HomeMy WebLinkAbout020-1158-00-000 (2)
V6accnsin DepanmerlolComner v PRIVATE SEWAGE SYSTEM Cu.ry. St. Croix
ti:3':-Pq I-d Building Divisicm
INSPECTION REPORT sani:wy Per-1 No
GENERAL INFORMATION {ATTA-_ TO PFRN-11I> SVe Plar ID No 605098
Pe ,onat in•Grmd!¢%e yob owvjc may be nsed rOr SetOncwv purposCs (P. ac, lam s 16 UG :11:^'r
Permd Homer S Name Cdy V'lace 7nwnsnp Pa-..el Tax No
Jerome C & Gail M Matz TOWN OF HUDSON 020-1158-00-000
CST H.1 I I-, 1 Inn Itb11 rr: Bt~1 Dew, p•ia, SeCic 7,vw Range_ Mar. 4e.
/a~ • c~ ~j - 6.51 1 26.29.19.887
TANK INFORMATION ELEVATION DATA
TYPE MANUFAC I URFR CAPACI I Y STATION BS HI FS ELEV
Septic Be-ichmark
IAJ; es<.._ EN; /rxx, 5, 3l0 /05~ /eo. (,011S
An BM
l ree,n Go ~ 3.1 142. %p
Arrah!rrI Bldg. Saver
Ho'dntg SVHI lilet
TANK SETBACK INFORMATION SLH1 OuBet S, tO5 1,06.3
TANK TO ~ L'JELL BLDG Ven•. b nllako ROAD of Inlet r, ILI • 7 146, Z {
0
Septic DI Bottom
81 3t~ 5 - ~ ~
mtw-,4 77 I Header:Man. S.g /d0.1~
C7 1
Ae,ation Dist Pipe
Ilaldr.rl Bot :iyslerl
PUMP/SIPHON INFORMATION F naI ade S. 3
Paaru`actu'e' Dercand St Cover
GPM I /OL . $L
Pd!n5cl ri r
TDI I 1 dl Friai:n Loss Sysler TDH F.
Forcerein Lenglh Dia I11I to iv,
SOIL ABSORPTION SYSTEM
BED'TRENCH Vvl.ltr _ ona.IUr No Of T'eo; nes PIT DIMENSIONS Nu p' P is msdc Do ac I Cupt-
DIMENSIONS
SETBACK SYS TFM TO P:L HIDG WELL U•r STREAM LEACHING
INFORMATION _ CI IALIRFR OR 1- 1 ll f7'• SL.
L` Cf 5ys'e^
G
CAKJ p-N7~ O/ o UNIT 39 '54 tAC:vI nC'
'4 !576- f
DISTRIBUTION SYSTEM Qbf- W 3 it-l3{1 = 3fl J 5
-leanPO'Ianilnl Hole Size Fo e spaoira ve^t •e Firl 4.-
Lcw;t•i Dia I er 'th Dia_ tillaarry
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
11eot"~0 r DeP'.h ,.er .x Death of "Seeded Sndrlel
i'rl'II I t. l.rlb:" Bel. I_dcs Tops,a
COMMENTS: .;delude cote discrepem:res, cersons present, etc i Irlspeclion #1 I Inspection a2
Location: 7.0'JEADO'uv LA 1 Gk a,' :s /_OG.{•Cfj D^
L) All BId Desuiphon = / lJ(-Be.ti ~l~-•x^ ~e J•li~. O l ~-'Q
2 : Bldg sewer engt'1
- amount of cover = EN 6 } r r '1
Plan revision Required? Yes -XINo Gcl
214
Use other side for additional information. D 1 !U O
Uate Irv: :u Si q Cvf Nc
SRC-b! Irp ,H., , 1: 8 .
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61 i
C9 , i g ~d9
lndlel*r swicw v®oo Crory-
laaoewahh7162 ji Cr~CI
JUL 26 2018 P.o.eoRn62
WI 53707-7162 Y Pat1m (m be d o hY Cw-` W)Sa98
it Application Stan Tmnasm N.dM
Ic wmdawoe With SPS 383 71(2), Wm Adm. Cod,, abmin m of this kno an tle ■WWFare B*aormw Look uA
is mpuhed on to obs.lvg a McKay pd Nola Applieati, loom For waftowmd P(Mf. are atltlimed b
the Dlyarhlwn m t of Safiry and P`o4mimbi Service Pdsmd a f®tudn you pmv* a" be mtd 6r monixy hgeaa Addnraa (\ddiffvlmt; O"M edtm)
sioNdm dewwb (Ie Pris lAw 5
S 1. 1 m SLta 1
i• Im4eeet4m- 1'bmrR bier All Imaart.aWm ~ME /
Ow.o's Namc FIN a
I,- -IL 114 1 1
Ropaly Owagr'a Mmlhg ndmcs
7/~' llDe L n Pmvtetriaeatoll 87
Cmy. sMte cmvt. l.at---
Zvcode Phone NnaMa
=v,=ice serJmr24,
IL// Type of Braiding (aback all tied apply) [ate T -~-1- N: R !c~ E o(M'J
pil w 2 Family DwsIIo6- Nmbc of 2' boomieum Xeoe ~j
~P9wax'aewwaei.l_Deeeibe We Hietf ,b1F.:~Duws 11-~ 0 city at-.
❑SMm Owned-Daaiba Use Csm Nlabes OViIwof
3 N,e~- ( 13 C _ rowwof_Ifc;DSG CIA.
UL Type of rea;t (Cb-k 1Me t C..pkh Br B if yplhahk)
A. ❑New sysbm Rephp®eMS
yMea TreaamtRmld,lg Tat RaVVocmms omly ❑qha Modifimriomm6awmRSysam (em`im)
g- ❑Pnaa Rewewd Revaim ❑(2agoofPhnber ❑Pa.r"rpmmErm Neo UK Ptew PC and Daft
, -
eefam Eapasum I ~ 2-7 74P
fv. of rovers s - [Clachasthamk)
❑ Nm•Re>enad mroMd ❑ Pternmd hSGeosasd ❑ AF(rede ~ amlaa > M M afaSamblp sal ❑ atoMd <yt al wfalmtge ema ' ` J
0 Holding Tank ❑ 09 ma DMizaal Cmpuow (ogflain 1 V, - 0 Prdmiwoaw Davim (mpIan) G. t Ff o P.
V. Am Lbfl~atiam- -
DeeignFlow (Spd) Dai(to sod ApplKnow - DnpwW Area Ragmmd( DupcrW 1tl (50 sy"m FJer.hm
CL& X11)6, 10 /7
e
v1. Tut 1.6 cvein in Tam # Of
h6Mmfiotraa
calicos Od m. Uem
N.Tab Takh
L1
fl E 3
VIL Fkampowell4ky 9d4maat- 4 the waesa4wN, aawummit 4lrheeaha of me P'OIM Shows r tea eWew pea
PhaoWs Name (Prot) Phahc's $igmhae
II'' \ ; atPrhans N1abm
I B1~ 1'hme Ntmbef
77±}Rl~(1G5 nt. 2ZVb3J 71S_
Pi 's Addamm (sheaa, City. Stab• Zip Cade)
CS F r4f E S7. ~ ~W Sq 7z
vut um 'Rowneymelim
Permit File Dale
S 85'~ i$
1x Camd for th apprwvw f
.nww,t ill. t,b1 31 ►Nt~c1- 3 tr G
aat,.r cre rw,a AN 4s~"'1~~:L^ `'K's:_ tL
M par 7ler.agarrtan! plan p-;,ioed W dlumbe,. ~I\
2. AA melbar* rKt.Yat.-areas m~n;l up r. e^ r.a ! 7 J A64. J64. 4A1~. 1 Z ~K..S 6 r Cab d
. per sop." M* / tfl1i1 val.
Arrhreea- pie it hogeaa awl wdMYr MrCrprba.ygMr awaaN 11 der MAe
DV{,a_ c aa,w,~ta~r/ 5 -
SBD-6399 (R- 0814)
A5 BULL': SANITARY ^:YS^_•EM7 REPORT
(NiNEP. __JC/'~•~ .J TOwNSii_P .Ur - ,x:__ T -4-N R 1.
ADDRESS _ - CROIX COMM', WISCONSIN
SUBDIVISION ixT
PLAN VIEW
Dis:anc-v and dimensions ro meet reoul.: cmrnca of IiAiR E3
83ne ~iVF.RYTNING WITE:N ICO FEET OF SYSTSM
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i
iI r 1, r ~ 1b~l,t /
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C' II
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INDL:.ATE NORTH AEROW
BENCHMARK: Deucribe the `-•erlica'i reference point used
Elevation of vertical_ reference point: a Propnned slope at site:
i
SEPTIC TANK: Flanu factcrcr: :.lauid capacity: -[:.ft.9.L
Number Y ringe unvd: C, Tank mnnholu rover cievav inn: _
Tank Inlet Elevat=on: Guc"_ttE_++~~cvotion.: - _
Number of feet free, reareac Road: F'rcntlo Side P.car, Q__~cr feet
From nearesc property line Fronr,O Side, Rear, O feet
Number of fPer T-Om: We.._ huf:ding:
;Include chic Snip^.a sf>n• a! plan i(-i.•r core dimeralons to dept Lc _ank)
C REVERSE SIDE
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component U"-W Design ROMmnces:
Version 2.0, Seo-10705-P (N.01ro1, R.10112)
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Dispersal Area Cross-Section & Plan View
Pg 4 of 4 Management Plan
Attachments: Enclosures:
°/~TCS ccz~ POWTS lication for Review
F,-rz~~ T~ SPCC Soil Evaluation Report & Site Ma
Project Name / Description
OwnerName(s): JL/~C.~.IE L 4A. /111177_ Phone:
Owner Address: '11(,' 41gflDCL~ si•v~ I~ r Zip:
ProjedAddress:
GovLLot: _ S\A) 1/4of1/4,Section_2,& :z/ N-R 1 _EQor WF>fl
Township: O LiR ooi County: 57 c r:CI/C
Project Parcel ID Designer Information
Designer Name: AlAiw 1 -Ag1Pcrzr Phi: ?i5 -_444 _
DeslgnerAddress: 2yLI9ti KIAI&Ae-THtUZS C~ mftkl2S , Gol Zip: 59831;
E mall: h011trdesrc~n orx+(co/~ c'avl
1 his
sP4q}re•'c~f ' Istamp.
License Number 19514 - 06 7
Remarks: /.rcC C -(s s° * i' VAR io
a It HUPPCRT
{ 41839 e
t,RIVCR FALLSf.WI
Hill,
Signature' Ccq I?~ ,
~g R1~ e adch x~,~d~. Date: 7-z>
AS BUILT SANITARY SYSTEM REPORT
OWNER Je Lq~w.T7= TOWNSHIP ~a~1s[7.✓ SF.C. -Y~ T ~L_N-R. i N
ADDRESS , 3G F7. 4; )✓,..e/s,..~ ST. CR01K COUNTY, WISCONSIN
SUBDIVISION,V,g/, fq)pidafitl LOT ~7 LOT SI2E
PLAN VIEW
Distances and dimensions to meet requirements of HAIR 83
511014 EVERYTHING WITNIR 100 FEET OF SYSTEM
Iatd
/00.01 1J1S~1'. i c
t P-/ ~ .d~ 00
II
!n Vie-
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: /OEr a Proposed elope at site: 3 7~
SEPTIC TANK: Manufacturer: Gl Liquid Capacity: /no Ci
Number of rings used: y Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front 0 Side p Rear, ® feet
From nearest property line Front,O Side 0 Rear,O 7t ~ feet
Number of feet from: well 5'J building: T I / '
(Include this information of the above plot plan)( 2 reference diner.afoes to septic tank)
SEE REVERSE SIDE
J
trr~: 3of
uA 1:7
-41NC Twt(. ~4tW.O.w'
IN-GROUND GRAVITY DISPERSAL AREA h G 7
Uniform Elevation Trenches with Quick4 Standard-W Chambers Soft re"MCO oer."It
3-ft Trench (down-sizing credit) i{~ ~w+ - a+ - a+ w
-
,L(! ~j /rFE 7'v(
~Q
taraq
SOIL Covrn
mmn TYPICAL TRENCH
CROSS SECTION VIEW
1 rmo (No Scale)
Pneride rrArAmrn 3 a
System Elevation = `FI (I R separeYrn between kenchm
auk" S4.1*maw
w em °a+ (Show location or inlet i outlet pipe connection on plan view.) pro-11 TYPICAL TRENCH
(hl*Jl r®pw.wmo.sz PLAN VIEW
(No Scale)
- 1
A=3oe
/ - ------Yr--- D
_ ci
s
(type) 'i5~ G. G = z F/ Sta,aard-' Char wa
w
INSTALL PER TRENCH: 7% : ZG &l S~4 _ 3Z S u. ~e At . 0Q
01Z ?N X y _ /'SL ~rrw p.~r...~.wao.wic la.wau.. }a
i? ou1ck4Sld-w02ex EMkkh roe= fe
+ Paws orew caps Qe tee Atpee- G. rt' -rK[."7i1
Proposed EISA Per bench - fe Req Arod Irwe.ren Arso- '.TC R' DBtrDtdbn Mason
x trembes - ProposedTotalEISA - Z w y,7~1ykFeLC)
In-ground Gravity Management Plan PAGE 4 OF 4
IMPORTANT,
The owner of this in-ground gravity system shall be responsible for its perpetual operation and maintenance pursuant to
requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 38152 (2). Wisc. Admin. Code, this system shall
be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
Maldmum Dispersal Area Ooeratino Limits:
Design Flow q1T gpd; BODs 220 mgL"; TSS 5150 mgL°; FOG 30 mgL-'
Inspection Checklist INSPECT EVERY 3 YEARS
c type of use
c age of system
c nuisance factors (i.e. odors, user complaints, etc.)
o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.)
o material fatigue (i.e., leaks, breaks, corrosion, etc.)
n solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution / drop boxes)
o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.)
o extent of ponding in distribution cell prior to dosing
o dosing irregularities - if app icable (i.e., pump re-cycling, float switch settings, etc.)
o electrical components - if applicable (i.e., wiring, Connections, switches, controls, timers, alarms, etc.)
U distribution lateral or lateral orifice plugging (measure lateral distal pressure - compare to design specification)
U surface discharge of effluent or seNege back-up into structure served
Maintenance Check lst MAINTAIN EVERY 3 YEARS (or when necessary)
Q Septic and dose tankfsl shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis.
Slats. when the volume of solids in the tank(s) exceeds oneafrird (113) the liquid! volume of the tank(s) or
as required by local ordnance. Disposal of contents shall be pursuant to NR 113. Wisc. Admin. Code.
o Effluent filterts! shall be inspected every 3 years and shall be cleaned when necessary to remove any
accumulated solids according to manufacturers specifications. A servicing period will always be greater than 12
months.
System maintenance reports shall be submitted to the proper local government unit In accordance with
SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to:
Name of Individual or company: - - Phone:
Local govemmentunit T•C{2FlK COMM.w17y D;-QF-bpMEN7- Phone: 7)5_33/0-`1W
Local government unit address: ft 1Y17IO,V In77_ ZIP: 4~0/ 7
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin.
Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code.
No product for chemical or physical restoration of the POWTS may be used unless approved by the department In
accordance with SPS 384, Wisc. Admin. Code.
929g2aency Plan
In the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to
a plan submitted to the appropriate agency for review and approval. A failed in-ground dispersal component may be
abandoned and replaced by a code-complying dispersal component in a pre-determined area of suitable sods.
System Abandonment
If use of this POWTS Is discontinued, it shall be abandoned In accordance with SPS 383.33, Wisc. Admin. Code.
U I
Tra litetine °dter
1'ne.IStM mks: eticea. w: rt TOW"'. An^arkel. J-3 tl(Fi:'W"TeL3c.: 11.:'
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Heavy-Duty Outlet
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I4o I_ed in Suppol t Hubs
Superior Desigied (literin La'
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Hie Only Septic Tank Filter You'll Ever Need
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Low Prolila for shallow applications.
5*' : • Quick4 Plus Standard Low Profile
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Quick4 Plus Equalizer 38 Low Profile
Low Profile Trench
f'" t- "°~as r Shallow ln%allabw
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Application Heduced height applications, 4" shorter than standard chambers. -••'t
36" wide trench, curved. Straight or side by side in beds
stut _ 34'W x W"L x 8"H (864 mm x 1346 mm x 203 mm) `
EHecliw Length 48" (1219 mm)
Endcap Quick4 Plus All-in-One 8 or Ouick4 Plus
Appasagon - , Reduced height applications, 4" shorter than standard chambers.
24" wide trench, curved. straight Or side by side in beds r s
Size 22"W x 53"L .x 8"H (559 mm x 1346 mm x 203 mm) _
Effective Lwgth 48" (1219 mm),
Endcap QuiCk4 Plus All-in-One 8 or Quick4 Plus
luw i.
ApDlicaGOn: Use at either end of a chamber row for an irlM(oWfet or can be installed
f mid-french. Side, end or top insetting.
Compatible with Quick4 Plus Low Profile Clambers.
iq
Size: 18'W x 13"L x 8"H (457 mm x 330 mm x 203 mm)
per EndcnalapLength: 10.4" (264 mm) Insert HeignC 3.3" (84 mml OpOmal Accessory: -
Per Fn All-in-One Penscope
;Tdcap
i Simple, flat design that allows for a pipe installation at the end of the chamber row.
Rping drill points are set for gravity or pressure pipe.
Compatible with Quick4 Plus I-ow Profile Chambers.
Size: 18-W x 7"L x 8"H (457 mm x 178 mm x-203 mm( -
Additional Length 4.5" (114 mm) I~ nvert Heignl: 3.3" (84 mm) r
per Endcap:
Contact lnwiralor Watr TGLS) iologle at 1-,900-221-4431, far additional information.
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48"
(EFFECTIVE LENGTH)
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1 t t 8•• ~flµ'~''. 8•, INVERT 9" .
INVERT 3.3' 1 1 'IIIII~IIJ t 1Qa"
17.8'
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4 5'.
F" - 11
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INVERT.3 3",., ~ k 8.. if 4t' 1 I
17.8" - 1 _ L - 5- g'
Quick4 Plus Standard Chamber Specifications
Site (W x L x H) 34" x 53' x 8" (86 cm x135 cm x 20 gym) Invert Height .................3.3". 9"
Lsfectlve Length 48" (122 cm) (8.4 cm, 22.8 cm)
N 9LTRATOR 3Y3TGM%J1 STANDARD A TED WAR A-M1y
e RATOR
i • P.O. Box 768
CT C6475
360.b' 'r'.'r'DC:) • FAX 860.577.7001
800.221.4436
www.infiltratorsystems.com
technical assistance. installation in.
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17.
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the following residence:
(Street address) j::1 I 1 1 , t ) ' located
at: ''/4. %A, Section Town '_X N, Rang- 174 W,
town of~(Sn,t St. Croix County Wisconsin.
Upon inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of SPS. 384.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service hq k
7-
Did flow back occur from absorption system? Yes__ No
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity:
Construction: Prefab Concrete Steel Other
Manufacturer (if known):
Age of Tank (if known):
Permit number (if known)
(LIns 4dl um ber Sig ure) (Print Name)
11 /r1> L- p~ t~~Ld~F , P-
(Title) (License Number) MP/MPRS
(Date)
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev. 2!2012
ti
Y
ST C- 105 t
r
y
SEPTIC TANK MAINTENANCE AURLIEMENT
St. Croix County O
O
Y
OWNER/BUYER IfR 01t F-
ROU'T'E/BOX NUMBER Fire Number CITYISTATe~_uoseR/ _.ZIP 3'''101.F _
PROPERTY LOCATION:
_I~lr„ Sect Lon TjLj__N, R_j_.W,
't'own of flG/DSDc✓ St. Croix County,
Subdivision/may Lot n.umbcr a~ .
Improper use and maintenance of your septk* system could result In
its premature'iallure to handle wastes. Proper malutcaaliCe Cun-
sists of pumping out the septic tank every three years or suouer,
if needed, by u licensed septic tank iLuuLer. What you put into
the system can affect the function of the septic tank as a treat-
ment stage In the waste disposal system.
St. Croix County residents maw be aligible to recuivu a grout for
a maximum of 60% of the cost of replacement of a failing system,
which was in operatfun prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requlreument that
owners of all new systems agree to keep their systems pruperly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
Certification form, signed by the uwner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-cite wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nuc-
essary), the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 10 days prior to
three year expiration.
G
I/WE, the undersigned, have read the above requirements and agree i
v
to maintain the private sewage disposal syscum in accordance with
m
the standards set forth, herein, us set by the Wisconsin Depart- of
ment of Natural Resources. Certification furor muSL be completed
and returned to the St. Croix County Zoning Utfkjpe within 30 days
of the three year expiration date.
S I C N E DATE 61~E 7
St. C,uix County Zoning Office
P.O. iox 96
Ha mmo~id;%NI• 54015
715-7 46-$2.39 or 715-425-8363
Sign, date and return to above address.
S"r. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
0wneril3uyer 4 t-C Mf (1 1A4z---
Mailing Address __71
c-
ProperlyAddress ~l jL z- A5_ -
(Verification required from Planning & Zoning Department for new construction.)
Citvistate ^ Parcel Identification Ntunber ~L ~j x s1 ~ v
LEGAL DESCRIPTION
C
Property Location , ,Sec., T ; N RW, Town of. _ ftj
Subdivision Plat: Lot #
Certified Survey Map # Volume Page #
Warranty Deed # (before 2007)Volume Page #
Spec house ❑yesdto 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 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 §SPS. 383.52(1) 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, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and or (2) after inspection and pumping (if necessary), the septic tank is
less than v3 full ol'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 Safety And Professional Services and the Department of Natural Resources,
State of Wisconsin. Certification staling 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 dale.
l./we certify that all statements on this finrm are true to the best of my'our knowledge. 1wc amare the owner(s) of the
property described above, by virtue of a warr ty deed recorded in Register of Deeds Office.
Number of bedrooms
SIGNATURE OF - PLICANT(S) DATE
""Any information that is misrepresented stay result in the sanitary pernut being revoked by the Planning & Zoning Department.
Include with this application a recorded warranty decd from the licgister of Deeds Ofice and a copy of the certified survey map if
reference is made in the warranty decd.
(REV. 04/12)
OEPAHTIMFNT OF INDUSTRY, INSPECTION REPORT FOR SAFETY at BUILDINGS
A DIVISION
LABOR d HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS
BUREAU OF PLUMBING
P.O. BOX 7969
MADISON, W 153707
ur..,euel
SW14, SEN, S26,T29N-R19W CONVENTIONAL UALTERNATIVE araw•LD. NnI•b•
Town of Hudson (7 Holding Tank C1 In Ground Pressure U Mound
i,ot 27 High MEadows INUf cnoN DATr
NMIF OF /ERNn IgLDE-_- JADONfNOFPENMIT MOINi
Jerry Matz 530 9th Street Hudson WI 54016 X7-6 7 J. 30
.FNCN MAPR Irn w+lx rllnm[Aw•••II Of KPIaL II UIFf fRENT FROM IIAN Nf F. K. Elf V. I IIf F IT f Lf V
...e Yywn. MPMINEw NO Cawlr Irv Inn NV•reF•
nail i Schlsmaker 6382 St. Croix M 102776
SEPTIC TANK/HOLDING TANK_ _ - L -
:-j FACIUR{R DAPACI IV TANNwLIT FLFVI.FK MOAIR' 'Xim
VIL)EO (,ZAj v N O QVES UNO r, YES 511,10
I NUMBER OF DADu0- vTn or u
IM1E IT
OM -7
~PM FEARE' 7
VES NO I~VtS .ShvO NEAREST Le
DOSING CHAMBER:
NVf}C1VP111 BEDOI4G IIUUIU PVNI NIIIIfL PVWMYNON MANUf 4CllllllP NAMNIND LAatL LOCKING
CAYACtI /RpwDED rPOVOVIOED
LIVES UNO LIVES i7 N0 (~~VES (]NO
GAI I ON%PER CJCI.t: 'LAW AND COV I. R I NAL NUMBER OF .IIMM . w u el,llumc, v w R
LINT d1R 14111
(DIFFFRFNCE BETWEEN FEET FROM
PUMP ON AND OFF) I-IYFS L7 NO _ NEAREST -
SOIL ABSORPTION SYSTEM. Check thesoa mornureat thedepnwf lowin Ilul•'N - IAMInu NA I RmL No A.....
of IMC:Ivmlor 111 soil um hl•. rolleo into a wire, construcuuP Lrull cease untd FORCE
the! a+I Is dry erwu9h to conuryle.) MAIN
CONVENTIONAL_ SYSTEM: - uowo
wmin n uo Msln aPE d/AU c JEn v'~ orn evn s- uEVSN
BED/TRENCH ~'E 7~INt N('+ns S MA ,AC PIT
DIMENSIONS I v / L
AVE, oEeyN 7 Ise ritrlsF onP I., IDL 1 AL uo nl NU OF Nul elmmuc vuT mFUlx+
nu ow P11 ano < lu I(I .111, tLEV ¢no r Hers uNF 3S A.S--/
L li L P.1 Z FEET FROM - S O ~oS
N
,ps EAREST +
MOUND SVSTEM:____
Mound site plowed perpendicular to slope Check th7letm"ure of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound sto make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the ia for medium sand. TIONS MEASURED.
UYES ❑NO
COVER IE}LVPE IMF.nINI M AMa(PS llII5r I1V AlIIW w1114
]YES LINO~ I_,YES LINO
)l I..Owli TNf NCN'eFC CFEIII I)VkN UFT , DlI iN o. MSllll N)IU rl:+l.) lI1 CNfC
Cf 41fP EM.It
OYES rJ NO OYES ❑NO I1VES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
mul uniln UO.a is tNAL SIACTw hFAV[{uErM D{ION nn ll IIA w .v N
BED/TRENCH 1Rfxcw%
DIMENSIONS
MM-11-010 tup - MA41 p. + mSin vML caul nul A FRIAL wT-tl lrv-- -IinT..TF~ap[ nl~ifuTlbti Dl I -•il a Mnuarrl.
f,Fv FLFV. DIA Flt, IvIF mA
ELEVATION AND
DISTRIBUTION
INFORMATION NOLI$•2E I(IIf SPACING NI II IILUIl1111.11VCOVfNMATfPIAI VfP+I(:AI :P RHIw U51p AIYNVVIV
vuus
1YEI- 1JNO ❑VES ❑NO
COMMENTS: 5;r( AIwMils NUMBER OF ^'MERTV F'FIL auILCINI:
FE AN N
1 INF
3 I '1 - FEET FROM
EST-
LIVES nN0 l ~\~-l_IYES I_-)NE, NEAR
a I 1p.1B Io.IC1
Z- y J4 t),
0 °vv~
s93 5'(02.
Sketch SVsINn An (0 I S Retain in county file for audit.
Reverse Side. I E -
SIUNAIW I
T,...- - 7.Dning Administrator
of LHR SBD 6710(H. 01182)
`l 7
Wisconsin DeppriawrnyT ilrp ofessFnal Se vices r! 1 1I -.l ' - ~ 0 I -
Givision9tfi*wAFys'-.',✓ - ~V
S
RPPORT
2018
Page of 4
JLI 2 n accordance with SPS 383. Wa. Adm. Code -
County
Attach complete site plan gtlttaper Than 8 72 x 11 inches in size. Plan must ST
include, but not lirgite to`.'~rq(p#aF tai reference point (BM), direction and . CROIX
percent slope; sygfgoP Fns, northarrow, andlocation and distance to nearestroad. Paroel I.
~-~r~,~-~ . ~ 20 - 1158 - 00 -00(1
Please print all WOrMation.
^ersonalmrormation you Provide may be used rot Secondary PwpoansPtrivac9 Law, S IS04pi(m)i RCVIe dby Date
ProperlyOwner 7 v~ y~ 7~y
. . / v
.ILROMF. C. K GAIT. M. MA 7"!. Property Location
Property Owner's Mailing Address Govt. Lot I14 1(4 S 26
Lot # Block # Subd. Name or SM# N R 19 E (or)
7 10 Meadow I..T 19
m
City State Zip Code Phone Number, 27 I ligh Meadow II
Hudson, W1 54016 ( ) Ity E]Udlage • Town Nearest Road
NewConsWction Meadow Lane
Use Residential / Number of bedroorr>s
Replacement Code derived design flow rate 450
Public of commercial - Describe: GPO
uarentmaterial__-.-_ Iucssovertill
-
General comments - - Flood Plain elevation if applicable
and recommendations- Conventional In-Rruund Shallow Trenches 0.6 loading rate cover required 8" Infiltrators R.
El 0 Boring #El Boring
Pit Ground surface elev. 100.60 _ft. Depth to limiting factor 57
Horizon in
Depth Dominant Color Redox Description Texture Structure Consistence soil tcatlon Rate
in. Munsell Ou. Sz. Cont. Color Boundary Roots
GPD/ff
I 0-14 I0yR2:2 Gr. Sz Sh. 'Eff#1 'Eff#2
2 14-24 I 2fsbk cis es wG-m 0.6 0.8
10YR34 I `
3 24-57 1OYR4'4 2fsbk ds cs Ivf=un 0.8
21=msbk ds as Ivf=f 0.6 0.8
4 57-63 10YR•U4 nrlavR4~r,~laYRa:,
I Ifsbk ds
0.4 0.6
Boring # ElBoring a
❑ Pit Ground surface elev. 100.61 55
B. Depth to limiting factor in -
Horizon Depth Dominant Color Redox Description soil lication Rate
in. Munsell Qu. Sz. Cont Color Texture Gr Structure Sz SConsistence Boundary Roots
. . . Sh. GPD11Y
1 0-12 IOYR2i2 'Etf#I 'Eff#2
12-24 I _'f-msbk ds
10YR3;4 0.6 0.8
1 21tik
3 24-55 101'R4;4 ds 0.6 0.8
I I 0.4 0.6
4 $5-60 10YR4;4 fll I0YR4;6&-If1YRd+? f=instil, ds
1 I fsbk d 0.4 0.6
r
Z 1!
Effluent #I = BOD, > 30 <220 mgrL and TSS >30 c 150 mg/L
CST Name (Please Print) - Effluent #2 = BOO 1130 mgrl and TSS 30 mg,L
MARY JO !Il!Pf I;RT (Hollister 's Soil Te tin t&l)esitm ~ptale ~T <Number
Address /zq r , UI
Date aWa'o 224831
28497 King Arthur's Court, Danbury, WI 54830 dulled Telephone Number
07.10.2018 '715 41(1-17'15
Property Ovmer MA J Z. Jerry & Gail 020 - 1158 _
Parcel ID # 00 - f100 q
Boring r. Boring Page - -of-_--
❑ Pit Ground surface elev. 101'00
It. Depth to limping factor _ 63 in.
Horizon Depth Dominant Color Redox Description Soil ication Rate
unsell . Sz Cont Color Texture Structure Consistence Boundary Roots GPD1tF
in. fd Du
. Gc Sr.. Sh.
I 0-14 10YR212 'Ef#J1 •Effn
2 14-18 I 2Gmsbk ds IOYK~ 0.6
0.8
~4 I 2fsbk tis
3 18-63 0.6 0.8
IOYR4:4 I 11=msbk
ds 0.4 0.6
f
E Boring # B Boring
❑ Pit Ground surface elev. ft. Depth to limping factor in
Horizon Depth Dominant Color Redox Description Texture. Soil icaff Rate
on I
in. Munsell Structure Consistence Boundary Roots GPO/if
Qu. Sz. Cont Color GI Sz. Sh.
'EIf#1 •EN#2
❑ Boring # Boling -
Pit Ground surface elev. fl. Depth to limping factor in.
Horizon Depth Dominant Color Redox Description Texture S Soil ication Rate
in. Munsell Structure Consistence Boundary Roots GPD/I'
Qu. Sz. Cont Color Gr. Sz. Sh,
'Efrirl 'Efl#2
' Effluent #1 = SOD, > 30 < 220 m91L and TSS >30 < 150 mg/L ' Effluent #2 = SOD < 30 0.
_ mg and TSS < 30 rrgrL
ial?+1~JO <Rn'~13i
1