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Home My WebLink About020-1448-36-000 I Wisconsin Department of Commerce ' PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) 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 West Lake Builders I Hudson, Town of CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER ,�q� II i CAPACITY Septic L60 d GPM f Dosing u� 5 �� F;� Z�. I U11 Holding ys em TANK SETBACK INFORMATION PUMP /SIPHON INFORMATION _ f manufacturer / eman 488083 L60 d GPM f o e um er Parcel Tax No: b 6 J 55 I U11 ric i n oss ys em 11-111 : ;4 L q�- G J.. o & or em i e �� I �7. 9f�• St/Ht Outlet W-W OWN 0 t Inlet PUMP /SIPHON INFORMATION _ f manufacturer / eman 488083 L60 d GPM f o e um er Parcel Tax No: b 6 J 55 I U11 ric i n oss ys em 11-111 : ;4 L q�- G J.. o & or em i e �� I �7. 9f�• OVIL Md.7V1[P I IVIV 0 T J 1 CIVI ELEVATION DATA County: St. Croix rN Sanitary Permit No: 488083 0 ZIA State Plan ID No: 3.'7 Parcel Tax No: b /ct 020 - 1448 -36 -000 Section/Town /Range /Map No: 32.29.19.2869 /1A STATION BS HI FS ELEV. Benchmark 3.'7 i63.1 b /ct Alt. P M u B dg. Sev4er : ;4 L q�- G J.. o & t Ht Inlet I , (� N $•75 9f�• St/Ht Outlet t Inlet \ Dt B ott om toZ. H eader/Man. is . Pipe 7 �� T6 .7 Z— o . system . � c 7 5 •7 FinaLurade 5 bt over DIMENSIONS �' 9Z / z— `� Spacing ` Pd011y I b INFORMATION CHAMBER OR : ;4 L q�- G J.. o & zL i I , (� N UNIT Lila 1rV6lJ11V1V aTaICivil -`;� . tl. D Z Z +-Z3 Lengt Dia Bed/Trench Edges Length Dia \ Spacing ` Pd011y I b JVIL VV V Grt X vressure Jystems Vniy xx IVIOUrIU yr AL UICIUV QYZI M11M viuy c•��.�( Bed /Trench Center Bed/Trench Edges Topsoil Yes 1 No ,-,,Yes No COMMENT5: (Include code discrepencies, persons present, etc.) Inspection #1: / / Location: 644 O'Neil Road Hudson, WI 54016 (NE 1/4 SW 1/4 32 129N R19W) Windsor Heights 1st Add Lot 36 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Req uired ? Yes I Use other side for additional information. b lam! SBD - 6710 (R.3/97) Inspection im: r r_ Parcel No: 32.29.19.2869 �� ,. '1 :.� ,. s Safety and Buildings Division 201 W. Washington Ave., P.O. Box 7162 County �sconsirn Madison, WI 53707 •- 7162 Sanitary Permit Number (to be filled in by Co.) L Department of Commerce ( 266 -3151 Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal information provide Ntl- _ Project Address (if different than mailing address) k may be used for secondary purposes Privacy Law, s15.04( I. Application Information - Please Print All Info > !!/ O t . ' a ` Property Owner's Na me / Parcel Block 1i e � �Z A6 zel e-� •� _— Property Owner's M ailing Address Property Location ST CROIX COUNTY � , t.4, t.6,Section � City, State Z , i $TW Phone Numbe 1J (Gl/ (CITCIe ) /' ZO V do T N; R / E o ((( II. Type of Building (check all that apply) k aA PA, S��pM; Subdivision Name CSM Number -1 or 2 Family Dwelling - Number of Bedrooms ❑ Describe Use PublicrCommercial - ❑ State Owned - Describe Use 2 +dk'' C_P_ k t..1 Z3w+ ❑City OVillage N( of u� T III. Type of Permit: (Chec only one box on line A. Com plete line B if applicable) Imo— ^— A. New�System ❑ Replacement System ❑ Treatment!Holding Tank Replacement Only 11 Other Modification to Existing System B. ❑Permit Renewal Before Expiration Permit Revision ❑ Change of 7 Permit Transfer to New Plumber j Owner List Previous Permit Number and Date Issued L�g� 613 ( ! u, Sat _ 1 I V. Type o POWTS System (Check all that apply) Non - Pressurized In- Ground J Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland L Pressurized In - Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter L7 Recirculating Sy nt h etic Media Filter Leaching Cham ❑ Dri Line ❑ Gravel -less Pipe ❑ Othe (ex lain) 0 V. Dis rsal,Treat_ment Area Infor atron: 0 e Design Flow (gpd) Design Soil Application Rate(gpds0 Dispersal Area Required (sF} Dispersal Area Proposed (sf) System Elevation � � r�S `. r j �,,�' `,�e�m�✓ tea -✓ . �'d'6 ✓ � ? _ .��-� VI. Tank Info _ Capacity in Total Number Manufacturer Prefab Site Steel i Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass _ New Existing Tanks Tanks Septic or Holding Tank ��il J � / �� Y ✓ ^ _ Aerobic Treatment Unit I T Dosing Chamber //yy _,1 _.._.. .1 l / r°,� Y' ' I i ✓ _1_ _ VII. Responsibility Statement- 1, the undersigned, a responsibility for ' at of the POWTS shown on the attached plans. ^ Plumber's Na me (Print) Plumber's St gnature _ / PRS Number Business Phone Number ,> 1� ?�Q 1S- Plumber's Addre ss (Street, City, State, Zip Code) ; VIII. County Department Use Only_ pproved isapprov Sanitary Permit Fee (includes Groundwater Dat Iss Issui gent Si nat e ( o t } 7 urcharge Fee) 00 Z O� 1 Given Reason tai t IX. Conditions of Approval /Reasons for Disapproval �' J � A,• vVtiJv�. SYSTEM OWNER: ta 1. Se 3�0 �� - a _ Sepik; to*, etthrent filter b�p� q ( aC.,¢_ dispersal cell must all be IMAM I 1111111111111111NIA v as per management plan provided by pkrKltWr. 2. AN at3ack MWtinmerna must be tnahtt WW /✓ code / crdktarttxs. /J as per Y& LJM4 Attach complete plans (to the County only) for the system on paper not less than 81:2 x 11 infies in size L onrn c13no m ret 1nav - d T .s6 0 � o �5 Ih u pr. ?a e - id a-,-,12 0 �,4 1;41 e, / d r 3v ,• / lk r Wisconsin Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County 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. Please prirtt all inf & >fj Revi Page —/—of 3 Personal information you provide may be used for secondary p y La 5.04 (1) Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Property Owner Structure Gr. Sz. Sh. Property Location Boundary W e-s - l o le- bu � ck - R ovt. Lot r 114 (.jj114 S T Z� N R � }1 W Property Owner's Mailing Address '�- Lot # Blod(# Subd. Name or CSM# Sfi I I ( �r ,..' a -� -4 _ 3Co Vv� r e�, � h f5 d d . f F City State Zip ity [3Village 0own Tiearest Road t� y. py ( 1 o „d dry L �d YY4 e S - ® New Construction User Reside 3 - Code derived design flow rate YsQ - c d U GPD Replacement Public or commercial - Describe: >m Parent material Flood Plain elevation if applicable X/ i ' Yj, ft. General comments and recommendations: Syst ' ` 3& �� U ✓�`J' F 7 Boring # Boring S pit Ground surface elev. / ft. Depth to limiting factor _ in. Soil Ann icaticn Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD *Eff#1 *Eff #1 *Eff#2 -10 In ,- - Vv� r C S I tr Z - 2,4 ow - 4 , 6 Sc Z.., S .4k YY4 e S - z -13A lbj r A6 >m it 7 Ov Boring # ❑ Boring pit Ground surface elev. i0 ft. Depth to limiting factor _ in. Soil Arniication Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD& *Eff#1 *Effn z -13A lbj r A6 < >m " Effluent #1 = BOD > 30!5 220 mg/- and TSS >30 < 150 mgA- * Effluent #2 = BOD < 30 mg/- and TSS < 30 mgA- CST Name (Please Print) ature CST Number o k, W N, .S� �7.42 "330 Address / Date Evaluation Conducted Telephone Number T* ST'" �J�.w1 ,c 1vrza f,,;`(,.5 o 7 /S = 744 -o�� Property Owner ft) - CS - � �a � Parcel ID 3 6 Boring # 13 Boring Pit Ground surface elev. Sd ft. Depth to limiting factor - Z!J�. in. Page _ � of Snil Amliratinn Rata Horizon Depth In. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDRf *Eff#1 *Eff#1 *Eff#2 S ri off W� r C 5 0 S/ 2 —) / 1 c r F Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor in. Soil Ann icaton Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/ff *Eff#1 *Eff#2 *Eff#2 r F-1 Boring # Boring Pit Ground surface elev, ft. Depth to limiting factor in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/ff *Eff#1 *Eff#2 r * Effluent #1 = BOD > 30 < 220 mgA- and TSS >30 < 150 mg1L * Effluent #2 = BOD < 30 mgll- and TSS < 30 mgA- 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 608-264-8M. SM- 8330reg(R.07100) v Property Owner tN SST �a L -e— Parcel ID a Boring # 11 Boring Ig Pit (around surface elev. . 5 - 6 ft Depth to limjting factor IZ3 in. Page _ of 3 Anil Annli, - Mt. Horizon D Depth D Dominant Color R Redox Description T Texture S Structure ' 'Consistence B Boundary R Roots G GPD/ff *Eff#1 " "012 " C C - - 2 C CjS Boring # 11 Boring rj pit Ground surface elev. ft. Depth to limiting factor in. And Amlirsiinn [iato Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIfP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F—I Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor in. Soil Anolication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/tF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD > 30 < 220 mgA- and TSS >30!5 154 mgA_ * Effluent #2 = B013 30 mgA- and TSS < 30 mgA_ 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- 8330TMt (R 07100) F—I Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor in. Soil Anolication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/tF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD > 30 < 220 mgA- and TSS >30!5 154 mgA_ * Effluent #2 = B013 30 mgA- and TSS < 30 mgA_ 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- 8330TMt (R 07100) * Effluent #1 = BOD > 30 < 220 mgA- and TSS >30!5 154 mgA_ * Effluent #2 = B013 30 mgA- and TSS < 30 mgA_ 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- 8330TMt (R 07100) PAGE --L NAME 6JeS .� LOT# �(,� LEGAL DESCRIPTION ,&F- � /.Si0A,S3Z-TZ 'Y,N,R ly E(OR)6) SCALE: 1" _ 416 BM 'I ELEVATION ('(6 , U BM 1 DESCRIPTION BM 2 ELEVATION BM 2 DESCRIPTION "- SYSTEM ELEVATION 3(e SYSTEM TYPE oGylu -ck �TcI�C 0 r') r` � �G� JAS Y k pu, SIGNATURE nt (, 7 DATE (Q 0 MZ. Safety and Buildings MisionjbL NVis consin 201 W. Washington Ave., P.O. B '71 County Madison, WI 53707 — 7 (608) 266 -3151 Sant Permit Num be filled in by Co.) Department of Commerce E Sanitary Permit Application State P .D. N u an her In accord with Comm 83.21, Wis. Adm. Code, personal information you provi F EB / V t may be used for secondary purposes Privacy Law, s 15.04(1 xm) rod t dress (i different mailing address) COUNTY ' l � /` /() r • , r V Blo t c�kk I. Applicat' n Information — Please Print All Information Property Owner' am e 3 Parcel # Lot # Property Owner's Mat g Address Prope cation e �3 ' /., Section 3.�2 City, State Zip Code Phone Number Z\e • G�6 cel circle o (. Z� W9 T�qN; R E� II. Type of Building (check al hat apply) Ok a5 / Stir`s Subdivision Name CSM Number 9 1 or 2 Family Dwelling — Number o edrooms ❑ Pub] ic/Commercial — Describe Use^^ "'1 , (' U t r ❑City_ ❑village Township of Ak.Z _.A/ \ ❑ State Owned — Describe Use 2 U� �S ,Z2- 1 Z 6", 5 III. Type of Permit: (Check only one box Nine A. Complete line B if apply ble) 0 20 _ /4 — 3 — 60 A. New System �t ❑ Replacement SystemN ❑ Treatment/Holding T eplacement Only ❑ Other Modification to Existing System B. El Permit Renewal El Permit Revision of Permit Trasfer to New List Previous Permit Number and Date Issued Before Expiration \hange Owner IV. Type of POWTS System: Check all that a 1 Non — Pressuri In Ground ❑ Mound > 24 in. of suitable soil Mound < 24 in. of suitable soil El At-Grade El Single Pass Sand Filter ❑ Constmcted Wetland ❑ Pressurized In- Ground ❑ Holding T eat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter Ching Chamber Drip Line Gravel -less Pipe ❑Other (explain) id 4 t V. Dispersal/Treatment Area Informa Ton: Design Flow (gpd) Design Soil Application Rate(g pds Dispersal Area Req ' ed (sf) Dispersal Area Proposed (sf) System Elevation / 7 VI. Tank Info city in Total Number Manufac rer Prefab Site Steel Fiber Plastic llons Gallo of Units I n A J ' { /L Concrete Constructed Glass Existing T _' � , � / Tanks (J •�� /� Septic or Holding Tank YTZks d ` I r'G -�� ✓ Aerobic Treatment Unit Dosing Chamber D t! r e>~ J f Y / VII. Responsibility Statement- he undersigned, assume responsibility for inst ation of the POWT hown on the attached plans. Plumber's Name (Print) Plumber's Signatu PRS Number Business Phone Number �•l<<;:W .1 j - 2a 2� Plumber's Address (Street, Cit Z Code) CS 2v S ` 7 / VIII oun /De art nt Use Onl Approved pprove Sanitary Permit Fee includes Groundwater Date Issu uin gent Sig to o St s) Surcharge Fee) � Z z � 0 (o ❑ wner Gi eason enial / IX. Conditions proval/Reasons for Disapproval S OWNER: 1. sepw bolt, emue d f1ker and dlswul cell nxW all be services /be maims as per ,.Wq a nW pion provklad by pkarlbsr. Z AN setback requirernsrds must be nai 4M at N par applicable code / ordlra Vn. Attach complete plans (to the County only) for the system on paper not less than 812 x 11 inches in size in SBD -6398 (R. 01/03) 0 . SOIL EVALUATION REPORT Page _ of _� Wisconsin Department of Commerce Division of Safetv and Buildings in accordance with Comm 115, Wis. twm. %.uue County Cir ol Attach complete site plan an paper not less then 8 1/2 x 11 inches in size. Plan must 10 2 Include, but not limited to: vertical and horizontal reference point (BM), direction and parcel I.D. �, _` in) percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Re --Dare. / (fi I ` �/ Please print all Informatlon. Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). , Property Owner - � - _ -. Property Location 5 f i" y Govt Lot fVC 1/451 1l4 S 3Z T 29 N R (G E (orV Property Owner's Mailing Add ;' 73 Lot # Block # Subd. Name or CSM# 3 (u �m 4 h F 0 otx z n r vq City S Zip C e Phone Number ❑ City ❑ Village Town Nearest Road / kAdsion IRV New Construction Use: ER�- Residential / Number of &edrooms Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: - j "i Flood Plain elevation If applicable Parent material _— -'s� - - - - - -- General comments and recommendations: R] Boring # F1 Bonng Pit Ground surface elev. _ -' ft. Depth to limiting factor _ I in. Sop 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 I i 10 2 f 0 3 Z 51`1 s i I 5 •g 2 I -Z- 3K r 414 s el 2 Vik Sie--! Cs k c S - -►I f jq S S. 2 Boring # Boring pit Ground surface elev. �► Z —_ ft. Depth to limiting factor 1 (y 9 in. Horizon Depth. Dominant Color Redox Description Texture Structure Consistence Boundary In. Munsell Du. Sz. Cont Color Gr. Sz. Sh. Soil AvOicittlon Rate Roots GPD/fF 'Eff#1 'Eff#2 i 0-)3 f 0 3 Z -- s i I 5 •3 2 3K r 414 - Sie--! 2m k c S - -►I f jq S ' Effluent #1= BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L T Name (Please Print) S re CST Numbw Address Date Evaluation Conducted Telephone Number Parcel ID # Property Own _ Page 2 of —Z— Boring # C] Boring 'jj�..pit Ground surface elev. . &ft. Depth to fimitutg factor / 13 in. Soil Application Rate Horizon Depth in. Dominant Cola Munsel tRedox Descriptio n Cant Color - Texture 5 Structure Gr. Sz. Sh. S� Consistence ( Boundary "- Roots -� -- GPD/fFEff #2 .I c4 . -7 Z - Z ! ii\ _ ..� �i ,. yin _u� e b- ' = Sd. 22 F] Boring # U Boring • . E] pi Ground.surface elev. ft. Depth to limiting factor in. Horizon Depth Dominant Cola Redox Description Texture Structure Consistence Boundary Roots In. Munsel Qu. Sz. Cont Color Gr. Sz. Sh. Sol Aaolication Rate GPDfIF 'Efl1#1 'Eff#2 Boring # U Boring Ground surface elev. R Depth to limiting factor in. ❑ Pit Sol Application Rate Horizon Depth Dominant Color Redox Desaiptbn Texture Structure Consistence Boundary Roots GPD1fF in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 . Etluent #1 = BOD > 30 <_ 220 mglL and TSS >30 < 150 mgiL * Effluent #2 = BOD,:S 30 mglL and TSS < 30 mg1L 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. 013.83301R.07100t . Etluent #1 = BOD > 30 <_ 220 mglL and TSS >30 < 150 mgiL * Effluent #2 = BOD,:S 30 mglL and TSS < 30 mg1L 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. 013.83301R.07100t t Property Ow — Parcel ID # Oring /I ;Z, Page ! of U '7 4.pit Gad surface elev. M CYJ ft. Depth to limiting ractor In. I Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots � In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. (1 3 Z F Sod Rate •E GPD�`Eit#2 M Boring # ❑ Boring ❑ Pit Ground,surface elev. ft. Depth to limiting factor in. Sol A00ft Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fi? In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Efr#1 'Eff#2 Boring Boring # Ground surface elev. ft Depth to limiting factor in. ❑ Pit - Soil Applica#5m Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 EMuent #1 = BOD > 30 220 mgA- and TSS >30:S 150 mg►L ' Effluent #2 = BOD < 30 mglL and TSS <_ 30 mgA- 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- 2648777. M- 63301R.07/001 Boring Boring # Ground surface elev. ft Depth to limiting factor in. ❑ Pit - Soil Applica#5m Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 EMuent #1 = BOD > 30 220 mgA- and TSS >30:S 150 mg►L ' Effluent #2 = BOD < 30 mglL and TSS <_ 30 mgA- 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- 2648777. M- 63301R.07/001 EMuent #1 = BOD > 30 220 mgA- and TSS >30:S 150 mg►L ' Effluent #2 = BOD < 30 mglL and TSS <_ 30 mgA- 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- 2648777. M- 63301R.07/001 PAGE SOF 3 NAME: GI e4 L LOT #_LEGAL DESCRIPTION:gz�,"1 /4Scu 1 /4,S37- T- ,N,R,jf--E(or)i0 SCALE: 1 "= �f0 N ml ELEVATION: /DO O BM 1 DESCRIPTION: T BM 2 ELEVATION: BM 2 DESCRIPTION: SYSTEM ELEVATION: C IS �y SYSTEM TYPE: d 2 14 , 1 1- ✓�s — �rLoT b I DATE: 7 - Z SIGNATURE: _._�'" -- Z �' IZ r Im I D Z IE/) N D N OD (n (D OD 4: O j C N N ` o 0 I� 10 IS I c v u SON`d'1 0311`d�dNfl � �•°Iln I W ;/L MN II 3N1 d0 3S LC LSn im ♦/� 3 t/L MS 3N1 Jo f/L 3N 3N1 d0 3Nn 1SX ,1+0'66£ M .Z L,O L LO N M . � 05.00 N — — — — r- I I W \ I OOD I � � I N \ LA o f m N 0) / 1 � N Z h It n z z o ♦+ 1 q nW v � zl z C) 14 / '" C1 I ~ � � �� i �� 4 OD I v � 0 D E/) i co CO om 0 I = _ 00 CO 0 O En m OD I D o E L [ z p O Wig Z A f 0 S 1 g Li [ z p O Wig Z A f 0 S 1 g OD / \ oil I N Q, 3 £5 LO l0 S Li / 1 � N Z h z z o ♦+ 1 q nW i C N OD / \ oil I N Q, 3 £5 LO l0 S �L��rn � 5.7AN ��N► ��JJ ,aZ vsaa _ - - -- _ _ 3 .9 L,9 S _ _• ,66'£Z£ 3 „91,99.00 S 3 „91 S c m o z y I 3Nn *A NL(IOS- NLtION Z Z W ; Z o I 3 .ot,a�.00 s= v a I W L�£ l_9d `5 'l0� I LtiSI 'Jd `5 ' 10� cn �Fn p I WS Z 101 I 'W'9 L 101 I w N N tn M'O � fnr0 I r-r C�r-r O U O Id rA D�tZm- D ~ rDD�- uf7=1 -n, O - 0 '0 ;a fA 0 8 zz w z p 0 pp Z a�c' z >�' -,$ 5 �m(> >110 w O C OX m -S �mNfAN z8 8 4 C.) 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R in 0 � z �o� mom y v D zZ N�`Z� C oomN sn� AOM8 o<% c mA mm cA ; m v_C m xF2 °: A i ir m$Z c DD NC to m mZ =o z o o ! $Az (A m D •0 O D O N ZU)M; z _�_ zo co A ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Buyer __ Mailing Address �, D. Q ti, Y 7 0 - :3— y.c�.s a N . W�� _ _ Property Address City /State (Verification required from Planning & Zoning Department for new construction.) LEGAL DESCRIPTION Parcel Identification Number O ZO — �3 & — O bC) 3 . 2,9 . / Property Locati 1 /o , Sec. ck , T a9 N R 1 W, `Town of 5t l Subdivision � _s�S� —.1� 1 S� E'�c�c� �t��1J Lot # Certified Survey Map # Warranty Deed # Spec house yes no Volume _ �, Page # Volume , Page # Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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 c eery 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. Owner maintenance responsibilities are specified in §Comm. 53.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The properly owner agrees to submit to St. Croix County Planning & Zoning Department a certification fonn, 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 andior (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 1 /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 Planning & Zoning Department within 30 days of the three year expiration date. V%'e 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. Number of bedrooms C CD S GNATURE OF NT(S) DATE Ice e ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made Ln the warranty deed. (REV. 08/05) RGOULDS PUMPS APPLICATIONS Specifically designed for the following uses: • Effluent systems • Homes • Farms • Heavy duty sump • Water transfer • Dewatering SP • Solids handling capability: 3 /," maximum. • Capacities: up to 60 GPM. • Total heads: up to 31 feet. • Discharge size: 1' /z" NPT. • Mechanical seal: carbon - rotary/ceramic- stationary, BUNA -N elastomers. • Temperature: 104 (40 continuous 140°F (60 intermittent. • Fasteners: 300 series stainless steel. • Capable of running dry without damage to components. Motor: • EPO4 Single phase: 0.4 HP, 115 or 230 V, 600 Hz, 1550 RPM, built in overload with automatic reset. • EP05 Single phase: 0.5 HP, 115 V, 60 Hz, 1550 RPM, built in overload with automatic reset. • Power cord: 10 foot standard length, 16/3 SJTOW with three prong grounding plug. Optional 20 foot length, 16/3 SJTW with three prong grounding plug (standard on EP05). •Fully submerged In high grade turbine Qlt fQr lubrication and O 'dent heat transfer. Available for automotic and manual opera, qp Autp= matic models 160yoe. Mechanical Floof owub assembled and *#0 dt the factory. FEATURES ■ EPO4 Impeller, Thgritivpla.,a- tic Semi -open design k -likh, pump out vanesr1f rnacbanical seal protection. METERS FEET 10 9 30 e qq 25 �5 7 W s v 6 20 5 o 1 15 a 0 3 10 z 1 0 Submersible Effluent Pump 3871 EPO4 EPOS eller. Thermoplas- design for jnd Base: Rugged tic design provides math and corrosion ousing: Cast iron beat transfer, 10 durability. over Thermoplastic l (itegral handle and ;attachment points. able: Severe duty d water resistant. EPOS s Hearings: Upper and lower heavy duty ball bearing construction. AGENCY LISTING a Canadian standards Association (C5A listed model numbers end in "F" or "C ".) Goulds Pumps is ISO 9001 Registered. 0 2000 Goulds Pumps ITT Industries Effective February, 2000 83871 = u ick4 ff 4p STANDARD CHAMBER Quick4 Standard Chamber MultiPort End Cap 12" 34" SIDE VIEW FRONT VIEW Size (W °x.L'x H) >" ,h f 3,4" x 52 •x`12" Size' Effective Length : �i8" , _ Invert Invert Height g" INFILTRATOR SYSTEMS, INC. STANDARD LIMITE WARRANTY (a) The structural integrity of each chamber, end plate, wedge and other accessary manufactured by Infiltrator ('Unils'j. when installed whd operated in a leachfield of an onsle septic system in accordance with Infiltrala's Instructions, i warranted to it" original purchaser (•Flolderl against detective materials and workmanship for one year from the dale that the septic permit is Issued la the septic system containing the Urns; provKled, however, that If a septic permit is not required by applicable law the warranty period wNl begin upon the date that installation of the septic system caranences. To exercise its warranty rights. Holder most notify Infiltrator in writing at its Corporate Headi loarlm in OU Saybrook, Corrtniclicul within fifteen (15) days of the alleged defect. Infiltrator will supply replacement Units for Units determined by Infiltrator to be covered by this Limited Warranty. Infiltrators lability specifically excludes the cost of removal and/or installation of the Units. (b) THE LIMITED WARRANTY AND REMEDIES IN SUBPARAGRAPH (a) ARE EXCLUSIVE. 11 IFRE. ARE NO OMER WARRANTIES WITH RESPECT TO THE UNITS, INCLUDING NO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARIICULAR PURPOSE. lot This Limited Warranty shall be void it any pad of the chamber system is manulaclnred by .iny!mn other than Infiltrator. The Limited Warranty does not extend to incidental, consequential, special or indirect damages. Infiltrator shall not be iahte for ponal as or liquidated damages; including loss of production and profits, labor and materials, overhead costs, or other losses or expenses incurred by the Holder or arry third party. Specifically excluded from Limited Warranty coverage are damage to the Units due to ordinary wear and dear, alteration, accident, misuse, abuse or neglect of the Units; the Units being subjected to vehicle traffic or other conditions whin are not permitted by the installation instruclixhs; failure to maintain the minimum ground covers set forth In the installation Instructions: the Placement of improper materials into the system containing the Units; failum of the Units a the septic system due to improper siting a improper sizing, excessive water usage, improper grease disposal, a improper operation; or any other event not caused by Infiltrator, This Limited Warranty shall be void t the Holder falls to campy with all of the terns set forth In this LlmMed Warranty. Further, in no event shall Infiltrator be responsible for any loss or damage to the holler, the Units, or any third party read" from instal4nllon or d* ment, or from any product fiabNity darns of Holder or any third party. For this United Wananly to apply, the Units m"usl be installed In accordance with all site conditions required by stale and local codes; all other applicable laws; and Infiltrated installation Instructions. (d) No representative of lnfilrator has the authority to change or extend this Limited Warranty. No warranty applies to any party other than the aigl- net Holier. The above represents the Standard Limited Warranty offered by Infiltrator. A limited number of stales and counties have different warranty require- ments. Any purchaser of Units should contact Infiltrata Corporate Headquarters in Old Saybrook, Ca"necticul, Ixlor to such purc to obtain a copy of the applicable warranty, and should camirufiy mad that warranty prior to the purchase of Units. SIDE VIEW nelgIIL TOP VIEW 8" or 125" "k wig O 7 A .1 510 SYSTEMS INC Environmental Onsite Wastewater Solutions 6 Business Park Road " P.O. Box 768 Old Saybrook, CT 06475 860 - 577 -7000 " FAX 860 - 577 -7001 800 - 221 -4436 U.S. Patents: 4,759,661; 5,017,041; 5,156,488; 5,336,017; 5,401,116; 5,401,459; 5,511,903; 5,716,163; 5,588,778; 5,839,844 Canadian Patents: 1,329,959; 2,004,564 Other patents pending. Infiltrator, Equalizer and SideWinder are registered trademarks of Infiltrator Systems Inc. Infiltrator is a registered trademark in France. Infiltrator Systems Inc. is a registered trademark in Mexico. Contour, Contour Swivel Connection, Miciol-eaching, PolyTuff, Snapi-ock, ChamberSpecer, Posil-ock, QuickCul, QuickPlay RECYCLEOPAPER and Quick4 are trademarks of Infiltrator Systems Inc. 0 2003 Infiltrator Systems Inc. Printed in U.S.A. 0011203HP -0 bt:UIIUN VILW SEPTIC TANK ,E PUM CHA MBER CROSS SECTION AND SP,CIFICATIONS 4" CI VENT PIPE 12" MIN. ABOVE GRADE >-25 FROM DOOR, WINDOW OR FRESH AIR INTAKE ---- -� FINISHED GRADE 4" CI RISER --� 18" IN. 6" MAX. ii INLET WATER TIGHT SEALS ,PPROVED 'IPE 3' )NTO SOLID 'OIL _ PUMP OFF ELEV . FT. WEATHERPROOF JUNCTION BOX APPROVED WITH CONDUIT MANHOLE COVER W1 PADLOCK 6 -- WARNING LABEL k z` � , 4 11 M N ds s4 r r� GAS- TIGHT, � VAPPROVED A S � P ' L ' JOINTS WITH — i— ; 'ALM APPROVED PIPE -B- i ON SOLID SOIL C r OFF 4st RISER EXIT D PERMITTED ONLY IF TANK MANUFACTURER HAS APPROVAL 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE TANK MANUFACTURER: k,)te.ser� NUMBER DOSES PER DAY: 4 TANK SIZES SEPTIC GAL. DOSE GAL. ALARM MANUFACTURER: ` - .�.ye�p►.�s. MODEL NUMBER: O�.V SWITCH TYPE: PUMP MANUFACTURER: ✓ MODEL NUMBER: SWITCH TYPE: `c 's&s•�, REQUIRED DISCHARGE RATE ' GPM DOSE VOLUME INCLUDING FLOWBACK: _j5'9 _ GAL. CAPACITIES: A = as INCHES = 4 ( o a GAL. B = 2 INCHES = L 4 DL, GAL. C = INCHES _ _ GAL. D = INCHES = GAL. PUMP 8 ALARM WIRING AS PER I LHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE . . I;I, _ FEET + MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . . . . . . . . _ 2.5 FEET + Ga a FEET FORCEMAIN X a.t�o FT /100 FT. FRICTION FACTOR . . f •5'7 FEET TOTAL DYNAMIC HEAD = 13� FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH -- ; WIDTH ; DIAMETER -- LIQUID DEPTH i - k1 & A) . ID ) �� SIGNED: ��,� , ,�' L•ICENSr NUMBER: A 7 9 9 CO DATE: 1/88 'POWTS OWNER'S MANUAL. & MANAGEMENT PLAN Page of FILE INFORMATION Owner Permit # DESON PARAMETERS Number of Bedrooms 9-7/ p NA Number of Public Facility Unite Inspect condkim of tanks) 0 NA Estimated flow (average) gre' sl /da Design flow (peak), lEstimated X 1.5) GGl d g al/da y Pump Tank Capacity Sod Application Rate alida /ftt Standard influent/Effluent duality Monthly average* Fats, Oil S Grease (FOG) 00 mg /L 0 NA Biochemical Oxygen Demand (SOD x220 mg /L ❑ NA Total Suspended Solids (TSS) 4150 mg /L ❑ Peat Filter 0 Wetland ❑ Other: Pretreated Effluent Quality Monthly average 0 NA D In- Ground (pressurized) ❑ Mound ❑ Other: Biochemical Oxygen Demand (BOD 930 mg /L 0 NA Total Suspended Solids (TSSi 430 mg /L 0 NA Fecal Coliform (geometric mean) 410 cfu /100ml ❑ NA Maximum Effluent Particle Size S( in dia. ❑ NA Ott 0 NA `Vsluss typical for domestic wastewater end septic tank effluent. MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS Septic Tank Capacity ,� �J a l ❑ NA Septic Tank Manufacturer Inspect condkim of tanks) 0 NA Effluent Filter Manufacturer d 0 NA Effluent Filter Mode! When combined sludge and scum equals one -third IY of tank volume 0 NA Pump Tank Capacity At least once every: al ❑ NA Pump Tank Manufacturer Clean affluent filter ❑ NA Pump Manufacturer 0 NA ❑ NA Pump Model ---- month(s) 13 (a) ❑ NA Pretreatment Unit 0 Send /Gravel Filter ❑ Mechanical Aeration 0 Disinfection ❑ Peat Filter 0 Wetland ❑ Other: 0 NA Dispersal Call(s) O In- Ground (gravity) ❑ At -Grade O Drip -Line 0 NA D In- Ground (pressurized) ❑ Mound ❑ Other: Other. month(al -� ❑ ar(s) 0 NA Other: ❑ NA other: ❑ NA Service Evem Semite Frequency Inspect condkim of tanks) At least once every: 3 rreo<t a s (M:ludmum 3 years) arl O NA Pump out contents of tank(*) When combined sludge and scum equals one -third IY of tank volume D NA Inspect dispersal cell(a) At least once every: morith (Maximum 3 years) O NA Clean affluent filter At least once every: rrlon(e) 0 NA Inspect pump, pump controls & alarm At least once every: ---- month(s) 13 (a) O NA Flush laterals and pressure test At least one* every: � mom (a) Cl carts) E3 NA Other: At least once every: month(al -� ❑ ar(s) O NA Other: O NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licensee or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must Include a visual inspection of the tankW to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The disperull cel shall be visually Inspected to check the affluent 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 (Y 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 S12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. 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Parcel #: 32.29.19.2869 020 - TOWN OF HUDSON Current I X, ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 08/06/2004 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner O - 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 * 644 O'NEIL RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.050 Plat: 10 /18- WINDSOR HGTS 1ST 020/04 LOTS 28/36 SEC 32 T29N R19W PT NE SW WINDSOR Block/Condo Bldg: LOT 36 HEIGHTS 1ST ('04) LOT 36 (1.050AC) . , Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) 32- 29N -19W NE SW Notes: Parcel History: Date Doc # Vol /Page Type 08/06/2004 770985 10/18 PLAT 7nnr% CI IMMAPV Bill M Fair Market Value: Assessed with: 94522 93,200 Valuations: Description Class RESIDENTIAL G1 Totals for 2005: General Property Woodland Last Changed: 10/25/2005 Acres Land Improve Total State Reason 1.050 95,100 0 95,100 NO 05 1.050 95,100 0 95,100 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 VOL 13`39oicF548 582863 Warranty Deed This Deed, ma. between NATALIE VANCE FILIPOVICH AND ALEXANDRA HULT FILIPOVICH, Grantor(s) and WEST LAKE BUILDERS, INC., A WISCONSIN CORPORATION, Grantee(s), WITNESSETH, That the said Granter(s), for a valuable consideration conveys to Grantee(s) the following described lv'? q S1T. CROix co WI JUL 13 1999 10:00 A M 11 '7491*40 of beads real estate in ST. CROIX County, State of Wisconsin: THIS SPACE RESERVED FOR RECORDING DATA 6� -- The South 66 feet of West 660 of the SE % of NW '/. NAME AND RETURN ADDR and the North 396 feet of the NE % of SW %, EXCEPT the North 66 feet of East 678 feet thereof, ALL in Section oll 32, Township 29 North, Range 19 West. / n/ Z TOGETHER WITH a parcel of land located in the NE' /. Of SW % of Section 32, Township 29 North, Range 19 West described as follows: Commencing at the N % comer of said Section 32; thence S0 0 12'40 "E (bearings 020 - 1093 -30 & 020 - 1093 -50 referenced to the N -S % section line of said Section 32 PARCEL IDENTIFICATION NUMBER assumed S0 0 12'40 "E) 3028.20 feet along said % section line to the point of beginning; thence continuing S0 0 12'40 "E 29.30 feet along said % section lina; thence S89L40'40 "W 1323.80 feet; thence N0 17.27 feet along the West line of the NE % of SW % of said Section 32; thence N89 0 09'26 "E 1323.96 feet to the point of beginning. EXCEPT a parcel of land located in the NE % of SW % and the SE % of NW % of Section 32, Township 29 North, Range 19 West described as follows: Commencing at the N % comer of said Section 32; thence S0 0 12'40 "E (bearings referenced to the N -S % section line of said Section 32, assumed S0 0 12'40 "E) 2698.18 feet along said % section line to the point of beginning; thence continuing S0 0 12'40 "E 35.40 feet along said % section line; thence N89 0 57'50 "W 678.01 feet; thence N0 132.48 feet; tlmme-SO °05'05 "E66.01 feet; thence c89 26"`M 1=2.09 feet; thence S0 "E 66.00 feet; thence N89 0 09'26 "E 678.04 feet to the point of beginning. TOGETHER WITH AND SUBJEC TO AGREEMENT FOR DRIVEWAY EASEMENT recorded in Vol. 389, page 325, Doc. No. 270466 as amended by certain Document recorded January 15, 1987 in Vol. 766, page 200, Doc. No. 421395. All in St. Croix County, Wisconsin. This is not homestead property. Together with all and singular the hereditaments and appurtenances thereunto belonging; And above named grantors warrant that the title is good, indefeasible in fee simple and free and clear of encumbrances except any easements, restrictions and reservations of record, municipal and zoning ordinances, and will warrant and defend same. Date: July 10, 1998. %t A -' 34211 � i t;(�,) ' a (SEAL) NATALIE VANCE O ICH (SEAL) ALEXANDRA HULT IP VICH T ANSFER F (SEAL) (SL- Al) AUTHENTICATION Signature(s) authenticated: , ACKNOWLEDGMENT State orwbeotwin, ) )SS. ST. CROIX county,) TITLE: MEMBER STATE BAR OF WISCONSIN Personally came before me on , the above named NATALIE VANCE FILIPOVICH AND ALEXANDRA HULT FILIPOVICH to be known to be the pctson(s) who executed the foregoing RUM V. >R� sirr,mcJ ged the same. NOTARY •IU THIS INSTRUMENT WAS DRAFTED BY:F06 (typ or print) William J. Radosevich N otary blic, ST. CROIX County, Wism aim My commission is permanent. (If not, state expiration date: _January 9, 2000