HomeMy WebLinkAbout030-2128-50-000 i
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM county: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
514823 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Miller, Troy St. Joseph, Town of 030 - 2128 -50 -000
CST BM Elev: Insp. BM lev: Descripti � G &Y Section/Town /Range /Map No:
®0 ` : BM b . C/4' /o eiyl/rI — rm 25.30.20.1047
TANK I FORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Bench k
w �C"� 3,3 163,
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
SUHt Outlet
TANK SETBACK INFORMATION /
TANK TO P/L WELL BLDG. Vent Air Intake ROAD Dt Inlet
Septic > / I D Bottom '3
> IM Dosing 44-- 3 _ Header /Man. 79 /� d 7 ,1 2 (�.
Aeration Dist. Pipe
Holding — - Bo 9
_
Final Grade 2.
PUMP /SIPHON INFORMATION � �Of —" XK3 _- /00 7 p..�b f}l ova I
Manufacturer n GPM t Co 3
GPM i
Model Number
TDH Lift� 2b Friction Loss System H d TDH a Ft
!�o
Forcemain Lent 5_ Dia. Dist. to Well
SOIL ABSORPTION SYSTEM 244 4P
BED /TRENCH Width / Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS l 3
SETBACK SYSTEM TO P/L BLDG ELL LAKE /STREAM LE 1 Ma 4Ter ; - -
INFORMATION T f S stem: ,� 1 r-7 C n BER R C�
YP� U r v" _ 3 5� 2 J ! �� / N IT Model Number:
_RIB ON SYSTEM
Hea r /Manifold Distribution / _ / x Hole Size x Hole Spacing Vent to Air Intake
Length Dia Length Dia Spacing I i
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center Bed /Trench Edges Topsoil
Yes No � Yes n No
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1:_ / Inspection #2:
Location: 1330 Birch Park Ridge Houlton, WI 54082 (SE 1/4 SW 1/4 25 T30N R20W) Ridge at Birch Park o / D Parcel No: 25.30.20.1047
1.) Alt BM Description = Qt,�y�.._ ""��
2.) Bldg sewer length N iTI cStt ve— / ( �
i3m � '? we; 4&), T�AkIr 1'►�S
- amount of cover = (( U . _ . _ 7 I rM F;�t_ — „ /J„ _41?,C w tild 1 ' hl(.t.t �c g�
w-,_ la /tva 1
Plan revision Required? ❑Yes L / No t- / �
Use other side for additional information. fa Date Insepctor's Cert . C No.
SBD -6710 (R.3/97)
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COfrNrt@.tAi gpy Safety and Buildings Division C
201 W. Waslungbon Ave., P.O. Box 71
soon s i n Madison, WI 53707 -7162 Sanitary Permit Numb ( be filled in by Co.)
51-V VZ3
Sanitary Permit Application T tic,
In accordance with a. Comm. 83.21(2), Vru. Adm. Code, submission of this form to the appropriate go
unit is required prior to obtaining a sanitary permit. Note: Application farms for state -owned POWS arc ax Address (if different than mailing )
submitted to the Department of Commerce. Personal information ,
in accordance with the Privacy Law, s. 15. 1 m , Stats. /� t r
L lication Information - Pb mw Print ormation /
Property Owner's Nam � DEC 2 6 2007 Farrel#
Property s Mailing Address Pte' Location /� /d L{7
ST. CROIX COUNTY ` I
3 - 7 7 3 3 0% ZONING OFFICE GOA Lot
City, State zip Code ne s Y+, Y' Section a
58e a,
H. Type of Building (check all that apply) mac, a 0 Lot
t ., Family Dwelling- NumberofBedrooms- j
Subdivision Name i- CJl
❑ Public/Commereiai - Deacn"be Use 6d`
�Y,,c... --
P � N � ❑ City of
❑State Owned - Dese CSM Number ❑ Village of
Describe Use rr
^ N A OTownof s � S •e �N
III. Type
// of permit: (Cheek only on boa n line A. Complete line if applicable)
A. *cw System ❑ Replacement system ❑ Treatmem/Hoiding Tank Replacement Only ❑ Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New fist Previous Permit Number and Date Issued
Before Expiration Owner
IV. T of POWTS S Com VDevice: Check ail that a
( (Non- Pressurized ImGround ❑ Pressurized M -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mond < 24 is of suitable soil
❑ Holding Tank ❑ Other Dispersal Component (explain ❑ Pretreatment Device (explain)
V. �
reatment Area Information:
Desi Plow (gpd) Soil Applirxdion R Dispersal Area Required (so Dispersal Area Proposed (sf) System Elevation
" j -, i � Cam;
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units
New Tanks 13xisting Tanks g
s ,
Septic Holding Tank 1 b� a00
_ .. -F-Dosing g ampber - _ _ t�(j_ :__ 1 - fir" - yy� /C --
VII. Responsibili Statement I, the us 4, assume tlity for installation of the POVM s the attached plans.
Pl 'a Name (Print) Pl s Signor - um t- Business Phone Number
.(I\ I �k P",
Plum 's Address (Street, City, State, Zip Code)
C f 01
VIII. cone tDe artment use Only
Approved ❑ sa $ e _ j Issuing signature
vum Reason nial Oa L 7/.
IX. Condjg,�%W4KWgj for Disapproval 3 JeTIO d
1. Septic tank, effluent filter and
dispersal cell must all be services / maintained
as per management plan provided byplunibw.
2. AN setback requirements must be makitaihad
__ .
- � W per 1pe system and sa6wN to the County nay on paper not less tkao a rn x I r iaehea to slat
SBD -6398 (R. 01/07) Valid thru 01/09
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EZ1203H
Oee ve - -t .
eoevvvv ^ > ' _i:_- .•teevvvvv
aoevvvv �.vvveovv
vvvevoe lryp
vee
VVW
24"
ovv ovv
4.62511 eee
vev vv•
e e e 1 i t eve 1/2 Clrc. =18.84"
vvv 1 'O°
eves
sys ovv
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24
son=
36"
12 -1/2 DIA. (tyg.)
Void Volume Sal Interface ra IIL jg Ft. 52 Ft
Void Coefficient in Aggrcgatc given at 57.4 %. Sidewall (2 Sidawalls) 2 * 18.84in 3.14
O.D. of 4" pipe - 4.625 inches 12111
_ tft
Void volume per linear ft = 3. 14 • z.3125ia tft -0.1171p Bottom 2.00
t2iaJft � •
Total Soil Interface Area 5.14 SQ.
O.D. of center cylinder a I inches
_ i
Void volume in aggregate ofuntercylinder =(3.14 6.25in 2 3t25o • 3.ta•` )'.574-.422 ft' t2inlft) � l t2in /ft
O.D. of outside cylinders - 12 inches Projected Trench Area
Void volume in outside cylinders - 2.3.14 bin • .574 -.901 fe Sidewall Height = 12 in. •2 - 2.00 Sq.Ft.
12 1ft
Bottom = 36 in. = 3.00 Sq.Ft.
Void volume at bottom between cylinders - l� 24in • 6ia ) -( 3. 1 J bin l
ll t 11 0.215 fV Projected Trench Areas 5.00 S Ft. [tor I ft 12in ! f12in t ft q•
Void volume at outside bottom comers (1/2 of void volume between cylinders) 0.215 12 - 0.108 fl'
Total void volume - 0. 117 + 0.422 + 0.901 + 0.215 + 0.108 - 1.763 cubic ft t ft
Gallons per ft - 1.763 X 7.48 - 13.:! eallons Per linear ft
3tp 5�
EPA Aggregate
Trench System
EZ1203H
Ring- Industrial Group
65 Indus#ciol Pork Rd. z ,,
Ockiond, TM 48060
SCALE FILE wwe: EZ1203H -vat SHEET: t of 1 11 -27 -01
NL (at 's
4" CI VENT PIPE 12" MIN. ABOVE GRADE WEATH£ROPROOF
25' FROM_DOOR, WINDOW -OR JUNCTION BOX APPROVED
FRESH AIR I14TAKE WITH CONDUIT MANHOLE COVER
WI PADLOCK &
�---- WARNING LABEL
4" MIN.
18'' I N
14LET • i
WATER TIGHT SEALS GAS- i
TIGHT i f
4 „ SEAL ` APPROVED
.-�- � ALM
Jo W/ CI
1I PIPE $ PIPE 3' ONTO
1 ON TO -- ! ON SOLID SOIL
30IL PUMP OFF 1rLEV . FT. •- -f— Y OAF ** RISER EXIT
PERMITTED ONLY
D
IF . TANK . .
MANUFACTURER
HAS APPROVAL
3" APPROVED BEDDING UNDER TANK
CONCRETE PAD
SPECIFICATIONS
SEPTIC t DOSE
TANK MANUFACTURER: (t�`.os er `Jtly`(� NUMBER 'DOSES PER DAY:
TANK SIZES SEPTIC fl GAL. DOSE VO M£ FLOWBACK: GAL.
ALARM MANUFACTURER; CAPACITIES: A = Z , 7 s I NCHES = 7_/ , GAL .
MODEL NUMBER: 0
SWITCH TYPE: - % B = 2 INCHES = �/� � GAL .
PUMP MANUFACTURER: S C = SI,C INCHES =
GAL.
MODEL MODEL NUMBER :
SWITCH TYPE: D = ld 7 INCHES = .137 G AL.
REQUIRED DISCHARGE RATE _ 65 GPM 6o , PUMP E ALARM WIRING AS PER ILHR 15.23 WA(
X5,9 Pm C 5
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE lo? FEET
+ MINIMUM NETWORK SUPPLY PRESSURE . . . . . . 0 . . FEET
+ 80 � FEET FORCEMAIN X � D FT/ 10 0 FT. FRICTION FACTOR FEET
TOTAL DYNAMIC HEAD = q_ FEET
INTERNAL DIMENSIONS OF PUMP TANK: LENGTH ; WIDTH ; DIAMETER
LIQUID DEPTH 3�0
�/ s
HGOULDS PUMPS Submersible
Effluent Pump
MODEL • a
WE Series
PROSURANCE AVAILABLE FOR RESIDENTIAL
APPLICATIONS.
APPLICATIONS ■ Shaft: Corrosion - resistant, Single phase (50 Hz): can be operated continuously
Specifically designed for the stainless steel. Threaded a Capacitor start motors for without damage when fully
following uses: design. Lodmut on all models maximum starting torque. submerged.
• Homes to guard against component • Built-in overload with ■ Bearings: Upper and
• Farms damage on accidental reverse automatic reset lower heavy duty ball bearing
Trailer courts rotation. • STOOW or STOW severe duty construction.
• Motels ■ Fasteners: 300 series oil and water resistant 0 Power Cable were duty
• Schools stainless steel. power cords. rated, oil and water resistant.
•
• Hospitals ■ Capable of running dry A –1 HP models have Epoxy seal on motor end
• Industry without damage to NEMA three prong provides secondary moisture
• Effluent systems components. grounding plugs. barrier in case of outer jacket
• 1'h HP and larger units have dams a and to pre vent il
■ Designed for continuous bare lead cord ends. g
SPECIFICATIONS operation when fully wicking. Standard cord is 29.
Three phase
submerged. overload ddp
Pump Optional lengths are available.
� *Class 10 overload protection
• Solids handling capabilities: MOTORS must be provided in ■ O -ring: Assures positive
3 10 maximum. separately ordered starter sealing against contaminants
• Discharge size: 2" NPT. ■ Fully submerged in unit. and oil leakage.
high-grade turbine oil for
•Capacities: up to 140 GPM •STOW power cords all have AGENCY US'1'INGS
• Total heads: up to 128 feet lubrication and efficient heat bare lead cord ends.
TDH, transfer. Tested to w. ns wd
Designed for • Temperature: ■ Class B insulation on O Controls US By c s
1047 (4M continuous IA-1 % HP models. with motor manutacbirer's As � y
•See order er nu
140°F ( bens ers on models. int ■ Class F insulation on 2 HP recommended working limits, Goulds p� b SO 90M numb
reverse side for specific HP,
voltage, phase and RPM's METE FEi r
available. 130 sewES: we
120 — — — — SIZE: 3�r s OUDS
35 500 &
FEATURES 110 + 5 1 ,
■Impeller. Cast iron, semi- 3 0 100 SFr
open, non -dog with pump- 90
out vanes for mechanical 25
so
seal protection. Balanced for 70
smooth operation. Silicon 20
bronze impeller available as o 50
an option. 1s So
■ Casing: Cast iron volute 40
type for maximum efficiency. 10 30
* NPT discharge. —
■ Mechanical Seal: SILICON 5 -
CARBIDE VS. SILICON id
CARBIDE sealing faces. ° 0 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 GPM
Stainless steel metal parts, i i I t L i i i t I i t I i
BUWN elastomers 0 5 10 1s 20 25 30 35 m 3 /hr
CAM"N Goulds Pumps
® 2004 itr water Technology, Im ITT Industries
9kctim December, 2004 www.goulds.com
83885
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County �
Attach complete site Plan of paper not less than 8 1/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point , di ion d Parcel I.D.
percent slope, scale or dimensions, north arrow, and location an a st /a — 5 O D Da
Please print al/ Information. Re ed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, S. 15.04 (1) (m)). l Z 7
Property Owner Property Location
Govt. Lot S 1/4 1 S T N R X)
Property er's Mailing A�ress Lot # I Block # Subd. Name or CSM#
3 NIA P14 ° cz i $ tY c,1' Rq r4�'
City State Zip e ❑ City ❑ Village own Nearest Road `
(C E 1 4
New Construction Use: Residential / N uWmryymAwA&j Code derived design flow rate GPD
Replacement ❑ Public or commercial - Describe:
Parent material e n c�c f�cH.n L _.9, Cx�e� Flood Plain elevation if applicable ft.
General comments
and recommendations: /
a [P Pit �ng# ❑ Boing Ground surface elev. ft. Depth to limiting factor > / 6 in.
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soli GPD�z Rate
on
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 "Eff#2
b'y r� L 4, m�r� LS .2 f , S
�- 9 -.gy !o ,• ---- S Y � c ! a►�, sb � : � s f / 5
V - � 1 �
Bonng # ❑ 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 GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff42
* Effluent #1 = BOO. > 30 < 220 mg(L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS _< 30 mg/L
Name (Please P ) Si lure CST Number
Addfess to Evah= n Conducted Telephone Number'
tqjocl M!� a — — D 5 I as
Property Owner ( Parcel ID # D30 -- QS . a� 3
�_5b �pe Page of
Boring "VA
f.
L..J Bonng # ,
❑ pit Ground surface eiev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Des Texture Structure Consistence Boundary Roots GPOl
in. Munsell Ou. Sz. Conk Color Gr. Sz. Sh. 'Eff#1 'Eff#2
El
F � # ❑ 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 GPD/ftz
In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Et'f#2
F Boring # ❑ Boring
❑ Pti Ground surface elev. s Depth to limiting factor In.
Soil Application Rate
Horizon Depth Dominant Cola Redox Description Texture Structure Consistence Boundary Roots GPD/1`I
In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Etf#2
EfkWd #1 = B00 > 30 < 220 mg/L and TSS >30 < 150 mgIL ' Effluent #2 = BOD < 30
_ _ s _ mglL and TSS < 30 mgll.
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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Wisconsin Department of Commerce SOIL EVALUATION REPORT p age 1 of 3
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County St Croix
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 0 3 0- `
Please print aH information. Reviewed b / �- Dat
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). yV
A - r I /—
Property Owner ,��p r Q �+ Property Location
Quest Development, Inc Govt. Lot E 1/2 1/4 SW 1/4 S 25 T 30 N R 20 E W
Property Owner's Mailing Address Lot # j Block # I Subd. Name or CSM#
Suite 150 10700 Old County Road 15 5 Ridge At Birch Park
City State Zip Code Phone Number aity F�Vllage Town Nearest Road
Plymouth MN 1 55441 1 ( 7¢3 - 595 - 9512 County Road E St, Joseph
n New Construction Useo Residential / Number of bedrooms 3 to 4 Code derived design flow rate 450 to 600 GPD
Replacement Public or commercial - Describe:
Parent material 1.ness over ut wash sands Flood Plain elevation if applicable
General comments
T his site is suitable for a mound system \'
and recommendations:
The possibility exists that there is a below grade system on the p X y p
Additional field work will have to be conducted to varif . r0
r
❑ 1 Boring # Boring T $;FO
Q pit Ground surface elev. 99.31 ft. Depth to limiting factor > in. �'
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary ' Roots' GP
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. E �E p
1 0 -5 10yr3/2 I 2msbk mfr cs 2f .5 8
2 5 -18 10 r4/6 sil 2msbk mfr cs if .5 .8
3 18 -39 10yr4 /6 sil lmsbk mfi cs - 2 3
4 39 -96 7.5vr5/6 fs lmgr " mvfr _ - ,5 .9
F 2 Boring # Boring 98.21 >96
Q pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -5 10yr3/2 1 2msbk mfr cs 2f .5 .8
2 5 -19 1 r4/6 sil 2msbk mfr cs 1f .5 .8
3 19 -40 10yr4 /6 sil lmsbk mfi cs - .2 .3
4 40 -96 7.5yr5/6 fs lmgr vfr - - •5 •9
* Effluent #1 = BOD > 30 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = 5 < 30 mg /L and TSS < 30 mg /L
CST Name (Please Print) CST Number
Thomas C Nelson 227387
Address Date Evaluation Conducted Telephone Number
1432.120th Street, New Richmond, WI 10/16/01 715- 246 -2454
�Ir
Quest Development, INc P 2 of 3
Property Owner Parcel ID # 9
❑ Borin # Boring
g 0 Pit Ground surface elev. 89'97 ft. Depth to limiting factor 20 in. Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/lf
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -5 10yr3 /2 - I 2msbk mfr cs 2f .5 .8
2 5 -20 10 r4/ - sil 2msbk mfr cs if .5 .8
3 20 -40 10yr4 /6 f2d5yr5 /6 sil Imsbk mfi - - •2 .3
❑Boring # � 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 GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
Boring
❑ 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 GPD/fg
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L
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.
SM- 8330Test (R.07 /00)
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o 3 a • Z d 31O , 70 - Daa Ulbricht & Associates
Private sewage Consultants
0 3 c)55 , Z a G55 O'Neil is.
o v � � Hudson, Wis. 54016
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ST. CROIX COUNTY
` SEPTIC TANK MAIN'TEN.ANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer _ � �/ - M 1 L t- tnL
Mailing Address 31'13 J N lzi:%E �t �� � 1 5 S(0 �(-Z
13 3 c) ;
Property Address AAA aC-44 P42-14- c
(Verification required from Planning & Zoning Department for new construction.)
City /State 405- -at-i I Parcel Identification Number t7`3 Q ` Z l Z `�o ° 5a - �5 • U ; )
LEGAL DESCRIPTION
Prop Location � 1 /1, �� %a , Sec. V 7 , T N R W, Town of ` j -
Sub ivi on _ al ► "z -�-�-4 pD�RvC , Lot
Certified Survey Map # Volume , Page #
Warranty Deed # 9 6 ('0 r 7 c b , Volume , Page #
Spec house yes <0 Lot lines identifiabl yes no
SYSTEM MAINTENANCE AND OWNER CERTWICATION
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.
Uwe 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 described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms
4 's ,
SIG OF APPLICANT(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.
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Septic Tank Capacity E3 NA
al
Permit #
Septic Tank Manufacturer Lo i ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer o ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model P L ❑ NA
Number of Public Facility Units ❑ NA Pump Tank Capacity S OD al ❑ NA
Estimated flow (average) Pump Tank Manufacturer � r 13 NA
O gal/da
Design flow (peak), (Estimated x 1.5) bs g al/day Pump Manufacturer ❑ NA
Soil Application Rate 45 gal/day/ft? Pump Model ❑ NA
Standard Influent/Effluent Quality Monthly average" Pretreatment Unit ❑ NA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetiand
Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other:
-Pretreated.EffluentQuaiity vatbl average 's{�erea4 Ge -- -- - -- - - -- - _ _ ___ --
Biochemical Oxygen Demand (BOD 530 mg/L Ain- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At-Grade ❑ Mound
Fecal Coliform (geometric mean) S10' cfu /100ml ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other. ❑ NA
'Values typical for domestic wastewater and septic tank effluent. Other; ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank ❑ month(s) s) At least once every; y ear(s) (Maximum 3 yam ❑ NA
-3 A Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑
JX month(s) (Maximum 3 years) ❑ NA
year(s) .
❑ month(s).
Clean effluent filter At least once every: year(s) ❑ NA
❑ month(s)
Inspect pump, pump controls & alarm At least once every: ❑ year(s) ❑ NA
Flush laterals and pressure test At least once every: ❑ month) ❑ NA
❑ year(s
Other: At least once every: ❑ month(s) ❑ NA
❑ year(s)
Other: ❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer, Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with- chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of 512 months, shalt be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
START UP AND OPERATION Page -OL--of -�
For new construction, prior to use of the POWTS check treatment tanks) for the presence of painting products or otherchemicals
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.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess' wastewater will be.
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
Within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the fife of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products, pesticides; sanitary napkins; tampons, and water softener brine.
ABANDONMENT
When the POWTS fails and /or is permanently taken out of service the -following steps shall be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative 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 properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material
CONTINGENCY PLAN
if the POWTS fails and cannot be repaired the following measures have beam, or must be taken, to provide a code compliant
replacement system:
A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be Infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances In POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
• 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.
• Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstruct of Su ch s must Comply -With the rules in effect at that time.
< < WARNING > >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name V�' w Name
PQ
Phone Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name
Phone Phone s 38' to
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
Page - avf r�
START UP AND OPERATION
For new construction, prior to use of 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.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater with be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
Within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative 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 properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another 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 for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances to POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
❑ 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 suitable replacement area. If no replacement area is available a holding tank
may be installed as a fast resort to replace the failed POWTS.
❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstruct of su ch syste :must.c npi with the rules in effect at that time. .
< <WARNING> > -
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES_ DEATH MAY RESULT. (RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
E Name
> Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name
Phone Phone s
This document was drafted in compliance with chapter Comm 83.22f2)(b)0)(d) &(f) and 83.54{1), (2) & (3), Wisconsin Administrative Code.
12/1 WED 14:58 FAX 7 15 386 4687 ST CROIX CO RE OF DEEDS DERRICK CONSTRUCTION U002/002
llflfl Ilfl ffl IIlII 1f1f1 IIIII fill 1!1111 11111111
* 865
8
5 4 1
STATE BAR OF WISCONSIN • 8 5
FORM 9 — 1898 8
WARRANTY DEED
KATHLEEN H. WALSH
REGISTER OF DEEDS
Document Number ST. CROIX CO., WI
This Deed. made between Riley Ruby. LLC.. a Minnesota limited RECEIVED FOR RECORD
liability comoenv _ Grantor, and 12/1B/2007 12:30PM
Troy Miller and Michelle M'P0er,h uSband qnd wife , Grantee_ WARRANTY DEED
Grantor, for a valuable consideration conveys to Grantee the following EXENI'T •
described real estate In St. Croix County Slate of REC FEE 11.00
Wisconsin (the "Property "): TRANS FEE: 40500
PAGES: 1
Lot 5, Plat of Ridge at Birch Park in the Town of St. Joseph, St. Croix County
Ftecording Area
Name and Redm Address
Edina Realty Title
400 South Second Street, #115
Hudson, WI 540�166 -1974
File # o b5a - L�q
arse Ideni leation Num ber (P )
This la not homeatead property.
(IS) On —t) O�8 ^ 6'0-
Together with all appurtenant rights, title and Interests.
Grantor warrants that the title to the Properties good. Indefeasible in simple fee and free and dear of encumbrances
except
Dated this 1'�th_ day of December 2QQ
(SEAL) (SEAL)
Riley Ruby, LL . , a Minnesota Limited Llabilty Company
Paul DeWitt as President
(SEAL) _ _ _ (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Minnesota
) so.
au Ramsey County tnanticatad this day of _ _ _ ,
Personally sauna before me this _1 day of
DeoMber 2007 the above named
Riley Rupy LLG __a Minnesota UgIMW Liability Commany.
* PaVI DeWitt as President to me known to be
TITLE: MEMBER STATE BAR OF WISCONSIN the person a Z 71nq Instrument
(If not, _ and acknoWed
authorized by §706.013, Wig. Stats)
THIS INSTRUMENT WAS DRAFTED BY
Caldwell Banker Burnet/Robert Nicholson Notary Pubk, State of Wisconsin
1301 Coulee Road
Hudson, WI 54016 My commlaalan Is permanent. (if not state expiration date:
7 -21999
(Signatures may be authenticated or acknowledged. •)
Both are not necessary.)
Names of rsons sig ning In an ca ac must be De 19 9 y P �Y tYP� orPdnted bE ff Ai1LSON Mrsirtf4% re, 31, 9010
STATE= BAR OF WISCONSIN Wisconsin Legal Blank Co, Inc.
WARRANTY DEED FORM No. t - 1098 Milwaukee, Wis.
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