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040-1005-60-000
H p360 Qo'. o� 4 ° 0 ts 4) m N o vco4)o m Q 0 o O U N j mN tl w yM co ti y E '�C m Cc y rn>.E m > o m ow O U N 02 a 0 m E.0 (D E N C wUU c p ° 4,5 LL E L mc ° v V y_ 3 a� �Y Q I cc -r 3 a v z w E rn Z j :.: 0 p z V 0 1 € 0 Cl) z a m a m _o o I E z v m z c c z N Z E o E v v Cl) �+LJ 4) I y I � � I •� v t p � L o I - I c c Q 0 Z Z O 1 0 Z Z O 'U N I d NI C141 E d co W d N O co W d N t O CL o C C a o� m c O O a U) m Z � > _ `° L a o n m o 0 0 0 Z o 0 o Z •N aan y aaa 5 CL N in � } = O O .- N N N LO }V C N y C O Z p _ 0 = 0 E p� _ E N v v l o o 0 O m c d 0 p=p C c a. U) ayi yl m n� ¢ in 0 d m Q n t4 is 0 .. I O `� p � ' O 0 H r H H o° o in c o E� w e $ v E ,n co 1 0 o O o a c c C rn ° v d o o ° o I CD M C j Y Y c-0 N N v O p O C N N C r a C O 7 C 7 w ►�i O N T CO co M '7 C T 9 N _ 1- S I� ao w�;�z. o o F= j `�° o v� m co R �c o o m o c6 • 0 ` C 2 5 0, z —gym 2 c (n vo Z U) zIL W C vt 45, € 1 1 a a o g ! �a�` maw m c d c o 0 3 3 oo 3 o _1 A c�IL Owc> 0 m0 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Divisiisn y INSPECTION REPORT Sanitary Permit No: 408225 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)1. Permit Holder's Name: City Village X Township Parcel Tax No: Skoog, Philip Troy Township 040- 1005 -60 -000 CST BM Elev: Insp. BM Elev:t BM Description: �� ft V i t7 t!"iTrr► -, o r— /'A' 1 D - . TANK I FORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. t Septic Alt. BM Benchmark D n Its s I r w — -b Dosing / l W*' 1 3 l I + • � O - t>aS V__ Aeration /J Bldg. Sewer '5 y Holding St/Ht Inlet - ' ' TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Sp Dt Bottom is�n R u m p 13.3 glv • 3 Dosing , Header/Mari. q 3 j t 60 3 Aeration _- Dist. Pipe ' C 6 Holding Bot. System _ ► ,.5' 4, q s` a r a� �t y ,I/ PUMP /SIPHON INFORMATION Final G r o'� t 4 3 c i / - Manufacturer Demand St over GPM Model Number S C O 46uA_Y- -� V 5 .s T / (0 TDH Lift r Friction L s System Head i TDH G I Ft 3 / -G —)- Forcemain Length Dia. Dis . to Well ., 1 ©U' Z N fSI� SOIL ABSORPTION SYSTEM BED/TRENCH Width Lengui No. if T�pnchqs PIT DIMENSIONS No. Of Pits Inside Dia. r epth DIMENSIONS —�' SETBACK SYSTEM TO P/L � BLDG WELL LAKE /STREAM LE � Manufacturer. INFORMATION Type��System: ` / Model Num r: DISTRIBUTION SYSTEM j 6 ; Hole Spacin Header /Manifgld Distribution 1� x Hole Siz x e it Intake f 11 l' Pipe(s 1, I / ��-61,71 f / /g V Length Dia Length Dia Spacing SOIL COVER t x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over _ , c� J Depth Over xx Depth of 7/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges ' n [I Topsoil / _ k -, — - 1 Yes No J Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / Inspection #2: 0 _ Location: 667 Deerwood Hudson, WI 540 J 6 (NE 1/4 NE 1/4 3 T28N RR119W.�) NA Lot 46 Parcel No: 03.28.19.33G 1.) Alt BM Description = hJ /A A PT. f � I S J 2.) Bldg sewer length = 1� - amount of cover 3.) Contour = revision Plan ( o Useothersideforadditionalinformation. Date Insepctor's Sig ture Cent. No. SBD -6710 (R.3/97) Safety and Buildings Division County t 201 W. Washington Ave., P.O. Box 7162 '1? N* 6co'nstn Madison, WI 53707 - 7162 Site Address OF De artment of Commerce 1/ 7- Sanitary Permit Application Sanitary Cp9z'� - In accord with Comm 83.21. Wis. Adm. Code, personal information you provide ❑ Ch if Revision may be used for secondary ses Priva Law s15. 1 m I. Application Information - Please Print All Information R Ptah I.D. Num Property Owner's Parcel Number ` JUL 0 1 2002 �`Jp '� /00 , tom- rl Property Owner's A s Property Location 'sr.U,0ix.couc�i; r f ; S W N. 7 E City. State Zip Code Phone Number Lot r Block Number 33 Subdivision Name CSM Number aj, of Building (check all that apply) ❑City • 1 or 2 Family Dwelling - Number of Bedrooms -/���� lV�' ❑Village ❑ public/Commercial - Describe Use p ❑ State OwnW rNeares Road III. Type of Permit: (Check o box on line A (numbering scheme for internal use). Complete line B if applicable) A. For County use 1 ❑ New 2 e went System 3 ❑Replacement of 6 ❑ Addition to sum Tank Onl Eris ' stem B. 1 ❑Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Ty pe of Permit: (Check all that apply)(numbering scheme is for internal rise) 51 Tec, � 44 ❑ Non - Pressurized In-Ground i�Iound 47 ❑ Sand Filter 50 ❑ Constricted Wetland 22 ❑ pressurized In-Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line 45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other V. D' eatment Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rau System Elevation Final Grade Required Proposed Rate(Gals./ Days /Sq.Ft) (Min./Inch) Elevation (,Jv VI. Tank I Capacity in Total Number Manufacturer Prefab Site Steel I Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank - Dosing Chamber VII. Responsibility Statement- I, the undersigned, responsibility for installation of the POWTS shown on the attached plans. Plumber' Name (Print) Plumber's MP/MP ZS N urnbep Business Phone Number ti Plumber's Address (Street, City, State VIII. Count /De artment Use Onl Sanitary Permit Fee (includes Groundwater Date Issued Issti Agent Signature (No Stamps) l Approved ❑ Disapproved Surcharge Fee) El Owner Given Initial Adverse Determination IX. Conditions of Approv ` easons for Disappr val AM 4 ,,, � e>eu,�.a� v - c 'G `( a a Ak Attach comp e p a o e 7 of em esa x 111achea size S• pp�� SBM398 (R. 05101) r PLOT LAN .,-VT Phil Skooa RESS 667 Deerwood Drive Hudson Wi 54016 f 1/4 NE 1/4s 3 /T 28 19 w TOWN Troy COUNTY ST. CROIX 6/8/02 BEDROOM 4 4-PRS Shaun Bird 226900 DATE CONVENTIONAL AT-6 CONVENTIONAL LIFT HOLDING TANK MOUND XXX SEPTIC TANK SIZE 1200 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 600 # of chambers none IL BENCHMARK V.R.P. Base of Siding ASSUME ELEVATION 100° Filter Sim -TEC ❑ BOREHOLE O WELL sH.R.P. Same as Benchmark SYSTEM ELEVATION 95.6 Deerwood Drive 0 0 Scale = 1/4 = 10' a Grading is to be done to divert run -off away from system / (D ✓ Existing mound is to be removed, owner wants to install shed at current mound location Existing Mound W II Force Main Existing 4 Bedroom House M' B-3 9 5' D 94 Tanks were inspected on 3 ' 6/8/02 by ST 92' Shaun Bird B- B-1 DT Force Main 10% Slope 1-aw t") ` New pump, floats, Area 15' Below System is to and alarm is to be be left undisturbed installed Safety and Buildings ' 10541 N RANCH ROAD HAYWARD WI 54843 s TDD #: (608) 264 -8777 J, scon swn www.comme w . wisconsin.gov www.wisconsin.gov Department of Commerce Scott McCallum, Governor Philip Edw. Albert, Secretary June 24, 2002 CUST ID No.226900 ATTN.- POWTS Inspector SHAUN R BIRD ZONING OFFICE BIRD PLUMBING, INC ST CROIX COUNTY SPIA 1008 192 ND AVE 1101 CARMICHAEL RD NEW RICHMOND WI 54017 HUDSON WI 54016 CONDITIONAL APPROVAL Identifi 7 Numbers PLAN APPROVAL EXPIRES: 06/24/2004 Transaction ID No. 757720 SITE• Site ID No. 646261 Phil Skoog Please refer to both identification numbers, 667 Deerwood Dr above, in all correspondence with the agency. . Town of Troy, 54016 St Croix County NE1 /4, NE1 /4, S3, T28N, R19W FOR: Replacement mound, 600 GPI) Object Type: POWT System Regulated Object ID No.: 856446 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: General Approval Conditions: P C • This system is to be constructed and located in accordance with the enclosed approved plans and with the Coija "Mound Component Manual for Septic Tank Effluent for Private Onsite Wastewater Systems - SBD- 10691 -P ( N.01 101) and the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment p l- F& MEN Systems" SBD- 10706 -P (N.01101). 01 igt ' SAF • In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. In a3dition, the owner must insure that the operation, maintenance and monitoring duties as described in section VIII of S -E CCIIjRE the mound component manual are complied with. A copy of this information must be given to the owner upon completion of the project. • A Sanitary Permit must be obtained from the county where this project is located in accordance with the " requirements of Sec. 145.135 and 145.19, Wis. Slats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Slats. • The maintenance plan for this system must be given to the owner of the POWTS. Key Item(s) • The actual liquid level for the specified pump tank is 39" and the capacity is 26 gallons per inch per product approval. The proposed pump settings have been adjusted provide a dose volume that is greater than 5 times the void volume and less than 20% of the design wastewater flow plus drain back. SHAUN R BMD Page 2 6/24/02 Note • The existing septic tank must be inspected for structural soundness, size and baffles and must be brought into conformance with the requirements of COMM 83, Wis. Adm. Code. If it does not conform a state approved tank must be installed. • The designer proposes to install a state approved effluent filter to achieve the requirement of wastewater particle size. Pursuant to outlet filter product approval stipulations, maintenance information must be given to the owner of the POWTS explaining that periodic cleaning of the effluent filter is required. The access opening used to service the filter shall terminate at or above finished grade with a watertight cover. Reminder • The orientation of the mound system must be such that the longest dimension is oriented along the surface contour per COMM 83.44(6)(a)2. • Limit activities in the area 15' beyond the down slope edge of the mound per Mound Component Manual. • Surface water drainage shall be diverted away from the system area per Mound Component Manual. • Materials shall conform to the requirements of COMM 84. • Holes must be drilled with a sharp bit and all burrs and foreign matter removed before installation. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. z(715)634-7810, Fee Required $ 175.00 Fee Received $ 175.00 k(715) Balance Due $ 0.00 " d ervices WiSMART code: 7633 150, M -F 7:45 am - 4:30 pm pshandorf @commerce.state.wi.us cc: Leroy G Jansky, , Wastewater Specialist, (715) 726 -2544 I Cover Page Shaun Bird Bird Plumbing Inc. 1008 192nd Ave New Richmond Wi 54017 715- 246 -4516 .6/8/02 Owner: Phil Skoog System type: M nd System Ma Is Use ound Component Manual version 2.0 (01/31) Pressure Distribution Manual version 2.0 (01/31) Page# 1. Cover Page 2. Mound Plot Plan 3. Mound Cross Section W T 's. 4. Pipe Cross Section /Pipe Layout ition,711y . PFC Y6 1 5. Pum P Chamber Cross Section 6. Pump Curve _ry_,_... +a 7 -9. Maintance and Contigency plan --;- 10-12 Soil test 'PONDENCE Signature License nur{i 226900 6/8/02 PLOT LAN PROJbCT Phil Skooa RESS 667 Deerwood Drive Hudson Wi 54016 NE 1/4 NE 1/4s 3 /T ;28 / 19 W TOWN Troy COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 6/8/02 BEDROOM 4 CONVENTIONAL AT- ADE CONVENTIONAL LIFT HOLDING TANK MOUND XXX SEPTIC TANK SIZE 1200 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 600 # of chambers none BENCHMARK V.R.P. Base of Siding ASSUME ELEVATION loo' Filter Sim -TEC ❑ BOREHOLE (DWELL *H.R.P. Same as Benchmark SYSTEM ELEVATION 95.6 Deerwood Drive A O O Scale = 1/4 = 10' O Grading is to be done to CD divert run -off away from system C •/ m Existing mound is to be removed, owner wants to install shed at current mound location Existing Mound Well �-- Force Main 0 Existing 4 Bedroom House M ' B-3 9 5' ;F Tanks were 94' inspected on 3' 6/8/02 by ST Shaun Bird 9 B -1 DT Force Main B- 10% Slope New pump, floats, Area 15' Below System is to and alarm is to be installed be left undisturbed vase gne��^'! No 4" Observation Pipe perforated Non -Woven Filter Fabric Below Filter Fabric Distribution Pipe / ASTIt C -33 Sand t �✓ " Topsoil '� o [ /0 0 / 0 slope l� w Bed Of Ir 2 t [ For ce Main ��Fl owed Drain Rock From Pump Layer Q , ' Cross Section Of A Mound • Systtrn Using E A Bed For The Absorption Area F G v �k A Ft. (D d s Ft. I Ft.- J 7,? Ft. - - K. al Ft. } ,r L /DO- Ft . 4 Observation Pipe os A J �o - - - -- ----- __ - - - - -- --------------- - - - - -- t Farce Moin _._._.{..._ .._.— - - - - -- From Pump • ; -s ° Oistrlbution Bed Of 7 2 \ Pipe Drain RocK I p 4 Observation Pipe Permanent Marker Pipe or Rods Plan View Of Mound Using A Bed For The Absorption Area PAGE OF Perforated Pipe Detait r End View )Peftoroteo PVC P6pe Halts Located tM Bottom. �•,�/ Art Equally $pocea A � P � + P ASf V PVC Force Main (. ftRST VWbLL JJJLXT t'6 CADFU'AC+6f PVC Manifold Pipe �� Sf � D j,� gislriouhon Pipe 4."/L - fr,g - , Distribution Pipe L ayout P � F --R Ft. X Inches Y Inches Signed: Hole Diameter o� -inch License Number: Z 6 Lateral Inch �_._� Manifold " .� Inches_ Date Force Main Z Inches # of holes /pipe..27 Invert ElevAtion of Lan r �bJ e als� Ft. f ►� ► Art •.AI.s wr 3S• �.rr JV' VCWT CA t WtAT�ff�tPRODF t4 *AO!w OOCR. i .:yVG".*Aj sox # A Plk jVta LOtIttAJG raffaw *J�+O�t C ovt� t.rA r;P"ANQ • � � I ORACC dL t i M'KfN. �yl.t T rROvrC; � AtRTfQKT fCA� � } "'"' ••+• i � t; w�.Aitiw caic t't JOINTSEbiITH mom APPMEO P I PE 3' ONTO oump o SOLID SOIL GdutcRtTl iWCK RIiCil tkiT RtRMttlrta OULY tN '1'AIi,IK �"�AWirACTtfRf:R MAIN L1ii4N !►l►i'RpYA� ft mot iIOR; /ht� v Ai1.Sfibt�t Of DGiti: ��R � dALl.Otrii d4iti�r YOLNMR w�►ACt �IrRtA: - -1/�°- ,fir rwau��b 6^c+tRLews 3 • s �' A�fr AiYM�fZ�. � L �i• CAlACitJ�A s��iyC11Cf � G��P GWITe" ?lofts ��� ✓ ' AWrACli1��0� G� fii ii of MoOtf. u1�4MtRR: S `� C * walitw Ou W t tC M Ty►O � rt 0 � tApC r►Rt dR �•� i.irlGr.. fM�.LOHt +�fWtirtYM 01ftCKA «� sTm. Puma Awo a ARt Te ac GOA #W461. O sto^i;A asita4srf vcar�cr►L QFrrtRSiwii at'C�l!►tirt *w� t i}TRtf 'r.'au Pi. ,, 49, / 'ate + rtrw�xu+�l AiCTMt41tK guPri.$ Nttjj/uR! , ....... , : '. ... s r Y � rciT Oft r0099 PMti 4" 4MAI. d {if#tialdai •MAM 4t;N6TMs "' — U I Engineering Details - SHEF40 n MEMO 9 no - -" No No 07 LOW t ! r ! r s a ! r - X ;`, I s i • PENTAIR PWIP GROUP -f®r Maintenance and Contingency Plan for a Mound System Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Dose Chamber is to be pumped at the same time as the septic tank. 3. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in order to extend the maintenance interval of the filter. 4. Once every 3 years the mound is to be inspected via the inspections pipes in the at- grade. The laterals are to be inspected via the cleanouts. 5. Owner agrees to limit greases, garbage, and water conditioner discharge into the system. 6. Pump and electrical components are to be checked at the time of the pumping. 7. Owner agrees to leave the area 15' below mound undisturbed. 8. The owner agrees to save this plan. 9. Trees, shrubs, and other similiar vegitation are not be planted on system. The system is not be driven over. 10. Effluent Quality is not to excede the requirements found in Comm. 83 Contingency Plan 1. Pump alarm goes off, call pumper and pump out dose chamber and septic tank if needed, then bypass pump float and try pump with out float. If this works, float is bad, replace float. If pump still does not work, check power at the pump with a electrical device such as a hair dryer. If no power, check breaker inside house and call a electrician. If there is power, then pump is bad and needs to be replaced by a plumber. 2. If mound fails, determine cause of failure, test another area or remove pipe and sewer rock, retill soil, install new mound system. 3. Replace any other failing components as needed. Important Phone Numbers Plumber: Shaun Bird 715- 246 -4516 Pumper: Tom Mondor 715 - 246 -5148 St. Croix County Zoning 715 - 386 -4680 Shaun Bird #226900 6/8/02 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pa of FILE INFORMATION SYSTEM SPECIFICATIONS E wner a Septic Tank Capacity al 13 NA # V Sep tic Tank Manufacturer ClN ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer 51 74 d ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model r �,� ❑ NA Number of Public Facility Units NA Pump Tank Capacity 0 d al ❑ NA Estimated flow (average) gal/day Pump Tank Manufacturer l B 00y ,/ ❑ NA Design flow (peak), (Estimated x 1.5) 6 g al/day Pump Manufacturer Gl /OG ❑ NA Soil Application Rate A 0 al /da /ftZ 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 (SOD X220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) <_150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L ❑ (n- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L A ❑ At -Grade >Kmound Fecal Coliform (g eometric mean) 510 cfu /100m1 ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other ❑ NA Other: XNA Other. ❑ NA *Values typical for domestic wastewater and septic tank effluent. ref: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA ear(s) 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: ?j ❑ year(s)month(s) (Maximum 3 years) E3 NA Clean effluent filter At least once every: S 13 Yea�� l(s) ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA years) Flush laterals and pressure test At least once every: 3 month(s) ❑ NA Year Other: ❑ month(s) A At least once every: ❑ 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, shall 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. GMW (4/01) ,• rage of II I START QP AND OPERATION For new construction, prior to use of the POWTS check treatment tankis) 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 tanks} 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 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 seated. • 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. Baffing 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 r `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. and and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems 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 ����/ Name Phone 1 j -,, ��� L Phone [Z.4 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone 71 Phone , .��j� - 6 83.54 11, (2) & (3), Wisconsin Administrative Code. This document was drafted in compliance with chapter Comm 83.22(21(b){1) {df & {f) and ( -Z Wisconsin 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 on paper not less than 8 1/2 x 11 inches in size. Plan must r 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. Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). co, Property r // Property Location />_)! J 3 / � Govt. Lot � 1/4 1/4 S �f N E (o W Property wner s Mai il ling Address Lot # , Block # Subd. Name or CSM# City tate Zip Code Phone Number ❑ City ❑ Village Town Nearest Road ❑ New Construction Use. Residential / Number of bedrooms Code Terived design flow rate d GPD eplacement ❑ Public %c - Describe: Parent material �g1�jJ � Flood Plain elevation if applicabl ft. General comments and recommendations: !:Iy5 fiL y S, JUN 1 1 2002 ` ST. CROIX COUNTY � ZONING OFFICE F/ I Boring # ❑Boring Pit Ground surface elev. � ft. Depth to limiting factor f in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD1ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 ® Boring # � Boring /� a pit Ground surface ele ' ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 O� Air 3 5' ,„ Z Z ' Effluent #1 = BOD > 30 < 220 mg/L and TSS >3 _ 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number Address D e Evaluation Conducted Telephone Number SBD -8330 (R07 /00) Y Property Owner Parcel ID # Page of _ Boring # Boring 0 Apit 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 Qu. Sz. Cont Color Gr. Sz. Sh. *Eff#1 *Eff#2 /V. dc Ali F-1 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 /ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *Eff#1 *Eff#2 F-1 Boring # ❑ pit Boring ❑ 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 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. SBD -8330 (R.07 /00) r - ' Soil Test Plot Plan Project Name Phil Skoog Shaun 4Bir Address 667 Deerwood Drive Hudson Wi 54016 csfm #226900 Lot 4 6 Subdivision - ---- -- Date 6/8/02 NE 1/4 NE 1/4S 3 T 28 N/R 19 W Township Troy FJ Boring ()Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Base of Siding System Elevation 95.6 *HRpSame as Benchmark Deerwood Drive 0 o Scale = 1/4 = 10' O -D CD CD Existing Mound /Well Force Main 0 Existing 4 B.M. Bedroom House B-3 95' 94' 93' ST 92 B -2 B -1 DT 10 °l° Slope ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM I I Owner/Buyer Tcj&L S KoQq Mailing Address li Property Address A (Verification required from Planning Department for new construction) I I City/State ----------- Parcel Identification Number 1 6 s � 60 ` 9) d LEGAL DESCRIPTION r y� Property Location `,, Sec. -R W, Town of r i # Subdivision Lo i Certified Survey Map # '� 2 `` 1 , Volume / . ,Page # Warranty Deed # ` Volume Page #/ Spec house ❑ no Lot lines identifiable es ❑ no SYSTEM NANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than I/3 full of sludge. Vwe, 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 Zoning Office within 30 days of the three year exp lion date. 6PA i IAI (0/ SIGN OF PLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. CA i Y � I ( n a 6 / 6 / De- SIG OF PLI ANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed r i t ST_ CROIX COUNTY ZONING OFFICE CERTIFICATION STAMM= FOR UTZLIZA.TION OF AN EXISTING SEPTIC TANK This irre to certify that I have inspected the septic tank presently serving tk►e � Ai S K o • residence located at : /, -_3f, L 9eC . � i , T2- X, R_W, Town, of , St. Croix County, Wisconsin. Upon inspection, I certify t t I have found the tank and baffles to be in good aooditiou, and it appears to be functioning properly. Last time serviced Did flow back occur from absorption system? Yes __.. 3io-!!�, (if no, skip next line. Approximate volume or length of time: gallons � minutes Capacity: /2-00 Construction: Pr Concrete - Steel Other Manufacture tit known) 422idw 4 Age of T if known) . tie - t z$ ;Name, Please Fr nt rnP2 2 -,�,769aQ 71 T T UM7 - (LicWhae Number Date) Forst to be campleted by Ucenved plumber (s 14S-1D6, Wisconsin statutes) or licensed disposer (NA 113 Wisconsin Administrative Code) Flurj*er (applying for sanitary permit) Certification: In accepting the above statement regarding exist' g aspt.ic tank condition, 1 certify that the tank, to the beast of my kno Sage, will conform to the requirements of ILUR 83, Wis_ Adm. Code (e:xae for inspection opening oYer outlet baffle) . ` Name � �,'. 1 3 i.��l' s ignatur MF /MPRS — 2- z VOL 1407PAcc595 STATE BAR OF WISCONSIN FORM 2 — 1982 KATHLEEN H. WALSH WARRANTY DEED I� REGISTER Of DEEDS DOCUMENT NO. ST. CROIX CO., WI - °= 11 RECEIVED FOR RECORD Eric D. Lawson and Judy M. Lawson, 03 -03 -1999 9:30 AM husband and wife, i WARRANTY DEED i EXEMPT I CERT COPY FEE: conve and warrants to _P h 111. COPY FEE co . y p R _ Rknnq and .Tnd i T. _ I' TRANSFER FEE: 706.50 Sknii hunhand and w fo an c rrvivet Rh1p RECORDING FEE: 10.00 marital prci arty, PAGES: 1 I jl THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in qt.. C rn i x County, State of Wisconsin: DAVID J. - ESTREEN j 304 LOCUST ST. �j HUDSON, WI 54016WI Sou 040-1005-60-000 PARCEL IDENTIFICATION NUMBER '! i. That art of NE1 /4 NE1 /4 Sec. 3- T28N -R19W described as follows: of 46 of Certified Survey Map recorded in V ol. 1 of Certified Survey Maps P age 1 as Doc. No. 326194. I! it I �I I II I This 18 homestead property. 'I (is) xxx&x j Exception to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this L "� day of February A.D., 19 99 II (SEAL) QV a (SEAL) i Eric D. Lawson u y M. Lawson i C (SEAL) (SEAL) I; j'. r I, AUTHENTICATION ACKNOWLEDGMENT .i It ii Signature(s) Eric D. Lawson, State of Wisconsin, 65. Judy M. Lawson � County. authenti ledthis�� day of February 19--9 personally came before me this day Of `! ` ' 19_, the above named i! 1 '/Ti Krist na O TITLE: MEMBER STATE BAR OF WISCONSIN (If not, ii authorized by 1706.06, Wis. Slats.) to me known to be the person who executed the foregoing instrument and acknowledge the same. ii THIS INSTRUMENT WAS "DRAFTt'U'HY Attorney Kristi Oglan I. W Notary Public Cou nt y , '! Hudson, W 54016 , ry Y (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date: necessary.) 19 J 1 • Names of persons signing in any apacay.should be typed or Printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wmcornh. Le@°L�ank CO tnc. ... Foiin No: 2 - 1982' , _ .:. .... ._....., 'MAG4ikae wg: ;, "' ~ Fit ED 0% APR 1 1975 0"6 O' CONNELL 0) It mw M Deeds S; Cr oix k�t cnr NE COAMER SECTION 3 26 N,Rtow CURVE DATA M z M M R + 4O T' O OUTMERLY RIGHT-OF- e • IE*OE'40" �- WAY LINE L : 632AW W —% — T.B.sSO.09'40 "W N � s f #,go 347.91' 351.16' s r . 0 ., e 0' \ ci ?': z a , 4g' \ � 0 N W \ 2 NE 1/4- W' 1/4 ~ " R 0 �x `�\ p RIGHT OF WAY LINE O 4 4 ,� 45 = c 46 47 0+ e '5.02 ACRES N 5.01 ACRES F N 5.Q2 ACRES \ ` t z • •_ z • 135 - 28' 10.. "' ' 46 2IO.Od 33' WESTERLY R16NT OF VAY LINE 90" 347. 33 1.08' 406.64 1 I WEST 1 POINT OF BEGINNING 1 ES c TRUE BEARING I 66.02' Safety and Buildings ` 10541 N RANCH ROAD A HAYWARD WI 54843 , TDD #: (608) 264-8777 EC E V® www.commerce.state.wi.us /sb us /sb www.wisconsin.gov Department of Corn erce JUN 2 4 2002 Scott McCallum, Governor Philip Edw. Albert, Secretary ST. COIX COuiv T Y ZONIfVG OFFICE June 24, 2002 CUST ID No.226900 ATTN: POWTS Inspector SHAUN R BIRD ZONING OFFICE BIRD PLUMBING, INC ST CROIX COUNTY SPIA 1008 192 ND AVE 1101 CARMICHAEL RD NEW RICHMOND WI 54017 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 06/24/2004 Identification Numbers Transaction ID No. 757720 SITE: Site ID No. 64 6261 Phil Skoog Please refer to both identification 667 Deerwood Dr numbers, above,;,,, in all Town of Troy, 54016 correspondence with the agency. St Croix County NE1 /4, NE1 /4, S3, T28N, R19W FOR: Replacement mound, 600 GPD Object Type: POWT System Regulated Object ID No.: 856446 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: General Approval Conditions: • This system is to be constructed and located in accordance with the enclosed approved plans and with the "Mound Component Manual for Septic Tank Effluent for Private Onsite Wastewater Systems _ SBD- 10691 -P ( N.01/01) and the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems" SBD- 10706 -P (N.01/01). _ • In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. In addition, the owner must insure that the operation, maintenance and monitoring duties as described in section VIII of the mound component manual are complied with. A copy of this information must be given to the owner upon completion of the project. • A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. SHAUN R BIRD Page 2 6/24/02 • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. • The maintenance plan for this system must be given to the owner of the POWTS. Key Items) • The actual liquid level for the specified pump tank is 39" and the capacity is 26 gallons per inch per product approval. The proposed pump settings have been adjusted provide a dose volume that is greater than 5 times the void volume and less than 20% of the design wastewater flow plus drain back. Note • The existing septic tank must be inspected for structural soundness, size and baffles and must be brought into conformance with the requirements of COMM 83, Wis. Adm. Code. If it does not conform a state approved tank must be installed. • The designer proposes to install a state approved effluent filter to achieve the requirement of wastewater particle size. Pursuant to outlet filter product approval stipulations, maintenance information must be given to the owner of the POWTS explaining that periodic cleaning of the effluent filter is required. The access opening used to service the filter shall terminate at or above finished grade with a watertight cover. Reminder • The orientation of the mound system must be such that the longest dimension is oriented along the surface contour per COMM 83.44(6)(a)2. • Limit activities in the area 15' beyond the down slope edge of the mound per Mound Component Manual. • Surface water drainage shall be diverted away from the system area per Mound Component Manual. • Materials shall conform to the requirements of COMM 84. • Holes must be drilled with a sharp bit and all burrs and foreign matter removed before installation. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation /operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. 9 p Y 9 Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. t SHAUN R BIRD Page 3 6/24/02 The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 Patricia L Shandorf POWTS Plan Reviewer, Integrated Services (715) 634 -7810, Fax: (715) 634-5150, M -F 7:45 am - WiSMART code: 7633 4:30 pm pshandorf @commerce.state.wi.us cc: Leroy G Jansky, , Wastewater Specialist, (715) 726 -2544 P STC - 104 AS BUILT SANITARY SYSTEM REPORe OWNER C k l Q ADDRESS SUBDIVISION / CSMI LOT SECTION T N -R W, Town of —��— ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 0 e e r L a6 h y� 0 yged. .. t 30 I,�vv /oa t p INDICATE NORTH A ROW "Pe Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. i R BENCHMARK 6 I rl S ice L ALTERNATE BM: SE C TANK / PUMP CHAMBER HOLDING TANK INFORMATION Manufacturer: re(4 .�� Liquid Capacity: Setback from: Well D House Other Pump: Manufacturer �Olc /A Modell LO Size / Float seperation �0 Gallons /cycle: 9-?o, n �I Alarm Location SOIL ABSORPTION SYSTEM Width: Length �� Number of trenches A��J�S Distance & Direction to nearest prop. line: 1 ► Setback from: well: House Other ELEVATIONS Building Sewer ST Inlet. ST outlet PC inlet PC bottom Pump Off Header /Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: / LICENSE NUMBER: 3 0 �1 INSPECTOR: 3/93:jt '�Nil�tr►rYi�r� drtrrreTtt6 IndG r y 28.19.33G I 5 RR&'TE 5E %AGE SYSTEM ount Y Labor and Human Relations INSPECTION REPORT Safety arad Buildings Division 5T_ rROTX (ATTACH TO PERMIT) Sanitary Permit No.: GE NERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 04Q-100-9- 0-000 r TANK INFORMATION ELEVATION DATA A9200389 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic i t , 1�, to y, /, » _ a j Benchmark 103, (14) t Dosing 01 Ix J Aeration Bldg. Sewer Holding St /Ht Inlet // TANK SETBACK INFORMATION St/ Ht Outlet l,�? TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet / t 0 Air Intake Septic >a5 >i ��r y � NA Dt Bottom aa 60 COC Dosing y _ t ',�,' t NA Header /Man. /9� /6a,.3/ Aeration NA Dist. Pipe Holding Bot. System PUMP / SIPHON INFORMATION Final Grade Manufacturer a Demand a° �"' _ k , Model Number I C !J3 ati ��� GPM . , /, �.9� e,& q $ TDH I Lift !?� Lrictioll�(� System TDH� Ft ��kk head Forcemain Length Dia. Dist. ToWelrjt� s SOIL ABSORPTION SYSTEM BED/TRENCH Width Lengt No.O�Xenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS IMEN I N SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type Of r Moe Number: System: fn,��zAA !G > 50 , X50 /'✓ OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length GY , Dia. 1 _ Spacing _ Ilq 6 >56, SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over !tfi�t Depth Over xx Depth Of xx Seeded/ bedded -- xx Mulched Bed /Trench Center \U Bed /Trench Edges \�` Topsoil Yes ❑ No Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY 03.28.19.33G, NE,SE, LOT 46, DEFRWOOD LAND ._'. -/0 e T - al*- /tlf Plan revision required? ❑ Yes [D No i/ 17 7 Use other side for additional information. - 7 P3 1 fir/ lc SBD -6710 (R 05/91) Date ('' In�pekior's Signature Cert No. r ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 3 i 1 LLHR S ANITARY PERMIT APPLICATION ZE '.,..,.,.,...,�. In accord with ILHR 83.05, Wis. Adm. Code COUN� , 1 � ) STATE SA TARY PERMIT # - Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. ❑ rev si a lt ious application - reverse side for instructions for completing this application. T PLAN 1. NU B R 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. 3 PROPERTY OWNER PROPERTY LOCATION © .. � /a /a,S �N�R E� W PROPERTY OWNE 'S ILIN ADDR / LOT# BLOCK# Cl 6 YE t2 TY, TATS ZIP CODE PHONE NUMBER SUBDIVISION NA OR CSM UMBER so 1 - 5 y ol� 1 y".) ri CITY 11. TYPE OF BUILDING: (Check one) El State Owned VILLAGE I, t NEA�0 g D ❑ Public � 1 or 2 Fam. Dwelling -�# of bedrooms PAR ELT NUMBER(S) ' (( L 1 , Ill. BUILDING USE: (If building type is public, check all that apply) /`^o Iq 1 El Apt/Condo [/ C/ �j 2 ❑ Assembly Hall 6 ❑ Medical Facility /Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales /Repairs 11 ❑ Restaurant/Bar /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 P Mound 30 ❑ Specify Type 41 ❑ Holding Tank El 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 13. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PRO SED (sq. ft.) (Gals /day /sq. ft.) (Min. /inch) n ELEVATION 5 oo ew „ e- 4 joc Feet Feet VII. TANK CAPACITY Site in g alIons Total # of Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name C oncrete Con- Steel glass App App Tanks Tanks strutted Septic Tank or Holdin Tank p© I N Z f C Lift Pump Tank/Siphon Chamber ABI> r 1 Vlll. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plu ignature: (No Stamps) MP /MPRSW No.: Business Phone Number: 4n 3d' d 9 Plumber's Address (Street City, 'State, Zip Code): !Q IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued ss A awreiNo Stamps) Surcharge Fee) W Approved ❑ Owner Given Initial _ Adverse Dete rm ination X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: ' SBD -6398 (formerly Plb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber - - - INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your'sahitaryl permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD 6399) to be submitted to the county prior tgtinstallation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608 - 266 -3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of . where the system is to be installed. II. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. , VI. Absorption system information. Provide all information requested in ##1 -7. VII. Tank information, Fill in the capacity of every new and /or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8'f x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a , 5 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of ) fees surcharges for a number of 9 (fees) regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. i I SBD -6398 (R.11/88) La son n nti� Ta IoLJ►� S � 'Dee LN be fl r �) tl a°S ► (00 Fi t` y 6 t�Q5%c Q.nce AV S eP l f �r►� � �' T oQ e 0 Pb f-r S py c r A p f 3 Acre- r o rC C PRIVATE, SEWAGE SYSTE �v o 1 Conditionally Is APPROV DEPT. Of INDUSTRY, LABOR & HUMAN RELATIONS DIVISION Of SAFETY AND BUILDINGS �� J 14,41 � ,n SEE CORRESPONDENCE 3D3 Page _ Of _ • t Straw, Marsh Hay, Or Synthetic Covering Distribution Pipe Medium Sand _ H _ G 6 Topsoil p _J E - -- �1 D i u 2. % Slope Bed 01 2 2 %2 Force Main Plowed Aggregate Layer (6 Below Pipe) D Ft. Cross Section Of A Mound System Using E 1 2 Ft. A Bed For The Absorption Area F .1$ Ft. G 1,0 Ft. G�$ j 1 1 /c A 1 O Ft. H ti 5 Ft. Signed:' x �' B 50 Ft. License Number: ,3 3 K O Ft. Date: JD L - 70 Ft. j_ Ft. Alternate Position I Ft. of Force Main W 3 Q Ft. Observation Pipe 6 -K — A - - -- -------- - - - - -- ------------------ - - --•I Force Main W ° — , —p -N E M - -- Of 2 2 Dist '2 � Aggregate l Obse RPROVE0 ermanent Markers DEPT. OF INDUSTRY, LABOR b HUMAN RRAT10NS p ,VlSle*-ff BkFR-W AND Ri HE�ppNDENCE Plan View Of Moung %Ang OR R Bed For The Absorption Area 2 -31123 Page Of I ' Distribution Pipe Detail For A Four Lateral Network Alternate Position Of End Cap � Y Force Main �`% P PVC Distribution Pipe PVC Force Main P '% ,Holes Equally Spaced PVC Manifold Pipe On Bottom X S 1 Zt X X * Last Hole Should Be Next To End Cap Y P oZ Ft. S L Ft. Inches PR IeJ �NAGE S Tp L ID` , Y � Inches Signed: Hole Diameter L1.... Inch License Nud'r: Date: MIU Lateral Diameter Inch(es) -APPRU3. QEPT. OF INDUSTRY, LABOR 8 HUMAN RELA Manifold Diameter 2 Inches �---- , OF SAFETY AND BUILDINGS Force Main Diameter 1 nches ` gEE CORRESPONDENCE I Holes Per Pipe . Invert Elevation Of Laterals J01.11 Ft. .. r , PAGI' (;F PUMP CHAMBER CROSS SECT10IJ AND SPECIFICA'r10u5 VCWT CAP 4*.I. RENT PIPE WEATHERPROOF APPROVED LOCKING 5' FROM DOOR, I JUNCTION BOX MA WHOLE COVER l i WI OR FRESH IZ "M {U. lc?uv✓ i� LCJ'< Alit IIJTAKE I GRADE I �! I - I B" lrC1 A1. .................. . f6 "MIN. CQWDUIT —_ - -- - - ^ - -- Con�ditionai y v -- ____ -- IMLET P * f _T DEFT. OF INDUSTRY, LABOR 8 lloomifrNmrD 6 I 1 A DIYI8ION OF SAFETY AND BUILDINGS B SEE CORRESPONDENCE i I ALARM ( 1 c *APPROVED ; i ON . JOINTS WITH I ELEV. FT. APPROVED PIPE PUMP - -� 3 ONTO "� ` OFF D SOLID SOIL H _ CONCRETE BLOCK RISER EXIT PERMUTED OIJL4 IF TANK MANUFACTURER HAS SUCH APPROVAL SPEGIFI'CATIOU TANKS MANUFACTURER: r e +Z' n rC WMBER OF DOSES: �3 PER DAS TA NK SIZE: - /DOD GALLO DOSE VOLUME 1 Z 2 3. )o ALARM MANUFACTURER: ti h k Aler INCLUDING BAC'.KFLOW: GALLC MODEL WUMDER: VJ CAPACITIES: A= 1 t INCH[S OR GALLC SWITCH TYPE' �� a, 15= 2 INCHES OR � PUMP MANUFACTURER: �'� u C = _Ld INCHES OR -2 3 z , S GALLC MODEL NUMBER: 3 B R S L J O3 M D-- - INCHES OR :279 GALLC SWITCH TYPE: I� NOTE: PUMP AND ALARM ARE TO BC z MINIMUM DISCHARGE RATE INSTALLED ON SEPARATE CIRCUITS � GPM VERTICAL DIFFEKEIJCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. 1 FEET S + MINIMUM NETWORK SUPPLY PRESSURE 2.5 FEET ♦ 1 1 5 FEET OF FORCE MAIN X' F'F,/ IIooFT.FRICTION FACTOR. FEET oil TOTAL 09&JAMIC. HEAD = t'� FEET 1 �I Zz -zs // INTERiJAL DI IJSION, OF TAWK: LF -MCsTH .^ • / / �' ,WIDTH �; LIQUID DEPTH 43 51GUED: �` , LICEA3 E E O 2 ! !� S NUMBER: 4Ld d Lai boran d Hu a ngel bons stry S — La OIL AND SITE EVALUATION REPORT Page of Labor and Human Relations g Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY 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 % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. REVIEWED BY DATE APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION DO OP TY 0 PROPERTY LOCATION CiYI GOVT. LOT 1/4 1 /4,S T N,R E (or) W P O � 0VrER':S AILING ApDRESS LOT # BLOCK # SUBD, NAME OR CSM # t S �ro ► k CI , ZIP CODE PHONE NUMBER ❑CITY ❑VILLAG I N EARE ST ROAD 6 crvl ( ) r© Z ea-r c,J eb�j [ ew Construction Use [r- rFiesidential / Number of bedrooms 4r— [ ] Addition to existing building I I Replacement [ I Public or commercial describe Code derived daily flow gpd Recommended design loading rate bed, gpd /ft trench, gpd/ft Absorption area required bed, ft trench, ft Maximum design loading rate bed, gpd /ft trench, gpd/ft Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUN IN GROUND P_ RE RE AT-GRADE S DE S M IN FILL HOLE NG T U = Unsuitable fors stem 1:1 S C1t1 �❑ U ❑ S 917 SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench -5 D K G 6, r Cr nt / Ground <5 9 -2�( D Y5_�_ Sr 2 iMS b tn't elev. ft. 13r Depth to C - 3Z-Y6 r �� Y S e. YV1 Wl ilk, limiting fact r � Remarks: 5i av �s ^ L� av � Pi �S C�., r„�S�ry, Boring # _ /I Ground elev. / ..... V ft. Depth to limiting factor Remarks: CST Name: — Please Print 4 Phone: A ddress: Signature: Date: CST Number: PROPERTY OWNER SOIL DESCRIPTION REPORT Page of PARCEL I.D. # Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell au. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: i Boring # .................. Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations • Division of Safety &Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but St. Croix not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION elk ick Lawson GOVT. LOT NE 1/4 NE 1/4,s3 T 28 N,R 19 for) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 648 B, HY., #35 46 n/a St. Croix Downs CITY, STATE ZIP CODE PHON NUMBER [ [:]VILLAGE SOWN NEAREST ROAD udson, Wi. 54016 ( n /)a Troy I Deerwood Dr. [ Construction Use Residential / Number of bedrooms 4 [ ] Addition to existing building i ] Replacement [ ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate bed, gpd /ft trench, gpd1ft Absorption area required -5"00 bed, 11: SD < trench, ft Maximum design loading rate bed, gpd 1ft trench, gpd /ft Recommended infiltration surface elevation(s) 101.42 ft (as referred to site plan benchmark) Additional design / site considerations Parent material � /y4l / � �� :/ S� d�ir► 4,,� Flood plain elevation, if applicable ! It S = Suitable for system CONVENTIONAL MOUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable for system ❑ S RV at El U 7 717SOUND ❑ l#J ❑ S ll D S 1 ❑ S SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon Texture Consistence Boundary Roots in Munsell Qu. Sz, Cont. Color Gr. Sz. Sh. Bed Trench 1 0 -9 1 3/3 none L. 2/f /sbk mvfr c/s 2/f .5 .6 }�'.Gy � is }:•:t 2 9 -18 10yr4/3 none L. 2/m /sbk mvfr g/w 1/f .5 .6 Ground 3 18 -30 10yr4/4 none sil. 2/m /sbk mfr g/w 1/f .5 .6 elev. 10 4 30 -36 7.5yr4/4 none ls. 0 /sg ml n/a a/I .7 1 .8 Depth to 5 36 -52 2.5yr7/6 none lime n/a rock n/a n/a 0 0 stone limiting factor 3.00 Remarks: Boring # 1 0 -9 10yr3 /3 none L. 2/m /sbk mvfr c/s 2/f .5 1 .6 k } 2.., ; - 2 9 -24 1 r4/4 none sil. 2/f /sbk mvfr g/w 1/f .5 .6 3 24 -39 7.5yr5/4 fff 7.5yr5/2 sc1. lJsbk mfr a/I n/a .2 .3 Ground ` elev. 4 39 -51 2.5yr7/4 none lime n/a rock n/a n/a 0 0 100 ft. Depth to limiting factor -� %ff v 3.25 Remarks: _ i ``'` 1" ' CST Name:—Please Print h qf� �U'J7Y Gar L. Steel 715 -24 W Addres : '� ' E 154 200t Ave. New Ric and WI 54017 Signature: T er: 9 -28 "" I PROPERTY OWNER Rick Lawson SOIL DESCRIPTION REPORT Page 2 of 3 i i PARCEL I.D. # Depth Dominant Color Mottles Texture Structure Consistence Roots GPDift Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 0 -10 10yr3/3 none L. 2/m /sbk mvfr c/s 2/f .5 .6 2 10 -34 10yr5/4 none sl. 2/f /sbk ml g/w 1/f .5 .6 Ground 3 34 -47 10yr4 /4 fff 10yr 5/2 scl. 1/f /sbk mfr c/w n/a .2 .3 99 lone - n/a rock n/a n/a .0 .0 99.9 &. 4 47 -5 2.5 7/4 none stone i Depth to limiting factor 2.83 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(R.05/92) � - 1 - - STEEL'S SOIL SERVICE Gary L. Steel Rick Lawson 988 N. Shore Drive C.S.T. 2298 0 S.3- T28N -R19W New Richmond, WI 54017 MPRSW -3254 Troy, township (715) 246 -6200 `rl � 4A- Lk -1 1 A 3� 1D boo '171171 � 11 ' 1. 3 STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER /BUYER ROUTE /BOX NUMBER S' �` II � C FIRE NO. CITY /STATE /t l ZIP / PROPERTY LOCATION: 1/4 `,~ 1/4, Section , T r� N, R W, Town of St. Croix County, Subdivision I '! 6 , Lot No. 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 SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning 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 (2) after Inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I /WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE /0 St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386 -4680 Sign, Date, and Return to above address S T C - 100 This application form is to be completed in full and signed by the owners of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property �i - h Location of property/VFl /4 5 E 1/4, Section T 22- N -RW Township G Mailing address 2 Address of site Subdivision name _. �� �h ��� Lot no . Other homes on property? yes Previous owner of property ) ( a Total size of parcel Date parcel was created _ -,01 70�) Are all corners and lot lines identifiable? Yes Is this property being developed for (spec house? Yes x - No Volume and Page Number w as recorded. with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DIED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available; ;would be helpful so as to avoid delays of the reviewing process. If the deed description references to a certified survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are t our knowledge rue to the best of my ( our) wledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded for t tt , ffice of the County Register of Deeds as Document No. a J , and that I we own the '! ( ) presently proposed site e sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly record i - he office of County Register of deeds as Document No. Signature of applicant Co-applicant Date of 'Signature Date of Signature �.��y _'�f.•_��. + +�N .`� �` ~ � ��� 555 i o • l" ,�• k Owl s"" . w y K Ot k r r o .t' i � i ` ST. CROIX COUNTY r WISCONSIN ZONING OFFICE 4. .,- • „ >���= - ST. CROIX COUNTY COURTHOUSE i 911 FOURTH STREET • HUDSON, WI 54016 (715) 386 - 4680 Sept. 24, 1992 Division of Safety and Building Bureau of Plumbing P.O. Box 7969 Madison, WI 53707 To whom it may concern: An onsite soil investigation of the Erick Lawson property, located in the NE1 /4 of the NE1 /4, Sec. 3, T28N, R19W, Town of Troy, St. Croix County, WI., has been conducted with the assistance of Gary Steel, CST# 2298. This onsite revealed suitable soil for onsite sewage disposal to a depth of 32” while meeting the requirements of the A + 4 rule. This site should be suitable for new construction utilizing a mound septic system having 12" of sand fill. Should you have any questions, please feel free to contact this office. Sincer ly, I I es K. Thompson . "Assistant Zoning Administrator cc: file I