HomeMy WebLinkAbout040-1209-10-000 (2)Wisconsin Department of Commerce
Safety and Building Division
PRIVATE SEWAGE SYSTEM
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]
Trevor & Amy Clune
CST BM Elev r Insp. BM Elev: BM Description'
�oo•o �oo.o' CST
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
5
Dosing
pp" ,�
l.0 GA4 AC-4 — � V
�ct,F F —TCf
Ae2tion
W,. �pydKLS
Holding
TANK SETBACK INFORMATION
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
Model Number
ift
� n Loss
System Heatl
DH Ft
in
H
ngth
Dia.
Dist, to wen
TOWN OF TROY
TA
STATION
BS
HI
FS
ELEV.
Benchmark
�,Sb
IOl.S
ap,0'
Alt. BM
Bldg. Sewer
St/Ht Inlet
SVHt O let „
�iLOuy'r�r,
Sl.,l
�•
9 .ro r
Dt Inlet
Dt Bottom
Header/Man.
b.o
9!•so'
Dist. Pipe
Bot. System
Final Grade
Orr t,ds�
St Cover
SOIL'ABSORPTIOJC,41,,,,64,r
Are µ
-
RENC V✓tl(h
Length No.
re has
PIT DIMENSIONS No. Of Pits Inside Dia.
Liquid Depth
DI S �/
ly,24H� J
SETBACK
SYSTEM TO
P/L
BLDG
WELL
LAKE/STREAM
LEACHING
Man uta rec
INFORMATION
CHAMBER OR
TCTfa�Y'
Type Of System:
Model Num
u <<k
1
20 a-
3l
(
) tM
/
UNIT
DISTRIBUTIONSYSTEM
`t� _
t1
Header/Mandolgh it
L.L
Length `/ Dia l
Distri utio
Pipe(s)
Length Dia Spacing
ale Si
z Mole Spacing
Air,
Vent to Air Intake
SOIL COVER x Pressure Svstems Only xx Mound Or At-Orada Svstems Only
Depth Over
Depth Over
xx Depth of
xx SeetletllSodded
xz Mulched
Bed[Trench Center
Bed/rrench Edges
Topsoil
Ell Yes ❑ No
[!A Yes � No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection
Location: 234 GLEN CIR �.55� 89' 9
1.) All BM Description = I✓I**
2.) Bldg sewer length = \ e /C � L2 •5- e+ I • �� r
3 � amQOMun/t of cover = J t�yp� .� - .4�(o(os�✓�-TT'y�,,� "�° '`• s , .Li 8 � . oS.�
Plan revin equired? ❑Yes X No
ITIO ot/[��r a for ciditional inf tion. r��� I- - _
SBD-6710�/ •I& � C. tk'e&4 -��o'or' 'nature Cad. No.
.�; -fee, - o 0
�r���n�,n n�l `S P. � StgN a_ a -iN�
{?=err;;. _�' -
industry Services Division
140(MEWashinbminAve
County
Sr G',eo/X
ai MAY p 2 9 ZRO
P.O. ao. 2
Madison, W 2
Sanitary Permit Number (to be filled in by Co.)
3
^/
Coma, 't Application Z
Stale Transaction Number
In accordance with SPS 383.21(2), Wo. Adm. Code, submission of this form to des appropriate govcmmental WEL
Project Address (if different than mailing address)
is required prior to obtaining a smitary, pvmiL Note Application forms for state-0mted POWTS arc submitted to
the Department of Safay and Pmkooteal Services. Personal information you pmvidc may be used fro secondary
in accordance with the Privet law, s. 15. I m , Sinus
.s //�� I r
/� / r li h i� Cm 7 G l�
✓✓✓ 1 UU'' 1111 1111
i. A lotion Tnfortmtloo-Please Print All inhn tim
Property Oamer's Name
Parcel C
Tocrome ' Ar skim✓.-
0y0- 1d9-A-400
Property Owner's Mailing Address
Property Location
3 y GCFN 6'eCAS
Covet Let
/Vdr r -56J y, soctine �s
City, State
lip Code Phone
Number
lIJr.t 1..4U5 lvr
saxes
(amle�
T_t%B N; R TO j
{I, Type of Building (check all that apply)
Lot
Subdivision Nome
5f I or 2 Family Dwelling- Number ofBcdromms 3
f
Bieck
Sr 6ce'X /vl6N[f.wS
❑ pwicicommereial - Describe Use
Qroiy, or
❑state Owned-Dcscribe Use CSM
9-"I eof _
Number
® Tower of TROY
lit. Type of Permit: (Cheek only one box on Noe A. Complete line B If applicable)
A.
❑ New System
® Replacement System
❑ Tmalmea Holding Trade Rephtecmemt Only
❑ Other Modification to Existing Syrian (explain)
B.
❑ Permit Renewal
❑ Permit Revision
❑ 01angc of Plumber
❑ Pmnit Truster io New
V'ri/ Previous Pemdt Number and Dale Issued
Before Expiration
Conner
IV. Type of POWTS S stem/Com oneat/Devke: Check aR that apply)
19Nan-Pressurisd io-Gmund ❑ Presunized In-Gmmd ❑ At -Grade ❑ Mo ud> 24 in, orsa abletoil ❑ Mond < 24 in. of suitable sail
❑ Holding Tank ❑ 0dur Dispmal Campoacm ( hut) ❑ P n Ucvuce (explian
V. Dis ersts" oatmeal Area Information: X A
Design Flaw (gpd) Design Soil Application Raielliptisfi Dispenal Arta Required (sf)
I Arta Proposed (so System Elevation
I
qso •7 Cy3
473.8 P40 at 88.0'
VI. Tank Info
Capacity in
Tool
9of
Units
Mamfaerwar
`
a
(milmn
Gallons
p
f/P.'�tC",
Ier
.2
NewTanks
Etunis Taa4
9Lo
= �
Y w
eel
$
a
Seek err ne4fpaia�
006
/COO
�
alr5,ct !!s.JtwftE
✓
Dosing Clamber
VII. Responsibility Statement- 1, the waders ed, aaumc respaaslAity for imu2dmiou of the PORTS shmvu on the allsched glass
Plumber's Name (Prim) Plumber's Si MPS Number Business Phone Number
o ,v �ELKE 3 3Y4 71S 677-Sr76G
Plumber's Address (Street. City, Sege, Zip Code) i
/V Ga798 Sr. /irr>,` s /JUtfAali Gli Y 36
VIII. Cmanqmeponrtment Use Only
PL,APpmved ❑
sQA91 F�
6�
Are Si
\
�wuar '
S
u fer Denial
❑ O 6rtson
IX. Conditions of Approw Ulteasms for Disapproval 3) I04 s
YSTEMOWNER:htD..a.� ,
1. Septic tank, effluent filter and
`F , `"
dispersal cell must be soulmdi-m-CMeined e ty trntN{ct�Qy
by
as per management plan provided plumber.
•-.•••••••••••••_••._�_.._••._..:rnugeia wmprrep�rsrtoc ryaxem.wrsauw.. .,.. �,,....'.1....y ..
as per applicable code/ordinances. lµp7tf`anL PY
IT
SUD•6398 (R. 08114)
CJtr7s o nJ./7 F,-V
,xt>£.S7 =� rosy = •b3a• 'rr�
r
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C37I7S op'7 AY/<73s - SHY
.�•s rY f £
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,
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Page 1 of
Private Onsite Wastewater Treatment System
Index and Title Page
Project Name: _Titfvc,t f/PwY Cia✓6- .3-Ac, XUAaw p& Awrs �RtPtat6�lar�
Owner's Name: is
" N
Owner's Address: R 3H Gu.+ 4*,1dec`
/�/d6A flee s/ L/1 J5'a.rt
Legal Description: /1/E JrJ ,?3- ?gA .10 eJ
Municipality: Town, Village, Gity of 7-,t0Y
County: CAeiz
Lot Number: / Block Number: CSM Number.
bcr++
Subdivision Name: 11/e#44.W5 - ?JY �iccrd
Parcel I.D. Number: OS'O- /Jo9- /a - aeo
Page 1
Index and Title Page
Page 2
Plot Plan with Cross -Section & Plan View
Page 3
Septic Tank Specifications
Page
FUMA J45/r /,✓fo.
Page 5
Filter Information
Page 6
POWTS Owner's Manual & Management Plan
Page 7
POWTS Owner's Manual & Management Plan
Name of Designer:
ovt#N ELKS' License #: /%/• ,73/3vL
Signature:
r'�-C— Date:
SBD-10705-P (N.01101, R 10/12) "In -ground Soil Absorption Component Manual" Version 2.0
Attachment: Soil Evaluation Report
�raraf v ns//j 1
11
7e
3rn,7 &"YR"2 aprd9!' '7uYrr 'xhr✓
t.yF67 =[' r osb ='b37 'riti'
i/ra IN,7 7 p FE' a ((�//'sr+3rS JS �rlMr/V% //
(6S•Aft C/�fyYvlN� h �r>`Jnb s.: rrl 7Jy p/ �siJ
(s7r7f Of9d' "37 - 5srr7
,b !b
088 f >3Y ! '72Y
v68 —
d
gig/rF ,nfr
Ow
iJ7'"rn 1 �i7srr
i 9 pt/I O y
L foe
a.
I '•�06,
'd
ki
s�ar�frt F6 -Firs SSS 77Y
,107 yray Jr 'sl•/ •cJ
oN or o N
l
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OD
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lwrra \ �
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i'»ri7 r17% ,r'fr -)rn77 ,II,�. r vvn)y
taaza .Und
u
a
`NLP1000-MR
TANK SPECIFICATIONS
DIMENSIONS:
WALL: 2 1/2"
BOTTOM: SEPTIC 3"
HOLDING 5` (ADD 1,300 LB.)
COVERT 4°
MANHOLE: 24" I.D. PRECAST CONCRETE RISER
HEIGHT: DOME COVER " FLAT COVER 531/4 O.D.
4" CAST -A -SEAL LENGTH: 104° O.D.
WIDTH: 860 O.D.
BELOW INLET: 42" O.D.
LIQUID LEVEL: 36"
WEIGHT: 6,790 LBS.
INLET AND OUTLET'
4" CAST -A -SEAL BOOT OR EQUAL
GASKET, CAST -A -SEAL BOOT OR EQUAL
INLET AND OUTLET BAFFLE AND FILTER:
W ISCONSIN, SEE DETAIL #10
(OTHER STATES SEE CHART)
LIQUID CAPACITY: 27.83 GAL/IN
HOLDING TANK:
OUTLET HOLE PLUGGED
ACTUAL CAPACITY: 1,085 GALLONS
LOADING DESIGN: 8' Cr UNSATURATED SOIL
MN TANKS:
WILL HAVE ONE VENT OVER OUTLET
OPTIONAL FLAT COVER AND WILL HAVE TWO VENTS IN COVER OVER Ih
IS AVAILABLE FOR EXCHANGE
_ FOR DOME COVER. TANK CAN BE USED AS:
SEPTIC/ HOLDING/ PUMP OR SIPHON
_ COVER: MIX DESIGN /8 NO FIBER)
INLET
OUTLET TANK: MIX: DESIGN #10 (STRUCTURAL FIBER)
N CUSTOMIZED TANKS:
FOR CUSTOM TANKS CONTACT WIESER CONCRETE
2� c "�' a ^
r
PUMP PAD JOB INFORMATION:
CUSTOMER:
JOB NAME:
SIDE VIEW BATE NEEDED:
APPROVED BY:
APPROVAL DATE:
ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227
L&M a
F
Lai
a
/c. yef7
4
18-inch External Effluent Filter Basin
Applications
The 18-inch (450-mm) External Effluent Filter Bassin provides an Ideal
solution for retrofitting existing residential septic systems. External Filter
Basins eliminate the need to make costly, and often hazardous, modifica-
tions to existing septic tanks with restrictive access openings or to unus-
able outlet haffles or tees.
Grade ring insert —
Handle assembly
4 .-.
v
—�r
Vault
5.
a------InBuem
holes
Biatube fixer
camoge
Materials
of Construction:
filter Basin.
Ribbed PVC Fie
Filter Basin Base:
fbaglass Nalkirced POtylsta
Bidube Enclosure:
PVC .. —
Biotube Cartridge:
Polypropyll and Polyethylene
BiotWe Handle tbmpanents: Soh. 40 PVC, Stall $186
Oder Gramrreet:
EPOM WAber
Olscllerge R":
PVC --
Specifications;
Binluhe Mesh Openings: Nominal 1y8-Inch (3-mm) diameter,
nominal 30% open area
General
External Effluent Fitter Basins are composed of an 18-Inch (450-mm)
diameter section of ribbed PVC pipe with a fiberglass base, and an 8-Inch
(200-mm) diameter Blotube" Effluent Fitter N.S. Patents No. 4439323
and 5492635).
Orenco Blotube Effluent Rhers are used to Improve the quality of effluent
exiting a septic tank. The Biotube cartridge has an extendible handle for
easy removal. The R131 B24 is designed to connect to 4-inch (100-mm)
diameter schedule 40 PVC pipe, using a 4-Intl 000-mm) diameter grom-
met on the inlet side, and a 4-inch (100-mm) diameter Schedule 40 PVC
fitting that is solvent -welded to the ribbed pipe for the discharge side.
Call Orenco for a alstorn configuration when connecting the External
Effluent Fitter Basin to a 4-inch (1 DO-mm) diameter 3034 type pipe. An
18-Inch (450-mm) diameter grade ring is supplied, but the riser and a
fiberglass lid should be ordered separately to bring the basin up to grade.
Standard Models
FTB1824-0812
Product Code Diagram
FM 18 24 08 12
T
Fixer caVluye regun:
12 - 12 iMms (aep-Mi
Filer damelen
08 - 8 incnes (200-mm)
Basin hexlt
24 = 24 Ydes (800-M)
Basin dermal
18 = to ialrs(450-M)
Blrxube` elaualt lifter bean
Oranno ayateni Inc., 814 Almsy M., SUMMIn, OR 27479 USA • 900-34&11W • 941.4119 4449 • www.orenoocom f1 "ll-M4
11WA Pi, • W14
199419f 1
5., 7
°A ..
8-in, to 15-in, Dia, Biotube Effluent Filters
Application
Orenco® 8-inch to 15-inch Biotuhe® Effluent Fifers are designed 10
remove solids from effluent leaving commercial septic tanks. They can be
used in new and existing tanks.
General
Orencdo 8-inch to 15-inch Biotubee Effluent Fillers` are used to improve
the quality of effluent exiting a commercial septic tank.TheaMube
cartridge fits snugly in the vault and is removable fur maintenance, the
handle assembly snaps into the notches in the top of the vault, and the
tee handle can be extended for easy removal of the cartridge. Abase
Inlat' model (see p. 2) is available tar low -profile tanks. An optional slide
rail system, available on larger modals, simpifflea installation and provides
tank access for servicing.
Handle assembly
darn Boat assembly
Gateway view srda view
Ormv°&W,be'ff .1 FAMPrs m. arxW lurbnaYbY U.£aM blk=LWPP.vtle.
Standard Models
F10854-36,FCI254-36,111554-36, aO822-14B, FT1 254-36AR
Product Code Diagrams
A . YCNT trtltl WNR-J
P . 'JOeNx�P
orv�s�eycnWa:
nP�lrxega'.r WvKK
W. nxexln
Sn . Si I,Slx
®. WIISxI
a , mnsrsmW
ro.asaarie.s
r. ■r-
nx- ,xP77
ns- spq
rarwmm
ar,. wim+rstrmm
P .Yw.11As+vl,TanaF
•SbMW iN0 k+e axuuxwsc
iaan'1xlc,.anm:wl.rnlaxiase tuon®,,.,y
«W.�np4�ta�4�w uansia e�ilm�sau�
fi e ltsiSwq lm'n7 Y M1LL a S4nE r m Wmrs.p
�w,i..a,seaa.am Wmaa,raaPlm
gmaryn¢vmkuiYY Yitme Ca -
FT❑ i2-146❑
�" �i- T TPr.maaes.r.roar.r
ems•.. ,wocaua[,m
� �IsmP„�neteeu
Fh imPW+kWel
�uenaw
pMOgv npq,
w . u mfrC
x}. 1x6:�.4+,rZtl
F41e.sY[&Wt
n
1. Mon
an
RW�
Sea . vb.pmyNrrm
zwv'emn,ue
Materials of Construction
vault NO
Poe Wong PVC
Hmrdecmnpmn" PVC
suppon Coup" am br &A PVC
BioeOa" cubldoe Pdly n4mone and POINStoom
ride: Stmpo.4 mupPn9 and sl¢pM Mi'A,:I sa s,WYm 72-i9rx I540-n a*
ar mo Sydsn! Inc. , 814 Airway Ave., Suthlaea, OR 0479IMA . UD-3411.O t • 84140440 - WM11.Wares.com ,rb." 2
Rex Le. ®&1111
upIMY
Page 4_ of 7
POWTS OWNER'S MANUAL AND MANAGEMENT PLAN
FILE INFORMATION
Owner I rAAtIOAf wP tom✓
Permit fl
DESIGN PARAMETERS
NumberofBodtooms(100 om)
Number of Commercial Units
Estimated flow (average)
340 PY41LY
Design flow (DWF) = estimated x 1.5
YSo galtday
Soil Application Rate
] Uday/fe
Influent/Effluent Quality (D NA)
Monthly Average
Fats. Oil & Orease (FOG)
5 30 mgA-
Biochemica) Oxygen Demand (BODs)
:5 220 mg/L
Total Suspended Solids (fSS)
< ISO mg/L
Pretreated Effluent Quality (® NA)
Monthly Average
Biochemical Oxygen Demand (BODs)
530 mg/L'
Total Suspended Solids (TSS)
c 30 mg/L
Fecz Coliform (geometric mean)
< tO cfu110vu,L 1
Maximmn Effluent Panicle Size
1/8 inch diameter
Dispersal Unit M(gJModel Number:
SYSTEM SPECIFICATIONS
Septic Tank Caplacity
/Odd gal
ON
Septic Tank Manufacturer
N E &c.
DNA
Effluent Filter Manufacturer
doc4rocd
O N
Effluent Filter Model
Fr6_a27 trt
DNA
Pump Tank Capacity
DNA
Pump Tank Manufacturer
❑ NA
Pump Manufacturer
O N
Pump Mode]
DNA
Pretreatment Unit (D NA)
O Sand/Gravel Filter
O PestFiher
❑ Mechanical Aeration
O Wetland
Cl Disinfection
D Other.
Manufacturer.
Model:
Soil Absorption Component (O NA)
0 In -ground (gravity)
❑ In-ground(pressurized)
O At -grade
D Mound
D Drip -line
O Other.
Vertical Distance TankBottomtoServicePad:
ft !
Horizontal Distance T s to Service Pad:
ft
Calculations:
Soil Dispersal End Cap (Dispersal Unit EISA)
DWF + Aoplication Rate = Area Required EISA - or (Trench Width) 8 Units or Total Lenath of Trench(s)
iso + .7 — G yJ 40-3) + ?A0 sr' 33 cdon44 s
O "ICC Flowlech Mound Component Manual" Version 1.2
O "EZ Flow Mound Component Manual" Version 820/2007
O SBD - 10854-P (R. 1/12)"At-Grade Component Manual Using Pressure Distribution" Version 2.0
0 SBD- 10705-P (N.OI/Ol)"In Ground Soil Absorption Component Manuel" Version 2.0
O SBD - 10691-P (N.01/01) "Mound Component Manual" Version 2.0
O SBD-10657-P (R.6/99) "Drip -line Effluent Disposal Component Manual"
O SBD - 10706-P (N.01 /Ol) "Pressure Distribution Component Manual" Version 2.0
MAINTENANCE MONITORING SCHEDULE - MAINTENANCE AND MANAGEMENT
Service Event
Service F ueacy
Pum m di cells clean filter
At least once every,
M 13 months
OF 3 years
D Other.
Inspect pump & pump controls, alarm, pretreatment unit
At least once every:
l7 _ months
O 3 vears
® NA
Flush and pressure test laterals
At least once every:
C3 months
O 3 years
® NA
START UP AND OPERATION: For new construction, prior to using the POWTS check treatment tank(s) for the presence of painting
products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have
the contents of the tank(s) removed by a septage servicing operator prior to use. Systemstart upsball notoeeur when soil conditions are frown
at the infiltrative surface.
The property owner is responsible for the operation and maintenance of the POWTS and submission of required mpona. The quantity and
quality of the wastewater stream will affect the performance and longevity of your POWTS. The installation of water -saving appliances mid
fixtures along with prompt repair of Ica'lks rcdoccs the wastewatcr volume. Also the brine or waste from :water softeners, iron removal units,
other clear water treatment devices and foundation drains should be discharged to the ground surface whenever possible. Note: this does not
include laundry waste, showers, dishwater, etc.
This system is designed to handle domestic strength wastewater, however, the disposal of food based greases, oils, vegelabldfruit peels,
seeds, bones, and food solids, such as those produced by a garbage disposal should beminimized. Toilet tissue is the only paper that should
be discharged into the system. Other non -biodegradable items, such as baby wipes, tampons, sanitary napkins condoms, cigarette buns,
dental floss, and cotton swabs, should not enter the system. Chemicals, such as petroleum products, paint, disinfectants, pesticides,
antibiotics, solvents, etc., should not be flushed into the system bemuse they can seriously damage your POWTS and contaminate your
waters Page _7 of 7
drinking supply. Maintain a regular steady flow by spreading laundry washing throughout the week. Avoid vehicle traffic over
all system components. Compaction ofsnow over the dispersal unit may cause it to fieeze up.
INSPECTIONS & MAINTENANCE: Inspection shall be made by an individual carrying one of the following licenses or
certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Maintainer, or Septage Servicing Operator (per the attached
Maintenance Schedule). Tank inspections must include a visual inspection of the tank to identify any missing or broken hardware,
identify any cracks or leaks, measure the volume of combined sludge and scum and cheek for any backup or pending of effluent to the
ground surface and test all electrical equipment such as pumps and alarms. Any defects shall be promptly corrected. Exposed openings
greater than 8 inches in diameter shall be secured with effective locking devices to prevent accidental or unauthorized entry the tanks.
When the combination of sludge and scum in any tank exceeds one-third (1/3) or more of the tank volume, the entire contents of the
rank shall be removed by a Septage Servicing Operator and disposed of in accordance with Ch. NR 113, Wisconsin Admin. Code.
Specific servicing mechanics must be provided ifvenical is>15 feet or if horizontal is>l50 feet and instructions to be provided below.
'I lie Outlet ti itra(s) shall be inspected and cleaned to remove any accumulated solids according to manufacturer's specifications. Solids
washed from the filter shall be retained in the tank. Filter cleaning may be necessary at more frequent intervals than stated in the
maintenance schedule to keep the system operating.
Alarms should be tested on a regular basis by the home owner. If an alarm sounds, contact an individual licensed to service P O WTS,
There is normally a I day reserve under regular operating conditions, however water should be conserved until any problems with the
system are corrected to prevent back-up of sewage into the dwelling or surfacing.
.ABANDONMFNT- Wl,.en the pnprTc rails a;rd�nr pcmlancody taken out Of 32rvice Crc following steps shall be taken to ensure that
111e System is properly and safely abandoned in compliance with Ch. SPS 383.33, Wisconsin Admin. Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and property disposed of by a Septage Servicing Operator.
• AI1cr pumping, all tanks and pits shall be excavated and romoved or their covers removed and the void space filled with soil,
gravel, or other inert solid material.
CONTINGENCY PLAN: if the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a
code compliant replacement system:
A suitable replacement area has been evaluated and may be utilized fur the location of a replacement soil absorption system. The
epiacenleni arca siuniid be protected from disturbance and compaction and should not he infringed upon by required setbacks
Gom existing and proposed structure, lot lines and wells. Failure to protect the replacement area renders it unusable. Replacement
systems must comply with the rules in effect at the time of replacemenL
1 A suitable replacement area is not available due to setback and/or soil limitations. Baring advances in POWTS technology a
holding tank may be installed as a last resuri to replace the failed POWTS.
X The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must
be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last
resort to replace the failed POWTS.
O Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative
Surface. RCCOnSVuc[innc nfcrmh sycfemc mUct enmply with the n�lrc in, _rftttar rha,time.
WARNING!:: SEPTIC, PIMP, AND OTHER TREATititENT TANKS MAY CONTIAN LETHAL GASSES AND/OR INSUFFICIENT
OXYGEN. DO NOT ENTER A SEPTIC, PUMP, OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH
MAY RESULT. RESCUE OFA PERSON FROM THE INTERIOR OFA TANK MAYBE Di FFICULT OR IMPOSSIBLE -
ADDITIONAL COMMENTS:
POWTS INSTALLER POWTS MAINTAINER
Name: TON•I Aft A'F /W— .r!/3 yL Name: zxx Lu.rdi✓L
Phone: 7/.f G79- S'244 Phone: 7i5 L72- S>!L
SEPTAGE SERVICING OPERATOR (Pumper) - LOCAL REGULATORY AUTHORITY
Name: Name. Sr, [,reix �nivr.✓irr �tr6 ultN.vlrT
Phone: Phone: 7/J' _W - I/K
Division of Industry Services
SOIL EVALUATION REPORT
In accordance with SPS 395. VMs. Adm. Code
Coun1Y
Attach complete site plan on paper not less than 812 x i i Inches in size. Plan must kxA de,
�' Crobc
but not limited to: vertical and horizontal reference point (BM), direction and per elope,
Parcel I.D.
scale or dimensions, north arrow, and location and distance to nearest road.
W41209-14000
Please print all information.
Reviewed by
Pape I of I
Ref =73
Date
Property Owner Property Location ❑ CM
Steve 8 Robvia Kefier Govt. Lot NE '% SW '% S 25 T 28 N R 20 E (or) W
Properly Owner's Mailing Address Lot t! Binds R Subd. Name of CSW
234 Glen Or. 01 1 Na I St Croix Highlands
.City State Zip Coda Phone Number ❑ City ❑ Yrsage ®Town Nearest Road
❑ New Constnrction the: ® ReaMemial/ Numberofbedrooms $ Code derived design flew m* 40 GPD
® Replacement ❑ Public or commercial - Describe: _
Parent material Glacial Outwash Flood Plan elevation d applicable De it
General consrbnb and reoorroerdaltons: Slte suitable for In -ground POINTS with 0.7 gpdhgft design loading rate. Reco rriended system kNYtrative
surface elevators to be 90.0', MAY 8 MAY with infiltrative surfaces at approximately 42^ - 60' below grade.
1-1 It 0 Boring
® Pit
Ground surface elev. 90.23 It
D90 to limiNlp factor >= in.
0-9 e.,.
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Ou. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPDIFP
*01011
'Efta2
1
0-6
10y(3l3
Iona
oil
21gr
mvfr
ca
3fm1c
0.6
0.8
2
5-11
10yr4/4
none
sit
2fsbk
mvfr
cs
31mc
0.6
0.8
3
_-
11-23
7.5yr4/4
none
Is
069
ml
ca
2fmtc
0.7
1.5
4
23.48
t0yW4
none
6
069
IN
aw
tfm
0.7
1.6
5
48-62
7.5yr4/6
none
Icon
Dap
IN
gw
0.7
1.6
6
82-80
t0yr518
none
cos &car
Dag
ml
aw
10.7
1.6
7
80.100
t0yr8/6
none
a
Oeg
ml
0.7
t.6
1 2 I Bormp ff
❑ Boring
® Pit Ground surface elev. 96.63 it
Depth to filling factor >= in.
Horizon
Depth
In.
Dominant Color
Munser
Redox Description
Ou. Az Cont Color
Texture
Structure
Gr, Sz. Sh.
Consistence
Boundary
Roots
^. GPD/FP..�
'E1N7
'Efha2
1
0-16
lDyr3/3
none
as
21gr
mNr
ca
21mrlc
0.6
0.8
2
6.30
10yr4/4
none
ail
2fsbl
mvfr
cW
2fmc
0.6
0.8
3
30.38
10yr4/6
none
Is
0110
ml
ow
ltmc
0.7
1.6
4
38.70
10yrW6
none
a
089
ml
ow
0.7
1.6
5
70.127
10yr6/4
none
s
osg
mt
aw
0.7
1.6
CST Name (Please Prim)
Signs
CST Number
James K.
'�--
30021
Address
A96a Evaluation Conducted
Telephone Number,
340 Poulson Lake Lane Osceola W154020.5413
AprII29,2020
15 248.7767
F9-t�1 fit
® Pl Ground surface elev. M.M ft Depth to Wn81og factor >103 in.
SON Appicabon Rate
Horizon
Depth
In.
Dominant Color
Murmall
Redox Downphon
Qu, Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/F*
•Ef #1
'EMI2
1
0.5
10yr3/3
none
oil
2fgr
nrvfr
gs
2vf,f
0.6
0.8
2
5.19
1Oyrn
none
st
21sbk
mvfr
9w
-
0.6
1.0
3
19-M
7.5yr4/4
none
ad
IMsbk
mvfr
oa -
0.4
0.6
4
34-46
7.5yr4/6
none
Is
lmsbk
mt
ow
-
0.4
0.7
5
4"1
10yr4/6
none
gr s
Osg
ml
ga
0.7
1.6
6
51.107
10yr516
none
s
0n
di
0.7
1.6
FEM
❑ Boring
❑ Pit Ground surlace elev. _ R
Depth to Wniting factor _ in.
❑ am" #
❑ Boring
❑ PR Ground surface elev. _ R.
Depth to WnlBng factor _ in.
Soil AmWmtlnn Rs1a
. Effluent 01 = SOD, > 30 5 220 mg/L and TSS > 30 5 150 mg/L • Effluent 02 = GOD, > 30 9 220 mlyt and TSS > 30 5 150 mgfL
C,ri ,+q /, wo P,64 n
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P6, 3 ee3
LOCATED IN THE N.E. V4 01- THE S.W. 1/4
,;,�,,;„ ;tl AND THE N.W.1/4 OF' THE . - 1/4 OF SEC.25.
T28N,R20W, TOWN OF TROY, ST: CROIX
- as - .......... +r! COUNTY, WISCONSIN.
U[PU177[D LANDS OWNEY 9T OTN[RA -
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ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
� pp OWNERSHIP CERTIFICATION FORM
Owner/Buyer L\d
itiaiiiti$ niidress c%_ 1 u 11 1�'C , \fit L V 6' i'j \tom 1 '51-4 C)22
Property Address 2 '�' t1 L Av cu , C%Vit c �Ct � �A> . �,�, � `J' { C.2�
(Verification required from Planning & Zoning Department for new construction)
City/State `�-1\t(��al, 1 _ Parcel Identification Number
I.Ei;AL DESCRIPTION
Property Location �/, , �,J 5<, Sec. a�) IT ' 2I� N R � U W, Town off
Subdivision _ S% C� iX t ft * 1kLA4'UQS , Lot #
f P liNPd Su. ,'2F rtup ii Volume �— , Page #
WarrantyDeed # 31 Z
� j ti 2 . Volume Page #
Spec house yes no) 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 ]candle 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 §Corms. 83.520) 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 condilin., and'nr (?; a' t a: p.crios ant pumping (if itCCeSSary'L the septic !ark is
less Mail i.".i fuR of sludge.
T/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.
Ilwe certify that all statements on this form are taste to the best of my/our knnowled-- I:ve ;,.!;rc t o uu(si o iita
property described ,hm;e, by -uWc iii a warramy deed fcorded in Regisnrr of deeds' Office.
Npimber of bedrooms
SIGNATURE OF APPLICANTS)
/ 12/ ALL
DATE
..*Any information tln! is mjaeorr..J:Ci is riffs r:.ull in the sanitary perruiE being rcvokcd by the Planning & Zoning Deparmient.
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of die certified survey map if
reference is made in the warranty deed.
(REV. 08/05)
R-01EC ND 657-2,o2D-100
Wisconsin Department of Safety and Professional Services Page 1 of 3
Division of Industry lees - MAY 2 0 2020
Is SC I L EVALUATION REPORT
St. Croy County
In accordance t8CSR8rW5ttW@e0dtrprGede County
Attach complete site plan on pa not less than 8 1/2 x 11 inches in sae. Plan must include, St. Croix
but not limited to: vertical and horizontal reference paint (BM), direction and percent slope, Parcel I.D.
scale or dimensions, north arrow, and location and distance to nearest road. 040-1209-10-000 Ref #2573
Please print all information. (eytewed by , a a Dile
Property Owner Property Location ❑
Steve & Robins Keller Govt. Lot NE % SW % S 25 T 28 N R 20 E (or) W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
234 Glen Cir. 01 1 Na I St. Croix Highlands
City State Zip Code Phone Number ❑ City ❑ Village Z Town Nearest Road
❑ New Construction Use: Z Residential! Numberof bedrooms 3 Code derived design Bow rate 41W GPD t ��
Z Replacement ❑ Public or commercial - Describe: _ •_
Parent material Glacial Outwash Flood Plan elevation if applicable na ft.
General comments and recommendations: Site suitable for In -ground POWfS with 0.7 gpd/sq/ft. design loading rate. Recommended system infiltrative
surface elevatons to be 90.0', 89.0' & 88.0' with infiltrative surfaces at approximately 42" - 60" below grade.�..L.,er)
TI Boring #
❑ Boring
® Pit Ground surface elev. 90_23 R
Depth to limiting factor >100" in.
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/Ftr
"EB#1
"EfW
1
0-5
10yr3/3
none
sit
211gr
mvfr
ca
3fmtc
0.6
0.8
2
5.11
10yr4/4
none
sit
2fsbk
mvrr
cs
3fmc
0.6
0.8
3
11-23
7.5yr4/4
none
Is
Oag
ml
cs
2fmtc
0.7
1.6
4
2348
10yr4/4
none
s
Osg
ml
aw
lim
0.7
1.6
5
4M2
7.5yr4/6
none
Ikos
Osg
ml
gw
1.6
6
1 62-80
1oyr5/6
none
cos & gr
osg
ml
aw
-
0.7
1.6
7
80-100
10yr6/6
none
s
Osg
ml
-
0.7
1.6
DBoring #
❑ Boring
® Pit Ground surface elev. 96_63 ft
Depth to limiting factor >127" in.
e..a e....k:.."e-. owe
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/Pe
"Efr#1
'EB#2
1
0-i8G
10yr3/3
none
sit
211gr
mvfr
cs
211mlc
0.6
0.8
2
W30
IOyr4/4
none
all
2fsbl
mvfr
rw
211mc
0.6
0.8
3
30.38
1Oyr4/6
none
Is
Osg
ml
cw
lima
0.7
1.6
4
38-70
1Oyr5/6
none
s
Osg
ml
cw
0.7
1.6
5
70-127
10yr6/4
none
s
Osg
ml
aw
-
0.7
1.6
CST Name (Please Print)
Signet
CST Number
James K. Thompson
"s`
30021
Address
Me Evaluation Conducted
Telephone Number
340 Paulson Lake Lane Osceola, WI 54020-5413
Aril 29 2020
715 248-7767
SBD-8330 (R04/15)
L. 3 I ,Boring #
-�
❑ Boring
® Pit Ground surface elev. 93_01 ft.
Depth to limiting factor>107 in.
c..a e....I , Q.... R�
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/Ft°
'Eff#1
•Ef6t2
1
0-5
10yr3/3
none
$il
2fgr
mvfr
gs
2vf,f
0.6
0.8
2
5-19
10yr3/6
none
at
2fsbk
mvfr
gw
0.6
1.0
3
19-34
7.5yr4/4
none
sit
tmsbk
mvfr
rav
0.4
0.6
4
3446
7.5yr4/6
none
is
lmsbk
ml
M
-
0.4
0.7
5
46-81
10yr4/6
none
gr a
Osg
mi
gs
0.7
1.6
6
81-107
10yr5/6
none
s
Osg
dl
-
-
0.7
1.6
❑ Boring # El El
❑ Pa
Ground surface elev. _ ft. Depth to limiting factor _ in.
cna Annl lRab i
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Cu. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/FF
'Eff#1
'EfW
7 Boring #
❑ Boring
❑ Ph Ground surface elev. ft. Depth to limiting factor _ in.
Rnil Amlir Jinn RM
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD1W
'Eft#1
'Ef1#2
Effluent #1 = BOD, > 30 s 220 mg/L and TSS > 30 5 150 mg/L ` Effluent #2 = BOD, > 30 5 220 mg/L and TSS > 305 150 mg1L
/,c+tl9w/,
aJrescYC�crw= r —
3v6k. t�e.
SOil e✓a/(Ad&&n
• �xs �.-nv P r� � rer.-
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K /i,,,/orga.
srcas
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//1/.bons,AEW n--ccz6
T 284, K 20c0, Tn. of Troy,
1E.0 Oix G-, IJ/,
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bel S.;/acrms
AIV.73
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--- t —ro'lf11 Crrc1G
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6. 3 W3
AS BUILT SANITARY SYSTEM REPORT
OWNER Robert Mansfield TOWNSHIP Troy SEC._aT2EN-Ryy
ADDRESS 979 Charles Ave.. ST. CROIX COUNTY, WISCONSIN.
St. Paul. Minn, 55104
SUBDIVISION St. Croix Highlands LOT 1 LOT
PLAN VIEW
Distances and dimensions to meet requirements of H63
■�■��■
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BENCHMARK: (Permanent reference Point) Describe:X;A vw
Elevation of vertical reference point: It) lope at site:. S' �
SEPTIC TANK: Manufacturer: Weiser
Number of rings on cover
Capacity:1000
cover eleva�on:
PUMP CHAMBER
"Manufacturer: Number of gallons
Number of gal. pump set or a cyc a gallons; total capacity o
distribution lines gallon: s�z—e--0F pump head;
gallon per minute horsepower r—b and name of pump
and model number
Type of warning device
HOLDING TANK: Manufacturer
Elevation of manhole cover
Typpe of warning device
�EEPACE PIT SIZE: Number o pits
feet liquid depth -- seepage pit ii
bottom of seepage pit-- eleion IA hn
'SEEPAGE BED SIZE: number of lines _width
y;
SEEPAGE TRENCH: width length
PERCOLATION RATE r,I IRE
Number of gallons
th 4tile depth-�aQ
INSPECTOR
DATED October 28, 1983 PLUMBER ON JOBGUdd
LICENSE NUMBER Z1.7Y
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & IgUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 796.9 BUREAU OF PLUMBING
MADISON, WI 53707
®CONVENTIONAL ❑ALTERNATIVE
❑ Holding Tank ❑ In -Ground Pressure ❑ Mound
st.I. rl.n LD. NemEe.
111 FNgnMI
NAME OF PERMIT HOLDER ADDRESS OF PERMIT HOLDER
INSPECTION DATE -
obert Mansfield 979 Charles Ave.,St.Paul, MN
,0 j�-3d
BENCH MARA IPWmN tnNrmae WInH DESCRIBE IF DIFFERENT FROM PLAN
REF. PT. ELEV.
CST REF. IT ELEV
NE SW, Section 25, T28N-R20W, Lot 1, Town of Troy
N.—uI PWmEe.
MPIMPgSW Na
Ceumv
twY M1.m�I NumMr'
Paul Cudd
2739
St. Croix
43690
SEPTIC TANK/HOLDING TANK:
MANUFACTURER w L IGUID CAPACITY. Tq AwLETELFV
ITANPk OUTLET
L
N R
//•( �C / ��'
�^E
CC
PP FD PL R
L/I/�
S NO
NOq
BEDDING
VENT ply
VENT MATE HIGHWA ER
C ` ALA"M
NUMBER OF RO�q.�
FEET FROM
PROPERTY
Ll`t
WE L
ULLDIN4 VENT TO FRESN
AIR; '
❑VES
{.•I
(
Z-V I
L 'L-
7
/�
NO
DYES N
NEAREST
�'��
v
DOSING C AMBER•
MANUFACTURER BEDDING
LIUUm[NPAc H' PUNPMODEI PUMP,$I NMANUF OFFER WARNING LABEL LOCKING COVER
❑YES LINO
PROVIDED. PROVI DED.
DYES ONO []YES ONO
GALLONS PER CYCLE: PUMr
wxD corvT Ls oPFRAno"
NUMBER OF PROPERrr wELL BUILDING
v NT TOF H
(DIFFERENCE BETWEEN
FEET FROM LINE
AIR INLET
PUMP ON AND OFF)
DYES
NEAREST
SOIL ABSORPTION SYSTEM. Check thesod moistureat thedepth of plow' LENGTH IAMETFn MgTERaL AND MARKING,
or excavation. III soil can be rolled into a wire, construction shall cease FORCE
the Soil is dry enoughto Continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCHrR
WIDTH LENGTH ND i UKTR PIPE SPAC L
V
RI PIT
INSIDE IN
aPRS 'I."
DIMENSIONS
Z ,�/- }
/
G l OEPTN
RF LOW PIPE S, -/
Il DFP H
ABUVF COVER
UISTH PIPF DISTR PMF DISTR N A IAL
ELEV INLFr ELEV�Np A
NO DIETR
IVe;
NUMBER OF
FEET fROM
no E TY
Llx
WELL
J
BUILDING
I !
VENT TO FRE
AIRINLET
�-
�•'"
MOUND SYSTEM:
Mound site plowed perpendicular to slope
Check the texture of the fill material for
PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope:
mound systems to make Certain that it
ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand.
TIONS MEASURED.
❑YES NO
IL COVER TEXTURE PERMANENT
MARAS 15
OBSERVATION WF LES
DYES ONO
DYES ❑NO
DEPTHOVEII TRENCH BEO
OPTII fIVrR TRENCH.BEO
DEPTH OF TOPSOIL
OOED
5E[OED
MULMED
CENTE"
EUUfS
YES O
DYES ONO
❑YES ONO
PRESSURIZED DISTRIBUTION SVSTFU-
A
IOIN
LENGTH
OF
LATERAL SP INL LRAV OFPT ELOW PIPF
ILL DEPTH ABOVE COVER
BED/TRENCH
TRENCHES
DIMENSIONS
-.
MAN60LD
PU
MANIFOLD
DISTR I
MANI A ERIAL
D4l
ISTH PI
DISTRIBUTION PIPE MATERIAL&MARKING
ELEV.
ELEV
OVIAELEV
PIPES
OIA
ELEVATION AND
IND
DISTRIBUTION
INFORMATION ,WOLESQE
HOLESFACING
DRILLEOCOROECT Y COVER MATERI
VERTICAL LIFT LOgRESPON TO MPRDVEU
PLANE
-
V ONO
DYES ❑NO
COMMENTS:
PERMAN NT MA 11 BS.
pESERVAbON WELLS.
NUMBER OF -
PRMERTY
WELL
BUILOING'
2
DYES ❑ O
❑YES O
FEET FROM
NEAREST
LINE
"/ l 71 q
0
`D
Sketch System on
Reverse Side.
01 LHR SBD 6710 (R. 01182)
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