HomeMy WebLinkAbout040-1272-60-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No: 488056 0
ATTACH TO PERMIT)
GENERAL INFORMATION ( State Plan ID No: ��
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)
Permit Holder's Name: City Village X Township Parcel Tax No:
Fox, Troy Troy, Town of 040 - 1272 -60 -000
CST BM Elev: t Insp. BM Elev: I BM De Section/Town /Range /Map No:
40 V q �•(o� CS V.A 2 ,rc�cgt2� 17.28.19.1513
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic � � Benchmark 2-
Dosing 0 Alt. BM d • t
Aeration Bldg. Sewer
12 .01
Holding St/Ht Inlet �►,p
TANK SETBACK INFORMATION St/Ht outlet p,lS� q' •Gp t
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic , t 2 t Dt Bottom
Dosing Header /Man. 10•rn () t
Aeration Dist. Pipe ®• SD 0.65
Holding Bot. System , Final Grade � T ST Fl. S -p !
O '
PUMP /SIPHON INFORMATION 4.10 q�•OS
Manufacl,4K Demand St Cover
M
Model Number
TDH Lift Fri Loss System Head TDH Ft
Forc ain Length Dia. to
SOIL ABSORPTION SYSTEM 2,
Krat_f RtgCe Width Leng �Z • No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIME 1
SETBACK SYSTEM TO P/L BLDG IWELL LAKE /STREAM LEACHING t e
INFORMATION CHAMBER OR Cf�
Type Of System: t UNIT Model
.r �Q ber:
p t ^V . O 4 �"
DISTRIBUTION SYSTEM
Header /Manifold N Distribution x Hole Size le Spacing Vent to Air Intake
pi (s) OI
Length Dia Leng Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded /Sodded x Bed/T rench Center Bed/Trench Edges Topsoil t
� �,��/ [Q No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1 �Iw • � Inspection #2: / +.
Location: 415 Lost Rock Lane Hudson, Wf�I�5544016 (NW 1/4 SW 1/4 17 T28N!_R_1.9�W,)s�T;roy W000d Lot 7 �Parcel No: 17.8
1.) Alt BM Description =�� "�°�"'�ti"r "i� "�dtNCr °'"��dT _ O1�'Q/r�"""'
2. Bldg sewer length= Z. '
- amount of cover
Plan revision Required? [] Yes No F
Use other side for additional information �30� T
Ai -PA
9 07� A Q
to
SBD -671 R.3/97)� r1 , ��� �
Safety and Buildings Division County
IN VIsconsin m 201 W. Washington Ave., P.O. Box 7162
Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce (608) 266 -315 E $p�
Sanitary Permit Application State lan I.D Number o
In accord with Comm 83.21, Wis. Adm. Code, personal infonnatio pr ide, .)
may be used for secondary purposes Privacy Law, s15. LOUNTY
ddr (if different than mailing address)
L Application Information - Please Print All Information
Pr operty Owner's N e Parcel # Lot # 77 Block #
Prope er's Mailing Address Property Location
City, State Zip Code Phone Number �4LI X14 —1 idL A, Section � 7
(circl o o e
�
H. Type of � t ding (check all that apply) � j S .4t
or 2 Family Dwelling - Number of Bedrooms Subdivision Name �r
❑ Public /Commercial - Describe Use
❑ State Owned - Describe Use ❑City ❑VillageJI of
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. YNew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. Type of POWTS System: Check all that a pply)
0 Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑
Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter . ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter Leaching Ch ine El Gravel-less Pie ❑ Other (explain)
V. Dis ersaVl reatment Area Information:
Design Flow (gpd) Design Soil Application Rate( Area wired (sf) Dispersal Area Proposed (sf) System Elevation
v0 0. (00 i '0j () .(,0 9's Sa
VI. Tank Info Capacity in Total Number Manuftwrer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank r
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, a ume responsibility for installation of the POWTS shown on the attached plans.
Plum Nam (Print) Plumber' i e MP/MPRS Number 7 7 /5- siness Phone Number
- - 3/ S
Plumber's Address (Street, CityZr
ip Code)
_3�
VIII. Coun a artment se On
Sanitary Permit Fee ncludes Groundwater Date Issued Issui Agent Si o Stam s
Approved C1 Di prov -='`� Surcharge Fee) � � P )
❑ Reason for ial
IX, Conditio Approv s`approval
SYST I�ER; 3 � `� 1 ' s � r
1 Septic tank, effluent filter and
dispersal cell must all be serviced / maintained r c aQ 1
as per management plan provided by plumber, ) C
2. All setback requirements must be maintained
as per applicable code /ordinances.
Attach complete plans (to the County only),for the system on paper not less than ad x 11 ioc es in sv�e
SBD -6398 (R. 01/03)
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3 �r
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 81/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Paroel I,D
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. R 'ew�ed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). A • TO 6
Property Owner Property Location
Govt. Lot 1!� j 1/4 S N R ortV
Properly er s Mailing Address Lot # I Blo # Subd. Name or GSW
37
City State Zip Code Phone Number ❑ City Village Town Nearest Road
JK ( ) '/ sC
New Construction User Residential / Number of bedrooms �/ Code derived design flow rate GPD
❑ Replacement ❑ Public or commercial - Describe: TTT�
Parent material �l�Ta! �0� Flood Plain elevation if applicable ft.
General comments
and recommendations: y �Ef�r� r9 ) s 1 'e
2 Boring # ❑ Boring
,Z pit ' Ground surface elev. A ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPQM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 •Eff#2
r
s 1.17�`
❑ 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 GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
Efflugnt #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L Efflypnt #2 = B 91) < 30 mg/- and TSS < 30 mg/L
CST Name 1 Print) r Signature CST Number
Address Date Evaluation Conducted Telephone Number
.,..,,
Properly Owner Parcel ID # Page of
F-1 Boring # ❑ Boring
❑ pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Stnuture Consistence Boundary Roots GPDIfF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 "Eff#2
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDlfF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
F 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 GPD1fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *E02
* Effluent #1 = BOD > 30 < 220 mgIL and TSS >30 < 150 mg�nn * Effluent #2 = BOD < 30 and TSS < 30 rn n
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 (R07 /00)
1355
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page _ - of _ 3_
Division of Salaty and Buildings in accordance with Comm 85, Wis. Adm. Code Ouatum Septic Service
AttaO can lets site Cow ty
P plan on paper not less Nan 8Y: x it inches size. Plan must
include, but not limited to: vertical and horizontal reference poini (BM), direction and St. Croix
percent slope, %rate or dimernsions, no* grow, and location and distance to nearest road. ParcO 1.0.
Please print all infornlatt/on. ReAL� By pending
Date
Personal fmamatbn You proulaa may t* geed for - wrodarypurpeces (P6scy law, s, 15.04 (1) (m)).
Properly Owner Property Location
Humbird Land Co .,_____.__.._._..... Govl, Lot
W/d 14 SW 104 S 17 T 28 NR 19 W
PrOPeny Ow;i'S Meull Add ress . .
n9 . L # Bl M Subd. Nan* or CSNItt
332 Mi nnesota Street, East 1404 37 08 Troy Wood Subdivision
City State Zip Code Phone Number J Clty J Village !e, Town Nrrarag Road
Saint Paul i MN 55101 651- 222.5555 Troy E Cove Rd / Lost Rock Lane
Y New Construction Cso: if Residential 1 Number d oedrooms 3 Code derived design flaw rata 450 GPD
_ J Replacement I Public or CommffcW - Describe:
Parent material !i_a h plain - -.._ _. _ ...... .... _._ -- -..... Flood ptair elevation, 0 applicable Na
General comments
and recommendations: Part of 1.52 acres. 8M #1= 100,0'. 6M #2= 9865'. Recommend 96 5' system elevation. P25 from
Preliminary boring work done 5.5 -00,
[ P725 Boring# t Bonn9
4' Pit Ground Surfaoo elev. 99.0 h. Aepth to !imiling factor >75 in. Sail Appscatim Rate
Horizon t Depth I pominalnt Cabr RedcA Description Texture I Structure Consistence Boundary I Roots 1 VOW
'Erfkt 'Eff#2
- _
1 0 -10 i 10yr2r3 none St ! 2msbk mvfr as j 2f,1 m 0.5 03
2 i 1015 I 10yr314 rore sl 1 2msbk rnvfr cw 1f 0.5 0.9
.27 1 _ ^ 1 - 0 r414
- - - -- _
' 15
_ Y none st I 2msbk mvfr cw
- 4 --- 27.36 t 0 r4/6 .. �
4 . y none Is 1 msbk mvfr cw -
0.7 1.2
5 36.68 7.5yr4/6 none
gr. 0s
9 9 ml cw 0.7 1.2
B 68 -75 10yr5/6 - none —
r.s �..
9 0 sg ml - 0.7 1.2
E ► Sexing 4 J Wing
Pit Ground Surface elev. 987 tL pelpt}t to limiting factor ?72 ....In. Sol AppUcagon Rate
Ho6zcn Depth 00ninant Color Redox cription Texture Structure Consistence ' Boundary Roots I . QP0111•
Effort I 'Effe
1 0.10 11 y, 31 1 none �' sit 2msbk mvfr as
if 1 10 05 08 �
— 2 x_10 -17 f -- _ y1314 ...... ; none sN 2mpt mvfr _.. , -
- 1f f 05 08 D •off
3 17 -23
0 r413 I i myfr ..... _. _ . . —._—.
Y none sl 2msbk
cw - 0.5 1 0.9 - -�
4 123 1 10yr412 none , sl 2msbk mfr cw j - i 0.5
I
5 34 -56 10yr2r2 none ;( '
� s I 2msbk + _
mfr Cw - 0.5 0.8
6 5 1 10yr314 n �sil T 2 _ mfr ow 0.5 i 0 1 8 -
10 r4/4 i j it j 2msbk ( mn _ -�—
7 55 -72 none -T ... -- -r- 0.5 i 0.8 lO
Effluent # - B 30 < 22 mgrL and TSS >30 < ISO � -:5
/
EKluant tit= BOD <30 rytalt. and TSS <�30 mcyt.
CST Name (pteaso Prtrn) Signs gnat S Number
Tom Gustu 227618
_.,. �_...._— ... - -- - -
Address
Gusturn Septic $srvlce Date Evaluation Comiucted Telephoto N _
N13450 937th St, New Aubum, WI 54757 11/20/04 715.858 - 1344
L0 /b0'3 080trt792t59 N3S83(M )Z - 1dM,3N3a 0:60 9002- t?0-Nb1
roc ertY Owner tiu rnbitd l Corpo - _ Parcel 1D# -.22nding_.,.._..._ - . - - -._. Page 2 _of 2_
: �j Boring # J Boring
}/ N Ground Surface elev. .. 98.2 _ -_- _ ft. Depth to limiting factor >72 in. got Application Rate
r�orizon i oth Dominant Color Radox Description Texture Structure Consistence i Boundary Roots GPDA'
'Eff#1 'EM
0.
r..., 12 , 10yr3/3 ....,.. no ne SI 2 m s bk I .. mvfr as 1f,1m 0.5 � 0.9
� 1 !
2 i 1 2-20 1OyrS /3 none St 2msbk mvfr . , 0.9
•
• cw 0 5
3 '40-27 i t Oyr5 /4 r -'
none
$l 2msbk 1 mvfr cw - 0.5 0.9
/
4 27-39 i 1 Oy r416 none r Is 1 msbk mvfr cw
. - -- - 0-7 1_2
- ..- -. ... 9
39-48 7.Syr4/6 none $l 2msbk mvfr cw j - 0.5 0.9
5 48 - X'� - i 7.5 x418 n
I y one fs 2msbk mvfr - 5 0.9
�
3 boring # I Boring
✓J Pit around Surface elev. 98 15 _ ._ ft. Depth to limiting factor >72 in. Spat Appiicafiott Rale
Hatton Depth j Dominant'.'Okx Redox Description Texture Structure — ,consistence : Boundary Roots
� r i i i '�ffk1 EffN2
1 0 - f 10yr312 r n0ne sil 2msbk fn Or as ; 1f,1m i 0.5 0.8 _ .8
-- -:
- — _
2 9 -14 1 Oyr 41 4 none sit 2msbk mvfr _
3 _..�._ cw 0.5
4 -20
7.5 r41
Y 4 r none � gr. st i 2msbk mvfr cw - p.g 0 -9
4 20 -33 7 . 5 yr 41 6 none sl 2msbk mvfr aw 0.5 09 . 6 1
! i
S 33 -57 i 7_5yr418 I none is 1msbk mvfr cw 0.T 1.2 7
s 57 1W 7.5yr51$ -- .j....._... none f. '
� 5 1 2msbk mvtr D.5 0.9
All
-1� Bing 0 j Saing
A Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Oaninant Color i Redox Description i Texture Structure Consistence I Boundary Roof. I „ jaMW
t � I
. Eitkrent k1 s WD y > 30 _270 mgr, arxi TSS >30 < 150 rro& • Ef ent #2 = SOD < 30
my+L and T5S < 30
The peprstsnentofCorruncrceis , rn u80 5- rt '�'
eq pporttinity se rvice provider and employer. If you need assistance to acacss services of
need rnwrial in an alternate format, otdam oonwt the deoarGrtent at 608 -266.3 15 1 or TTY 608- 2644777•
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1355
Wisconsin Department of Commerce SOIL EVALUATION REPORT page 1 of 3
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Gustum Septic Service
Attach complete site plan on paper not less than 8'% x 11 inches in size. Plan must County St. Croix
include, but not limited to: vertical and horizontal rgjerw"- point(BM), direction and parcel I. D.
percent slope, scale or dimemsions, north arr and Jodatign'8r4ddistance to nearest road.
_ pending
Please pdntW!,fiWpirmatfon, awed By Date
Personal information you provide may t used,fef secondaq�,puT a 'vary Law, 9.'15.04 (1) (m)). /� f I
Pr aQ6
op"y Owner / ._ _ .. '. ti 4.
Go4t, Lot Lice
Humbird Land Corporation 1/4 SW 1/4 S 17 T 28 N R 19 W
� n � ; „ ,
Property Owner's Mailing Address LUVU ; ti# Block # Subd. Nam or CSM#
332 Minnesota Street, East 140+x. -.', ' cRO i` 37 n/a Troy Wood Subdivision
City State\�ip.Gode ®j City _j Village ✓ Town Nearest Road
Saint Paul MN I �2 01; 651 222 - 6ee "/ Troy E Cove Rd / Lost Rock Lane
✓� New Construction Use: 6 j Residentia rooms 3 Code derived design flow rate 450 GPD
J Replacement _j Public or commercial - Describe:
Parent material outwash plains Flood plain elevation, if applicable n/a
General comments
and recommendations: Part of 1.52 acres. BM #1= 100.0'. BM #2= 98.65'. Recommend 96.5' system elevation. P25 from
preliminary boring work done 5 -5 -00.
[ F2�5Boring # I Boring
i/ Pit Ground Surface elev. 99.0 ft. Depth to limiting factor X75 in. Sal Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
*Eff#1 *Eff#2
1 0 -10 10yr2/3 none sl 2msbk mvfr as 20m 0.5 0.9 (P
2 10 -15 10yr3/4 none sl 2msbk mvfr cw 1f 0.5 0.9
3 15 -27 10yr4/4 none sl 2msbk mvfr cw - 0.5 0.9
4 27 -36 10yr4/6 none Is 1 msbk mvfr cw - 0.7 1..2
5 36-68 7.5yr4/6 none gr. s 0 sg ml cw - 0.7 1.2 �-
6 68 -75 10yr5/6 none gr. s 0 sg ml - - 0.7 1.2
Boring # j Boring
1/ Pit Ground Surface elev. 98.7 ft. Depth to limiting factor >72 in. Sal Application Rate
Horizon Depth Dominant Cora Redox Description Texture Structure Consistence Boundary Roots GPD /ft'
*Eff#1 *Eff#2
1 0 -10 10yr3/3 none sil 2msbk mvfr as 1f 0.5 0.8
2 10 -17 10yr3/4 none sil 2mpl mvfr cw 1f 0.8 0
3 17 -23 10yr4/3 none sl 2msbk mvfr cw - 0.5 0.9
,v( 4 23 -34 10yr4/2 none sl 2msbk mfr cw - 0.5 0.9
5 34 -56 10yr2/2 none sil 2msbk mfr cw - 0.5 0.8 t _
6 56-65 10yr3/4 none sil 2msbk mfr cw - 0.5 0.8 ,
7 65 -72 10yr4/4 none sil 2msbk mfi - - 0.5 0.8
* Effluent #1 = BOD ? 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD S mg/L and TSS <30 mg/L
CST Nam (Please Print) Signature: CST Number
Tom Gustum 227618
Address Gustum Septic Service Date Evaluation Conducted Telephone Number
N1 3450 937th St., New Auburn, WI 54757 11/20/00 715 -658 -1344
r �
property Owner Humbird Land Corporation Parcel ID # - Pend - - Page -2 of -_ 3
F2 I Boring # J Boring
wi Pit Ground Surface elev. --- 98 ___ ft. Depth to limiting factor >72 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots - _ _ - GPD& - .. -___
*Eff#1 *Eff#2
1 0 -12 10yr3/3 none sl 2msbk mvfr as 1 f,1 m 0.5 0.9 tP
I
2 12 -20 10yr5/3 - none sl _ 2msbk mvfr cw _ 0.5 0.9 , b
3 20 -27 10yr5 /4 none sl 2msbk mvfr cw - 0.5 0.9 (P
s 4 27 -39 10yr4/6 none gr.Is lmsbk mvfr cw - 0.7 1..2 ,
5 3918 7.5yr4/6 none sl 2msbk mvfr cw - 0.5 0.9 (�
6 48 -72 7.5yr4/6 none fs 2msbk mvfr - - 0.5 0.9 S
O
F3 Boring # J Boring
IM Pit Ground Surface elev. - 98 .5 - _.. -._. ft. Depth to limiting factor - >72 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots CPD/ft'
*Eff#1 *Eff#2
1 0 - 10yr none sil 2msbk mvfr as 1 f,1 m 0.5 0.8 (
2 9 -14 10yr414 none sil 2msbk mvfr cw - 0.5 0.8 (P
3 14 -20 7.5yr4/4 none gr. sl 2msbk mvfr cw - 0.5 0.9 fP
( 4 20 -33 7.5yr4/6 none sl 2msbk mvfr cw 0.5 0.
33 -57 7.5 r4/6 none Is 1msbk mvfr (�
Y -- - - -- - _- - _- _ - - -- -- - .
- - -- - - --- I cw - 0.7 1.2
- 5
6 57 -72 7.5yr5 /8 none fs 2msbk mvfr - - 0.5 0.9 5
Boring
F-1 # J J �
Pit Ground Surface elev. ft. Depth to limiting factor in. Sal Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots --- SPDLtN -
*Eff#1 *Eff#2
I
I }}
* Effluent #1 = BOB 5> 30 < 229 mBIL arW TSS >31 < 150 MI/L • Effluent #2 = BOD -j 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.
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page / of
FILE1NFORMATION SYSTEM SPECIFICATIONS
Owner Septic Tank Capacity a l ❑ NA
Permit #
Septic Tank Manufacturer 11 2 ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model S ❑ NA
Number of Public Facility Units fi�NA Pump Tank Capacity al ANA
Estimated flow (average) g al/day Pump Tank Manufacturer ANA
Design flow (peak), (Estimated x 1.5) g al/day Pump Manufacturer JR NA
Soil Application Rate gal/day/ft' Pump Model -ANA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit ANA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD 530 mg /L ) ( In- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) 510 cfu /100m1 ❑ Drip -Line ❑ Other;
Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other: ❑ NA
*Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(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: ❑ month(s) (Maximum 3 years) ❑ NA
2. years)
Clean effluent filter At least once every: ❑ month(s) ❑ NA
21 years)
Inspect pump, pump controls & alarm At least once every: ❑ month(s) E"A
❑ year(s)
Flush laterals and pressure test At least once every: ❑ mo nth ❑ yea r(s) l NA
Other: At least once every: ❑ month(s) _,3-NA
❑ year(s)
Other:
O 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)
START UP AND OPERATION Page of-2
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products of other Chem
that may impede the treatment process and /or damage the dispersal collie). If high concentrations are detected have the corn
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater w
discharged to the dispersal Collis) in one large dose, overloading the collie) and may result In the backup or surface discharl;
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to rest(
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump contro
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
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
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications;
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 syste
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled
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 comp'
replacement system:
A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorp
system. The replacement area should be protected from disturbance and compaction and should not be infringed upo(
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems n
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POV
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
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding t
may be installed as a last resort to replace the failed POWTS.
❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at
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 h
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OI
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALL R POWTS MAINTAINER
i
Name _ / Name
G
Phone Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY UTHORl
F
Name Name
Phone Phone
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
ST. CROIX COUNTY
SEPTIC TANK MAINTAI'NA AG REEMENT
AND
OWNERSE'UP CERTIFICATE FORM
Owner/Buyer
Mailing Address /O 7 0 �` �_!� �, �v p s �s• M� S /
Property Address
(Verificabmreqmredfix= Plamomg Department for new cootruetion)
City/State Parcel Identification Number �� /� 7 - � D - ��JO . 151 3
LEGAL DESCRIPTION
Property Location' /,, Sec. j � T�R /_W, Town of
Subdivision I'kdt/ 0L> 00 Lot# 3
Certified Survey Map# , Volume Page
Warranty Deed# / 7yyyn Volume --- e/ Q - g 2 Page
Spec house yes 10no Lot lines identifiable es no
SYSTEM MAINTENANCE T
Improper use and-mamtenance of your septic system could result 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. Whatyou put- into the.system can affect the fimction of the septic tank as a treatment stage in the waste
disposal system
The property owtaer agrees to submit to St. Croix Zoning Department a certification form, signed by the
owner and by a masterplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-
site wastewater disposal .systemisinproper.operating condition and/or (2) after inspection and pumping (ifnecessary),
the septic tank is less than 1/3 full of sludge.
I/we, the undemgnedluveread theabove_requarements and agree to maintain the private sewage disposal system with
the standards set forth, herein, as set by th Department of Commerce and use the Department of Natural Resources,
State of Wisconsin.Ced ificationstating that your.septic system has been maintained must be completed and returned to
the St. Croix County Zoning Office within 10 days of the three year expiration date.
:A - 0 6
G APPLICANT DATE
#of proposed bedrooms
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:
SIG OF APPLICANT DATE
****** Any mformatim that is misepresm2ted may reauk in the sanitary Pam being revoked by the Zoning Depar mal'
*' hidude with this application a stamped warrai ty deed from the RVter of Deeds office
a copy of the certified on vey maps if refamce is made itulte wonv oty deed
U 1859P 636
• STA'1 E BAR OF WISCONSIN FORM 2 - 1998 6 �7 4 4 4 tm
WARRANTY DEED REGISTER OF DEEEDDS
Document Number ST. CROIX Co. VI
This Deed, made between Day Farm Investors, LLC a Minne RECEIVED FOR RECORD
Limite Com _ 03 - 25 -2002 11:30 AM
Grantor, and Tro • A. Fox a Tcra L. Gras t , E�XD PT # OEE�
Troy P _ a s - ioint
REC FEE: 11.00
- - -- -- TRANS FEE: 260.70
COPY FEE:
CERT COPY FEES
Grantee. — - — -- - PAGES: 1
Grantor, for a valuable consideration, conveys and warrants to
Grantee the following described real estate in St. Cro
County, State of Wisconsin:
Recording
Area
N ameepl�i - iT NATIONAL BANK
Lot 37 Troy Wood, Town of Troy, St. Croix County, Wisconsin 1 109 E 2nd St
PO BOX 89
New Richmond, WI 54017
040- 1272 -60 -00
Parcel Identification Number (PIN)
This is not homestead property
(is) (is not)
Exceptions to warranties: Subject to notes, easements ,restrictions,covenants and rights of way of record, if any,
including but not limited to those for drainage,water retcntion,ponding,and or utilities as may be shown on the plat of Troy
Wood recorded in Vol. 8 of Plats, page 28,St. Croix County, Wisconsin.
The warranties of this deed, either expressed or implied are limited by the grantor to the
grantee, or anyone in the chain of title, to the consideration expressed herein, that being the sum of $ 88,900.00.
Dated this Sth day of M arch 2002
Day Farm Investors, LLC
` — - --
b �- President
Austi J. Baillon -
AUTHENTICATION ACKNOWLEDGMENT
STATE OF WISCONSIN )
Signature(s) } ss'
-- — _ --- -- Ramsey Co1111ty. )
Personally came before me this 8th &IV of
authenticated this day of March , 2002 — the above named
Au stin J. Baillon
- TITLE: MEMBER STATE BAR Oh WISCONSIN to me known to be the person(s) who executed the foregoing
(If not, instrument d acknowledge s I
�tb+17 r r
authorized by § 706.06, Wis. Stats.) 1ILA. BAILLON
THIS INSTRUMENT WAS DRAFTED BY r4OTA : - NsNNFS6rA
Paul A. Baillo Attorney at Law ' P aul A. Baillon " °co M <Nnes,•t,•zoos
Notary Public, State of Wiscdt ~'r .vwwv.
(Signatures may be authenticated or acknowledged. Both are not My Commission is permanent. (If not, state expiration date.
necessary.) Ja nuary 31 2005 )
-Names of persons signing in any capacity should be typed or printed below their signatures
WARRANTY DEED STATE BAR OF WISCONSIN
F'OILM N.. 2 .1998
INFORMATION PROFESSIONALS COMPANY FOND DII LAC, WI NW, 655 -2021
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