HomeMy WebLinkAbout020-1441-75-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
430463 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:
Bast, Kernon Hudson Township
CST BM Elev: Insp. BM Elev: BM Description: 11 Section/Town /Range/Map No:
100.0 (et .o 1 1 .11 72 5 =CST 6tM 'I 36.29.19.
TANK INFORMATION U ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 12 6Q Benchmary 1 1 i, 0 3 - O � • J3) 1 ov, a I
Dosing ( Alt. BM `` J f '
Aeration Bldg. Sewer
Holding — St/Ht Inlet /
7.32 96. 1
St/Ht Outlet
TANK SETBACK INFORMATION •S7 lb.*.
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic I C-k) ) 3 .----- Dt Bottom
Dosing Header /Man.
Aeration Dist. ¢ipe_ r, �+'' 95- `
'S7 WMA,„. Z3
Holding ------ Bot. System a:22. p pr
Final Grade
PUMP /SIPHON INFORMATION 3 ico.0
Manufacturer Demand t St Cover 2 4 r 0( -1 } r
Model Num. -r
I
TDH (Lift - ' tion Loss 'System Head TD Ft
Forcemaiy Length Dia. Dist. to WTI
SOIL SORPTION SYSTEM
BENCH idth 3 / Length 1 INo. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Depth
DIM 81•� lact. ` /Z` 1Liquid
SETBACK SYSTEM TO D P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: n
INFORMATION — CHAMBER OR [3 t O GCc suers
Type Of System: / i .m h J, ›cio 44 GO '_ UNIT
l Model Number: 0 it
DISTRIBUTION SYSTEM
Header /Manifold Di tribution x Hole Size x Hole Spacing Vent to Air Intake
, fir �{ N Pipe
Length `e� Dia 1 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 [l No E] Yes iJ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: f(Oai 2 zoo 3 Inspection #2:
Location: 667 Mary Jo Court Hudson, WI 54016 (NE 1/4 SW 1/4 36 T29N R19W) Cottonwood Ridge 1st Add Lot 755 ���� P - arrcel }-36.29.19.
1.) Alt BM Description = 5. 1 T. wAarn.Ke� -- C ttytt , T) -Es - Ico E•""""""`^ �+ '
2.) Bldg sewer length = 1 1
- amount of cover = 18
(3) was& wdr cryInS- Q iec i;10h eQ. e
Plan revision Required? I 1 Yes X No Dt1. . Z S '
Use other side for additional information. _ __,
SBD -6710 (R.3197) �
gat C., Insepctor's Signature Cert. No
•
. - Co (, 4_ hi Ptc C c y, fety et Buildings Division
201 W..Washington Ave.
Sanitary Perm .Application PO Box 7302
V
isconsin In accord with Comm 83.21, Wis. Adm. Code Madison, WI 53707 -7302
Department or Commerce Personal information you provide may be used for secondary purposes (Submit completed forth to county if not
[Privacy Law, s. 15.04(1)(m)) elate owned.)
Attach complete plans (to the county copy only) for the item, on paper not less than 8 -1/2 x 11 inches in size.
County State Sanitary Permit Number 0 Check if revision to previous application Stale Plan 1. D. Number
�f rv +3011(03 -_ W _,_�.
. _ __..4 . .
I. Application Information - Please Print all Information HO. 4 = 01 >-- Location:
Property Owner Name Property Location q
rt H. 1 b L u li WE 1/4.52d 1 /4, S 3ha T 49',N, R/ E (er) ()IIJ
Pro ms rty Owner's Mailing Address Lot Number • Block Number
)
City, • Zip Code Su ivision Name or CSM Number
G( l sfl tJi J /lo q S e
II Type of Building: check one / ^ w � ,) /
.4 YP Q ( ) y mot'( o.� --S -,t``Ue•1). (�( ) CI City
" I or 2 Family Dwelling — No. of Bedrooms: ` � - 5 , 1 S • ❑villa
0 Public/Commercial (describe use)) Town of
O State -owned K : • 'V , 1 � ALL d`S"r
III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Near Road - .... •
/ 7/ A AAI/ Jo Lou 1'
A) I • ki New System 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Addition to Parcel Ta Number(:)
. I System I Tank Only I Existing System , 6 i /Dq 0 00 �u
B) Permit Number Date Issued v
]
❑ A Sani Permit w
Lary as previously issued I I Qu.rc.ek 4Ws .
IV. Type of POWT System: (Check all that apply)
on- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
• ❑ ressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
❑ At -grade ❑ Aerobic'freatment Unit ❑ Recirculating ❑ Other:
V DlspersaVireatment Area Informaton• C 'i c, A.. - -lop �.� - i
1. Design ROW (bpd) DispenalArea 3. Dispersal Area 4. Soil Application 5. Percolation Rate ystem Elevation 7. Final Grade
Required � � Proposed � � Rate (Gds./day/sq. R.) (Min./inch) Ekwt •
GO ��
-1 — 9Smo g
VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks
5 C_ '/ ' /2140_ . _ ___L_ _ i?.Q.5
❑ ❑— ❑ ❑ ❑ . F
VII Responsibility Statement.
•
I, the undersigned, assume responsibility for ins . . of the POWTS shown on the attached plans.
Plumber's . , • , P�fmbbr's SI i y nd .tamps): • - MP/MPRS No. Business Phone Number
Plumber's Address (Street, City, State, Zip Code)
iziO J i t)
VIII County/Dep rtment Use Only Igt ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued ssui' Ageq{.Signstu a (No stamps)
rge
Approved ❑ Owner Given Initial Adverse Surehd Fee) ,� n \
. Determination . 2 (. 21 2�3 " c ..�,; . • " 1 ,.
IX. Conditions of Approval /Reasons for Disapproval: '• . 3) 5 p- Q.*te lam g0,,42r-
SYSTEM OWNER: , / f
1 Septic tank, effluent filter and �C\P^ - °( S o S-e€ 56 rerorij
dispersal cell must all be serviced / maintained
as per management plan provided by plumber.
2. All setback requirements must be maintained •
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Wisconsin Department of Commerce SOIL EVALUATION REPORT / 3
of
Division of Safety and Buildings
M accordance with Comm 85, Ws. Adm. Code
CountY sr. cRo /x- .
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. le-e, 4e. As Lt, -V-
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. '
Please print all Information. R= : >, by ► ► Date
Personal Information you provide may be used for secondary purposes (Privacy Law. s. 15.04 (1) (m)). ' p
s / C'f� � M u 1 , � /Z.(/o,�
Property Owner RECEIVED Property Location DP t
4151 Lt1 /LGD)C S DN ovt. Lot S £ /4 A/W 1/4 S 3(0 T 2 7 N R if /E (or) W
Property Owner's Maili Addr dot # Biodc # Subd. Name or CSMfI fkt>p /,V(�— / 06,¢
!� cry. ma y / t /
jAN 0 9 2003 ra,. , �.,ad le -' /VC
City State Zip Cade E
Ptlene a yj,.° ❑City II Village 0 Town Nearest 12. •
#149.50/ KO. 1 SO/ 4 � 1(13 t ,` , Hl/pS0 1 moV N
16--New, Construction Use:() Residential / Number of bedrooms 3-y Code derived design flow rate y5 — CO 4v GPD
❑ Replacement ❑ Public or commercial - Describe: _ _
Parent material /0E 5S O( ...5.9AID �/ 0l9{ZJ� Flood Plain elevation if applicable �/� —~Y ` ft.
comments
rments /
and recommendation: . 7S 7 4 j e , ¢ - 5 /771/3/6 7 ..e co v / /,E v 4.z._
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I / wing # 0 Boring �j 1 f0 I ® Pit Ground surface elev. / ft. Depth to limiting factor 7 fin. Rate
Soil Application Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDNf
in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2
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Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIff
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• Effluent #1 = BOO, > 30 < 220 mg& and TSS >30 < 150 mglL J • Effluent #2 = 801) < 30 mgll. and TSS < 30 mgll. '
CST Name lCO /3E2 T �fh�/ CLt S TGtJr 21C.3 S
Address Date Evaluation Conducted Telephone Number
Ulbricht & Associates 1,1 • / . 2 !f 7 /S' 3 2(• V8S
555 O'Neil Rd.
Hudson, Wis. 54018 .x- P/,)5
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Property owner
Neil- Ge�i1C o X 54A) 0).0 • //b ? • 2 °' 6r(r) .2-
3
Parcel ID # Page of
13 Boring # k..70, Boring 9• 70
!Pit Ground surface elev. ft. Depth to limiting factor x1- in.
Soil Application Rate
Horizon Depth I Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDAf
,In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
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Sob Application Rate
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•
• Effluent #1 = BOD > 30 < 220 mg/1 TSS >30 < 150 mg/L • Effluent #2 =BOD < 30 mg/L. and TSS < 30 mg/I_
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.
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Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In- Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code Private Onsite Wastewater each s e as ewater Treatment
System (POWTS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or govemmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
10567 -P (R.6/99).
Table 1: System Design Specifications
Sanitary Permit Number 4 (3 p `f (0 3
Number of Bedrooms hrl
Design Flow - Peak (gpd) V (
Estimated Flow - Average (gpd) 11 6D
Septic Tank Capacity (gal)
Soil Absorption Component Size (ft') $70
Type of Wastewater Domestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Desi• n Flow - Peak (• pd) ; p
Maximum Influent Particle Size (in) ' S 1/8
Maximum BOD (mg /L) a a b 220
Maximum TSS (mg /L) S U 150
Table 3: Maintenance Schedule
Septic Tank Inspect and/or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3
P rY years
Y
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stets. The contents
of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the sepf , k and outlet filter shall be assessed at least
once every 3 years by inspection. Theoil - shall be cleaned as necessary to ensure
proper operatinn. The filter cartridge shou d not be removed unless provisions are made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
•
Management Plan for a Septic Tank and Soil Absorption Component
•
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next service
a accumulation in the sludge needs to be performed to maintain less than maximum scum and g
tank.
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, defective, or subject to failure must
be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the •
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in
extending the useful life of this component.
Y g p
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
Management Plan for a Septic Tank and Soil Absorption Component
Plantings of deep- rooted trees and shrubs directly over or within ten feet of the .
component should be avoided since root intrusion into the component may obstruct wastewater
flow.
, When system fails, we will replace with another system
at owner's expense. Alternate area must be left undisturbed.
St Croix County Zoning Office 386 -4680
Boumeester & Sons Excavating 386 -9020
•
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer A?, ijC'/
Mailing Address ?` S' ( e / 9=GC. //6 a 7 3
•
Property Address Q o f
(Verificatio I required from P anning Department for new construction)
City /State /7 Jd, &) / Parcel Identification Number -
LEGAL DESCRIPTION 0F L �J fcre%- .
Location //4, C e,Y4, Sec. , T !! �� Town of /�'�ad
Property S (�,L N - R W, To
Subdivision �� / / � i i m.?"''L Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # C , Volume /75, Page # 355
Spec house ❑ yes Arno Lot lines identifiableyes ❑ 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
1 system.
e dis sa
as a treatment stage in the waste ys
can affect the function of the septic tank g disposal
property owner agrees to submit to St. Croix 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 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
sta: ' :.. • t our septic system has been maintained must be completed and retumed to the St. Croix County Zoning Office within 30
• ys . e three year ex.' on • "S .
• GNATURE O 'fI' PLICANT 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
• . erty descri • • = • ve, b irtue of a warranty deed recorded in Register of Deeds Office.
01
-
SIGNA ' ,)F 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
•
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"• • J 2 1 3 5 P 3 5 5 70 88812,
KATHLEEN H. MALSH
WARRANTY DEED REGISTER OF DEEDS
ST. CROIx CO., WI
Neil L. Wilcoxson and Mary J. Wilcoxson, a /k/a
RECEIVED FOR RECORD
Mary Jo. Wilcoxson, husband and wife, conveys 02/07/2003 02:00PN
and warrants to Kernon J. Bast the following EXERT it
described real estate in St. Croix County, State of
REC FEE: 11.00
Wisconsin: TRANS FEE: 2880.00
COPY FEE:
CERT COPY FEE:
PAGES: 1
Exception to warranties: all easements and restrictions of record.
This is not homestead property.
Parcel Identification Number(s): 20- 1109 -40 -000; 20- 11 -9 -20 -000; 20-
1109 -10 -000; and 20- 11 -90 -55 -000
Name and t A � Wealty us to.
A parcel of land located in part of the Southeast 'A of the Ediina Title
Northwest 1/4 , part of the Southwest 'A of the Northwest 400 South 2nd Street
1/4 , part of the Northeast 'A of the Southwest 1 /4, and part Suite #115
of the Northwest' /. of the Southwest' /., all in Section 36, 7 � r J ,1 Ip on, WI 54016
Township 29 North, Range 19 West, Town of Hudson, St. �.. ' 1 `! i
Croix County, Wisconsin described as follows:
Commencing at the South 'A corner of said Section 36; thence North 00 degrees 10 minutes, 01 seconds West
along the north-south 'A line, 1634.77 feet to the Northeast corner of a parcel of land described in Volume 526,
page 259 at the St. Croix County Register of Deeds Office, being the point of beginning; thence continuing
North 00 degrees, 10 minutes, 01 seconds West along said North-South 'A line, 1977.22 feet to the South line of
the North 350 feet of said Southeast %4 of the Northwest 'A; thence South 88 degrees, 49 minutes, 51 seconds
West, along said South line and the Westerly extension of said line, 1324.14 feet; thence South 00 degrees, 09
minutes, 43 seconds East 2,096.73 feet to the centerline of County Trunk Highway "N" being a point on
1,999.00 foot radius curve, concave southerly, whose central angle measures 03 degrees, 00 minutes, 19
seconds, whose chord bears South 80 degrees, 02 minutes, 21.5 seconds East and measures 104.84 feet; thence
Easterly, along the arc of said curve and centerline, 104.85 feet to the point of tangency; thence South 78
degrees, 32 minutes, 12 seconds East along said centerline, 712.54 feet to the West line of said parcel described
in Volume 526, Page 259, thence North 00 degrees, 10 minutes, 01 seconds West along said West line 304.75
feet to the North line of said parcel; thence North 89 degrees, 49 minutes, 59 seconds East along said North line
523.00 feet to the point of beginning, all in Section 36, Township 29 North, Range 19 West, St. Croix County,
Wisconsin.
/L.
Dated this � day of j6,77a..61-7, 2003.
1 L. ilcoxson Mary J W o on „y„,2:,
ACKNOWLEDGMENT t
STATE OF WISCONSIN ) 2 Y P(/
? iPR e
COUNTY OF ST. CROIX ) / :ter O
Personally came before me this day of .'? , 2003, the above 1 -med Neil L. Wilcox `olF d Mary . f1
Wilcoxson to me known to be the persons who executed th fo oing instrume l acknowledge the f me D
PRESTON
Nota Public _ _6 .,r� d 2 2
My commission expires: b J 9 44
This instrument drafted by Robert F. Wall. Wilc oxsontoBastWD03 -1 / / h OF WtSCs�•
9•AnN ate`