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HomeMy WebLinkAbout161-1094-50-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix 'SafCty and Building Division INSPECTION REPORT Sanitary Permit No: 515116 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 X Village Township Parcel Tax No: Matev, Kamen & Vesselina I Village of North Hudson 161- 1094 -50 -000 CST BM Elev: Insp. BM Elev: BM Description: nn Section/Town /Range /Map No: 00 1 LST 13.29.20.748 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic GX� ; ij t ear Benchmark e /05 .b /60 D + r Alt. BM I J 3 . IS /t/117 Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD M77A 5 ' Septic N �Z� Z� 7 2 D _ Headel Sa "C' B , l C • Sig Aeration Dist. Pipe 1-45 5 Holding Bot. System 16. '7Y. 57— d� Final Grade 5. 35 `3 •� . (.7 PUMP /SIPHON INFORMATION Manufacturer Demand St Cover 3 i5 W $ GPM Model Num TDH Lift Friction Loss System Head H Ft V. Forcemain Length Dia. Dist. to Well ctJ �O I SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 5/ _ 3 �l _�_„A -- SETBACK SYSTEM TO P/L BLDG ` WELL LAKE /STREAM LEACHING Manufacturer:► INFORMATION �� CHAMBER OR Type f System: ` n �Q UNIT Model Number: ( j DISTRIBUTION SYSTEM - t/ t l . = z4z, Header /Manifold a i Distribution x Hole Size x Hole Spacing Vent to A' Intak I Z `� P�Pe(s) Length Dia Length Dia Spacing e� 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 5, 15 Bed/Trench Edges \ Topsoil Yes No 0 Yes 0 No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 273 Station Circle North Hudson, WI 54016 (NE 1/4 NW 1/4 13 T29N R20W) St. Croix Station Lot 24 Parcel No: 13.29.20.748 1.) Alt BM Description = �' ( �"�`""` � t.pJ 4, 2.) Bldg sewer length - amount of cover - - -T /ignatu Pla n revision Required? � Yes No Use other side for additional information. SBD -6710 (R.3/97) �� Date Insepctor'e Cert. No. CommerCe.wi.gOV Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 St. Croix i seo n s i n Madison, WI 53707 -7162 * Sanitary Permit Number (to be filled in by Co.) — VP Department of Commerce Sanitary Permit Application Nta Transacti Number In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary purpo in accordance with the Privacy Law, s. 15.04 1 m , Slats. Same Z 7 C (C14 I. Application Inform! ' - Please Print All Information Property Owner's Name Parcel # 161- 1094- 50 -00& Kamen G. Matey Property Owner's Mailing Address Property Location 7'1 J 273 Station Circle North Au7 Z�dg COU NTY Govt. Lot City, State Zip Code f1lm SE %,,SW ' /., Section 13 Hudson, WI 54016 P�gNNI 8� 381 -3526 (circle one) IL Type of Building (check all that apply) Lot # T 29 N; R 20 W ®1 or 2 Family Dwelling - Number of Bedroo s 4 Subdivision Name a 24 Plat of St. Croix Station ❑ Public /Commercial - Describe Use Na City of ❑ State Owned - Describe Use CSM Number ® Village of North Hudson L Na ❑ Town of III. Type of Permit: (Check only one boa on line A. Complete line B if applicable) A. New System E Replacement Treatment/Holding Tank Replacement Only Other Modification to Existing System (explain) System B. ❑ Permit Pennit Revision ❑ Change of ❑ Permit Transfer to List Previous Permit Number and Date Issued Renewal Before Plumber New Owner - 75o t p Expiration 11 Z IV. Type of POWTS System/Component/Device: Check all that appl Non- Pressurized In - G round ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil Mound < 24 in. of suitable soil Holding Tank In Other Dispersal Component (explain) ❑ Pretreatment Device (explain)Hoot H -600 V. Dis ersaUTreatment Area Information: ,2 f.J 'C1t a n bz. ,20.0 E /5.4 + - 3 . trill s S 8 Es5,4 = 857 1 1O Design Flow (gpd) Design Soil Application Rate(gpdst) Dispersal Area Required (sf) / Dispersal Area Propoped (sf) System levatio 600.00 sq. ft. 0.70 V 857.15 sq. ft. J 857.40 sq. ft. 94.50 VI. Tank Info Capacity in Total # of Manufacturer w a Gallons Gallons Units z U <` U11 a a� New Tanks E xi , hnp Tanks P. . 7 C Septic or Holding Tank Wieser filter 1200 1200 I Unlrnown fC. '` canister w t Dosing Chamber VII. Responsibility Statement- I, the and rsigned, asso6e responsibility Ws a tion of the POWTS shown on the attached plans. Plumber's Name (Print) Plumb s Sign MP/MPRS Number Business Phone Number James K. Thompson _ 5.--- 30021 (715) 248 -7767 Plumber's Address (Street, City, State, Zip Code) 340 Paulson Lake Lane, Osceola, WI 54020 - 5413 VII J. Coun /De artment Use Onl Approved roved Permit Fee Date Issu d Issuin ent Signatu Owner Giv a F Denial $, p-O $(/ / I O 9 IX. Condi>8 r1oy�/Reasons for Disapproval - 1. ' Septic tank , .effluent filter and dispersal cell must all be servkea/ maintahled as per management plan provided by plumliw. 2. All selback- requirements must be maintained Attach to complete plans or the system and submit to the County only on paper not less than 8 1/2 a 11 inches in size SBD -6398 (R. 01/07) Valid thru 01/09 o 0/ .45,5amed eIe -v.' = /cam o � V' oFs,d; a E bu ;/d; T 5r...o /03.0 '' � "'2172 lb �� B3 • So i/ eda /ua�io r��r'� /c ec v; l�, ��00%�/ � • � E�Gs�'.� �rce.de e./ev.� a.� �i Srpb GX� / - - b(, e,•cd -ya A ve- _, � � Proposed c1 i 5pzr - -raj ce/l. - rAre� i Coe// � « ` � •�° �` Sj S�cm e l(� �D � C 95 50 " o �Qes•�uee -- -� ' �i4s,fet .� ` �op• h2QJil y ct)dtc open _ • • _ /CA wn 1 �P � o�'�Xisfin i � k -Qtuli l,, [cJtoo�aGJ � � de �acl�Fd i� Nj � 7copy lee S 64,41 S64,(e- ,¢s, utm ed 2 1 Q-V _ A 7' G==, .2172 67777 �� � � �ji/ 2✓4 /ua�ia�/D rn.de elev.` � b � 9'I.CO• /oca_•Ecd�o�•go. Sf�(Je -�" Proposed c! ;sp4,-- sa,/ // 7/ircC (3) c at dtc0 el<;[f.' �D.�X Ilke � F \s ¢ brtisk�y de�ctcl�ed P e/ s—. 0 21 Wisconsin Department of Commerce SOIL EVALUATION REPORT - Page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations Attach complete site plan on paper not less than 8' %x 11 inches in size. Plan must County St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel I.D. 161- 1094 -50 -000 Please print all information. Reviewe Date Personal information you provide may be us1 !E 3!1Ve �rivacy Law, s. 15.04 (1) (m)). $ 1, I -&q Property Owner Property Location Kamen G. Matev AUG 1 1 2 009 Govt. Lot SE 1/4 SW 1/4 13 T 29 N R 20 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 273 Station Circle North ST CROIX COUNTY 24 St. Croix Station City State FA01W 1 _j City jej Village J Town Nearest Road Hudson WI 1 54016 1 (715) 381 -3526 North Hudson I Station Circle North New Construction Use: y_f Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement J Public or commercial - Describe: Parent material Glacial Outwash Flood plain elevation, if applicable Na General comments and recommendations: Site suitable for replacement conventional POWTS using 0.7 gpd /sq.ft. loading rate. Recommended system elevation = 94.50'. Boring # J Boring 1 Pit Ground Surface elev. 100.28 ft. Depth to limiting factor >1 16" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -9 1Oyr3/2 none I 2fgr mfr cs 2fmc 0.6 0.8 2 9 -27 1Oyr3/4 none I 2fgr dsh gw 3fmc 0.6 0.8 3 27 -34 7.5yr4/6 none gr Ifs Osg dl gw 2fm,1c 0.5 1.0 4 3448 7.5yr4/6 none Is 0 sg dl gs 1fm 0.7 1.6 5 48 -71 1Oyr4/6 none s 0 sg dl cw lfm 0.7 1.6 6 71 -116 1Oyr5/6 none s Osg dl - - 0.7 1.6 ' Boring # -� Boring .3� f/ Pit Ground Surface elev. 98. 7 ft. Depth to limiting factor >108" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -6 1Oyr3/2 none I 2fgr mfr cs 2fmc 0.6 0.8 2 6 -22 1Oyr3/4 none I 2fgr dsh gw 2fmc 0.6 0.8 3 22 -33 1Oyr4/6 none gr Is Osg dl gw lfm 0.7 1.6 4 33-43 7.5yr4/6 none Ifs 0 sg dl gs lfm 0.5 1.6 5 43 -61 1Oyr4/6 none s 0 sg dl cw lfm 0.7 1.6 6 61 -108 1Oyr5/6 none s Osg , dl - - 0.7 1.6 q4. i * * Effluent #1 = BOD 30 < 220 mg and SS >30 < 150 g/L � ffluent #2 = BOD < 30 mg /L and TSS < 30 mg /L CST Name (Please Print) tur CST Number igna James K. Thompson 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 8/4/2009 715- 248 -7767 1 i S�Cc rl e f e V aE 6 u ; /d;.�g5c. mar= ,Zl72 � • soi/ a ✓a /uac�i'o��0�� g, b�us� - � ~ y'9� - -- • /aCa '�cd��go .S�EJe s,/:nc _ Ni rom h ea ,); ( I v cod ccl o �ae'aJe � P Ole 1 �� SySL �M 'v � b�tis�y \ / dc�ctcl�Pd q wa�� i� i � u � '��� � E � y�. 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CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /B� p� �lr �2(� Mailing Address Z 73 /'loyz� Property Address c )Qvwf (Verification required from Planning & Zoning Department for new construction.) City /State �cccjson� to Parcel Identification Number 49 — AOFPf S'O LEGAL DESCRIPTION Property Location,.54�f 1 /a , -S� 1 /a , Sec. 13 , T �_ N R W, To ad //a/Z� Subdivision Sty C ra %t'i??� , Lot # �. Certified Survey Map # //¢ , Volume.... , Page # n Warranty Deed # _ 73 '72 71 , Volume 2382! , Page # Spec house no Lot lines identifiable yes 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 §Comm. 83.52(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 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 Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the property d c 'bed above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of drooms RE OF PLICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. REV. 08/05 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) 2 576 C',- /-C% located at: 5,5 ' /4, StJ /a, Section / , Town Range W, ' OWM VNee A0' - 17 0e-d( A4496s21 -) , 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 Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service l Did flow back occur from absorption system? Yes Q No (if no, skip next line.) Approximate volume or length of time: -- gallons / S� minutes Tank Capacity: /2a) Construction: Prefab Concrete P-"' Steel Other Manufacturer (if known): A nk (if known): ermit n mber (if known) icensed Plumber Signature) (Print Name) Y (Title) (License NumberMPRS (Datey Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 Conventional Septic System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD- 10705 -P (N.01 /01). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Septic Tank Septic tank servicing mechanics comply with Comm. 83.54(1)(e). Septic tank to be located within 150' of service pad, with bottom of tank to be <_ 15' below service pad elevation. The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. 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 filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes 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 individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface within and above the system and will promote frost penetration during cold weather months. Cold weather installations (October - March) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Effluent flow shall be alternated between dispersal cells on a two -year schedule by use of a diversion valve. Valve to be switched diverting effluent from dispersal cell currently in use to resting cell on a two -year cycle coinciding with septic tank inspection and maintenance. Contineencv Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil absorption cell to bring the system into proper operating condition. Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Thompson at (715) 248 -7767 or the St Croix County Zoning Department at (715) 3864680. • � 737271 �( pp A KATHLEEN H. WALSH VOL 22 Prat 497 ST. CROIX CO., W STATE BAR OF WISCONSIN FORM 2- 2000 RECEIVED FOR RECORD Document Number WARRANTY DEED 08/25/2003 10:00AN WARRANTY DEED THIS DEED, made between Gordon V. Klemp and Linda K. Klemp, EX9V # husband and wife, Grantor, and Kamen G. Matev and Vesselina S. Mateva, REC FEE: 11.00 husband and wife, Grantee. TRAITS FEE: 1183.50 Grantor, for a valuable consideration, conveys and warrants to Grantee COPY FEE: the following described real estate in St. Croix County, State of Wisconsin: CC FEE: PAGES: 1 Lot 24, St. Croix Station in the Village of North Hudson, St. Croix County, Wisconsin. Rennrdinv Area Title Recording Services, Inc. 364884 1043 Grand Avenue #259 SL Paul, MN 55105 Wi5005 Exceptions to warranties: ST. CROIX A GP JUNIOR Easements, restrictions and rights -of -way of record, if any. 111111111111llln11ln�u 11//1101 WD 1611 - 1094' -I50 - 000 II Parcel identification Number (PIN) This is homestead property. Dated this 30th day of May, 2003. Z4,4z Z4� Z� * ordon V. K16mp rinck K. Klem AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ST. CROIX COUNTY. ) ss. authenticated this 30th day of May, 2003�re�� Personally came before me this May 30, 2003 the above * named Gordon V. Klemp and Linda K. Klemp, husband and wife to me known to be the person(s) who executed the TITLE: MEMBER STATE BAR OF in IMMSIN forego ' strument and acknowledged the same. (If not, authorized by § 706.06, Wis. Slats.) f�1� THIS INSTRUMENT WAS DRAFTED BY * Cheri Brown Notary Public, State of Wisconsin Edina Realty Title — Doug Berg My commission is permanent. (If not, state expiration date: 400 South Second Street #115, Hudson, WI 54016 3/11/2007 ) (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 WARRANTY DEED STATE BAR OF WISCONSIN FORM No.2 -2000 I � f COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715- 962 -3121 800 - 962 - 5227 ST. CROIX ZONING REPORT NO.! 04048/01 PAGE 1 ST, CROIX COUNTY REPORT DATE! 4/22/91 COURTHOUSE DATE RECEIVED! 4/19/91 HUDSON, WI 54016 ATTN! THOMAS C. NELSON OWNER! James Stewart �/' 70. -) j LOCATION! 273 Station Circle, Hudson COLLECTOR! M. Jenkins SOURCE OF SAMPLE! Kitchen faucet COLIFORN! 0 /100mL INTERPRETATION! Bacteriologically SAFE NITRATE -N! < Ippm Above 10 ppm exceeds the recommended Public Drinking Water Standard. CoLiform Bacteria /100 ml Nitrate - Nitrogen, mg /L LAB TECHNICIAN! Pam Gane WI Approved Lab No. 19 n "r) ST. l; OE .\NDEDENO. ter\ 7;�h f i ?lJ� �"I:.�: •. o` is t z f Means "LESS THAN" Detectable Level Approved by! °- S o PROFESSIONAL LABORATORY SERVICES SINCE 1952 ST. CROIX COUNTY ZONING OFFICE (� St. Croix County Courthouse 911 4th Street 1� Hudson, WI 54016 P Telephone - (715)386 -4680 The St. Croix County Zoning Office offers the service of septic and water inspections to Lending Institutions, Realty Firms, and private individuals. Completion of this form is essential so that the Rroperty can be located Please provide the following information, enclose appropriate fee made payable to St. Croix County Zoning Office, and mail, along with form to the above address. Testing will be done as soon as possible after fee and form are received. WATER TESTING--------------------- - - - - -- -FEE: $ 25.00 (For nitrates and coliform bacteria) WATER TESTING FEE: $175.00 (For VOC'S) SEPTIC SYSTEM INSPECTION ----------------- FEE: $25.00 (Determines if system is properly functioning at time of inspection) Property owner's nam e ( ���a Property owner's address Zile"" Legal Description 1/4 of the 1/4 of Section , T N -R Town of Lot Number Subdivision Name FIRE NUMBER LOCK BOX NUMBER /V/ T� Color of housed - Realty sign by house ? If.so, list firm: PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP,i.e,COPY OF PLAT BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. Testing of residential water requires a sample that is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running the water for several hours before the test can be conducted. WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. Firm or individual requesting services q g Telephone Number :: REPORT TO BE SENT TO i tee/ Closing date Signature > ; G���i