ISO eool Reyi Umd. • Solids handling capability; FEATURES cover with integral handle and ' of maximum, float switch attachment points. ■ EP04 Impeller: Thermoplas- ■ Power Cable: Severe duty • Capacities: up to 60 GPM, tic Semi-open design with rated oil and water resistant. • Total heads: up to 31 feet. pump out vanes for mechanical • Discharge size: 1'b° NPT. seal protection. • Mechanical seal: carbon- rotary/ceramic-stationary, BUNA-N elastomers. • Temperature: 1040F (4000) continuous 140OF (60°C) intermittent. METERS FEET • Fasteners: 300 series stainless steel. 9 30 -r~ • Capable of running dry without damage to - $ 2s Fr components. 25` _ z Motor: x • EP04 Single phase: 0.4 HP, 115 or 230 V, 60 Hz, 1550 RPM, built in overload with > 5 a 15 automatic reset. 4 • EP05 Sin~gle phase: 0.5 HP, +S EPOS 115 V, 6U Hz, 1550 RPM, 3 10 built in overload with EPUa automatic reset. 2 • Power cord: 10 foot standard length, 16/3 1 SITOW with three prong grounding plug. Optional 20 0 °p to zo 30 ao 5o Gana foot length, 16/3 S1TW with three prong grounding plug ° z a b s 10 12 M11h (standard on EPOS). CAPACITY Goulds Pumps Goulds Pumps ITT Industries Effective February, 2000 63871 uiCk4 - STANDARD CHAMBER FQuickili Standard Chamber 48„ (EFFECTIVE LENGTH) 12" ~f I 1 Fj ~1 - SIDE VIEW SECTION VIEW MuitiPort End Cap 34"-__..~__-------,-~- SIDE VIEW TOP VIEW FRONT VIEW Yrl,:- 7 F.;' -,X fr 5 14 Y1~rf nuIcM Standard Chamber Nominal Specifications ,`MultjF.arf End Cap Naminal'Specificatioesr Size{WxLxH) 34`x52"x12' Size WxLxH) 34"x16"x12" Effective Length 48" Invent Height 8' or 1.25" Invert Height 81I INFIJRATQR SY 1W_&iNV--MAMLRD I ITS WARRANTY 4a) 1 he st cyral t eg'ly of each rnamber enJ plate weng f .1 or nu.e spry mur clw x.. by I-,r „reel )'llrnts"J, wren Inge dLxi ago utxaraled ,n a leachfl¢Id of an ?II.. a serniG systarn in aax:rcaltc.e w!h lr fltra:ur s list irclat5, is wl r.ml-x1 Ic ftie'~npinal Iwn.hager ("HuK3aY 1 a~arr?s; r7yfer-!!ve In ttenals and wo'kn n,. t for one year from the date that the sraptio 1>emul 1s ias ,Kl toe d+e stio c sYSlelr clx !aoiny the ur-its; wiyvxled,,waver, Inaf a sepir penrlil iS not requ~.ed nY apt>tlr2bly l:NV, the warran±l Iwriod will begin a ,on nc, datn that installation of the w.)tre System Comrrtenc95, rklo 5 0f ( IN; N; Bs wa ailepfcxJefrv.M!y ol. inl klriNm,il wni ,t s' Mrty Intel! slut m vrtt r-Q el 95 Gxplxate Hen ,,triers in Oki 9sybrcck, Corlr;aLtlGu; wlln"1 iiNeen (15) tc (r t>f r , • . P a(rornan[ ,nas w Urn 3 dotanany[1 Ly ntiUela to he .+r+rered by ling LYrlvlu iNarra: try. Infiltraror iahiNf Y Nw.a Celly' 6%C jq the (-1 91 Yg-I,Oy~ of /Cf ngia1131N 1 U he UIIIS =l THt LlI1VT5n WMPANTX ANC RENAMES N' SUHPARA RAPH ARE FX L it` V f IFRt- ABE No of i-EH VdARrtAN7lER' WrrH FFSPECT O ,II FHE UYrI;, Ihr LUILA4 , NO ImPLICU vrAf#3ANTlkS ul NER HAN TA,91t P cR Nc Fl.,-'I A I''ARTICULAH PURKriF_. SYSTEMS F ^ J ` V tt' 711 t U W a ty Y Mint;— U(I ! /kn UI Inc lilt Up' ~yrvl?Ii n lW (N(%7 L f i Y• JI of Ih l,li '31 Yee L nlI<x} W If 1Yfk%+5 d" ' r i f n 1 !o k I Kl P^tal 'I}3c1a1 di 1 ,.ages Inafl IV Y UI r FrA I e ! ! l 1,r t F 1I .s IMj(~.1 l 7-L 19y7e 1' C ruJ a55 ,•I ~l1V1lOllfll@At81 Of78ite W&StlewAti9! SO1<ltloflS"~ pr xY I- .1 an V "fit" bol malerrarg, a c0,,d G.1'. or citric, ios v w,,ensa., Incenrato Y tie Holder pray Ihir!I part~y{~.~~,~rfx,rfi; ally ex I icd imm L r t(i~ Y H I U Jra(jH Fre (IaTa(,y to the f,) ii: cue 1' ordfuu, WBaf and Ir, 'll?e 116Jn. di Gldtlrt 1114.ga, i.,aw{g+ of f rx,gl. 1 cltUnit - the Uo 14 Lwhg .(anly ~,j ud U v[rlrtly IraNG )r pines cprtd }inns w!%(it are not pumllo7 by th I tatarla4pn uls.rnol, tar- . to I ra'rcl the CC ri c m n r rm gralrvl rne-rs se! hxih n the trs'aAai On Instru:r x s.:ne pk+cement of wtl4vXtHr Irrate. wls nl(t lne V Bushels Park Road " P"Or BOX 768 Kiratre of rile Units a the sop c s'YStom due to -Uiper sill ainyar;rp~,r siz!nd, e%(~ssiv2 watu ¢ system curdarelrtg dte UnRS, anH or Im0f, VY,* greagP # 31ale31rms cr set [ol . h,iimitetl env p!Ixu ever?! nr r uee-! by lnANratb:; Thus Umited Wanarr,e 0void `0 ! the HJI , aL Old Saybrook, CT 06475 +Narrargy, h shaft b der I6 r cvyuy troth all o. tea t forn in Ibi$ Ls Limited 860-577-7000 " FAX 860-5 7 7 7001 Fhn ter, kr ec ev ni steal Infiltrator oe rnslx!nsible icr am !r_is n daft. ge tc the Hilly :e, it a Jn-ES alp liv l party rescNmg IMP T,StalWtgn pr ship 800-221-4436 rile or Irom any tt duct Ili r r!axns of Holder or any rh r] Dar For ht4 L^tiia' Wa nnfy to duph' Ihri Urats n use be insia0en 17 aunxdvnoo .YIIn at SAE [pll:kl Gn., "k-0-1 by state and local code; al of er aUpllr;X,le law.; an: Inir I atc, s In;lallatl(xt alStnx:lltr;l5 ' {di No wpresel illo,,e cl Illanlalp' f:1.) ~It!hrJniY tO dllnyr, pr -tarxi tn5 L ,joo w,,,-y Tr0 wa1r3'lty alipiieg 10 arty uanY nal Holder. e!n!If Irian the (,YIJI the al; ov8 neprestNttS the Stan faro t' ,i1Fr,'VyarryltY <'Nergi I Y Y IN rat-ar. A h it -r- clales -rI ccrunl'rys have dean-- w ~ 11Vy -,.e- r,tents. Airy purtl 3 r o/ U,ti15 5h-l. crxt!act Irylllt+tltti'S C'. µaa.a HEtipdyrouarta n (id b,.ry urWk, G 1r xIICu1, Ix" to such purrnt,se, to Wait a copy bl the aP!)"Caple wurxltY+ and chou;a'~afeb ly lead trial warrarny , to the Irucnaa Gt terms US.r'atents:4,759615 1;5,01 J41;5,1,66,488;.5,3360175401.11t 401459; 1.9()3.5,716163.:,b3 E,776;5.839,844 Canadian Patents 1,329.959; Z 0)4 664 Other patient penaing Infiltrator. Equalizer and SideriVinder are registered troderrarks at Irrfi'trato S terns ul', Infiltrator is a reglsterea trademark in France. Inhftndrx System, inc. is a regi, tared trademark it MexcoCwtour t"omour Swivel Goni Wit) MIC,0Lea0 in , r olyTUtt, Snaps-ock, ChamberSpacer, Posl ax k, Oatcl CLI!. Ch Ray rr£cvacurAVea and Qu'ck4 are trademarks of G1fAretrsr System3 br. 0 2003 Infiltrator Systems li Prinlea in tj S.A. r , I—— „ ' Wiscorlsm Departmer►t of Commerce SOIL EVALUATION REPORT Page of 3 Division of wifely and Buildings in accordance with Comm 85, Wis. Adm. Code ~ - Attach complete site plan on paper not Less than 8 112 x 11 inches in size. Plan must aunty include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. IPA percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all Informadon. a Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). fl ~foperly Location Property Owner La-he U 1' l dGovL Lot N~" 114,5 kj 1 /4 S 3 Z T 29 N R/ P E (ore Property Owner's Melling Address •Lot # Block # Subd. Name or CSM# P 0 - 3 r X57' City State Zip Code! Phone Number ❑ City ❑ Village .Town Nearest Road 41 ( ) Lane Y3-New Construction Use: a Residential I Number of bedrooms _ Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material --A Flood Plain elevation W applicable - ft. General comments 3 , 6. 3 j and recommendations:3 ystn'i eIC on -top 9-7 W - / f Lower 9(n.180 d ~g'0 . S z 'Z-4'nq/ g ~ Boring (~y~ ❑ Boring Pit Ground surface elev.~~~ _ ft. Depth to limiting factor- (00 in. Sol lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDff in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 i -I 2 s I Y 5 8 Z J 5 c rrr r C S , l 3 /Ovrq to M4 s s c~ - -_7 Boring # ~r31 Boring R-1 L Pit Ground surface elev. Depth to limiting factor in. Soil Application Rate Horizon Depth. Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD& In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 0-1Z I Si I Zmsbl I (1 r cS I J-~~ 5 8 12 - 4D ID qJq Sicl 2 c5 C° 3 y0- 1 S Z k - - _ BOD> 30 <220 mg1L _ and TSS >30:E 150 mg/ L L ' Effluent #2 = BOD < 30 mg1L and TSS < 30 mg1L Effluent M7 _ • CST N (Please Print) Signature CST N r Address Date Evakiadon Conducted Telephone Number 226 n ~r 7 -D 1 r Page ~ of .3 Property Owner Parcel ID # - - Boring # ~❑f1 Boring >r pit Ground surface elev. 1022ft. Depth to limiting factor in s. So' ication Rate Horizon Depth Dominant Color Redox Description Texture structure Consistence Boundary Roots l ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 I -IZ l0 s1 Z r c tv .B 2 IZ- / ,cl 2 S C5 `4 3 s cw _ ,7 Z 2nnsb SL ❑ Boring # ❑ Boring ❑ Pit Ground,sutface elev. ft. Depth to limiting factor in. Sod ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM 'Eff#1 'Eff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. IF2 ❑ Boring # Boring Ground surface elev. ft Depth to limiting factor in. F-1 ❑ pit Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDlifr in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 I Effluent #1 = BODS> 30:S 220 mglL and TSS >30:S 150 mg1L " Effluent #2 = BODE < 30 mg1L and TSS 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. [f you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-2648777. SBD-83301R.07/00► Ct G-Ovlb w `•~J `PAGE_101 3 NAME: W t S-La LG-- LO ~i EGAL DESCRIPTION:1/4..~-c-v 1/4,S S- T-.?-$N, Rd~ LE (Or*) SCALE: I"= gD ELEVATION: (OCR . Q 1 " BM I DESCRIPTION:y rre BM 2 ELEVATION: • f9 S e• 3 Z BM 2 DESCRIPTION: c~o® SYSTEM ELEVATION:D SYSTEM TYPE: wrtot Li -A 2 . co 70 6 ~ Lf }o ~ ~ Z ~a 7~a 27 ~j 9 ool I - 3 SIGNATURE: DATE: 7 ST C ROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM. Owner/Buyer e< M1 ~ -Q Mailing Address Property Address _ 6 Y - - (Verification required from planning Department for new construction) City/State I"- - Parcel Identification Number OZ 0 -J _ 0 2,0 1vt 3o 1013 LEGAL D.VCR.II' i0N Property Location r Scc. 3 , 'C N-R~iY1 Totivn of f{cc is'o sT Subdivision t Lot # Certified Survey N1ap # Volume Page # Warranty Deed #SS` Volumei421 , Page # a'n'l~ /335 Spec house ❑ yes 1l no Lot lindS identifiable ( yes ❑ no SYSTEM MA11NM1NCE 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. Tl)e property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master pltunber, jouruey7nan 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 inspectiou and pumping (if necessary), the septic tank is less than 1/3 full of abAdge. U,-ve, the undersigned have read the above requirements add agree to maintain the private sewage disposal system with the stand-ards set forth-, herein, as set by the Department of Corarierce 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 days'of the three y r expiation date. SIGNA"I RE OF-APPLICANT , DATE OWNER CERTI KATIOv I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the o%vner(s) of lh petty desctibcd a ove,,by virtue of a %varranty deed recorded to Register of Deeds Office. SI~G°NA~'T,UE Ord-, P LI AN - DATE *w.n. 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 frost; the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of -Z FILE INfrORMATWN i I V(~ F~D n'1 (~tJitJ SYSTFlb18PE F caner CiICATIONS Permit Septic Tank Capacity z al ❑ NA 11 a Septic Tank Manufacturer 0 NA MOWN PARAMETERS Effluent Filter Manufacturer 0 NA Number of Bedrooms ell, p A Effluent Filter Model d(f O NA Number of Public Facility Units NA Pump Tank Capacity sf ❑ NA Estimated flow leverage) 0 al ds Pump Tank Manufacturer ❑ NA Design flow (peak}, (Estimated x 1.3) gal/day Pump Manufacturer C7 NA Soil Appiicaftbn Rate , y 41/da /fib Pump Model ❑ NA Standard lnfiuent/Effluent uality Monthly average'' Pretreatment Unit NA Fate, Oil & Grease fFOG) 530 mg/L Cl Sand/Gravel Filter ❑ Peat Filter (Biochemical Oxygen Demand 180%) 5220 mg/L 0 NA ❑ Mechanical Aeration 0 Wetland Total Suspended Solids (TSS) ,5150 mg/L 0 Disinfection 0 Other: Pretreated Effkmt Quality Monthly average D Cell(s) O NA Biochemical Oxygen Demand tBODa) 530 mg/! In-Ground (grovit D In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L NA 10 At-Grade C] Mound Fecal Collform (geometdo mean) !r-V04--Vft ,0Om1 13 Drip-Line ❑ Other: Maximum Effluent Particle Size Ys in dia. DNA other: d NA Other, ❑ NA Other. 0 NA avalusr typical for domestic wastewater and septic tank eftluent. Other: ❑ NA TOW ME SCHEDULE Service Event Service Frequency inspect condition of tank(s) At least once every: 2 - ,3 W~fMs s (Maxidwm 3 years) O NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Ys) of tank volume 10 NA Inspect dispersal cell(s) At least once every: 2~3 mew(g) (Mtudmum 3 yeah) ❑ NA Clean efftueM fiksr month s) S At least once every: / ,'JQ' ar(e) (3 NA 0 month Inspect pump, pump controls S alarm At least once every: ❑ arts 12all(e) ❑ NA ) Flush laterals and pressure test At least once every: mom (s) O NA O s) other: month(s) At least once every: ❑ ear(s) O NA Other: ❑ NA MAINTENANCE MSTRUCTIONS Inspections of tanks and dispersal cake shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintalner; Septage Servicing Operator. Tank inspections must Include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and :o check for any back up or ponding of effluent on the ground surface. The dispersal celi(si 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 tarik 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 chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Malntalner. A service report shall be provided to the local regulatory authority within 10 days of cornpletbn of any service event. Page .2- of START UP AND OPERATION For new construction, prior to use of the POWTS chock treatment tank(s) tothe:preisence of painting'products ar'other chemicals that may impede the treatment process and/or damage the dispersal cell(el. If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal ceeisl in one large dose, overloading the cell(s) and may result In the backup or surface discharge of effluent. To 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 area within 15 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 prolong the life of the 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; medications; oil; pointing 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 63.33, Wisconsin Administrative Code; • AN piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWT falls and cannot be repaired the following measures have been, or.must be taken, to provide a code compliant rel learn system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. failure to protect the replacement area will result In the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. 4 A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding, tank may be Installed as a last resort to replace the failed POWTS. ~a a T It P" dsil site RQEi ~ "@ 'Q1 hn'dana tank D Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL BASSES ANDIOR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS )INSTALLER pO1NT5 MAINTAINER Noma ~~1. at sw. ~h~c Name Phone 7 C - J ;Z Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REpULATORY AUTHORITY Pr LNamo Name S7- I I p ~ one 1 86:, Phone 7/,' -_3 - ~d This document was drafted In compliance with chapter Comm 83.22(2)lb)(l)(d)6(f) and 83.54(1), (2) do (3), Wisconsin Administrative Code. Parcel 020-1093-50-000 11/30/2004 11:19 AM PAGE 1 OF 1 Alt. Parcel 32.29.19.378B 020 - TOWN OF HUDSON Current 0 ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): * = Current Owner * WEST LAKE, BUILDERS INC BUILDERS INC WEST LAKE PO BOX 703 HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description SC 2611 SCH D OF HUDSON SP 1700 W ITC Le res: 11.000 Plat: N/A-NOT AVAILABLE SEC 32 T29N R1 9W PRT NE SW N 396 FT EXC Block/Condo Bldg: COM N 1/4 SEC 32 6 3028.20`-POB S 9.30' 89 DEG Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) W 1323.80' N 17.27' N 89 DEG E 1323.96' 32-29N-19W -POB EXC THAT PARCEL DESC IN 766/200 Notes: s~,~-G{ -YL A 1 Parcel History: /JPate Doc Vol/Pa e %foe - WD I A J / 71JL~ g/2 07/06/19 8 582421 1337/568 QC 98 07/02/1998 582317 1337/296 TI y `7 07/23/1997 766/199 more... 2004 SUMMARY Bill Fair Market Value: Assessed with: 111,700 Valuations: Last Changed: 10/29/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 11.000 94,000 800 94,800 NO Totals for 2004: General Property 11.000 94,000 800 94,800 Woodland 0.000 0 0 Totals for 2003: General Property 11.000 94,000 800 94,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 t w Parcel 020-1093-30-000 11/30/2004 11:11 AM PAGE 1 OF 1 Alt. Parcel 32.29.19.377C 020 - TOWN OF HUDSON Current 0 ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): Current Owner " WEST LAKE, BUILDERS INC BUILDERS INC WEST LAKE PO BOX 703 HUDSON WI 54016 Districts: SC = School SP = Special Prope Address(es): ) * = Primary Type Dist # Description SC 2611 SCH D OF HUDSON SP 1700 W ITC 2 L/ Legal Description: Acres: 1.000 Plat: N/A-NOT AVAILABLE SEC 32 T29N R19W PT SE NW S 66 FT OF W Block/Condo Bldg: 660 FT Tract(s): (Sec-Twn-Rng 401/4 1601/4) w N D P~_ 32-29N-19W Notes: Parcel History: ate Doc # ~i Vol/Page Typ 07/13/1998 582863 1339/548 WD 07/02/1998 582317 1337/296 TI 12/23/1993 511036 1057/207 WD 2004 SUMMARY Bill Fair Market Value: Assessed with: 7,100 Valuations: Last Changed: 10/29/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.000 6,000 0 6,000 NO Totals for 2004: General Property 1.000 6,000 0 6,000 Woodland 0.000 0 0 Totals for 2003: General Property 1.000 6,000 0 6,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 !M,~ . . . . . N 'N %I . .,%,.,K Y"i 1\0 \n- At 'a M, tw t-A; . . it C."! > vv,- zll!;~:~iz~, AA, XW t, AS S\~ v tz Zzl V.] v . -~t~t n* -N R t:%t S A" vv;1l t;,: t A, NN, tv- C l;V . . . . . . . . . . T n xl~ V\1" 10 V11 . N"I" ~n "N 1'1'1~1~1.11~"111~'11.1~ l`l-x,,!:~i% VN -6, dk , 1. xOtt%, "N. . N" -i. W1, \:\Nt Parcel 020-1093-60-000 12/01/2004 08:16 AM PAGE 1 OF 1 Alt. Parcel 32.29.19.378C 020 - TOWN OF HUDSON Current ❑X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): Current Owner * WEST LAKE, BUILDERS INC BUILDERS INC WEST LAKE PO BOX 703 HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): = Primary Type Dist # Description SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 0.500 Plat: N/A-NOT AVAILABLE SEC 32 T29N RI 9W PT NE SW N 66T OF E- Block/Condo Bldg: 678 FT SO PT NE SW AS DE IN 76 NKA WIND Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) c 32-29N-19W x093- 10 3 Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 SSSI 36 1221/064 WD 07/23/1997 1202/026 TI 2004 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/10/1998 Description Class Acres Land Improve Total State Reason Totals for 2004: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2003: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 I • j `STATE BAR OF WISCONSIN FORM 2 - 1982 t 555130 WARRANTY DEED I DOCUMENT NO. I PA 6 CHOIR co, 'yl Mary K. Kral, a single person, ST. pal bt PAM FE8 3 1991 conveys and warrants to West L$ e Builders, nC. , ! ut 10:00 ) A. M a Wic one n corporation ~ fioplsw d DNdB i ! I THIS SPACE RESERVED FOR RECORDING DA 1 NAME AND qETURN ADDRESS St. Croix !O ~:t/~~ II the fdknvirtg described teal estate in County ji State of Wisconsin: 020-1093-10; 020-1093-60; PAR 1. I EN t CA N NUMBER ! (See Attached Exhibit 11Ar1) ~0~ ! ANS R i+ II a q ,I This i3 homestead 2roperry. j; (is) f Exceptiontowarrarnies: Easements, restrictions and rights-of-way of record, if any. I i r ~ ~ I Dated this dayof January _ A.D., 19_27 k IC..~ 11 ~ r t vim. H ; (SEAL) (SEAL) ! Mary K. Kral (SEAL) (SEAL) II AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St. Croix n authenticated this day of '19- Personally carne before the this day of l _ Ja otary 19-91_, the above named I Marv K Kral, a singllepgrson, TITLE: MEMBER STATE BAR OF WISCONSIN ! (If not, authorized by §706.06, Wis. Stars.) to the known tc be person who executed the foregoing inst wledge the same. THIS INSTRUMENT WAS DRAFTED BY At tnrnetr Kri a i na Oland Eludcnn 611 56016 Notary C. County, Wis. (Signaitums may be authenticated or acknowledged. Bah are rax My o n Is rmanent. (If not, state expirra~t►d~ate: i ! ! teary) Z- 'Aff Names of persons ytJt1n3 in any capacity should by typed yr P^nted below their signatures. - STATE BAR OF WISCONSIN WiscmertLogo BIN* Co..wr- I~ WARRANTY DEED Fors No. 2 - 1991 Mewitukw. w-s' VOL 1221 PACE065 CT ~ EX IRIT "A" SE1/4 of NW /4 EXCEPT the South 66 feet of West 660 feet thereof and EXCEPT t at 3-1 2 ro s _ e art~1 ina E f O'Neil Road; The North 66 feet of East 678 feet of NE1/4 of SW1/4; elvac o u 0 Zo-10 3 i- Part of SWl o tlot 1 of Certified Survey Map filed October 15, 1980, in Vol. "40, page 1001, =OWS: All in Section 32, Township 29 North, Ran ix County, Wisconsin. Pa oand part ofSE1/4 of NW1/4 of Section 32, Town ge 1 descriCommencing at the N1/4 corner of said Section 32; thence S0012140E (bearings referenced to the N-S1/4 Section line of said Section 32, assumed S0012140"E) 2698.18 feet y along said 1/4 Section line to the point of beginning; thence continuing S0012140"E 35.40 feet along said 1/4 Section lire;' thence N89057150"W 678.01 feet; thence N001614811E 132.48 feet; thence S8903713011W 647.66 feet; thence N0005'0511W 19.24 feet; thence N89009126"E 660.06 feet; thence S0005'05"E 66.01 feet; thence S89009126"W 12.09 feet; thence S0012'4011E 66.00 feet; thence N89009126"E 678.04 feet to the point of beginning. r TOGETHER WITH AND SUBJECT TO A non-exclusive easement for ingress A and egress as described in Quit Claim Deed dated January 12, 1987, recorded January 15, 1987, in Vol. "716", Page 200, Doc. No. 421395. ti :F i I 4-^WC~f~!'R~'e1~1 7~L!3 °.~~f`-~.`~3z,7~."i~►.$rxSr:'_~'~i~it'l~~i1 ~3a r .tom \ NIO Cn CY) \ l p 00 - ;u (D OD C-0 y O ZV rri (f) 00 I n / ()o 0 cli ED -00 / W 4~ CD N oo 0 00 C.> Z / ~ti• /tip N C,4 co N wN 00 0 II N Cn -pt _ N / O W CWA) I --i I CJn W. o 07 N ~ --si i a, NCI rn D I w O cn D Z I I c/ Cf) n = p I I o I z c o z U) 00 p 3 ,6Z,Z 1.00 N J O z ,ZE ~5l rn I Z7 C M „99, l0. l0 N .I r C.4 Cn CP rr C3) M o J l \ I II J I C I rn I ° I c O~ i I~ -P Crt N N ~ Q I N CA) I D rn oo c W D (n w c cr -r~ v I c D~ 100 < ND OZ t rr, ME A II v r O 00 r l z o m En - I O ro 11 -4 rri /M <