HomeMy WebLinkAbout020-1374-06-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Buildiog Division
INSPECTION REPORT sanitary Permit No:
399433
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:
Green, Judith I Hudson Township 020 - 1374 -06 -000
CST BM Elev: Insp. BM Elev: BM Descriptio
67n t X1 / �e �►=� [d 19 Ak, - 1 r,� e . 4
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
J
Septic Benchmark t
Dosing Alt.
n' /J / 1 ,06
it
Aeration er o
! LL
Holding
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. t to Air ntake ROAD Dt Inlet f _�
Septic�� , I / r Dt Bottom
Dosing Header /Man. 2 %� S
Aeration Dist. Pipe
Holding Bot. System
PUMP /SIPHON INFORMATION Final Grade
Manufacturer Demand St Cover
Model Numb /
7rBliCfi1 S AK h t
TDH Lift Fr Lo System Head TDH Ft
Forcemain Dia. t. to Well 7
SOIL ABSORPTION SYSTEM (74 L � �
BED/TRENCH Width
Length/ No. Of TrencJ�es PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS =? 4 I )�l
SETBACK SYSTEM TO P/L DG WELL LAKE/STREAM LEACHING M fact er.
INFORMATION CHAMBER R
Typ P ber:
f System: / �, t / Model N tu
�� '�� L , �cft r�w�' -
DISTRIBUTION SYSTEM �. s
Header/Manifold ' Distribution _ ole Size x Hole Spacing to Air Intake
i ��{/ / Pi / �_ _ 1-
Length Dia C Length ) 6 T �i Spacing , b 1 t_) /)t, v 4 = * cl l
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over I / Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Berrench Center / Bed/Trench Edges /� Topsoil
\ lF �] Yes No Yes [] No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / 3 / Inspection #2:
Location: 204 Starrwood Hudson, WJj5 016 (N 1/4 SW / 1/4 12 T29N R20W) Starr Wood Lot 6 Parcel No: 12.29.20
1.) Alt BM Description = `t I i�� / �;/ , , Fl �2k _ ��, �.,� L 1t 44 tl1�
2.) Bldg sewer length = �f n ; :�✓ 'f ' ✓� /,WUL' �/�� LiZZC ►r G�f -lam G ft�
- amount of cover = 16,
e G 4 1-14 _
Plan revision Required? ❑ Yes J0 1
Use other side for additional information. h �` ✓ �����G . (<P U
Date Insepctor's Si nature Cert. No.
SBD -6710 (R.3/97)
� 9S"
ZOc� OD Sanitary Permit Application Safety & Buildings Division
In accord with Comm 83.21, Wis. Adm. Code 2 W. Washington Ave.
W .. See reverse side for instructions for completing this application PO Box 7302
i sconsRn Personal information you provide may be used for secondary purposes Madison, W[ 53707 -7302
Department of commerce [Privacy Law, s. 15.04(l)(m)] (Submit completed form to county if not
state owned.
Attach complete plans to the county copy only) for the syste r t than 8 -1/2 x 11 inches in size.
County State Sanitary Pe it Number ❑ Check if 'o t pll State Plan I. D. Number
,
I. Application Information - Please Print all Information location:
Property Owner Name O perty Location
.� 114 /4✓114, S JT or
Property Owners Marling Address Number Block Number
c�aax 1 �
City, State Zip Cod P ne b2ONING 0VM0E Sfibdivision Name or CSM Number
S .
❑Ci ty
.r i
L
II. Typ of uilding: (check one) �/ r g ❑villa e
YP g
® 1 or 2 Family Dwelling - No. of Bedrooms ® Town of
❑ Public/Commercial (describe use) :_
❑ State -Owned
,_ 3 r k r Z Nearest Road
() �� / t i � ` r 0 ,_
Parcel TaxNumber(s)
II . e of Permit: Check only one box on line A. Check box on line B if applic able — o
A) 1. ®New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to
System System Tank Only 3 Existin System
13) Permit Number Date Issued
❑ A Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply) -I E
-. N
G5 Non - pressurized In-ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
13 Pressurized In- ground
❑ Holding Tank ❑ Single Pass ❑ Drip Line "
❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
V. Di s ersal/Treatment Area Information:
1. Design Flow (gpd) .2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. Syste n 7. Final Grade
Required Proposed Rate (Galslday /sq. ft.) (Minlinch) Elevation
7S v r7 6Y
.�K /�,r , rr ?s 9! 2
.s;r
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel 4iber - Plastic
Information Gallons Gallons Tanks Con - Con- glass
New Existing crete structed
Tanks I Tanks
® ❑ ❑ ❑ ❑
❑ ❑ ❑ 1 ❑ ❑
VIII. Responsibility Statement
I, the undersigned, assume responsibility for inst allation of the P OWTS shown on the attached plans. Business Phone Number
Plumber's Name (print) Plumber's 'gnature (n stamps): }r�iMPRS No.
Plumbepf Address (Street, City, State, Zip Code)
IX. County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued su' g Agent Signer (No stamps)
Approved ❑ Owner Given Initial Adverse Su rc a Fee) ri p D
Determination 2 dg ZlA1
X. Condit'ons of Approval /Reasons for Disapproval:
S(4'.'
4. 8fv S"4 36 = cl
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PLOT & CROSS SECTION PLANG
ZAPPA DROO. EXCAVATM INC
KUMDINQ UNIT ..
PROJECT
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DATE: 1-7
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Side View &EVAZIOA I KAc H 6o 7r4-- Af So,c TEST
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PLOT it CROSS SHCTION PLANS
ZAPPA EROS. EXCAVATIM4 INC
KUMBlNQ U NIT ..
PROJECT
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Pivision0 Safety and Buildings - Page of
Bureau of Integrated Services in accordance with 83.Oj Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in an mgjk:. ° C /
include, but not limited to: vertical and horizontal reference point (B �frkction and ,' 1 IY - 5T )7t
percent slope, scale or dimensions, north arrow, and location and di Canoe to nearest road. Parcel 1. . #
APPLICANT INFORMATION - Please print all informhtion. cj Re d by Date
Personal information you provide may be used for seconds ' . ,, ,?
Y P Y ry Purposes (Privacy La�nt 15Ag�1� �'. F { �
Property Owner V y Locatigi
Property
Govt. Lot. 1 � /4 � W1 /4,S T 2 q / ,N,R Z O E (or) W
Property Owner's Mailing Address T7 # Subd. Name or CSM#
o 1171 - 414"C 5 T'4o'W60m
City State Zip Code Phone Number ❑ City y llia e W Town Nearest Road
9 New Construction Use: t9 Residential / Number of bedrooms y Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow bop gpd Recommended design loading rate gi bed, gpd /ft2 gpd /ft
Absorption area required e:j�o bed, It 2 _2�� trench, ft Maximum design loading rate 0.2 _ bed, gpd /ft gpd/ft
Recommended infiltration surface elevation(s) _Jo - 9 ft (as referred to site plan benchmark)
Additional design /site considerations E'YA -U L 'PL Q, Pl LA - r A PP RC)VAL
Parent material C i Lb C f A t;. T 7 LL - Flood plain elevation, if applicable ft
S = Suitable for system Conventional �M In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system S❑ U S ❑ U [K S❑ U 14 S ❑ U S ❑ U ❑ S U
SOIL DESCRIPTION REPORT 7mfD — Ifs coke—
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
g Texture Consistence Boundary Roots
NE' �....»` in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
e vund 10-k4 S�, �f 5 A 1 � o'
X5,3 ft. $ -7(: OR 01 - }
Depth to
limiting 1. ;
;P TI in.
Remarks:
Boring #
S -1 /6,W _ m l CS t?\ o.
Gro
J -A7
6 .4. A ni I C-S 0 O .$ I - T
,9
I `76 , ft. 31 I tn Q
S
Depth to
limiting S
factor S
1 6Z in. Remarks:
CST NM (Please P L wsdN . Sign
Print) a r Teleph a No.
3�'& Z&O
Ad ess Date CST Number
&, 9 / S cal 0 2--60 - zZ7 57
PROPERTY OWNER SOIL DESCRIPTION REPORT Page � ~
f.
PARCEL I.D.#
Boris # Horizon Depth Dominant Color Mottles Ltructure 2
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color . Bed , Trench
,.... - ol � / 3 —
�.- 1 rU c � m CS ON 6.
.� .
Ground -* 7,T-14 '¢ _ 6 t S /1t' C OT 0 g
Depth to
limiting
fa for ✓t
7 in.
Remarks:
Boring #
Ground 8 /f k e 4 015 M1 0' ;0,9 - }
Depth to
limiting
fair
C_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 # Q 1U` l ►'� �f S 0 A '0 .y
j 8, O id` /R 3
Ground /ft M
ev �,
Depth to
limiting
I t in. 7 � in. Remarks:
Boring #
13
Ground
elev.
ft. ,
Depth to
limiting
factor
in.
Remarks:
SBD -8330 (R.9/98)
P A LE o� 3
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X 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.6199).
Table 1: System Design Specifications
Sanitary Permit Number 3 33
Number of Bedrooms s" - -
Design Flow - Peak (gpd) ' 913 - 0
Estimated Flow - Average (gpd) -
Septic Tank Capacity (gal) A -
Soil Absorption Component Size (ft)
Type of Wastewater Domestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow - Peak (gpd) -
Maximum Influent Particle Size (in) 1/8
Maximum BOD (mg /L) 220
Maximum TSS (mg /L) 150
C
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 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 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 t he tank that may slough off the filter when removed from its enclosure. If the
I.Jd 17/YE/ —ZIVG J �j/9 lr,
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
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer l /Qar./v /5"'z 86y -
Mailing Address /D/,` kX z yv /6
Property Address �� `� .�t`a x. &)oae /
(Verification required from Planning Department for new construction)
City /State f— arv.� ,4 , Parcel Identification Number - .•
a_
LEGAL DESCRIPTION (74$"'� t? , 29t , 'W , Z?- 3'9
Property Location &,_c ' /a, %4, Sec. _,IA , T_gl_N -RAW, Town of /,/,'zLW �-✓
Subdivision 17A "0 n , Lot # 1<
Certified Survey Map # . Volume , Page #
Warranty Deed # . Volume ,Page Y
Spec house 1Z yes ❑ no Lot lines identifiable ® yes ❑ 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 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, State of Wisconsin. Certification
Na tural Resources
here' as set b the Department of Commerce and the Dep artment of Na
�, � Y P P
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of ee year expiration dat
/f //
S ATURE 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 prop" scribed above, by v' e of a warranty deed recorded in Register of Deeds Office.
S TURF 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
V11 324 6,29835
K H. WARRANTY DEED REGISTER OF DEEDS
DOCUMENT NO.
ST. CROIX CO., WI
RECEIVED FOR RECORD
09 -13 -2000 10:15 AN
This Deed made between JUDITH A. GREEN a/k/a
JUDITH ANN GREEN a/k/a JUDITH GREEN, a married WARRANTY DEED
EXEMPT q 15M
woman, Grantor and STARRWOOD PARTNERSHIP CERT COPY FEE:
LLP„ a Wisconsin limited liability partnership Grantee, COPY FEE:
TRANSFER FEE:
RECORDING FEE: 10.00
Witnesseth, That the said Grantor conveys to Grantee PAGES: 1
the following described real estate in St. Croix County, State
of Wisconsin:
Outlots 2 and 3, and Lots 1 through 25 of the Plat of Starr Wood
in the Town of Hudson, St. Croix County, Wisconsin.
Subject to a 40 -foot wide easement for driveway purposes for the Tax Parcel No. 020-1111-60 & 80; 020-1112-30
benefit of grantor, her heirs or assigns over that Southerly 75.87 RETURN TO:
feet of the walkway easement to Outlot I as set forth on the Plat of
Starr Wood.
This is not homestead property.
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And Grantor warrants that the title is good, indefeasible in fee simple and free and clear of
encumbrances, and will warrant and defend same.
Dated this L 7' t day of September, 2000.
' (SEAL)
ith A. Green
STATE OF WISCONSIN )
SS
ST. CROIX COUNTY )
Personally came before me thi--V*ay of September, 2000, the above named Judith A. Green, to me known
to be the persons who executed the foregoing instrument and acknowled ed the me.
RkY
u�r JR c«1� otary Publi S ' e of W sconsin .
My Commission (expires): 12ir cal
THIS INSTRUMENT DRAFTED BY:
Robert W. Mudge
MUDGE, PORTER, LUNDEEN & SEGUIN, S.C.
110 Second Street, P.O. Box 469, Hudson WI 54016
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