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HomeMy WebLinkAbout020-1474-06-000 r Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 483982 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: Wormke, Patrick & Nautia Hudson, Town of 020 - 1474 -06 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range/Map No: I 9 4 6- 2— GS - 13.29.19.3003 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER ?r�s CAPACITY STATION BS HI FS ELEV. Septic p �„..„ ! i Benchmark (J: t s4.,... Al 4., z /zoo y 4 5 /6[1' 97 I/ Dosing Y Alt. BM 664,J00 Z f��0 I. J.r(k o c -- �a,) 4- /ate Y .4.5 93, Z 5 J Bldg. ewer + 1.,.. Aafe4iaT>' dg S A h IC . 2S A.1 q/. s P � S Holding St/Ht Inlet 9 /� _ X0 .55 y 35 St/Ht Outlet TANK SETBACK INFORMATION TANK TO ' I P /L WELL BLDG. Vent to Air Intake ROAD Dt Inlet W Septic ! / Dt Bottom 33 AM— -- I3.IS S7. 9 Dosing 33 Ai4- ! ! / _ Header /Man. 7.47 S 1. `1 z U Aeration Dist. Pipe 1. v q4. Holding Bot. System 8• 93.3 CA Final Grade PUMP /SIPHON INFORMATION t) or- i 3 97. Manufacturer / - /� ..r.,,. Demand St Cover ��(( l�ov S 'Jr GPM Pv to.i<... - 7'G0 9/". 3 Model Number 4 50 EPb / / TDH 1Lift Friction Loss System Hexi /) ITDH 7 Ft Forcemain LengZ t Dia. z !! Dist. to Well N � _______----><\. SOIL ABSORPTION SYSTEM BED/TRENCH Width ! Length i No. Of Trenches PIT DIMENSIONS No. f Pits Inside Dia. Li 'd Depth DIMENSIONS 3 /26 z rra.....I..rQ SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION ! CHAMBER OR .1,,,,k--t• L +! 4 , Type Of System: 9 33 A M-- i 4 UNIT Model Number: / j p_ a p ....41.42_, DISTRIBUTION SYSTEM 4.434 -- 30 4 30 (o 6 6 .i"1*S 1 - Header /Manifol9 ! 1 Distributiok \ x Hole x Hole Spacing Vent o Air Intake A / Pipe(s) \ \ 4:%4) 5 ,J Length G Dia Length Dia Spacing b e SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Uc. a h, P 0—J.-- Depth Over / Depth Over xx Depth of xx Seeded /Sodded xx Mulched /1 Bed/Trench Center , Bed/Trench Edges � Topsoil ` Yes g4 No "Yes EI No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 881 YellowstonA Trail Hudson WI 54016 (SW 1/4 SE 1/4 13 T29N R19W) Yellowstone Valley Lot 6 Parcel No: 13.29.19.3003 1.) Alt BM Description = d n,gt ;A..5 d-- 1-o c-k- o". 2.) Bldg sewer length = / Z - amount of cover = \ / v 1/ a n n / Plan revision Required? • Yes No /b 21 10 M61. 6 ���7 Use other side for additional information. 1 SBD -6710 (R.3/97) Date Insepctor . Signature / Cert. No. f commerce.wl.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 S7G i t X is n ison, WI 53707-7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce "V' 3 7 g2_. O Sanitary Permit Appl at ' "� 8 State Transaction umber In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of s form to the appropriate govemmen , 1 unit is required prior to obtaining a sanitary permit. Note: Applicat in form €Eps�fe WTS e Project Address (if di �t jhanmaili address) submitted to the Department of Commerce. Personal information y u provideimay besldUf s econd ry G/! /d purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. t, is\ti, ' ^ + }F, '! I. Application Information — 'Please Print All Informatio ;Gr ■ „ , `.UU Tl " Property Owner's ame 4., ' ` • Parcel 8 r - et, 77s „ e_ ' jj �� , ', M-- dome) - if/ 79-0‘.- moo' Property Owner's Mailing Address . z Property Location 1 Yd / - .✓Amo - 'yt c `a / 5 C r L I$+' # ,5 Govt. Lot 340 3� City, State Zip Code Phone Number S' y j - ir 1/4, Section /,,3 t /..v ..$ 7/5"- 1'.12-5'757 (circle one) T q N; R /9 Eorb' II, Type of Building (check all that apply) 7 • , i 0 ,A, 0 ,A, Lot if _ - 1 or 2 Family Dwelling - Number of Bedrooms ' / Subdivision Name Block Ct Ze f/ Gi) 5 T6.ia U !'Q j / ❑ Public /Commercial - Describe Use 'ID City of 0 State Owned - Describe Use 1 CSM Number ❑Village of 2 t+0;4- c 11 t,..4 364-3Z� 1 vV► (.. Town of , 14,4 ,- ,:s.4.) III. Type of Permit: (Check only one ox on line A. Complete line B if applicable) A. KNew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner In. Ct`lk...6fi . IV. Type of POWTS System /Component/Device: (Check all that apply) ©t4������ i Non- Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil Holding Tank OtQ her D spersal Component (explain) ■ Pretreatment Device (explain) V. Dispersal/Treat, nt Area Information: ..7 i c a7 Design Flow (gpdy Design Soil Application Rate(g t • : tspersal Area Require Dispersal P uire a Dis ersal Area Proposed f) System Elevation 5 God e S 4i? de/ ✓.. /,2 oo /2. I Z q.5 ,C c VI, Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units 4 / New Tanks Existing Tanks / w c t T '^ / / 6 ld �/j (fir t 1 U rn g, r4 Septic or Holding Tank • , i rn i, . C7 0. Dosing Chamber - ZOO . / /4 `e. s,v tom' , k VII. Responsibility Statement 1, the undersigned, assume responsibility for installation of the POWTS s own on the attached plans. Plumber's Name (Print) Plumber's Signature RS Number Business Phone Number 4E ' - ,22 y ?Qd 7() Plumber's Address (Street, City, State, Zip Code) l / 2 e2' /GI 'ft's,./ es) f` S yo -( _VIII, unty/Department Use Only Approved Permit Fee te Is Ljf75 lac Da c�� /Sued �D Issui gent Signatu wne 2ReasonDeniag IX. Conditi asons for Disa s`1`l't'JV'IDisapproval '1. S t ank, effluent filter and dispersal cell must all be services / maintaineg as per management plan provided by plumber. 2. A71 stetback must be maintained as Per code/ ardinanc * Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size SBD -6398 (R. 02/09) Valid thru 02/11 r a � v i-- /1/sl. , A/6 e 4,7 ty.ec w s 7 fr av ve_ USG e ads�,.l ,gymr�P6r « - ft r /V s, tom ' i h � r r C ■ 1 2 9 9' j// °,,/ / ►,„ Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County 0•�1C Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. � percent slope, scale or dimensions, north arrow, and location and distance to nearest road. �a 0 —/ 7 7 b b /nn7 Please print all information. Revie by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). I 9/ / P Owner Property Location � �. N Q ,..,} -, c u..)0 f „ Govt. Lot .64) 1/4 ,5,4 1/4 /3 T 27 N R l9 E (oCW Property Owner's Mailing Lot # Block # Subd. Name CSM# f 70 / -1 �ius/-� r s7`-. #S" 6 — Allno ft),fZ LIJ City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road h A4,,. 1 cAe I sYvf 61( 715 -)02aa -57,0 _ II 64 41( 1 K / /La-A/ s X \New Construction Use Residential / Number of bedrooms . -rived design flow rate l- 0 6 GPD ❑ Replacement ❑ Public or commercial - a = • Parent material 0C_C'.cia.n_./ Flood Plain e -vation if applicable /1/ I 7 ft. General comments 7 Q � /, C,` r^ and recommendations: S Q � System Type . a ... ..A. - CROIX Cox ; v. lion 7 SD G & ZONi�@ Boring # Boring Pit Ground surface elev. ? Q l ft. Depth to limiting factor // 9 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 1 v —? 10 3/ �. ..� � . ` (J C9iA-A' , 6 2- 7-V.2- layrr,>l/ - ---- -- �,efZ /< 9�J 1? , g , ,4 3 Y22/1? 1O Sj4 s' nj /77/ it r r )--/}/4 - S / D / t q3• 11 ,l 9 f , /� Boring. Boring —7 d~ G� pit Ground surface elev. / !i / ft. Depth to limiting factor // in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 r? - /a 3/2 L r9/ i r� ('-)--- cl , 6 -3 . 2--, 8-3� 1U7- r / .mx - -Sk /zJ I1^ 4 3 $$_ // 1 $ 0s b4 1 e✓ Nl4 , ---- d 1 ,4 • Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 r • • Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) , f r, • - 1 CST Number Bird Plumbing, Inc. Shaun Bird 226900 Date Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, . 4017 —�- -/ p 715 - 246 -4516 Property Owner _ Parcel ID # Page of ❑ Boring Boring # I/ Pit Ground surface elev. 1 1 1 ft. Depth to limiting factor .1 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 3 1 0 2 - ; IMPAME=MIgill as iv ,wi, JIM _ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. 1 Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. • Soil Application Rate Horizon 'lepth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 -264 -8777. SBD -8330 (8.6100) Property Owner Parcel ID # Page of 3 Boring # ❑ Boring J � 1 Q , pit Ground surface elev. / v i 1 ft. Depth to limiting factor 1/8 in. I Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff #1 *Eff#2 1 0 t 7 /07/-5/z. ,cj ( 9, Aq . -- m L,-• 4,r- (- ,, 0 ? /0,574 L'/ i i/K - /-'' , 3 11,3 YA , 5 s »7l , e y - q ' ( :% --- il 11 9b 5 . Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. • Soil Application Rate Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 • ' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777. SBD -8330 (8.6/00) Soil Test Plot Plan Project Name Pat and Nautia Wormke Shau : ird Address 1901 Industrial St. #5 � Hudson Wi 54016 ir #226900 • Lot 6 Subdivision Yellow Stone Valley Dat : /2/10 S W 1/4 SE 1/4S 13 T 29 N /R19 W Township Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of Steel Fence Post System Elevation TBD *HRPSame as Benchmark Scale is 1" = 40' unless otherwise noted Property Line Pro 4 Bedroom House B -1 5' • 55' B -3 V 90' ❑ 1% Slope 45' 98' 30' .40 B -2 5' 97.5' 50' Property Line B.M4 • CONVENTIONAL COMPONENT DESIGN Residential Application • INDEX AND TITLE PAGE Project Name: /z./ y A' Owner's Name: Pa- � � � �k/1 ' "i� , .0e0 Owner's Address: t �*✓�� � ���� �,�— /7 �� /tee. /. 0/6 Legal Description: _ 3 5 l j 2� 4 1 y 4f Township: 22‘4_4954,z./ County: Subdivision Name: G -, l Lot Number: Parcel ID Number: lf.2�_ / y7g/ rj ' '" Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross - Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer /Plumber: h Z - ___,5'G144. ai efr e ,, License Number: 227 S Date: /�// /e/ ! Phone Number 7/5 - ��// zI2J Signature Designed pursuant to the In- Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD- 10705 -P (N.01/01). Page 1 Q f�- //rav A/5 K dr� y��w ��oti�U� �y " e-- it /or, o 14/ Jlaas� oY t, S� Ye- Go t i l t( i h 0' t 1 4 . o 4 L M, , •(3ti 2 A 1 S �... �c`� o 3 2 ' 1 - • a 'j - . '4l , p '� 1 . c9 s a j - ,\ I , e . a , Q se: \ t o IIC'J 4 r } f /, Y L� ` • _.� I' } Soil Absorption System Cross Section ft Final Grade 4 Schedule 40 PVC Vent Pipe f�� ft With Vent Cap Leaching � Chamber '� — System Elevation 3 ft S ft Soil Absorption System Plan View ft ft I1lI11I NII111111111111II11111111I111111111IIIINIII1IIIIIl11II1 1111I111111 IIIII � ft Leaching 1 Trench 1 Vent Or Observation Pipe Chambers 1 IIIIIII 1 1111111111111111111111111111111 11111 ��4» Dia. II 111A 11111111M111111111111111 I 1 Trench 2 Header Leaching Chamber Soeciflcations Manufacturer And Model 2.4/ i � 5-- EISA Rating .26 sq ft per chamber Soil Application Rate - gpd/sq ft Coo gpd Design Flow + " Soil Application Rate + 1 EISA = Chambers 2 rows of .0:Va chambers each. P ---- -- , of • • 1 — _ ' _14110 I el pd P a I a ` © .. ( N._ ®, O 1 AI Pe O i N Lra c7 M r o 0.- N M OD cci i A J i o CO —, s 1____.441 , C 0 .. - I NES ' 1 WER11 ! -4- /Allah4111 Ir _ ___7rto•■■• ,T, E Lc, q) , 1 _I __II __I __•I b .---- - --- ,,, I - - - - - -- / , _ _ /,...b• .._ /= 7 4.4' , - / 1.1.1 I>ji = 4 4 ' .40 7 ' / CO I— w p CO -./- W 5 C.9 v Z W O v � rr� 1 . 1 .• WNW IOW Q = n- t CD Z t = U5 N C7 m 1 0 0u o SOcfl ) 1117 ■ u... cs „.".. .,/,,_! 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I I1 I II I !I I I�III�d1 1 11 1i ��! 111 111 1 ! tIIl I 16hh1 1 ,1, 1 1 l i 1H IVI�I Ii 11 111 � 111 ®11111111111111111111 IIIC X11. 1111 NII1 1NI1 B�' 111 111 1111 61111uiIIlIbP111111111111►Illif 0 x 1 ilIIII9�6191'I!N 1 iillLIII'1J911IJ m iIlr IIiI91 1' I!IVIIil!911111!N!INI119�I9iI!4 �III9�111Ui111I1 itiliI il.111111i1N' ;Pi i r: . , 1 1 1 I 1 I DI1 1 111111 11 1 ., I 1 uiinnu111nnlliionuill,l i,, I1,11� IiJI I 1 I1 i II 1 1 II li 11 i, L�I I iga11I 1 1IIilliffIllin t III POWTS OWNER'S MANUAL. & MANAGEMENT PLAN Page of FILE INFORMATION YggTEM SPECIFICATIONS • Owner 4 9 ea \e_Ae, eA.> t,, °Ler\ `� Septic Tank Capacity iZS 0 gal 0 NA Permit # Septic Tank Manufacturer W e.S e,FL ❑ NA DESIGN PARAMETERS f t ent Fitter Manufacturer / ,I y A.eg r ❑ NA _... Number of Bedrooms 3..:25,-. 3..:25,-. _ 0 NA Effluent Filter Model ,' ❑ NA Number of Public Facility Units 0 NA Pump Tank Capacity V CID ga l ❑ NA Estimated flow (average) C p 0 1/d Pump Tank Manufacturer Lx) e._\ . S e.. R. _— ❑ NA 900Y Design flow (peak), (Estimated x 1.51 lo 0 O !� aiY pump Manufacturer G O ti..1 _ ❑ NA 07 Soil Application Rate all a /ft x Fume Model ❑ NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit 0 NA Fats, Oil & Grease (FOG) 530 mg/I. Q Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand 1800 5220 mg /L 0 NA 0 Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) x150 mg /l. 0 Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cellist ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L 3 In.Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /l; 4 NA A At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100m1 0 Drip -Line ❑ Other: Maximum Effluent Particle Size Ye in dia. 0 NA Uth elr. ❑ NA Other O NA)thfer; - ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other ❑ NA MAINTENANCE SCHEDULE .. """" Service Event Service Frequency } ❑ month's! (Maximum 3 years) ❑ NA Inspect condition of tanks) At least once every: v Ili years) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume - ❑ NA ❑month {s) (Maximum 3 years) ❑ NA Inspect dispersal cell(s) At least once every: R year(s) _ _ _ ❑ month {sl ❑ NA Clean effluent filter At ! oast once +wQryt ,� / Et year(s)__ _ _ ❑ month's! ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ year(s) __ Flush laterals and pressure test At least once every: ^— ❑ month(s) ❑year {si ❑ NA _ ❑ month's) ❑ NA Other. At leapt once avert': ❑ year(s) _ _ Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator, Tank inspections must include a visual inspection of the tank'') 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 dispersal cell(s) shall be visually inspected to cheek the effltaer t 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. Page of STARTUP AND OPERATION tha t may imp new construction, impe the treatment process prior a use c she POWTS or other chemicals S check treatment rankle/ for the presence of Painting products impede the ss and/or damage the dispersal cell(s). If high concentrations are detected have the contents that 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. is restored the excess wastewater will be or s urface d ischarge e discharged • power to the dispersal tanks may one rge dose, e ov loading the levels. When power a e Servicing Operator ac ed to restoring discharged To the dthis situation a io in the contents of the pump tank c removed by a Septlgrn the backup controls to po wer to Th avoid t have the Conte operating the Pump power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually p or compact the area restore normal levels within the pump tank Do not drive or park vehicles over tanks and dispersal soil pried ardea,e or park over, or otherwise disturb he life of the within 15 feet down slope of any mound or at-grad improve the performance and prolong t di disinfectants; o f the Reduction or elimination the following from the wastewater stream may POWTS: antibiotics; baby y wipes; cigarette butts; condoms; cotton swabs; degreasers: dental floss; diapers; grease; herbicides; meat scraps; medications; oil; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; painting 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 c properly and safely abandoned in n complianomplian ce with chapter Comm 83.33, WiscansinAdi nistr abed Code: openings • All piping to tanks and pits shall be disconnected and the abandoned pipe • The contents of all tanks and pits shall be removed and properly disposed of by a Se Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled witt soil, gravel or another inert solid material. CONTINGENCY PLAN taken, to provide a code complied If the POWTS fails and cannot be repaired the following measures have been, or. must be ant soil absorptio replacement system; be utilized for the location of a re ❑ A swi m. re replac ene area ass b ev a l u a ted protect and may action and shout not be infringed upon b re system. The rck a area should o osed s ed t rom dittlines and n and comp ant area. t h replant systems e ar w su lt in the need for a new soil and site evaluation iced setbacks from. existing and proposed structue. a uitablelrepl Failure to protest the replacement area w resu to e advances in POW comply with the rules in effect at that time. A suitable replacement area is not available due to setback P�� the failed POWTS S Barring $d technology a holding tank may be installed as a last re •• 1e + s • , ,, . s' e a caamsba jaitamadwiroverregerporminewooritsisidiaograu de soil absorption systems may be reconstructed in place following removal of the biomat at 1 ❑ Mound and at-grade with the rules in effect ' infiltrative surface. Reconstructions of such systems must comply at that time. < SEPTIC. PUMP AND OTHER TREATMENT N ®> > TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. [10 N ENTER ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRC BME TANCES. DEATH MAY RESULT. RESCUE 01 PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOS ADDITIONAL COMMENTS POWTS MAINTAINER POWTS INSTALLER Name Name ,Jr'�1r u � I yr4 a l^ Phone Phone 7 l - J .7 -- s " ...z SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL R EGULATORY AUTHORITY t t ....................:j:...7.j Name J �'�'� • ti Name , r Phone l Pho 3 . ! YJ V _ This document was drafted in co mpHance with chapter Comm 8 3.2212)(b1(11(dl &tf► a nd 83.54(1 (2) 81 (3), Wise isconsin Administrative Code. ST. CRUMX COUNTY • SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer i G �C.1< L )D r Ke JU�t, i s / o r&4 Mailing Address NO 1 -r.y�du Q (� v�d; n (,(_)I 5 o Property Address . - 6 • /o S re-( Sow w Z (Verification required from Planning & Zoning Department for new construction.) 8�e City /State _ gfi L _ Parcel Identification Number Z O - /L/ 7 4 / - 0 - 0oo (LEGAL DESCRIPTION n S W '/. 5 G t/4 Sec. _ 5 , T a? N R 9 W, Town of Property Location tt , __ - -- // Subdivision 4-6.2- r l� sacs \JCS � -� { . -. -�. , Lot it l� Certified Survey Map # _ _, Volume — Page t# • Warranty Deed # Volume Page # Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFI AT 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. Owner maintenance responsibilities are specified in *Comm. 83.52(I) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & zoning Department a certification form. signed by the owner and by a master plumber, jourmyntan plumber, restricted phuticber or a licensed pumper verifying that (1) the on -site . S septic disposal system is in proper operating condition andior (2) after inspection and pumping (if neceS necessary), the s p tic tank is Less than 1/3 full of sludge. we the undersigned have re ad the above requirements and agree to maintain the private sewage disposal system with the U Wisconsin. set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of V4 tsco nsin. Certification stating that your septic system has been maintained must be completed and reamed to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. 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. Number of bedrooms / ' / 3 , • 'i ..._ SIGNATURE OF APPLICANT(S) DATE ** *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 in the warranty deed. (REV. 08/05) • 11111111111111111 I1iII 11111111111111 IM1111111111 * 9 1 3 6 0 2 1* FORM 1 - 2000 913602 STATE BAR OF WISCONSIN BETH PABST Document Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI THIS DEED, made between Environmental Holding Company LLC RECEIVED FOR RECORD and, Grantor, and Patrick L. Wormke and Nautia A.R. Wormke, Grantee. 03/23/2010 02:30PM WARRANTY DEED EXEMPT 1 Grantor, for a valuable consideration, conveys to Grantee the following REC FEE: 11.00 described real estate in St. Croix County, State of Wisconsin (the TRANS FEE: 149.70 "Property "): PAGES: 1 Lot 6, Yellowstone Valley in Town of Hudson, St. Croix County, Wisconsin Recording Area ll Name and Return Address: Title One Premier Group 706 19th Street South Hudson, WI 54016 Together with all appurtenant rights, title and interests. 020 - 1474 -06 -000 Parcel Identification Number (PIN) This is not homestead property. Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except Roadways, Easements and Restrictions of Record: Dated this 23rd day of March, 2010. E I vi i nmental Holding Company LLC i P i \k_)(1 4AWQ0 * Envi inmental Holding Compan LLC — • Jeffrey Warren , President * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ST. CROIX COUNTY. ) ss. Personally came before me this 23rd day of March, 2010 authenticated this 23rd day of March, 2010 the above named Environmental Holding Company LLC and to me known to be the person(s) who executed the foregoing * ins u t i • t and , knowledged e. TITLE: MEMBER STATE BAR OF WISCONSIN (3fGP authorized by § 706.06, Wis. Stats.) !r c, *Evelyn Jr Jaeger l Notary Public, State of Wisconsin THIS INSTRUMENT WAS DRAFTE BY My commission is permanent. (If not, state expiration date: 8/26/2012 ) Michael H. Forecki, Attorney (Signatures may be authenticated or acknowledged. Both are not necessary.) *Names of persons signing in any capacity must be typed or printed below their signature WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 1 -2000 1 !`T 9 99 w4• `43 ,p�pF +, 3 {'24 N V s6 ( o s1 30• w \ \ \ QO p Q a ow , / 8 32.4 3 f 26,79 �� � � ,>, LOT 6 44 2.002 ACRES \ �� 87 SQ. FT. - N 60' RADIUS elf, • � • TEMPORARY o • 1 '4 °C CUL -DE -SAC N h S1 \ EASEMENT - TO BE 44 f i , a o EXTINGUISHED UPON ,h \ 0 I j .. . ROADEXTENSiON h LOT 5 4 •o ��1 y,, \�` m � 2.R ?� N I 87,594 011 AC SQ• EFTS . • . 1) s �� 3s vim? • s. • �r {� ' _ � . 149 . ( L �. �,........ -- �:� S ��� 9. • 4 •\ \ 'ge . 9 °' \ + LOT 4 LOT 7'' • • • . 9 , • \ \ 2.057 ACRES \ 2.027 ACRES • r,5.. \ • I �`� �` .997 � \ BM .. 89,603 SQ. FT. .; 88,299 SQ. FT. 3 �� .7 ) A \ HWE =996.0 8 ' LOT 8 • \ � ` \ N2 \ \ HWE = 994 . 0 r m ' \, LB0 =998.0 P 2.005 ACRES \\ \ ' 1_80=996.0 i \ \e io n; '' h 87 ,352 SQ. FT. `. \ 0 A • \� \� BM \ , \o, \ G 998.7 HWE =996.0 �v1 \ \�\ .... '�: �5 33 C V10 •, V14 ��• ♦ \ . V :'� v/ • \ \� LBO =998.0 J1 . • __ :. \ • . \ s . ° 3 w s \,,,2, � \a 40. •� to • to DRAINAGE EASEMENT N' Ig \ \ C� • \ \ m '� \ DRAINAGE EASEMENT V � � Int m ' •,��� 'IG \ N N 195.66' 1 o cr 307. ' 6' \ • \ U N85�50 04 , W • • 3.62 .a Boa,. V 2 • — — ' "• \ '2 � � I BM P , I • ''.. • i D RAINAGE E4SEMENT •V' \ I : `996.0 • y CA J I • 1 I U • ( CO iw L 9 \ • .— • —.. I 4 — � I CP ti= w a I I• . 41 % 13 : 4.302 ACRES •� 1 187,387 SQ. FT. / • i � .- J�� 1 44 __ / \ i I U ' SEPTIC TANK & PUMP CHAMP E os$ SE 'IQN AND SPECIFICATIONS 4" CI VENT PIPE 12" MIN. ABOVE GRADE 6 WEATHERPROOF 25' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE— WITH CONDUIT MANHOLE COVER W/ FINISHED GRADE WARNING LABEL 4" CI RISER j` r--1- - -4" MIN. w , li 6" ** 6 MAX, 3 n IN. .......2 I •• LI 2 I INLET 7-r i , , ",,,,.''., WATER TIGHT SEALS '� ' CAS- i + TIGHT i ■ \APPROVED A SEAL ` / JOINTS WITH PPROVED � ; ALM APPROVED PIPE 'IPE 3' f I '10N 3' ONTO )NTO SOLID ' F SOLID SOIL `OIL RISER C ' ' PUMP OFF ELEV ELEV. FT. •- --+►� I 'OFF PERMITTED E ONLY IT I 4- IF TANK ( I MANUFACTURER , .,;;. ,r HAS APPROVAL 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SP CIFICATTON SEPTIC / DOSE TANK MANUFACTURER: tte.,Sit-R. NUMBER DOSES PER DAY: TANK SIZES: SEPTIC 1 GAL. DOSE VQWME INCLUDING DOSE r $ �?Ct GAL. FLOWBACK: 1 GAL. ALARM MANUFACTURER: r 4yO gNRt`'N CAPACITIES: A =',,, INCHES = ( .163., GAL. MODEL NUMBER: p_1.�V B = 2 INCHES = �a- GAL. SWITCH TYPE: ' ns,...c _______, dd PUMP MANUFACTURER: tot S C = 0 INCHES = ) 68 GAL. MODEL NUMBER: .iad ! SWITCH TYPE: ImeAkc D = i0 INCHES = J a,43 GAL. REQUIRED DISCHARGE RATE 1 10 GPM PUMP 8 ALARM WIRING AS PER ILHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFT AND DISTRIBUTION PIPE . • is . FEET + MINIMUM NETWORK SUPPLY PRESSURE . , . . , . 2.5 FEET + D FEET FORCEMAIN X 4.4011/ 100 FT. FRICTION FACTOR . . 5 Z6 TOTAL DYNAMIC HEAD = /. ?. FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH ; WIDTH ; DIAMETER LIQUID EFTH , 3 8 '' C-AL pe ! 9 SIGNED: 410444E77=:.-- ` . LICENSE NUMBER; ,,e„,`7 qq 0 DATE: 1/88 EGOULDS PUMPS Submersible Effluent Pump a: l MODEL i Q EPO4 3 V� EP05 • EPO5 impeller. Thermoplas- • Bearings: Upper and lower APPLICATIONS • grade de turbine g ed oil for submerged r tic enclosed d design for heavy duty ball bearing g o Specifically designed for the lubrication and efficient improved performance. construction. following uses: heat transfer. • Casing and Base: Rugged AGENCY LISTING • Effluent systems thermoplastic design provides • Homes Available for automatic and superior strength and corrosion 41 cam standmds Association • farms manual operation. Auto- resistance. • Heavy duty sump matt models include ■Motor Housing: Cast iron (CM listed model numbers end • Water transfer Mechanical Float Switch for efficient heat transfer, in "F" or "C ".) • Dewatering assembled and preset at the strength, and durability. factory. M Motor Cover: Thermoplastic Gads is no 9001 Re9ist SPECIFICATIONS cover with integral handle and • Solids handling capability: FEATURES float switch attachment points. '/;' maximum. • EPO4 Impeller: Thermoplas- • Power Cable: Severe duty • Capacities: up to 60 GPM. Semi-open Semi -o en design with rated oil and water resistant. • T o ta up l heads: u to 31 feet pump out vanes for mechanical . protection. seal e size:l : NPT rot p Discharge ! • Mechanical seal: carbon - rotary/ceramic- stationary BUNA -N elastomers. • Temperature: 104°F (40°C) continuous METERS FEET 1 ______ 140°F (64°C) intermittent 10 i i _.. • Fasteners: 300 series ' stainless steel. 9 3oi _._ l • Capable of running ti ; .... a - 2S FT dry without damage to 8 ; -` c 25 k..., a s.... I • EPO4 Single phase: 0.4 HP, a 7 t .... Motor: s �. _,.. u 6 20x_.. EP0 RPM, built in overload with 115 or 230 V, 60 Hz, 1550 s _ ^_ _ -- _— 3 ' � J I j 1s { automatic reset. a 4 • EPOS Single phase: 0.5 HP, o i ;. _ I r -.__ ._ .._ I -- __ I.. -..._ 115 V, 60 Hz, 1550 RPM, 3 10 . i EPO4 -- ' .......,._._.._L ......_- -.__.i built in overload with automatic reset • Power cord: 10 foot 5 ... . i I standard length, 1613 1 'i � " SHOW with three prong so GPM 0 0 . ,. _ ...... .. grounding plug. Optional 20 0 10 20 30 foot length, 16/3 SJTW with s 10 t z m�lh three prong grounding plug 0 2 4 s (standard on EPOS). CAPACITY Goulds Pumps ITT Industries ® 2000 Goulds Pumps '421 Effedfve February, 2000 83871 RECEIVED ,41 , . 4 -,,, , , p,, Wisconsin M Q d 3 consin Department of Commerce Y Sb tl_ 69 '' Li ' 'JON RT Page f of Division of Safety and Buildings in a p•rda STwttK C�r , Coun §t01W. Ad . Code C ty c, _) e r �7 �` J Attach complete site plan on paper not less th n 8 1/2 x 11 inches in ' - • - ust include, but not limited to: vertical and horizon .'- • • int (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Z U '7 y�(/1 ��� Please print all information. �2evie Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ` �(/�liw 1 ✓< / 4 "" Property Own r / Property Location li(,- Sr X j am 4 44e, Govt. Lot .5c„� } 1/4 5E1/4 S / -3 T 2, 9'N R /9 E (or() Props is Mailing Address / ( / L ( Block # Subd. Name or CSM# '7 03 )i . a. 1 /. , /� ,e /a /7 City State Zip Code Phone Number ❑ City ❑ Vil g e own Nearest Ro a L r.r ia.e>v --' i ) 15Yl) /JI ( ) /7 L�2 1 0/4s ..5,1 ,.g. i`/ Construction Use: esidential / Number of bedrooms y Code derived design flow rate . Q __ GPD ❑ Replacement ,o ❑ Public commer al - De: Parent material v� [ / f, `" ' ► (>1 loud =ation if applicable - ` /� ft. General comments S Gir F f 1, / 3 e , l i s N'L .4 i jer-4_ S / J f C / del a'SGin1-o id and recommendations: f 0 'I `- 0 s - 6 04541-14.44-1- System Type 7(Ds'r/1J e ,- I J/L-. . .terb$Ie lion / - ._.) • ' 6` ,,r _ di 1, 4 Boring # / Boring � / 0 ,) pit Ground surface elev. 1 q, ft. Dep to limiting factor // V in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 •Eff#2 1 v i Z / /,. 'it- . •• 5/ , 9a , , ?r, 1 I 7X 024,r, t C , - z L . � -3h / oi„ ../y el k9 6, .n yaJ ba 3 34 1 tv Jo V/ S O s- , rn I ,/Jed /✓1� , `7 1 C B or i ng # ❑ Boring �j / }^� it Ground surface elev. f /' 1 ft D epth to limiting factor /< (l . in (` . Soil Application Rat T' `' ( APp Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 •Eff#2 6 - 1 2.. 3 . __■ S ( - • 4 r "Ie■ -. IA .) /0 -- 3 /� 6 , . _ `S . ... IA . .!_ • - t // Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < r • Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) gnature CST Number Bird Plumbing, Inc. Shaun Bird �/ 226900 Address Date Evalu tion Conducted Telephone Number 1008 192nd Ave, New Richmond, W 4017 7 --e 6 715 246 - 4516 ‘r) Property Owner Parcel ID # Page of Boring # ❑ Boring A Pit Ground surface elev. 7, 6 ft. Depth to limiting factor / I / V in. I Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 1 6 — lam 1 0ae l' -- St 4 �r ES R -Co 1.0 , f I Boring # 0 Boring _ ❑ Pit Ground surface elev. ft. Depth to limiting factor in. sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fe in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 I ❑ Boring I I Boring # , ❑ Pit Ground surface elev. ft. Depth to limiting factor in. I Sod Application Rate Horizon . ')epth Dominant Color Redox Description_ Texture Structure Consistence . Boundary Roots GPD/ff in. Munsed Qu. SL Cont. Color Gr. Sz. Sh. *Etf#1 'Etf#2 • Effluent #1 = BOD > 30 < 220 mglL and TSS >30 < 150 mg/. * Effluent #2 = BO; < 30 mg/L and TSS < 30 mgll. 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. seo-eaw (R.a/oo) • Soil Test Plot Plan Project Name Hudson Holdings LLC Sha i : it Address 703 Pine St. N. Hudson Wi 54016 C #226900 Lot 6 Subdivision Yellowstone Valley Date 4/26/06 S W 114 SE 1/4S 1 3 T 29 N /R19 W Township Hudson ❑ Boring Q Well PL Property Line County ST. CROIX h BM or VRP Assume Elevation 100 ft. Top of Survey Iron System Elevation 95.2/94.9 *HR PSame as Benchmark Alternate Benchmark Top of 1/2" pipe @ 100.5' 230' Property Line * Scale is 1" = 40' B.M. ,At1.B.M. 20' B -1 40 unless otherwise noted 70' ' 3% Slope 80' V 282' property line B-2 60' B -3 100' 98' 252' property line