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020-1288-40-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s 15. 04 (1)(m)] Permit Holders Name City Village Township Timothy & Erin LaCoursiere I TOWN OF HUDSON 10 - c. 3 1 £xa v• TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic £ i �`t 1t17tStf �OtJo c tJ ieSR r �( (e L' SZ5 1, �zo Holding TANK SETBACK INFORMATION to(, LS DL Ctivk KS TANK TO PILt\ WELL BLDG. Vent to Air Intake ROAD Septic r 320 ?25' $8' 3o Aeration Holding PUMP/SIPHON INFORMATION Manufac rer Demand GPM Model N mber TDH ift Frictio Loss System Head T Ft Force n Length r. Disl to Well SOIL ABSORPTION SYSTEM ELEVATION DATA STATION BS HI FS ELEV. Benchmark p 0 10�. 3 !to • (63 A[(r l'0C) 44 V, Ix- 3.v 6 l oi5 . S 7 Bl�ddg. Sewer �XS t'Yl SUHt Inlet SUHt Outlet 8• Z)8,4 0b• 4 3 of Inlet d r o9 10 e, ! , ) Dt Bottom 6d,1S /Do•q$ Header/Man. 8 •` 8 99. !t5 Dist. Pipe �' Br 1 J Bot. System pp . ?7 Final Grade I 1QLl -73 St Cover O N L' 3.e6 7 Valve S.Z6 /so.37 BED!TRENCH DIMENSIONS Width 3 r Length No. Of Trenches -7 !(/ A '7 I,-j- PIT DIMENSIONS INo. Of Pits I Inside Dia. ILiquid Depth SETBACK INFORMATION SYSTEM TO Ply BLDG WELL LAKEISTREAM LEACHING CHAMBER OR UNIT Manufactury 1 n ) / Type Of System GNP , , OhG ` 3 � zL ' b � ` __ Model Number E-2, P'y l DISTRIBUTION SYSTEM Header/Manifold` r t Length Dia Distribution Pipe(s) x Hole S¢e x Hole Spacing Vent to Air Intake T-ldvi Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Bed/Trench Center [ t J Depth Over ` BedfTrench Edges / !'z �s iLJ x Depth of Topsa' m Seeded/Sodded m Mulched No YesN NO COMMENTS: (Include code discrepancies, persons present, etc.) Inspection 41 Location: 851 ZANE GREY CIR -All ��� 1� /'t 1.) Alt BM Description =3 Z U �.c.v. }c' (OV4'r -/J.'�- 2.)Bldg sewer length = ,vrTT``NY�q —I lt,A� rnsAj&v - amount of cover = �I�V-+i`1 J Inspection #2. !h Oh Crv/i Plan revision Required? of Yes [ NO %a Z Use other side for additional information SBO-6710 (R.3197) Date Insepctors Signature Cart. No. 0 nt\_I; _�e ,�nI—')_ t L) C-`,;, r,''•� �i Industry C punt Srcmix L� -�; SerV)Ce5 Division S 1400 E Washington Ave (' S APR 27 2021 Sanitary Permit Number oo be filled in by Co ) i. Madison,Wlob37 1 Comn-Sa'- i't '1N it Application Slate Transaction Number In accordance with SPS 313 21(2),'his Arm ('ode submssam of this form to the appmprime gosemmemal unt is required prior to obtaining a sanitary permit. NoteApplication forms for statcawned POW I are submitted to Project Address (if different than mating address) the Department of Safety and Professional Seances. Personal information you provide may he used for s<wndarn u oses in accordance w.th the Pnvacv Law s 1' (+ Iml• Stan 951 Lane Ore% C rrele 1. Application Information- Please Print All Information Propem Owner's Name Parcel p "I imothy & Fnn IaCourstere 020-1288- 0-000 Property Owner's Mailing Address Property Location 951 Zanc Grey ( Tele 5ectinn,} Z I City, Slate /Ip CPlumeode Pc Number Iludson, WI 54016 !x'C. 1}} tine) �I,rcle INN R19Eore Lill® 11. Type of Building (check all that apply) �7 Lot Suhdrvlsmn Name 1 or 2 Family Dwelling - Number of Bedrooms ) 14 Wells Fargo Station Rlock P ❑ Public/Commercial -Describe Lse _ ❑City of ❑ State Owned- Descnhc Lse ❑ s,tllage of 7_01UE x CSM Number ® Town Hudson of Ill. Type of Permit: Check only one box on line A. Complete line B if applicable) A ❑ New Svstem ® Replace `,System ❑ I reamient,I folding lank Re IacementO nic t p ❑ (when Modification to Foisting System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Penns TFri to Nee List Previous Permit Number and Dare Issued Before Fxpiranon Plumber Owner 193397, a/28/1993 IV. Type of PO WTS S stem'Com onent'Device: Check all that a I Non-Pressunzcd In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 m of suitable sod ❑ Mound- 24 In of suitable soil Holding Tan Other Dispersal Component lexplaml ❑ Pretreatment I.kvtu (cxplmn) t V. Dis ersal/Tre ment Area Information: Design Flow (gird Design Sod Apphc pn Dispersal Area Regw (sf) Dispersal Area Pr sfl �yslem CI mron 450 Rate(gpdsp 643 70(l 9Q p 0' VI. Tank Info Capacn) in Fill, c Gallons Ioral A of Manufacturer s - 3 New Tank, Lxunto lands (tallons LIniLS u 1 G ie 2 ! J s j W Septic or Holding Lank 1 320 1LIN) 1320 2 N'leser Concrete ❑ ❑ (losing Chamber VII. Responsibility Statement- 1, the undersigned, assume rcspmrtlbfiip for installation orthe PORTS shown on the attached plans. Plumber's Name (Print) Plumbers ig rc MPN1PRS Number Business Phone Number John Schmitt /� /L✓ 223760 715-760.0486 Plumber's Address (Smxa. CiI3. State. Zip Code) 586 Vallee View bail. Somerset- WI 54025 ill. Count v/Department Use Only _ Approved ❑ Dnappnncd Permit Fee Date Issu/ suing Agent Sifu ature� - ❑ Owner Given Reason for Dental S '.5. oD �U Z� �.f IX. Conditions of Approval/Reasons for Disapproval 3 6vif VC, WsC.'10 Ife !n5 )!p see ws t"�3 Syr&A t SYSTEM OWNER I oit �S,. 1 tank, effluent filter and 'V-n d// 1. Septic ` , dispersal cell must be Serviced I malyiamed Ar 4)ZAS-A I&r Ot. 5`/- �•'o d'(� S�/5kM /"I4'N f-rrt{c.� � �„v b as per management plan provided by p k rornent —,,at be maintained 4 ?AV rr-1/ Ow het' 1 e11 and'A nit b the Dunn ash on as per apPhcable co b dTrfSfl t piper not lesx then A I4 a t lacnn In rt P 5� L)Ec- o. SBD-6398 (R03/14) F // SYSTEM PLOT PLAN LaCoursiere 3 Bedroom Septic System Project Address. 851 Zane Grey Cide BMt Symbol A SM Elevation. 100,00' SM DescriptionSoutheast Lot corner marker BM2 Symbol A BM Elevebon 100 63' BM Description Exisbrig septic tank outlet Slope Gradient of Tested Area (5%) Well Symbol (H applaable) Notes- See Plat map for complete lot OA Y Ddvaway Design Flow. 450 GPD Attach design flow calculations for commeroal plans Pipe Materials! ASTM Standard Tables 384 30-3 & 384,30-5 4' SCH 40 PVC pipe ASTM- D2665 4" 3034 PVC pipe ASTM-D3034 4" 2729 Pert pipe ASTM-D2729 T1- 3'x70' EZ Flow "rich El.- 98,00' T2- 3'x70' EZ Flow trench El - 98.00' W EM Scale: 1" = 50' 0 60 90 120 15' ♦ BM1 m W Well Exiahng 3 Bedroom �$ House T S2 S Fasting N/ P100D-MR I I 1 septic tank 1 I l \ Proposed! M20-MR septic tank w/Paylok 625 BM21 I 1 \ valve \\t1 Ba �--: i 108' � m 1 Q/ roj l i I 1 a•' B2 Ti T2I ■ B5 R1 Stage 102, BM1 CONVENTIONAL COMPONENT DESIGN INDEX AND TITLE PAGE Project Name: LaCoursiere Replacement Septic Ststem Owners Name: Timothy & Erin LaCoursiere Owner's Address 851 Zane Grey Ci,cle Hudson. Wl54016 Legal Description: NE1/4, SW1/4, S21, T29N, R19W Township Hudson County: St, Croix Subdivision Name: Wells Fargo Station Lot Number: 14 Block Number Parcel LD. Number 020-1288-40-000 Plan Transaction No. Page 1 Index and title Page 2 Plot Plan Page 3 Existing Septic Tank Specifications Page 4 Existing Tank Certification Page 5 Proposed Septic Tank Specifications Page 6 Effluent Filter Information Page 7 Bull Run Valve Page 8 System Sizing & Cross Section Page 9 EZ Flow Information Page 10 Management and contingency plan Page 11 Sanitary System Ownership/Address Form Page 12 Warranty Deed Page 13 CSM or Plat Attachment 1 Soil Evaluation Report Designer: John Schmitt Licnese Number: MPRS 223760 Date: 4/25/2021 Phone Number: 715-760-0486 Signature: L 241ZAI /L In -Ground Soil Absorption Component Manual Version 2.0 SBD-10705-P (N. 01/01) Page 1 SYSTEM PLOT PLAN LaCoursiere 3 Bedroom Septic System Project Address 851 Zone Grey Clde 8101 Symbol A BM Eovation 10000' BM Description Southall Lot comer marker BM2 Symbol A BM E evation 100 63' BM Desorption. Existing septic tank outlet S'ope Gradient of Tesled Area 15%) Well Symbol if applicable) Notes See Plat map for complete lot Driveway Design FIOW 450 GPo Attach design low calculations for commercial plans P pe Matenas / ASTM Standard Tables 384 30-3 8 384 30-5 4" SCN 40 PVC pipe ASTM- D2665 4" 303d PVC pipe ASTM-C3034 4" 2729 Perf qpe ASTM-D2729 T 1- 3'e70' EZ `low trench El - 98 00' T2- 3'Y70' EZ =bw Lench EI - 98 CO' Garage m Well Exlat rig 3 Bedrocm� rlauee Existing VVLP1000-MP t / BM2'i \ Pmpoaed W320-MR j l j septic tank wrPolylor 525� ) 1 Valve / BIN { `fed 106'� /mom `1 r 1 10W l B2 T21 T1 / ■ B5 RN✓ SMae r02' / Coach Trai( BM1 ME vo Scale: 1" = 60' 0 60 90 120 15' � EM1 4"" CAST -A SEAL 8' 8" BAFF1 r TOP VIEW WLP1000-MR TANK SPECIFICATIONS DIMENSIONS: WALL: 2 1 /2' -4" CAST -A -SEAL BOTTOM: 3' COVER: 5" MANHOLE: 24" I.D. PRECAST CONCRETE RISER HEIGHT: 53 1/4' LENG IH: B'-B' WIDTH: 7•-2" BELOW INLET: 42' LIQUID LEVEL: 36" WEIGHT: 6,790 LBS. INLET AND OUTLET: 4" CAST -A -SEAL BOOT OR EQUAL GASKET INLET AND OUTLET BAFFLE AND FILTER: WISCONSIN. SEE DETAIL f610 (OTHER STATES SEE CHART) LIQUID CAPACITY: 27.83 GAL/IN HOLDING TANK: OUTLET HOLE PLUGGED ACTUAL CAPACITY: 1,085 GALLONS LOADING DESIGN: 8'-0' UNSATURATED SOIL TANK CAN BE USED AS: SEPTIC / HOLDING / PUMP OR SIPHON COVER: MIX DESIGN Q8 (NO FIBER) TANK: MIX DESIGN #10 (STRUCTURAL FIBER) OUTLET w �u = _ 1 `, PUMP PAD EXCEED ASTM CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE REVIEWED BY REVIEW DATE DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: APPROVAL DATE: PRODUCTS NEEDED BY: OF 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) 951 Zane Grey circle located at: NE /4, SW '/4, Section 21 , Town 29 N, Range 19 W, Town of Hudson , 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 SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service 5- / 7 ` a Did flow back occur from absorption system? Yes_ No (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: 1000 Construction: Prefab Concrete X Steel Manufacturer (if known): Wieser concrete Other Age of Tank (if known): 4/2811993 Permit number (if known) 193397 John Schmitt (Li sed Plumber Signature) (Print Name) MPRS (Title) 15-- (Date) 223760 (License Number) MP/MPRS Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 Page 4 TANKS ARE 4- I�AST-A-SEAL —4 2"L i -- IFF —__- -__111 \ I II i I I d it 1 II FILTEP CH BAFFLES TO MEET A" CAST -A -SEAL a 11_l 7+ -T OUTLET REMENTS W320-MR TANK SPECIFICATIONS DIMENSIONS: WALL: 3" BOTTOM: 3" COVER: 4" MANHOLE: 24"I.D. PRECAST CONCRETE RISER HEIGHT: 58" LENGTH: 4'-2" WIDTH: 4'-2" BELOW INLET: 46 1/2" LIQUID LEVEL: 43" WEIGHT: 3,880 LBS. INLET AND OUTLET: 4" CAST -A -SEAL BOOT OR EQUAL GASKET INLET AND OUTLET BAFFLE AND FILTER: WISCONSIN, SEE DETAIL #10 (OTHER STATES SEE CHART) LIQUID CAPACITY: 8.00 GAL/IN LOADING DESIGN: 8'-0" UNSATURATED SOIL TANK CAN BE USED AS: SEPTIC / HOLDING / PUMP OR SIPHON COVER: MIX DESIGN #8 (NO FIBER) TANK: MIX DESIGN #10 (STRUCTURAL FIBER) CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE REVIEWED BY REVIEW DATE DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: APPROVAI DATE: _ PRODUCTS NEEDED BY: r, f lfIt; 4 1)1 [iIto I Pt: ;253 1 ilter The PL-525 Filter is rated for 10,000 GPD (gallons per day) making it one of the largest filters in its class It has 525 linear feet of'1/16" filtration slots Like the Polylok PL-122, the Polylok PL-525 has an automatic shut-off ball installed with every filter. When the filter is removed for cleaning, the hall will float up and temporarily shut off the system so the effluent won't leave the tank Iralrnr- Rated for 10,000 GPD (gallons per day) • 525 linear feet of 1/16" filtration. • Accepts 4" and 6" SCHD 40 pipe • Built in gas deflector. • Automatic shut-off ball when filter is removed. • Alarm accessibility. • Accepts PVC extension handle. Ideal for residential and commercial waste flows up to 10,000 gallons per day (GPD). 1. Locate the outlet of the septic tank 2. Remove the tank cover and pump tank if necessary. 3. Glue the filter housing to the 4" or 6" outlet pipe. If the filter is not centered under the access opening use a Polylok Extend 8r Lok or piece of pipe to center filter 4 Insert the PL-525 filter into its housing 5. Replace and secure the septic tank cover "f he PL-52S Effluent Filters will operate efficiently for several years under normal conditions before requiring cleaning. It is recommended that the filler be cleaned every time the tank is pumped, or at least every three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the filter needs servicing Servicing should be done by a certified septic tank pumper or installer. 1. Locate the outlet of the septic tank 2 Remove tank cover and pump tank if necessary 3 Do not use plumbing when filter is removed. 4 Pull PL-525 cartridge out of the housing 5 Hose off filter over the septic tank. Make sure all solids fall back into septic tank. 6. Insert the filter cartridge back into the housing making sure the filter is properly aligned and completely inserted 7 Replace and secure septic tank cover. 1/161 •!tritiim `,}I,t, �� -- Alarm Switch 1Or��0 GPD (Optional) Accepts 1" P% Eelrnslan Handle Accepts 1 SCFtD 4e pipe Rated for 1 0,D00 GPD 525 Linear Ft of1/IN' Filtration Slots Certified to NSUANSI Standard 46 Gm Deflator Automatic Shut -Off Ball _:,,✓„r sn;r I 'gun II.,: % Polylok, ZaNx l A Rr,J Bln-ra a,repI Easily mctal6 the SmartElltcrM1 N9tch and alarm into ex m,rt; tank+ Polylok, Inc 3 Fairfield Blvd. Wallingford, CT 0(492 Toll Free: 877.765.9565 Fax 203.284 8514 %mv polylok.com Page 6 Home F About site Map Order Info Videos & Literature Contact Drip Systems Treatment Controls Products Downloads .- Design Guidance rrT; ,Y t " The Bull Run Valve'" is designed to split flows to septic fields or systems. to addition to the advantages of longer life and easier installation it is the most public health safe alternating device available for wastewater disposal applications. The use has absolutely no contact with wastewater due to the valve's leak -proof and external operating characteristics. The change over from one drainage field to another can be accomplished In less than a minute by simply turning the valve without digging or contact with wastewater. F C ITEM DESCRIPTION BRV4 BULL RUN VALVE 4" BRVBULK BULL RUN VALVE & KEY ONLY BRVCIRISER BULL RUN VALVE RISER W/ CAST COVER BRVKEY2B BULL RUN VALVE KEY 28' BRVKEY36 BULL RUN VALVE KEY 36' BRVKEY48 BULL RUN VALVE KEY 48` 2 Its f 4( " R SE R CAP ADAPTER RI SER TUBE 4'OUT PORT WATER -TIGHT ACCESS CAP VALVE DIRECTION HANDLE 4' OUT PORT 4" !N PORT The Bull Run Valve is available In 4" sch 40 pvc and Is suitable wherever septic disposal systems are used - in commercial, industrial, and residential applicatlons. OPERATING THE VALVE The direction control handle should be rotated periodically to direct effluent to one or the other of two septic fields. After removing the screw cap at the top of the riser tube, the valve handle can be turned with the valve key furnished. BULL RUN VALVE Complete Valve Kit Contains 1. Bull Run Valve body 2. 28" Valve Key 3. Riser Cap Adapter 4. Watertight Access Cap BRVCIRISER - 4" ADJUSTABLE TO 28" HIGH Page 7 IN -GROUND GRAVITY DISPERSAL AREA Uniform Elevation Trenches with EZ1203HP Bundles 3-ft Trench (down -sizing credit) I C er m Ce Corer SOIL COVER ` t. f irvn bench /A de" t Nl»mq System Elevation = 98.0 ft. (typical) min 12' (typwp Septic Tank(s) Manufacturer Wieser/Wieser Septic Tank(s) Vdume(s)- 1000 gal 320 gal gal gal Effluent Filter Manufacturer Polvlok Effluent Filter Model # 525 TYPICAL TRENCH CROSS SECTION VIEW (No Scale) Provide minimum 3 ft separation between trenches TYPICAL TRENCH (Show location of inlet 1 outlet pipe connection on plan view ) PLAN VIEW 4^ 0 Oheervebon pipe e�all hw inaiakd (No Scale) at "a. t...nt., "ts Perforated Lateral Observation Pipe (typical) (typical) r--- — — — — ---i-------- ===___==b===- t B=70 ft (typical) INSTALL PER TRENCH: m 00 CID 7 10-ft bundles @ 50 f EISA/unit = 350 ft' + 0 5-ft bundles @ 25 fF EISA/unit = 0 fP = Proposed EISA per trench = 350 ft, OBSERVATION PIPE DETAIL (No Scale) s supp cap Ctype a an ` set a'O PVC Plpe I o0 0l ppe to termneie _ at or afp G tmista" .=.e (4) 1k 6' Sm, $ 9b apad AM onn9 Deis 10 ft (typical) A=3.0 ft (typical) I � ' I Bundle (typical) (mfd by Infiltrator Systems, Inc) Install pursuant to manufacturers Instructions Required Infiltration Area = 643 x 2 trenches = Proposed Total EISA= 700 Finishod Grade (mulched 8 eeetled) �:. TOp,,O corer rmin non Infiltrator Surface ft' Distribution Method: ft; branched manifold m W O RESET Installation Instructions for EZflow Systems in Wisconsin Wisconsin Department of Commerce, Safety and Buildings Division, has reviewed the specifi;atons and,'o, plans for this product and determined it to be in -_ompllance with chapters Comm 82 through 84, Wisconsin Admin. Code, and Chapters 145 and 160, Wisconsin Statutes. All sites must meet the Site & Sod Cond t ons & L)catlpns_&1solatton distances as noted In local regulations. The approved products are 1203H (3-12" bundles with pipe in center bundle In 5' or 10lengths) and 1203HP (3-12" bundles with ppe in each bundle in 5' or 10' lengths A single pipe bundle contains a four inch perforated pipe sur- rounded by EPS aggregate and is held together with poy- ehtylene nettng. A sngle aggregate bundle contains aggregate only and is held together with polyethylene netting. Materials and Equipment Needed • EZflow Bundles • EZflow Geotextde Fabric • EZflow Internal Pipe Couplers • Pipe for Header and Inlet • Backhoe,Excavate, Installation Instructions The instructions for installation of EZflow products are given belnw This product must he installed in accomance with state rules defirec In cnapters Corrm 82 through 84, Wiscons,n Ad- ministrative Code, and Chapters 145 and 160, Wisconsin Stat- ues, as well as the local health department's current design manual. 1. After the local health department has determined .sizing, configuration, and layout for the EZflow systems, stake or mark with paint the location of trenches and lines. Be careful to set cored' tank, invert pipe, header line or dis- tnbutior, box and trench bottom elevations oefore instal- lation of pipe bundles. 2. Remove plastic EZflow shipping hags pnar to placing bundles in the trench(es) Remove any plastic tags ,n the trench before system is covered. 3. This product must have geotext,le tab,ic that meets re- quirements of s. Comm 84,30 (0) (Li). W=_. Adm Code, installed directly on top of the product and ex -tenting down along the s des of the product to a point at least six inches from the bottom of product. 4. When installed in a trench, the trench should be dug to a width of 36 inches. This not only saves labor in excava- tion, but also provides better load-beanno capacity after backfilling is complete. 1 EZflowry Ey INFILTRATOR 5. The Abscrptior area (SF) necessary for a given site shall be sized based on max mum daily sewage flow (GPD) and the Permeability for the site. If certan criteria is met, the EISA sizing can be used in Wisconsin, resultng in a 40�;, smaller drainfield. 6. Place EZflow oundle(s) in the EZflow confgurahon ap- proved by system design permit specified for the particu- lar site The top or center -mast bundles contaning pipe are joined end to end with an internal pipe coupler. Any addrhonal aggregate only bundles that may be required. should be butted against the other aggregate -only bun- dles and do not require any type of connection. 7. The top of each GEO cylinder contains a filter fabric pre - mar ufactured in between the netting and aggregate. The fabric is inserted to prevent sod intrusion. The installer shall make sure the the GEO is positnored upward and is in contact with the fabric con',ainec in the adjacent cylin- der before backfill.ng. 8. The EZflow Drainfield Systems should be installed i't a level hench in all directons (bcth a_ioss and along the trench bottom) and should follow the contour of the ground surface elevation (uniform depth), with all contnuous adjoining 10-foot cyl ndrical bundles placed end to end, with central bundle distrludbon pipe interconne-ted. without any dams, stepdowns or other water stops, 9 The trench top shall be graded such that water will not Pond, Backflll should be seeded or sodded immediately after completion to -edace erosion 10. EZflow EPS bundles are flexible and can fit in curved trenches as may be necessary to avod trees, boulders, or cther ocstack s. 11. EPS aggregate is lighter than water, therefore. it might be expected that natural buoyancy forces would tend to case EZflow assemblies to float out of ground when pending occurs. Field eypenence has shown, however, that this is not a problem when systems have a minimum rf 6" of sod cover as recommended by manufacturer 1203H-GEO l;entcx'i e i Material Page 9 In -ground Gravity Management Plan IMPORTANT: PAGE 4 OF 4 The owner of this in -ground gravity system shall be responsible for its perpetual operation and maintenance pursuant to requirements of SPS 382-384, Wisc. Admin, Code Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this system shall be considered a human health hazard if not maintainer in accordance with this approved management plan. Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in accordance with SPS 383.52 (3), Wisc. Admin. Code. Maximum Dispersal Area Operating Limits: Design Flow = 450 gpd; BOD5 5 220 mgL"; TSS 5 150 nri FOG 5 30 mgI_` Inspection Checklist INSPECT EVERY 3 YEARS o type of use o age of system o nuisance factors (i.e. odors, user complaints, etc.) mechanical malfunction (i.e., pumps, valves, switches, floats, etc.) material fatigue (i.e., leaks, breaks, corrosion, etc.) o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution / drop boxes) o neglect or improper use (t.e., exceeding design capacities, prohibited activities, etc.) c extent of ponding in distribution cell prior to dosing dosing irregularities - if applicable (i.e., pump re -cycling, float switch settings, etc.) n electrical components - if applicable (i e , wiring, connections, switches, controls, timers, alarms, etc.) distribution lateral or lateral orifice plugging (measure lateral distal pressure — compare to design specification) surface discharge of effluent or sewage back-up into structure served Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary) o Septic and dose tank(sl shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis. Slats. when the volume of solids in the tank(s) exceeds one-third (113) the liquid volume of the tank(s) or as required by local ordinance Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code. o Effluent filter(s) shall be inspected every 3 years and shall be cleaned when necessary to remove any accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12 months System maintenance reports shall be submitted to the proper local government unit in accordance with SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to: Name of individualor company: Schmitt & Sons Excavating, Inc. Phone. 715-760-0486 Local government unit: St. Croix County Community Developement Phone: 715-386-4680 Local government unit address: 1101 Carmichael Road, Hudson ZIP: 54016 Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin. Code. Repair or replacement of faded or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code. No product for chemical or physical restoration of the POWTS may be used unless approved by the department in accordance with SPS 384, Wisc. Admin. Code. Contingency Plan In the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to a plan submitted to the appropriate agency for review and approval. A failed in -ground dispersal component may be abandoned and replaced by a code -complying dispersal component in a pre -determined area of suitable soils. System Abandonment If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383,33, Wisc. Admin. Code. Page 10 S-r. CROI (-)LJN-t-Y SANITARY SYSTEM File #: „e- Office Use Only - OWNERSHIP/ADDRESS FORM Crerted 212021 Community Development Department will utilize this information to provide the property owner with information regarding operation and maintenance of your new or replacement sanitary system' This information will be provided as part of our ongoing efforts to protect public health, your well, groundwater, surface water, property values, and county resources. Once approved, this completed form and educational information will be sent to you by email. If ynu would like to vlPw your issued sanitary permit online, you can do so by using the Property Files Scawiod weblink OWNER/BUYER INFORMATION Owner/Buyer Timothy & Erin LaCoursiere Mailing address 851 Zane Grey Circle City/State/Zip Hudson, WI 54016 Phone Number (required) 651-214-4618 Email Address (required) Tim Lacourslere@hotmaiLcom Parcel Identification Number 020-1288-40-000 (found on the property tax bill) NEW SYSTEM: LEGAL DESCRIPTION iv r- Property Location SW 1/4 , SW 1/4 , Sec. 21 T 29 N R 19 W, Town of Hudson Subdivision Plat. Wells Fargo Station Lot # 14 Certified Survey Map # Volume Page # Warranty Deed # 1053100 (before 2006)Volume Page # Number of bedrooms 3 Spec house 0 yes ■ no Lot lines identifiable ■ yes 0 no OFFICE USE ONLY New Property Address xt+� (VenficaUo f new address regmred from Community Development Department for new construction ) (Staff Imtialsl (Date) This form must be submitted with all Private Onstte Water Treatment System (POWTS) applications New System: Include with this form 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. Community Development Department - Land Use Division 715-386-4680 St. Croix County Government Center cddt:_eewi_aoL, 1101 Carmichael Road, Hudson, WI 54016 715-245-4250 Fax tr., rascry_ty Page 11 i BENCHMARK: TS eF rcoT fc at 5E ALTERNATE BM: EPTIC TANK PUMP CHAMBER / Manufacturer: W4f'sme HOLDING TANK INFORMATION Liquid Capacity: /OD �/j Setback from: Well 5'2 ' House /t ' Other I/e , 7io.* &u -?..4 Pump: Manufacturer i[//1 Model# — Size Float seperation - Gallons/cycle:,-- Alarm SOIL ABSORPTION SYSTEM Width: /$" Length '/O� Number of trenches Distance & Direction to nearest prop. line: y3 to Setback from: well: 17 7 House L 1 ' Other Al _ 'rD T<w K ELEVATIONS Building Sewer6•5'0=/07-/� ST Inlet.(.?z`/0/-4z ST outlet %D2c /D/•bL PC inlet — PC bottom Pump Off -4 N 7• SS c l01-of Header/Manifold0z7r: 100.29 Bottom of system 8-10 = /00.1I6" Existing Grade Y, 70 = /D�LO� Final grade `/. iD AJANNarE a R;nS, 3.s0 = /Osvy, DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: / INSPECTOR: 3/93:jt 29. 19, N%t AT&?MhE SifftM OACH TR Labor and Human Relations "Sbfety and Budd ings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Permit Ho der s Name: U City Village Town o CST BM ev .1 , 4d, GC; Insp By E : ev /Ud BM Oescnpnorc �/ / C /'> TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Rosin Aeration Holding TANK SETBACK INFORMATION TANKTO P/L WELL BLDG. Ventto Airintake ROAD Septic Sv 15 NA Dosin NA Aeration NA Holding PUMP / SIPHON INFORMATION Manufa Demand Model Number GPM TDH Lift Friction System DH Ft Loss m Forceain Length Dia. H Dist Towel SOIL ABSORPTION SYSTEM ELEVATION DATA TtMnty Sanitary r rt State Pan W,: Parcel Tax No J-74 4S : y4S A9300055 STATION EIS HI FS ELEV Benchmark g �` Bldg Sewer St/ Inlet 9G �:r19 St Outlet Inl t Header/-Adar. YS 8 so' ,dy Dist Pipe G r? Bot. System Final Grade Er1/a!5.r r d 20 BED / TRENCH Width , Length No Of Tr nches ,Pfi— — f Pits Inside Dia Lrgwd Depth SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING uacturer: INFORMATION Model Number ORUNIBTER DISTRIBUTION SYSTEM Header I „ Distribution Pipes �, I x Hole Ize x Hole Spacing Vent ciAulnta e Length DIa length __,�7 Dia Spacing SOILCOVER st Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over 'I Depth Over I xx Depth Of xx Seeded/Sodded xx Mulched Bed) bmw* CenterYY �L— Bedw.e rah Edges Tupsoil ❑ Yes ❑ No ❑ yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 21.29.19,NE,SW, LOT 14, STAGE COACH TRAIJ, n� Plan revision required? Q Yes ly"ryo ��.�'-j�����Q'��� Useotherside for additional information. � n��--- SBD6710(R05r91) Date inspector's Signature Cert No I all SANITARY PERMIT APPLICATION CiiLHR Code COUNTY In accord with ILHR 83.05, Wis. Adm. STATE SAN ARV FEB M —Attach complete plans (to the county copy only) for the system, on paper not less than 8'1A x 11 inches in size. lon k) appligson ❑ w -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION. PROPERTY OWNER m/ S�j/y R PROPERTY LOCATION E '/a ''/a, S Z T N, R Zt E (or PROPERTY OWNER'S MAILINGrADDRESS LOTS BLOCK �-- B L e L / CITY, STATE 4DION I, ZIP CODE O/ PHONE NUMBER 38f. z�G9 SUBDIVISION NAME OR CSM NUMBER LIJJEION « s 7AR6o s7 0 It. TYPE OF BUILDING: (Check one) ElState Owned VILLAGE : njyST 6E CDAC/l 7AA/ L- ❑ Public ®1 or 2 Fam. Dwelling -#of bedrooms 3 ( 1 Ill. BUILDING USE: (If building type Is public, check all that apply) D z _ Z ye/— ! v 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranUBar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ® New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # — Date Issued V. TYPE OF SYSTEM: (Check only one) Non -Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specity Type 41 ❑ Holding Tank 12 N Seepage Trench 22 ❑ In -Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE AREA REQUIRED ft.) PROPOSED (sq. tt.) (Galslday/sq. tt.) (Min./inch) ELEVATION I Q (p Y3 %ZQ Q. % /0000'Feet 10Ar Feet VII. TANK INFORMATION CAPACITY in all Total Gallons #of Tanks Manufacturer's Name Prefab. �re Site Con- Steel Fiber- glass PtasOc Exper. �p New iatl Tanks Tanks st Setie Tank or Holdino Tank /009 Er SE Litt PumD Tank/Sihon Chamber Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No ) MP/MPRSW No.: Business Phone Number. k Sf.obf�.a .., �Z e-�C7 3z3� Plum 's Address (Street, City, State, ZIP CON1:10 1C�¢/ Ah d k0 IAJ'r 57dl IX. CO (DEPARTMENT USE ONLY Disapproved tary Permit Fee (ode r Froundwarer lesultp A nl ro Approved ❑ Owner Given Initial �� �^ X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL SBD-6398 (formerly Plb-87) (R. I IM) DISTRIBUTION: Original to County, One Copy To: Safety a Buildings Division, Owner. Plumber wmoo�. sWn Departnnnt of Industry. SOIL AND SITE EVALUATION REPORT (Z Page 1 of 3 Lsbof and Human Rslations Divisioo'of Sahy a Buildings ;•., ii uo on n. w:., Ate— r-A- OU Attach complete site plan on paper not less than B 1/2 x 11 inches in size. Plan must include, but C X PARCEL I.D. a not limited to vertical and horizontal reference point (BM), direction and % of alope, scale or dimensioned, north arrow, and location and distance to nearest road APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PT90EMYOVINER: ,�,/� ( a J �M ICO ✓: K PROPERTY LOCATION GOVT. LOT /V , 116 W ti/,SZ r T ZI ,N,R I g E fort W P ERTYOWNERS NGADDR? �Q b d> fCekd LOT,* BLOCKS SUED NAME OROEM Y S ATloN 1 CS CI ,STATE P CODE PHONE NUMBER ❑CITY ❑VILLAGE OWN NEAREST ROAD,t i i..) I LSON N New Construction Use ]p(] Resiclential / Number of bedrooms U N K ( ] Addition to existing building (j Replacement ] Public or commercial describe _trench, gpdrtt2 Code derived dairy flow god 750 *11 Recommended design loading rate 4 .i bed, gpdnt2,, e/ Absorption area required bed, ft2 trench, ft2 Manmum design loading rate Li.i bad, gpcf t'w. o trench, gpMt2 Recommended infiltration surface elevahon(s) QO It (as referred to site plan benchmark) Additional design! site considerations z 9 ,Do Parent material Flood plain elevation, it applicable fl $ Suitable for system U- Unsuitable for system C VFMIDNPL $❑ U �uND $1 S❑ U W RDUNO PRESSURE S❑ U AT- RADE S❑ U SYSTEM f'til ❑ S U HOLD T [Is Boring N w� Ground elev. /tk1 q/ It Depth to limiting fac -1-.2i Ground elev. Depth to limiting factor >/&eg— SOIL DESCRIPTION REPORT MW Remarks: N t ANt, 6 M69 Zp0S A AB S?AUCTyRC eIYL/•7 • 5�a �.� s AWMEMMOM0 0 ME ).6 .6. 1.4 PROPEAVOWNER'S hMILI-Cll- SOIL DESCRIPTION REPORT Page 2 of 3 PARCELIA.I (. LF S SAGO Ground elev. /Aj3t. Depth to lim ling > Boring # a Ground elev. IOL0t ft Depth to limiting factor > &.17 Boring # 15 Ground Btev. IQ,4¢tt. Depth to iimi6ng Ground elev. It Depth to limiting factor Horizon Depth in. I Dominant Color Munsell Wdles Ou. Sz. Cont Color Texture Structure Gr. Sz. Sh. Consistence Baniary Roots GPD/ft Bed ner& -3 Q 3 -- L / r Q 2 0A 3 !2 / I L 3 c a6k ll C 2 N>4 ? $ zzt !o — 5>C 3cgb NP z $z34 -u '/oYte§ — S n, J 7 , 7q .0q1114, v tnIL�)7�i:7t�©M i► MME a a ll Remarks: ©e me© 6 oMr,"O'KI'M ®ems® wMOon M Remarks: 68"M(A.05M) O.� M t.6 Vot-�i -----57•_` 5� 1 I �-3 I O 1 1 I 3z, _ Z' (Ido/) AA( Lar /4 W&-"F;gzo Sr t".nrJ I S7' / , 86n1cwwa2K- / /ir2nu P,ALr ar Le- Caa�e� LOT IS I LOT I Et;K«NDEttAys SAMMIILER WEll5 FARGo sTiti t-ol1�r SycTEMEI. PP.T.MAR Y A /DO,DD S'IS iEM Ei. ALTE Pt W = 99. Do' SLALE Vv"=10- o BORES (84tt MOE) �)BFNZ#MARK- I"PIPE AT S.E. CORNER EM [r LOT 114 2.I64 ACRES TSB' LOT NE CIRCLE P% Gw.roya- NOUSE av'KSa jQ XSO D e R I T weft IE �. /ya BER04MARk-11"1RoMAW ,4 r ar cc tN6R rcEVAT/ON = /oo"oD' 34 a i' 6 E p � '� I /8 I �w i 5' iils�✓ � � ^ I gi ya --M ' ` - 56 1 1 2 < tj ; ilk V � fW i v 1� N i I � r obi X COUNTY NO. 633341 STATE SANITARY PERMIT PLUMBER TOWN OF SEC Z i ,T 41 N, AND/OR LOT A 951 zopv- &ftv Gr< it xr??M_1L- PAVIOUS tAw�; LIC.# ZZ 3 7 BLOCK SUBDIVISION NO. 113Sq 7 ZcwE )C CHAPTER 145.135 (2) WISCONSIN STATUTES (a) The purpose of the sanitary permit is to allow installation of the private sewage system described in the permit. (b) The approval of the sanitary permit is based on regulations in force on the date of approval. (c) The sanitary permit is valid and may be renewed for a specified period. (d) Changed regulations will not impair the validity of a sanitary permit. (e) Renewal of the sanitary permit will be based on regulations in force at the time renewal is sought, and that changed regulations may impede renewal. (f) The sanitary permit is transferable. History: 1977 c. 168; 1979 c. 34,221; 1981 c. 314 Note: If you wish to renew the permit, or transfer ownership of the permit, please contact the county authority. AUT O ZED ISSUING OFFICER -DATE THIS PERMIT EXPIRES S JOZOZ.S UNLESS RENEWED BE O THAT DATE POST IN PLAIN VIEW VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION SBD-06499 (RI1/20)