HomeMy WebLinkAbout020-1441-86-000 4 � " . County:
Wisconsin Department of Commerce P RIVATE SEWAGE SYSTEM St. Croix
Safetynd Building Division f r S anitary Permit No:
INSPECTION REPORT 430431 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be 4sed 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: • . M Elev: BM Description: Section/Town /Range/Map No:
4 /44.8 a1- 4 36.29.19.
TANK INFORMATIO E NATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic W S 1246 Benchmark ctF y8 3 62-s S� 94 -!d
Dosing CY AIt M
Aeration Bldg. Sewer / 97• �3 i
Holding St/Ht Inlet J /
5 '/0 ?3.
TANK SETBACK INFORMATION SUHtoutlet 6;65 9?.. /g r/
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic , LI d (44/ 1 0 ' — Dt B o ttom
Dosing Header /Man.
40 96,3
Aeration Dist. Pipe
9 41(111 )
Holding Bot. System
PUMP /SIPHON INFORMATION Final Grade t/ 3 ( 6 -
to
Manufacturer G I
emand St Cover 2 1S (Jae vg 1
Model Number
TDH 1Lift OP.... Loss System Head TDH Ft
Forcemain ength Dia. Dist. to Well
SOIL ABSORPTION SYSTEM i- ,, r ref-" 4(.0 4y4 Y• ^ 4J_ �
idth f ength No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIM - 3 L.' 1 0 : (3)
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING M I� p mm
INFORMATION CHAMBER OR 7 • By D�.ILI,"t' .A.SQ,('�
Type Of System: - UNIT
, j � � l Model Number: 1 t • D it
t/�. >20 - "r J
DISTRIBUTION SYSTEM
Header /Manifold L. if Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pi
Length 4 7 Length Dia ing
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
A' Ej Yes No R, Yes i No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:'`� at/. 2 - 43 ( 211 0.3 Inspection #2: ' -1 '
Location: 823 Wilcoxson Drive Hudson, WI 54016 (NE 1/4 SW 1/4 36 T29N R19W) • - • . Ri : • - = . • - - `o: 36.29.19.
1.) Alt BM Description = {f O' ja erK • C q / S• 03
2.) Bldg sewer length = „-) Z K 6 ,$�- `14.91 •
- amount of cover= > /�, ‘,$429 - 3 ' 00 z /5,03
bh uv 6-T.4 x4 = 55—:.1S. - z = 14. S 9,9 I ammi -
Plan revision Required? ❑ Yes X No � � /
Use other side for additional information. r , _ / _ �
—'' 1� 1 1
SBD - 6710 (R.3197) Date sepctor's Signat e ' ert. No
6 a i) MO kx) st,A ASIIQS)t4K1 CCIIZ .5 S 47;6 __-../ e LI ' Iert-s-AMIQ —111
(4 823 (4 ►1.C,0)(.Strrt! Oki) •
Safely & Buildings Division
Sanitary Permit Application PO Box 7302
\i 201 W Ave.
sconsin 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 form to county Irma
[Privacy Law, s. 15.04(I)(m)) sla1E owned.)
Attach complete plans /to the county copy onlyyfor the system, on paper not less than 8 -1/2 x 11 inches in size.
County' ; X jStste Sagil_ry i lumbe 0 Check if revision to previous application Slate Plan 1. D. Number
I. Application Information - Please Print all Information Location:
!livery Owner Nrirr _ Property Location
t'. ` W d I 4t. RECEIVED A I /45 & I /4,5.7'/ To�?,N.R (or))
r perry Owner's Maifin Address Lot Number Block Number
' ' C N ' _ G / , S EP 3 0 2003 x'23 & iiczxson (D' 86 Ab9
C State 1 - Zip Code Phone Number Subdivision
, // tar Subdi isron Name or CSM Number /� /
I ioh WS U c F cE v i /7 i — ll 6o��o�u r.�q t� ,4I
II Type of Building: (check one) oe P .vr ub"AA ❑ City /
)' 1 or 2 Family Dwelling — No. of Bedroo' s: f s S . , A 0 Village
O Public/Commercial (describe use): d e _I, (Z - Town pf
O State -owned ger 3 q p , . /, .. / -- , 4dswri
III Type of Permit: (Check only one box on line A. Check .ox on line 13 if applicable) Nearest Ro■d
f�!'AX ,SnYI
A) 1. y New System 12. ❑ Replacement 13. ❑ Replacement of 14. 0 Addition to Parcel Tax Number(,)
System Tank Only Existing System
B) I Permit Number 1 Date Issued
❑ A Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
likNon-pressurized In- ground 0 Mound 0 Sand Filter 0 Constructed Wetland /
O Pressurized in- ground ❑ Molding Tank ❑ Single Pass ❑ Drip Live c1,p
O At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: , p ^' 7 , �,rq
V DIspersalrl'reatment Ares Information: (-*-Z-15-6.1. (-*-Z-15-6.1. A-- I o d- a. (�^" rj mo ,
1. Desi Flow (gpd) 2. DispersdArea 3. Dispersal Are,, 4. Soil Application 5. Percolation Rate S stem levation 7. Final tirade
Required Pro sed Isz q Rate (Gals. /dsy /sq.11.) (Min.Mch) 1.. , ► Elevation 991 b
500 -- . • 4,1 v /0 t9:•
VI Tank Capacity in Total q of Manufacturer Prefab Site Steel Fiber- '
Information Gallons Gallons Tanks Con- Con- glass
New Existing Crete slructed
Tanks Tanks
•
❑ • ❑ ❑ O
0 — ❑— ❑ ❑ ❑
VII Responsibility Statement. -
I, the undersigned, assume responsibility for installatioO of the POWTS shown on the attached plans.
Plumber's N t) Pin 'a Si (nd stamps): MP/MPRS No. Business Phone Number
.0 .ii A L .. 7/5 3'b goaZ) Plumber's Address (Street, City, State, Zip Code) 1 r A s,;_ A
VIII County/Depa tment Use Only ,
•
0 Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued 1 suin . - Sigaalwe (No slangs)
)Approved 0 Owner Given Initial Adverse Surchirge Fee)
Detlrmination ." .`. � 1i 25t ....lo ?Aft E��� , i
IX. C SYST o on ofIAp_nrvat /Reasons for Disapproval: `' 3) Q ., , / i/ S ; .- „I O.j & „, _ 1 rho"' , 4 1 �
1 Septic tank, effluent filter and rwe. , .. - , 4 I -
�
dispersal cell must all be serviced / maintained cciutiL S1 S ` r
as per management plan provided by plumber.
2. All setback requirements must be maintained
as Der applicable code /ordinances.
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Wisconsin Department of Commerce SOIL EVALUATION REPORT / of 3
Division of Safety and Buildings
In accordance with Comm 85, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must . County 5 GR 0n
Include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. 5 ee.. 4.x/6 GV 4
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please prim .434,;;k:44,. ,Re by Date ,,,�
Personal Information you provide may be used for • •• - t P►N6ey Laws*. 15.04 (1) (m)). I Date Cwt 3 , P / 3
Property Owner Property Location A/6 e .SLu> a.iI-
/VE / L elf / AOX.SOA) JAN 0 9 2003 Govt. Lot SE 1/4 0h /4 S 34 °1■-2'/ N R C9 I (or) W
Prope O 1er's Mailing Address _ l 1 - L it - Subd. or CSM# i- r(� .Vo,,0 6...
'/ I/e , y /�/ S T . CRNIX COUNTY /� Y! i / / . '
City State ZIP C Town Nearest Road/
111425o, av /. s/4 7 /S 3 x6.111.9 ❑ City ❑ Village 6�1
f2 3-New Construction Use: [l Residential / Number of bedrooms 3-y Code derived design now rate y5'0 Co O GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material /oe5S DUB 5,4A407 oU ) 145 • Flood Plain elevation if applicable N/ _-----_ ft.
and General comments 8. ,4 RC4 T &SITU / 5 50l7'�9/3/E foe 4, /�vf/Pov.J27
and recommendations:
Coy tieAJTio v q _ P. D. W • T. 5 . 2t5i,u6- T.3,:ev f f"vSz-,e.
ceus- (.$)2e_ Pq.3)
El Boring ft .
9 4
/ # Ground surface elev. �� ' to factor >' ✓ in.
® Pi
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fe
In. Munsell flu. Sz. Cont Colo Gr. SL Sh. "Erg/1 'Eff#2
/ o• /r7 /o yg 3/ t 1,5 •144�� ;w 3 f- •y . C-
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y 2.9 .90 /4yx5* 1..//s /f f/Z As .' .
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# Boring
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( 1 Pit Ground surface elev. / / • 4 / o ft. Depth to limiting factor in. Soft Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD1Ff
in. Munselt Qu. Sz. Cont. Color Gr. Sz. Sh. 'EQ#1 'Eff#2
0 -/ /c we 3 5/- / shie " C5 3 f . s' -4
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jov1Rs /y MVOS of . s D,ss 12 4,5 •7 , I. Z.,
s.Yo
• Eft f lu s e e nt #1 = BOD > 30 < 220 mgll and TSS >30 < 150 mg/t ' Effluent #2 = BOD, < 30 mgll. and TSS < 30 mg!L .
CST Name � KO 13E Print) GG T S / 21c, : 5
Address Date Evaluation Conducted Telephone Number
Ulbricht & Associates )_( . 4' - 7_,Oo 2- 7/5.3'G . k/
655 O'Neil Rd. �
Hudson, Wis. 54010 .-X- P/ /U 7 •
Ng or s to o a5- / /ay•yd'
Ulbricht & Associates
Private Sewage Consultants s o �(� O 2 (� . /�� 9 (' • •
cur 655 O'Neil Rd.
Hudson, Wis. 54016
•
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T. 1
buy `�_ # z . ,
/� 020•//09• g'9.4-611) Properly Owner /V t� L GUI/ o % so Parcel ID # °.). - ,qb 9 - o • °T Pa 2- a 3
13I Boring #❑ v.Zg
z it Ground surface elev. ft. Depth to limiting factor In.
Sol Application Rate
Horizon Depth Dominant Col • Redox Description Texture Structure Consistence Boundary Roots GPM?
In. Munsell : • Qu: Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff #2
In 6. g Jo YR 3 _ ' • SG /fsbc nt f fie P,s 3f- . 4/ . Co
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I Boring ❑ Boris
❑ pit Ground surface elev. ft. Depth to limiting factor . in. ,
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD1W
In. Munsell Qu. Sz Cont Color Gr. Sz. Sh. •Eff#1 •E
Ong # ❑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 PDI
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In. Munsell Qu. Sz Cont. Color Gr. Si: Sh. •Eff#1 •Eff#2
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Boring # ❑ Boring
L ❑ Pit Ground surface elev. ft. Depth to limiting factor , In.
Soil Application Rate
Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPIJWW
In. Munsell Qu. Sz. Cont. Color ^ Gr. Sz Sh. i, •Eft#1 •Ef#2 .
•
• Effluent #1 = BOD, > 30 < 220 mg& and TSS >30 < 150 mg&L • effluent #2 = BOD, < 30 mg/ L. and TSS < 30 mglt_
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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For issuance of permits and designing
Contact: Ulbricht & Associates
Registered private wastewater consultant and plumbers ( 7 —
655 O'Neil Road )
Hudson, WI 54016
715 - 386 -8185 or 715 -772 -3442
/.
Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In- Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater 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 governmental 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 1 7 4 3 0 3 I
Number of Bedrooms
Design Flow - Peak (gpd) 4
Estimated Flow - Average (gpd) c.{p•0
Septic Tank Capacity (gal) )
Soil Absorption Component Size (ft') 13 15D0 1Z 4
Type of Wastewater Domestic 0
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow - Peak (gpd) I (4 0 P405/ ,, n,nnes�.,
Maximum Influent Particle Size (in) ► 1/8 MStO`
Maximum BOD (mg /L) ' a 220
Maximum TSS (mg /L) 1 5 O 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 years
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stats. The contents on ents of the septic tank shall be disposed of in accordance with
P P
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 septic tank and outlet filter shall be assessed at least
once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure
proper operation. The filter cartridge should 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
needs to be performed to maintain less than maximum scum and sludge accumulation in the
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.
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
kern OP‘._ ( i/
Y
Mailin g Address 1 Z. ' e_ ,z" 1,, /d'^ cJ7 a
Property Address '-' 0 7 ...3 , r G UxScv''-,- Or 0
(Verification required from Planning Department for new construction) \ `
City /State /1//I1'4L-1 ed/ 5 Parcel Identification Numbea10 // lo -66f) J -1 / 9 dow
,e //o y /d o, Jv l/ 9 3.oU
LEGAL DESCRIPTION
'A
TION ff
Property Location , fed '/4, Sec. 3g J . To Nt / � f W, Town of �(.U'1 fri
Subdivision A' 0$4 _ • / / ,..A.,_, ' . ir �40 ` .1 i v Lot # F? .
Certified Survey Map # , Volume - , Page # .
Warranty Deed # 7ogVio , Volume p1/4 35r Page # 35Y .
Spec house %yes ❑ no Lot lines identifiable Ayes ❑ 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 plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewaterdisposalsystem
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 fo i. . in, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
. • ..: t o septic system has been ma; : • . ed must be completed and returned to the St. Croix County Zoning Office within 30
•.ysof.. years ira•., e.
AP/ / /&,C
SIGN ; TURE OF AP C
DATE
O / R CERTIFICATION
I (we) certify that all stateme : on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
-sic r4 . ro • - described a it » . y v' • a warranty deed recorded in Register of Deeds Office.
4.h,. 4 /// /2 oe
sit ATURE OF N LIC DATE
* * * ** Any informtion 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
J 21.3 5 P 3 5 5 7:2,1:3E3130
KATHLEEN H. KALSH
WARRANTY DEED RESISTER OF DEEDS
ST. CROIX CO., MI
Nell L. Wilcoxson and Mary J. Wilcoxson, a /Ida
RECEIVED FOR RECORD
Mary Jo. Wilcoxson, husband and wife, conveys 02/07/2003 02:OOPb
and warrants to Kernon J. Bast the following EXEMPT #
described real estate iri St. Croix County, State of REC FEE: 11.00
Wisconsin: TRANS _ 2880.00
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 10'
A parcel of land located in part of the Southeast '4 of the Edin Title
Northwest 1/4 , part of the Southwest 'A of the Northwest 400 South 2nd Street
1/4 , part of the Northeast '/4 of the Southwest 1 /4, and part Suite #115
of the Northwest 1 /4 of the Southwest 1/4, all in Section 36, 1 ,�'lytison, WI 54016
1 � r
Township 29 North, Range 19 West, Town of Hudson, St. 1 `ig`C!'
Croix County, Wisconsin described as follows:
Commencing at the South 1 /4 corner of said Section 36; thence North 00 degrees 10 minutes, 01 seconds West
along the north -south 1 /4 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 '/4 line, 1977.22 feet to the South line of
the North 350 feet of said Southeast %4 of the Northwest '/; 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.
Dated this , f day of ..J , 2003. C (// ge\i > g
f2Vi Mary J. W' oon
ACKNOWLEDGMENT ,.h '':�i;i
STATE OF WISCONSIN ) �. P t i lt
COUNTY OF ST. CROIX ) - t1. -. v @L
Personally came before me thi d ay of JGt , 2003, the above • = med Neil L. WllcoXfO d Mary . y
Wilcoxson to me known to be the persons who executed th instrume : - a cknowledge the e
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Nata Public � PRESTON s=
My commission expires:
This instrument drafted by Robert F. Wall. WllcoxsontoBastWD03 -1 OF WtS co f
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