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HomeMy WebLinkAbout020-1353-24-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County. St. Croix Safetyand Building Division • INSPECTION REPORT Sanitary Permit No: 453002 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: Henke, Lisa Hudson Township 020 - 1353 -24 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No 10 f I OD • t Cs 1 F3 r^^ ' I — r1/4 aJ..Q, tn.. oals., 4ree� 36.29.19.2024 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark UL-)6iSe ( 2_ 58 (0.32- QD(o..?Z.) JOT Dosing Alt. BM f Aeration \, Bldg. Sewer 3 .613 loo .t, 4, • 644A, ) /off s5 f Holding % ----.__________ SUHt Inlet C. bZ , TANK SETBACK INFORMATION St/Ht Outlet (p 2. TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic S b t (1) I g r __� Dt Bottom — Dosing IL. /-'. j - Header /Man. o c°" .o 4 0. / ll 0-1-1.4 ( Cci..43c ) 3a Aeration ---__ Dist. Pipe / `f• ZS' 'N m0110. i3 .de ' r Holding - `'-- 2 Bot. System \ (9-"jt'u) PUMP /SIPHON INFORMATION Final fGrad9 I � -� z � D.31O qs 9(0 / Manufacturer Demand St Caver / f GPM 1. -/ coq -SI Model Num r - - --° - TDH (Lift riction -Loss System Head -- ))H Ft Forcemain Length - '` , -,Dia. Dist. to Well SOIL ABSORPTION SYSTEM ( 6� a' s{,i( .6 -e - P/ ,-r /-f - (fir f ( - 1 4 4:s R�NCN idth 3 ] Length No. Of Trench U PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIME r ( &.) 0) SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: r / ��++ e-r a� 8 , ,/ J /`/) UNIT Model e F t rV • — LL (7�J li DISTRIBUTION SYSTEM 0 cf-s4- Q(L, Header/Manifold . Distribution x Hole Size x Hole Spacing Vent to Air Intake ,�,� Pipe(s) i LengthAte Dia Len . :ia Spacing �, > 5� SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed /Trench Edges Topsoil �, � �i' Yes [;I No Yes No i l COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:5(1 0)/ ter° -Y Inspection #2: Location: 668 Hillary Farm Road Hudson, WI 54016 (NE 1/4 NE 1/4 36 T29N R19W) Cottonwood Ridge L. 24 11 . - - , -Parcel kin* 'AR 2SD.10.30 4 1.) Alt BM Description = 1 -�' r S 1 2.) Bldg sewer length = ^ `�5', II a. 1 12..4: = . , 8'ti - amount of cover =(-- 5,o s�-tl (,dt,2r- ,) " 1`4,04 = 72 .2S: 3 ) 4{ 2444 -G 4--- 1 (t CIS )ct ' cy& 1 S o Z Plan revision Required? Yes X No /J8'() /O( � T `� oth ide for I addition infer ation. �" .�,�,� T C� ✓ S /¢ . ate Insepctor's Signature Cert . No. SBD- .3/97) 1 Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 1U62—'' a C ro ■ *sconsin Madison, WI 53 1 4 ■ VED I 'tary Permit Number (to be filled in by Co.) Department of Commerce (608 .6 -3 � 53002 Sanitary Permit Applicati t n 2 Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal informati• you * r qq 2iO de � . may be used for secondary purposes Privacy Law, s15.04( (m) CRO \XCOF Proj ■ Address (if different than mailing address) s . O I. Application Information - Please Print All Information �� � L (o& / t t 1 S Q r y cot. r r'►'N Rd ;Y y Property Owner's Na me Lot BI�k�I 1 0._, rY) , -e o‘< • —0.1 O.S !V I`f Owner's M ailing Address - S oa (.20 , Property g Property Location I • I 1ct •Q • 1t) - S N • t�, N 'k,Set:tion 3 (l, City, State Zip Code Phone Number S Q3.) •, NO . S 53 t / ( circle e) • T R.q N; R�E o r W� II. Type of * Ming (check all that apply) d Py g � 1 ' • W 1 or 2 Family Dwelling - Number of Bedrooms -9■6 , , Subdivision Name CSM Number ❑ Public /Commercial - Describe Use r • WOO ° t N • I - ❑ State Owned - Describe Use -- ❑City ❑Village ilownship I fici I ucl S O y III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ►:� ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Is ued Before Expiration Plumber Owner 36 31,1f OI ( . , M _ r IV. Type of POWTS System: (Check all that a..1) , o ,�Y� 71 Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line • Other (e lain)C� 7 Fie, LJ_ \ V. Dispersal /Treatment Area Information: 2)tw..a :4•0 P Sc4f'rern S / Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Requir (sf) Dispersal Area Proposed (sf) System Elevations: L,Qd : 1 S''7 9 O 0 94t3 VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks ! f ptic . Holding Tank �/ t t f f i .fie,r. f , - h�0 A it A' Aerobic Treatment Unit 1 � Al , /: Dosing Chamber VII. Responsibility Statement I, the undersigne , , as a responsibility for • i • on of the POWTS shown on the attached plans. P�lyg�.:''s Na me (P • t) / P1 bet's Si _nature OSZ umber Business Phone Number a Plumber's Addre ss (Street, City, State, Zip Code)'- n 1 4(09 1 ES' ' A-w2 lu i , r iifY) nnc,), t 0) 7 VIII. County/Department Use Onl Only K Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued I uing gent Signatur (No Stamps) Surcharge Fee) ❑ Owner Given Reason for Denial 1:63.2f;- if l )00 ` �/ IX. Conditions of Approval /Reasons for Disapproval ,, .� 1'7" �� At *CI OWNER: ,,q -c�n^"_ _ 1 Septic tank, effluent filter and Q�}C t91n. SY /2/0 3 . 1 ^'tS dispersal cell must all be serviced / maintained ) as per management plan provided by plumber. r'ovo-Q_ i s ( o �.a e40 . �, Q i, „ cd , 2. All setback requirements must be maintained � ��"` 25-33o71 as per applicable code /ordinances. t P r,�.. �� Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 01/03) a , 1 , • ■ , L el r c t 4 , . 1 + 1 . i f- -1-- , - ---1 L ' i --- — —f 1 1 i 1 11 s 144 1 - 5 . ....) I • A *0 • ___1 ., •• 019 a cl 1 I i 1 I i • Z"- 1 1 .. I I I I I ! 1 1 I 1 K ■ , .r._ ___1. 1 : 1 r 1 1 1 I ; 1 1 : d , i 1:4 [ 1 - ,---[ ...__.,_ 1 -H 1 i 1 , , —1-- . , 1 I i 1 , 1 1 , , 1 As OD VY-Ct I 4 i ' i... I— ‘ — e 4 , . , 1 1 i I iz 1 I , • , No c . 1 I 1 ..._ ; __,__ _ ,- --- I -1 , J. ___ ,-,- --,-- . . 1 _ i ,- 1 , i 1 i • , L i r" ---4- 1- 1 i --- 1 .._. . •[- - I , I • ■ , 0 ...e • i .1. 1 ,,,, OP • ...--- . 1 1 , 1 I - i 1 1 1 - 1-- 1 1...______1_____H-- [----! ! 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L`soL. m h e c 'i s t � , 4F 1 tt � � o N r� 3� �� �u h?_ h l�I►.t� In�lpa.► S t esZt G 0015 i ii2. t ay S 0.99,...) uhf , SS l4 r• - r C o S� � s �` zca�ol.Q 1H i _ � � b ad e -u, ►�r� _ ` �'� ,� . c.� coo � � to � ` � r � � oZ T"c n se ct 0 ` 8 9C3t 2 j5g s c_•cohs E Z... \ '- as '7 is A _ 4 '_ 1't8rr -PA i° ock0 E( i Yto tk hcp 6 °' N. 3t ir ...�+ ice �1.. -��' T - R g1 9( � 4 P 1 $z. 0 p 4 7 I�q r rn • ' POWTS' OWNER'S MANUAL & MANAGEMENT PLAN Pegg of 9 LE INFORMATIthe SYSTEM SPECIFICATIONS 1 t.v \ \ , 1 / 4 0S s S ❑ NA °ia UL Sa t _ 1T2 v∎ �� Tank Manufacturer Permit I 46 OO y I Septic 0 Dose ❑ Holding vol. I ,q5 c7 gal DESIGN PARAMETERS Tank , . 0 NA Number of Bedroom I ( 0 NA >: ■ , .., 0 Holding Holding vol. Number of Rubric FaaTity Units Kt 1A Effluent Filter Manufacturer 'ZIk. C} NA mated (average) ?km ki DO p Effluent Filter Model A- t.(D , Design (Peak! flow = (Estimated x 1.5) 100 0 gaUday Pump Manufacturer IsizliA Sep Application Rate v ge ud ay n t z Pump Model Standard influent/Effluent Quality Monthly average* Pretreatment Unit 1 NA Fats, Oil & Grease (FOG) 530 mg/L 0 SandfGravel Fitter ❑ Peat Filter Biocheaacat Oxygen Demand (8OD 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended SoNds (TSS) 1150 mg/L 0 Disinfection 0 Other: Pretreated Effluent Duality Monthly average Manufacturer Biochemical Oxygen Demand (BoD 530 mg/L Dispersal CeS {s! ❑ NA Total Suspended Solids (TSS) 530 rngll. ❑ NA (Skin - Ground (gravity) 0 In-Ground (pressurized) Fecal Conform (geometric mean) 610 cful'l OOmi ❑ At -Grade ❑ Mound irlaximum Effluent Particle Size Y in dia. ❑ NA 0 Drip-Line ❑ Other: Other: ❑ NA - Other: ❑ NA *Values typical for (Mimetic wastewater and septic tank effluent. Other: 0 NA frUUNTENANCE SCHEDULE Service Event Service Frequency Inspect condition of teals) At least once every: 3 6X } nrna tt(s) ( s) (Maximum 3 years) 0 NA year Pump out contents of teals) When combined sludge and scum equals one-third ()) of tank volume ❑ NA When the high water alarm is activated 0 rttoreth(s) (Maximum 3 yews) ❑ NA Inspect dispersal calls) At least once every: year (s) Clean effluent filter At bast once every: Ekmontis(s) ❑ NA inspect pump, pump controls & alarm At least once every: 0 month(s) r,�, A D - s) Rush laterals and pressure test At least once every: 0 mania (s) t7 ©yearls) Other: 0 month(s) A At least once every: d weeds) Weir: ttfiA INAMITENANCE INSTRUCTIONS Inspections of tanks and disperse( cats 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 (pumper). Tank ware any cracks or broken hard Tank ' must include a visual ' of the ta nks! to identify any missing a identify inspections inspection +�fY a leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The cellist shall be visually inspected to check the effluent levels lit the observation pipes and to check for any Ong of effluent on the ground surface. The pending of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accturnulation of sludge and scum in any treatment 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 Coda. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatmen units, and any servicing at intervals of 512 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. GMW (2JO2! START UP ` .. , For new construction, AN OP ERATfON Page • of prior to use of the POWTS check tn.*ment tank(s) for the presence chemicals contents m yf the and /or damage the sod �Is)of painting concentrations solvents are Or other ej have the tank(s) removed by a high conoerttrations a fg �etOf{) operator prior to use. System start tip shall not occur when sal conditions are frozen at the infiltrative surface. extended power s outagee poraE► tanks wastewater wfi be dirge outages s the may one normal highwatar levels. When power is restored the of effhierr To rg d to situation pane l o have s) dose and may overload them in excess surface to restoring power to the effluent pump or contact pump tank. Plumber or POWTS Maintainer to assist eta prior , controls to restore normal levels within the operating the pump Do not drive or park vehicles over tanks and dispersal cells. Do not drive or Park ova, or othaw a disturb or Pact, area 15 feet down slope of any mound or at -grade sod Reduction i born axles. R OWc i or on of the following from the w stream antibiotics; baby wipes; cigarette butts; improve the dental floss; and the life of the � dam (sump prop) wee; fruit and vegetable p Udine: g dental floss; ; disinfectants; medications; c d s; fat; ABANDONMENT pesticides; shy napkins; tampons; and water softener brine. meat ; Rieclit:at ores; oil; When the POWTS fails and/or is Permanently taken out of service the fold properly and safely abandoned in compliance with chapter Comm 83.33 � rhea be taken following to insure that system is • AN piping to tanks and pits she* be dim and the openings ed pipe openings sealed. . • The contents of an tanks and pits shah be and PAN deposed of by a Septage • Servicing Operator. soil, gravel or another inert solid material excavated and renwved or their covers removed and the void space filled with CONTINGENCY PLAN If the POVVTS fails replacement system: arid cannot be reps the following measures have been, or must be taken, to provide a code compliant 1 0 A sortable replacement area has been evaluated and May system. The replacement area should be protected be emceed for the location of a repo soil d absorption from . and proposed ire � and compaction and should not be infringed upon by lot rises and resu t kb the need for a new sod and site evaluation to eetabh a suitable replacement area, the area will replacement comply with the rtes in effect at that time. Replacement systems must 0 A suitable replacement area is not evadable due to setback and/or sal kmitations. technology tank may be installed as a last resort to replace the failed POWTS. Barring advances in POWTS O The site has not been evaluated to identify a suitable nspiacament area. evaluation must be performed to locate a Upon failure of the POWTS a soil. and site may be ins taaed as a last � t area. If no replacement area is available a hokting tank result to replace the failed POYYTS. CI Mound and at -made soil absorption systems may be infiltrative surface. Recorrstnuctions of such y must c omplyded w in place following in ef fe t removal of the biomat at the < < WARNING> > inerampll► ith the Wiles in effect at that time. SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAN Lams. GASSES AND/OR SEPTIC, PUMP OR OTHER TREATMENT!' TANK MAY E S LT. R 111. ANK UND ER DO NOT PERSON FROM ANY THE fiN1'E3ffOR OF A TANK MAY BE O�RCtRT pR DEATH MAY RESULT. RESCUE OF A IMPOSSIBLE. ADDITIONAL COIriempyTS • POINTS dIMTALLER Name C ` ��� P0'S MASNTA#I�i >triR_�•j�j� Phone S f Phone arrAGE SWIG OPERATOR (PUMPER! LOCAL. REGULATORY AUTHORITY Name CrjllWKQMIEMIRIIIIIIIII Phone Phone S i (O (O i �a� by the staffs of the Green i & i . and wausAa a County Zoning and Sanitation ageA in A�rarristsative Code. �Ce with 1 fTM (�oo� '' � co, �Qy 1 _ 1 EZ1 203y f l . : :;,. if/ f •• .L } �•• -.74, r • 1 VW .. :`,17 l VW* 1 tr •° :..; - =: 1/2 Ciro. = 18.84" ww wwwirw r if °„° ,;;° 1 Via, F -----36" f I2 -112,1 Diq. f r of 4° us7.4x OJ . a ..6u inches i o d w #, (xr linear f 2 ► r . • S+denna (2 $ eMaS a s. r4 •! s. � IB,Btip 1 t iadrT = #?.S rr,d► EfOrtorn j � � Aggregate wt rur e7 wta� - 3 >i' �raw i Twtat Snit Uterine, Ara 2,00 j ! ode c'!• 1 i2iar(}'y2 4, 22' re 5.74 $� t 12 menet 1 Void volume m °'mpk h' . � `' . - mow. s 1 t' P rojected 4 �i ?wi_ q i " .ST.e, 40i ft, reed' Area , Vow S+deW t wl� at cwt a ## Height -- #1 in. I t+rtw� cylter$ (� 24M 2 2.00 _ Bottom = i i ( Vote °Or1 at outside 12ra t fe ! x { J . r s (x ' O.� ; y f,� Pt° /te 36 rn. 3 pp Ft. ! b000m (tn. of void med T�c6 Area Twat Lwxl v°t between SOY $q"Ft. j volume 0.1 ! T r +tu+e c Gra ss per t$ .. 1.T 43 .+ #_; 941 • 0.215 . 0, t pS = t -ma cyi�ec h i f 63 X7 . I I i / 1 I EPA Aggregate Trench System E2'12p3H Ring •lndusfriol G . ft, 1 i 65 1^dustriul Pork Rd_ SCALE talc EIt .o swat t °t r t -xT-.0, r . • ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Ll SA M. /4E14 k — 6. L'° Sc Mailing Address / 41° 41- A‘'.A./t4"4 � S S4vA -LvE , /�kl t ? Property Address G Co 3 1/1 t - iss2. t4 /2c 440 4\ 0 / (Verification required from Planning Department for new construction) City /State JS / Parcel Identification Number 0 I 3-7-V--00 3 LEGAL DESCRIPTION Property Location s /, '/,, Sec. 3/6 . T 7" N -R 1 W, Town of Ku 0 S o c1/4l Subdivision �7 i wo 0Q g ©l- , Lot # 2 7 . Certified Survey Map # , Volume , Page # 'I/ l' / 9� Warranty Deed # / ,Volume , Page # Spec house ❑ yessno Lot lines identifiableeyes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman pliunber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days f the three ear e date. � `Truf C1 ©S 2.;i2/ SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property des d above, b virtue of a warranty deed recorded in Register of Deeds Office. Li S 4. ° Cio 2 1) 0,1 SIGNATURE OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed /* Wisconsin Department of Commerce SEWAGE SYSTEM County: i k Safety and Buildings Division INSPECTION REPORT , fiet St. Cr. GENERAL INFORMATION (ATTACH TO PERMIT) No Personal Information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. F _ Permit Holder's Name: ❑ City ❑ Village ( Town of: State PI. k o. V Lisa, Henke Hudson Township CST BM Elev. Insp. BM Elev.: BM Description: Parc • ax No.: 020-1353-2 -1. TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/L WELL BLDG. v Air Ientto ntake ROAD Dt Inlet Septic NA Dt Bottom Dosing NA Header /Man. Aeration NA Dist. Pipe Holding Bot. System PUMP / SIPHON INFORMATION Final Grade _ Manufacturer Demand St Cover Model Number GPM TDH I Lift I Friction I System I TDH Ft • Loss Head Forcemain I Length I Dia. I Dist. To Well SOIL ABSORPTION SYSTEM BED / TRENCH Width I Length I No. Of Trenches PIT No. Of Pits Inside Dia. I Liquid Depth DIMENSIONS DIMENSIONS SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHIN Manufacturer: INFORMATION Type Of CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header /Manifold I Length Dia. Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etrns pection #1: / / Inspection #2: / Location: 668 Hillary Farm Road, Hudson, WI 54016 (NE 1/4 NE 1/4 36 T29N R19W) - 3629192024 Cottonwood Ridge -Lot 24 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision required? ❑ Yes ❑ No 11111 Use other side for additional information. SBD-6710 (R.3/97) Date Inspector's Signature Cert No. " i ` e I r to v. Id .Ae 2 273' 1 • Sanitary Permit Application Safety & Buildings Division Wisconsin In accord with Comm 83.21, Wis. Adm. Code 201 W. Was g� Ave See reverse side for instructions for completing this application PO Box 7302 °spirtment atCoriimerie Personal information you provide may be used for secondary purposes Madiso 53707 -7302 [Privacy Law, s. I S.04(lxm)] (Submit completed fo to county if not state owned. Attach com • lete • tans to the court coy . for the , j ,,., •; not less than 8-1/2 x 11 inches in • i y tY� I State Sanitary P Number ❑ • , - I revaioatotsevto • liation State Plan I. D. N ., , ` L Application Information - Please Print ail Information \ it,, Location ,. Property Owner Name �� Pmp . .16 1 bau.4 -4 L isA ilEkx " : , t 'r_-- ivE 1/ !" u4. S.3b Tz 9,N, R (or) 0 Property Owner's Mailing Address t er , I: ' . • - _7L6 E w'IL F`2i Cn kDAL ■ .. \ fi � � i • Buck dumber • City, S Zip Code 'Phone Number umber f� , - bdivision Name or CSM Number u .Ht os ®► lilt I . 0 i - :� . *A � , • Cb n OwI le i D E ,,,� [� Type of Bni • • • • g: (check one) `; y. 0 City LkI. 1 or 2 Family ' • • g - No. of Bedrooms • V 5 per . � i t ❑ Village .. t I ❑ Public/Commercial (.1. 'be use):_ f (ah5 5 -b m 1 ti ett if grown of r/ V ❑ State -Owned / / Nearest Road . biW'' O0 Tan_ Para ax - 2.0 1363 -1-'0 00 III. Type of Permit: (Check only • box on line A. Check box on line B if,_ :•plicable) - . 20 - A) 1 . New 2. :Rep • -' - t 3. ❑ Replacement of 4. r'- 5 i 6. - •dition to S em tem Tank Onl % . : S - em B) Permit Number / Fr .:*.. ❑ A Sanitary Permit was previously issue IV. Type of POWT System: (Check all that app ` ..• KNon- pressurized In- ground ' Mound ❑ • . W .. d ❑ Pressurized In- ground el olding T . jilt ■ g e P .k- ❑ ' p . e ❑ At -grade ❑ • bic - tment U ❑ irculatin: ' • V. DispersaUTreatment Area Information: ` Ii, '/ G 1 i 7 //UP/ I . Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area ' - IF • it Appliari • '"="--- . • ercolation Ra • .. Elevation 7. Final G rade Required 3 -7 S / Proposed 3 1 / Jday /sq. ft.) Ovum/inch) Elevation VII. Tank Capacity in Total - , of . cttrer • fab T e Steel Fiber- Plastic Information Gallons Gallons anks • vi . Con- •n- glass New Existing ' crete structed Tanks Tanks ❑ ❑ ❑ ,❑ • SEPT! C /OW i / l �WEKS 1 i ❑ ❑ ❑ ❑ VIII. Responsibility Statement I, the undersigned, assume responsibili •r installation of the POWTS shown on e attached . tans. Plumber's Name (print) PI • - ignaoae no �„ ... ): 1 ;r:a o. Business Phone Number .EFF &x- ' 'j I , zz zL/ Z 7I S -a9 Y - 31 Y I Phmtbes's Address (Street, City, State, Zip . • • ) ' ' - &)x. 235 ' A REss r_IL WI „51 9 • IX. County/Department Use 4 my ❑ Disapprov • Sanitary Penn it Fee (Includes Groundwater Date Issued Issuing \ . Signature (No stamps) �� Detetnir • n Initial Adverse Surcharge Fee) ;• Z Z S� 0 O ( o / 410: .-------- X. C of Appr I /Reasoor Disapproval: / dal 'Mr * - }; /r(✓ Tt' lee 4in 4a ,.,e S e✓v(ci.cf 1 0e le■ AnrA4ci ✓e Comm andalfofry 5, • $c Welt /wrier ' - 0.c 5 /0 6 £7/ eon "el- c/fa d 4 'i .1_ r . f 1 Koa n S s d- L $A i k n J X X AO's' % y A % y S 34. - T 29, i!'R l 9 w 77,0 Z t41 LFIE D RnAn Pia at) 1' P. HLasarre iJ SNbh, 4 4 /FRS 2232 / Well wo...6k Q GAMIC -G o - d‘rdoN;riec w a< a S S BEARDON\ rcu Sc pii JJC /Dut G ' vitEEks sr PTJC'TANKC W1-n4 ; }i .-10D ZABLE FILTER... a g` p g r, 0 / 99.5 y ❑ A BM 1 97.5 A IIm2 . • 1 0 Z 7'l NCtI1 =S WILL rE7 , . • l'_ r dAP SI(J� ENarr2 L7 • P' ° ` • lir A Wi3cNrlc\NRic 1 NAIL I►U 16'' OAK_ c- L£V ioo ' 1 13ENcrinn AR 1C / IIL IN It " (/711` LGY /(..O ' , • d Solt_ 36161JL5 SCALr< 1''-- Nb' Y ;Wisconsin Department of Commerce SOIL AND SITE EVALUATION / 3 'Division.of Safety and Buildings Page / of Bureau of Integrated Services in accordance with.1L1718 .83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in S ize. Plan must � _ ' N C ounty include, but not limited to: vertical and horizontal reference poir{t (BM), dire qn old . 5 C r r-�d, percent slope, scale or dimensions, north arrow, and location and distance tO nealro$tngad. ',Parcel I.D. # 1 APPLICANT INFORMATION - Please print all Information. ' ^ot^4 ed by Date Personal information you provide may be used for secondary purpose(F�ivacy Law, s 5S(�y�m)) A �" 1 Property Owne _f ,, ;art rty Location / i ' klC-V.ard S-f-du�- Govt ot,. , 1/4 N �1 /4,S 3c Teo ,N,R /q E (ora Property Owner's Mailing Address r 'i Lpt, #'. ck# Subd. Name or CSM# 1353 A wgtuk-•ee - re. n to cad l�tciy, City State Zip Code Phone Number V e —Town Nearest Road tt II, ❑ City ❑ Village t 1UdSbr) 11.31 151.{01 b 1 "•115 )5`I k 131 4t f c5 o n 1 eo 4 world /-r- V I - New Construction Use: ('Residential / Number of bedrooms 3 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow COO gpd Recommended design loading rate 1 - 1 bed, gpd /ft . Y trench, gpd /ft Absorption area required 05 _bed, ft ltd trench, ft 2 Maximum design loading rate * bed, gpd /ft , trench, gpd /ft Recommended infiltration surface elevation(s) v pp 4- 9 L. 3 Goc,, « 9/• 3 0 ft (as referred to site plan benchmark) Additional design /site consid erations ✓� /t 'Pper 93 YO 4ow c/ 99Z YO // Parent material (- I �A (.IQ..1 a L-littiel. Flood plain elevation, if applicable ,v i4 ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system E ❑ u let ❑ U Ell ❑ U Eri ❑ U ❑ s E1 ❑ S ❑'r SOIL DESCRIPTION REPORT n(iki Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft 4 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench l °- ldyr 3 I Z 5L \ Mo& rrifr - -5 I `i ' . 5 .1 Z q -3g 16 y.r Li I`l 5, I 2 rnabk rryf ; c,S - . 5 ' (p . s Ground �Q -It(s Iv y r 4 1 to -- i is d3 m l GS -- - --1 • g 'q elev. g97° ft. Depth to d 9 3 • limiting +35.6 , fa for N _Vein. ' Remarks: Boring # o -/Z 16yrM2-. s� V rrbbi< rfr CS lF : 4 � .5 . 'I .5 � . r ILi 2 rz -/g IN � s; l 2mabk r4; � c.5 -- 4,0 , v l iSuo l0 y r y 1� rn5 os5 m I C5, - - — 1. • . 8' . Ground elev. Depth to n' Z l' ti , limiting factqr 110 in. Remarks: CST Name (Please Print) Signature Telephone No. f it_ fa c _ ii - , (7IS) --/00 lc/ Address Date CST Number 46? Ceder er Si. L/ S 4 » 5 Li-LS- -9 Z5 - 336 9 PROPERTY OWNER�3bc> SOIL DESCRIPTION REPORT Page Z of- PARCEL I.D.# H orizon Depth Dominant Color Mottles Structure 2 �QW Boring # P Texture Consistence Boundary Roots GPD /tt fle in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench (A 3 I loy 2 - 5L Imctbk M-c, cS 14 • 5 't{ 9-2z IU y r` I`f — 5; I 2ry,cubk rr-C-i 4-3 . 5 .(P Ground 3 •* IOyr4f'P nr►5 os5 r tl c — . - t yz loft. Depth to limiting ( Remarks: Boring # _ 1 0 - W yr3 SL l mGbk rn C5 1.0 • 4 : `-f Z ILI-1g i I q —_ S; I Z rr 3 k r n-P1 C.S — • 5: . / 3 4101 ler ' — (Y15 oS3 m l C s — • S • -3- Ground elev. 9 3ott. Depth to limiting Ile factor 6C3 in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # 1 0 u) r 3 I Z S �- bra*. rr r ; . 5 • y 2 io -' i , - [ 4 S; I 2rWibk m'+^ i CS — . 5 ; • Co , -3 18' IQyr yIla MS OS mI CS — _ . 8' .1 Ground elev. t - Oft. a- 113.1 yg „ Depth to /)ti" limiting factor 1/ g in. Remarks: Boring # ........................... Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) Pc1 3 4-3 _/"..---Ze.ie .... St'O F 1 -1-- aN - c w o., ro 2: d -P "..------- > ___ 1 `= 100 Nu: i , A Vo" aG•K _ 3 Cpl et-C.v. 1.6 N r3M7, eel- ,r. /00-0 9Z. 30 6 4 , '4.1.e.u. Geer j 1 . 3 o upper q 3,W() 141-f. e(e V. 1-0,,,3t.r q z•YO ,t-- / (k ` cf-* �J ` �5 r ,* • 4111 Ai-/- • • era • • ' ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT • AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 4e.-c-1 /coAJ !i X i S 1747�vA e Mailing Address 2 70 8 eiJ . I crcd R oeci 1/�/ cise"/ ct1 S 59-D(o 668 Nizl A Q Y FAerh 'b Property Address C_ -)7` '1't- ' /. o ' 40... , , .1 /..-.1 44 . v ,fs- ' ..,- (Verification required from Planning Department for new construction) 6 f /l. ' ' AL-. :i; vi City/State tb / G✓; 5co,�/S• A/ Parcel Identification Number Od k; ' /3 53 --? `t' -000 r r ' LEG • 1 ESCRIPTION 7 Property Loc. on /1/G %4, 4/g ' /4, Sec. 36 , T 2'1 N -R •15 • ' own of //, c4 o ^/ . Subdivision (_ O to Aiwa e J /e e t , Lot # . Certified Survey Map , Vol • r' , Page # . Warranty Deed # 6 759 , V I' e / 4 // , Page # 907 . Spec house ❑ yes g no L i lines iden' • • •- e 14 yes ❑ no SYSTEM MAINTENANCE 4 r Improper use and maintenance of your sep • s I • co • result in its premature failure to handle wastes. Pr • • er maintenance consists of pumping out the septic tank every three y Y . ' ; or . • oner, if needed by a licensed pumper. What you put ' the system can affect the function of the septic tank as a trea ••• ,,J t e in the waste disposal system. T h e property owner agrees to submit t • A. oix Zo ' • : Department a ce , i • • sign by the owne and by a master plumber, journeyman plumber, restricte • . um • r or a lice • • • umper ve • 1 • g • at ) the on ' e w ewater dispo < 1 system is in proper operating condition and/or (2) a ` _I ins. ction d pump'. (i nec 7 ), , ptic. 's less n 1/3 full • sludge. I/we, the undersigned have read the abov- .$'equir• ents agree to •• i • th ate • deposal system with th- tandards set forth, herein, as set by the Departm /of Co • ••erce d the D • • '. • • • a 1 sour, Salk of Wisconsin. C. ' cation stating that your septic system has be le .. • ta ■ ed must e corn. an • • • is e Crac Co • • ning Offic • within 30 da Alf . us. ye . expiration da C-- 27LPi a, q G l �G SIGN j i APPLICA DATE OWNER CERTIFIC: ION I (we) certify th• all statements on • 's form are true to the best of m • ur) kno dge. I • am e) the owner(s) of • e property d . • 'bed . • • e of a . my deed recorded in Register of Deeds • ffice. Ar - IIP Ylas SIG • gin' OF PLICA • DATE * * * * ** Any inf' • tion that is mis- represented may resu • • • • ••• • .: revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed i n - - � $11PAGE 9 2 / sj• STATE BAR OF WISCONSIN FORM 2 - 1998 64 1 754 WARRANTY DEED KA THI. FEN H. WALSH REGISTER OF DEEDS Document Number ST. CROIX CO., WI RECEIVED FOR RECORD This Deed, made between — 04 -02 -2001 9:30 AM —R ARD ate. - a- e 1 ' 'T Q J , • - - --- t u a ta,� nd _ - d d wife, -- - - - - - WARRANTY DEED Grantor. EXEMPT 11 — — - - -- — -- - — CERT COPY FEE: and LIS M. HENKE - - -- COPT FEE: TRANSFER FEE: 179.70 — RECORDING FEE: 10.00 PAGES: 1 , Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St - Croi x _ County. State of Wisconsin: Lot 24, Plat of Cottonwood Ridge, Town of Hudson, St. Croix County, Wisconsjn. Name and Adbrey f t j6 . Grantee, its successors and assigns hereby agree that a single family residence only will be constructed on the subject premises. 020 - 1353 -24 -000 Parcel Identification Number (PIN) This i q rint homestead property. (is) (is not) Exceptions to warranties: easements, restrictions, rights -of -way and covenants of record. Dated this 30th day of March , 2001 y(� 1HLMpa.a S (SEAL) / . '" - (SEAL) * Richard Q. Stout Janet P Stout (SEAL) _ _ (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature (s) State of Wisconsin, St. Croix _ County. ss authenticated this day of Personally came before me this 30th day of March , _ 7 (101 , the above named — Richard 0- Stout and Janet P Stout— * -- TITLE: MEMBER STATE BAR OF WISCONSIN -- — to (If not, me known to be the laNi Y F`NOliCif('(efuted the foregoing authorized by §706.06, Wis. Slats.) instrument and aS�'rTA( �e WISCONSIN KERNON J. BAST THIS INSTRUMENT WAS DRAFTED BY - -- — 1 - Janet P. Stout i * i f 1353 Awatukee Tr. -- Hudson, WI 5401 6 Notar Public, State of onsln My ommission is r- anent. (If not, state exp' lion le: (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. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. WARRANTY DEED FORM No. 'L - 1998 Milwaukee, Wis. 0/ 111/01 TUE 10:39 Fx 717 'I (:P.1 (H Z002 • • ' • - . . • Private Onsit,4 1 17e1 4 ,1r9mt. Stem Management Plan Septic Tank i C und Soil Absorption Component Pursuant to Comm - Cr fir:vate Onsite Wastewater Treatment System (POWTS) shah , a lync.0,:h ices for maintaining the system within the parameters of Cornni Lzd h conciitions of approval by the department, agent, or governmental unit. The appn:..-ied plariG and permits for system are on file at the county zoning or health department This management r,:-:11 with Comm 83.54, Wis. Adm. Code, and the In Soil Absorpti. 1 Comporicnil M for Pt Nate Onsite Wastewater Treatment Systems SBD- 10567 (R.6/• 1 SyAem Design Specifications / Sanitary - -Irrit — Number Design Flow - _NSO Estimated Flow - isk ape (gpd) 300 Septic Tank Capac Soil Absorption Compt e Of Type of Wastewar: Domestic Table 2: Soil C •, ones Limits of Reliable Operation - F - 7 7; Tank Component Soil Absorption Component 7 ' ------- — Design Flow - PcaJ. qt 6 Maximum Influent Parth.le 1 / 8 Maximum BODE (mg; L.) 220 Maximum TSS (mgl) 0 1111 •I A ' Septic Ta Inse c - or ever y3 e. • Outlet F er Ins[ Sr) - Adr2r1L SF 'very 3 years Soil Abso et.; Compcne?nt n A er ears - ygi The septic tank shall bc.) rir.aned by an certifie. • sr: tanks u -er s. 281.48, Slats Thc: m fth e septic tank shall b spo d •ccordance with 113, Wis. Adm. Code Eebtic. Or HOlding Tan', 'ump amb- -, Grease Interceptors, Seepage Bt:qiE, :7:•eeragf:"! Seepage Trenches, P , or Porta e Restrooms). The operating conditior: i and outlet filter shall be assessed at least once every 3 years by firter sh0 be cleaned as necessary to ensure proper operation. The lerricved tlnieSS provisions are made to retain solids in the tank tit Ca the filter wlen removed from its enclosure. If the Os-6)1-6m 10:34 PE':EIVEP FPOM:715 336 4686 P.02 .05/01/01 TUE 10:37 FAX 715 ;. .; 4. >'i Chi co ' ONING 1.1(13 - . - —• _ • __ _ _ Tank and Soil Absorption Component Septic Ta co ntinuously Man�9emen` peal fa. is activated tt�E filter shalt be seCV�ced if the alarm ntinuou5 alarm, Thtank e flows or an impending a in the next filter is equipped with an alarm, and slud9 Intermittent filter alarms may indicate sung t the per of when the service II have its en removed when the volum o scum k sha cont tank. If the contents of the tank are not removed a the Septic tan liquid volume of ts the accumulation in exceeds 113 the liA ursor►nel shall advise a time of to be performed ed maintenance nCe p maximum scum and stu d9 needs to be performed td maintain less than a fbe or water tightness a n', tank. tertl• ! "P �s risers and covers should be in act to fai must _Whole risers, access defective, or s ea ,; cured by Vua Win -s used for service and a ll seal • _ soundne . Access opt An opening deemed unsound, le •n of service. Any reater than 8 inches in diameter to the / the comp v x g de i c e to openings g bee effective to prevent accidental or unauthorized entry an effective loc • g device ` tank for tic o treatment or holdi nda for No on e o wit enter a sap r other. with OSH - i fu ll compliance e tic or other any yeas • without being here within HtI p entering a • •nfined spaCe_ The atrnosP n d rescue of a treatment fr o oiling tank may conl3Jfl let dt - } ` °r impossible. rescue person+ from interior of th® tank may ,f Code when the Tank abandonment .11 be in accordance with Co 83, his. Adm. tank is no longer used as a Pk S component - / • S. •1 Abso •tio :./ om •onent Wen ervin•ei is structure is designed to accept domestic The SOIL absorption compo I . r" operation of this component are shown in wastewater from a residential facility. Table 2. The longevity of a sal absorp' ' -'`• corn. •Went depends greatly on proper and timely maintenance, and system use withi • bed ' limits of reliable operation. Good water conservation practices by all • •• 1, :nts and the in llation of water conserving plumbing fixtures are key factors in extend•, "• the useful life o is component_ • The soil absorption cap,'ponent's operation must assessed by inspection at least on every three years. Th- ` nspection shall include recd' 'ng the levels of ponding, if arty, in the observation pipes, and visual inspection for any evide ' of surface seepage or discharge from the component. On - teeply sloping sites, e of r si om hcwastew identified or sewage r reported to the owner f• repair. The surface discharge from the system is pro 'Deed and considered a human health haz • . Traffic arou .+ or over the soil absorption component should be `• . oiled particularly during winter mon • s. The compaction or removal of snow cover over th omponent may lead to hydraulic failur by freezing- This type of failure is usually temporary, b _s di fficult this p. impossible to r- • air until weather conditions i ail In and dispersal c may lead to component wi educe diffusion of oxyg en into more intens and earlier, organic clogging of the soil. 1 1 2 i li 05 01 - 00' 10:32 RECEIVED FROM:715 386 4686 P•03 • • +r ter..+ I .... I -iln ig I j! ft: .. i I ' I C _ ,s j! 1 i � M %..........• ': MI ir I i e • t I ! i 1 , i i I j , : 4 4 441.1 , I I : . N 0 W - - - - - i =� 1/ 3 r i j i i i I I I I j �! ---------- - -- - ' J 1 1 ' i j i II . •� � i Q I:�? O <o . : i �i i s �: ti 4 1 N �� • i S: A .. . h • , ...8 : ...... . . , ; • ; , i . , , • ,621/6S AuE•I,CO•TON . !.. I I. I i N i •• o se 0 0 s. 3 '1 0 eD O O -o C r 5 E .. • CD - A - 1 3 pf 3 C O 0 O C ( n m ( W O CT ( 1 C O O) ) N `C • CD n N m a m o x , y m-. : •(n CO m c o o ., c) y o p p _ W R `A1 7 co l ° -0 0 v D) f (° a E (�� co 0) v 3 co t c7.) a "5 c71 ) ) ' p " !� cn co) 2 ° p a m co, Z D a 07 • D a 1 :C(D) CO D 0. C -n a c O v a W o o co �♦ — - . 0 1 0 m N `� �o � Ki m I o o=1 ° 2 N O C H. In TI 0 0 0 Z 0 0 0 I 71 I o - 0 71 g N 0 1 c 3 CA 07 CA c I w f ? o (D 70 A 0 o p' (D co ( a o -0 ii A G-. 7 I m St 0 al co 1 3 d I N Z. 3 d _ a-• E. ( f O Z C 2 Z C O Z o =� 7 o I 0 > = 7 c O = < s o 0 ' � m s p N m Co m m m 7 v N (/) 0 CA lD K N 7 0 N• C CD C 'O co (D - 77 a ' 'O (D (0 d m 7 s1 CD N ! y (b z y ( I o o C 1 ° (o w a c E. y a f a — 0 0 I 1 0 Z — I w I We I W mo o ' o z n 3 o 3 .3: ° e. 1 0° :► Z — xi I P. 3 Z 3 11 Z m CD I O * I co I I D I d a 1 a 1 a - a - I v c R- m c I z o. I o o I co m CD co I I 7 o 1 m to cm 0 1 a 1 O I A I I ti 1 I ti I I ° o A I I El I o I o co I co DO a c..) O to O 1 ti A o £ o 0