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HomeMy WebLinkAbout040-1273-30-000 Wisconsin PRIVATE SEWAGE SYSTEM County: St. Croix 6a-.ty and Building Division INSPECTION REPORT Sanitary Permit No: 463213 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: Weyer, John & Taren I Troy Township 040 - 1273 -30 -000 CST BM Elev: Insp. BM Elev: BM Description: Sectionrrown /Range /Map No: 17.28.19.1520 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. B Aeration Bldg. Sewer G] Holding St/Ht Inlet TANK SETBACK INFORMATION SUHt Outlet - 75 1 ,F4 , Z TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet \ Septic CO / > ZS / G i ' d / Dt Bottom d / U D Dosing Header /Man. 9, 9 3. 3 •Oo � Aeration Dist. Pipe Holding Bot. System / 6. 7 9 Z - vs PUMP /SIPHON INFORMATION Final Grade 5 • ] �'j 7 Manufacturer Demand St Cover GPM Model Num TDH Lift Friction Loss em Head H Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. LiquillDepth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufactured INFORMATION CHA Type Of System: /t ` r 50 ( UNIT OR Model Number J Q r ^ ! r 'e i 4 t DISTRIBUTION SYSTEM Z y ,�- ZZ L( t, ­ fad - -_9_ r tak Header/Manifold Distribution x Hole Size x Hole paang Vent o Aie Pipe(s) Length Dia Length � \ �eG ` Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over / Depth Over xx Depth f xx Seeded/S dried xx Mulc ed Bed/Trench Center ' Bed/Trench Edges Topsoil Yes � No Yes [] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 322 Day Farm Road River Falls, WI 54022 (SW 1/4 SW 1/4 17 T28N R1 9W) Troywood Lot 44 Parcel No: 17.28.19.1520 1.) Alt BM Description = C d vim•.- G � w ` OG_k,S O ✓� S �..,s c 2.) Bldg sewer length - amount of cover= T o 4o(J P tu�r�a� j �5V�c.� -iati_ ( fo Plan revision Required? Yes <'No ( r 2 information. C_ �oJJ Use other side for additional Date Insep tors Si tune Cert. No. SBD -6710 (R.3/97) i Safety and Buildings Division County Vi sconsirn 201 W. Wash', on Ave., P.O. Box 7162 Madi 53707 -7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce 3 3 Sanitary Permit A I j State rlan I.D. Number , In accord with Comm 83.21, Wis. Adm. Cod onnatio you per ; tit 1 may be used for secondary purpos y w, s15.04( )(m) 1 °" YY Pmje t Address (if diffefent than mailing addres$) L Application Information - Please Print All Informs ion �� �' `� + � Y N hl ZONI y NG OFFICE f l -- -� Property O Parcel is a # Lot # Block # D7N 1....t s'� 0Yo-OZ ?3 -.4060 Property Owner's Mailing Address Property Location - �orK.�: ill 1 - 7 Phone City, State Zip Code Phone Number �0 °, Section ` 5-4 (.14 17 17 / Y w ,�'3 8 9 d - L U Zb - I circle o e) . �SZ' 0 ) T Z8 N; E R o II. Type of Building (check all that apply) �1 F2�/ or 2 Family Dwelling - Number of Bedrooms 7� Su vision Name CSM Number / - / c �{ / �40 WO 0 sire/ / - ,0 , 1 , , ❑Public /Commercial - Describe Use ❑ State Owned - Describe Use 2 D /ST L Z 3 ❑City_ ❑Village Mownship of /:cam a III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. N ew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ r P Y g p y Other Modification to Existing System B, List Previous Permit Number and Date Issued ❑ Permit Renewal El Permit Revision Change of ❑Permit Transfer to New Before Expiration Plumber Owner IV. Type of POWTS System: Check all that appl XNon - 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 041zaching Chamber ' El Drip Line 13 Gravel-lepe ❑ Other plain) V. Dispersal/Treat ent Area Information: 07 f Design Flow (gpd) Design Soil Ap tion Rate(gpdsf) Dispersal Area Required (s Dis crs a Propos s �y ;vatio �8 8 c' . 0 ✓ VI. Tank Info Capacity in Total Number Manufacturer Prefab Si iber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic Holding Tank Aerobic Treatment Unit a P:" P 7qq i Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. PI 7 )I tier's Name 1( Plumber's Signal M /1 PR Number Business Phone Number icr awt�'tis �Z Z 87 L �{ -2 <1W Plumber's Address (Street, City, State, Zip ode) 1 -*, au f ,k c �i�. v` VIII /De artment Use Onl Approved ❑ Disapproved Sanitary Permit Fee (i cludes Ground ter Date ssued uing A ent (N ps) Surcharge Fee) �J� � ❑ Owner Given Reason for Denial 6 Z 1 t ` ZZ 9 IX. Conditions of Approval/Reasons for Disapproval S �, TS ?Al I c mplete plans (tot e C pun ty only) for the syste on paper of ess n 81/2 x 11 inches in size SBD -6398 R. 01 ems - i�.t r r� dl r Ql M l o M O 1 "t � a � o � r N o � f" G T t h � a o . w G 1 d � 11 r — Z Vic` � t7 9 s o 0 w � J o 0 Or � Z � 1 ti L a - l X a M c� b J b o o o V I \ v� CCai, 0 5� q3. 9 zit i lip � G 3'� P 5 LIO - 2�Z�7L s O O it C C w O c ° r' 01 co m c T ID 3 I ID Q! n O C I D O O 0) G O O O -� v A ;r • W ` OD CD y N Cp CA CD O W N n fD C_ CD O L CD W O U1 W O S to CD = CD 9 ? O p 90 CD O !� a d O ■�+. CD 01 C W p� C CD O !mil W Z y CD W U? 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O O N _ < CD CD C N a O j O I y ti O O O m A r 6s 0 tn0 ti W I POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page / of y FILE INFORMATION SYSTEM SPECIFICATIONS F 4, Septic Tank Capacity 02� al ❑ NA # Septic Tank Manufacturer l�Q w 13 NA DESIGN PARAMETERS Effluent Filter Manufacturer 2— ,gl5r ❑ NA Number of Bedrooms Y ❑ NA Effluent Filter Model Z 16 d ❑ NA Number of Public Facility Units —^ ❑ NA Pump Tank Capacity a l ❑ NA Estimated flow (average) - &4X al /day Pump Tank Manufacturer i- ❑ NA Design flow (peak), (Estimated x 1.5) 9�6600 g al/day Pump Manufacturer ❑ NA Soil Application Rate f 7 al /da /ftz Pump Model ❑ NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit A 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) _ <1 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L Pjn Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L NA ❑ At -Gra e ❑ Mound Fecal Coliform (geometric mean)_ 0" OOm ❑ 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: 02 0 nth(s) (Maximum 3 years) 13 NA ear(s) Pump out contents of tank(s) When combined sludge and scum equals one -third W of tank volume ❑ NA Inspect dispersal cell ❑ onth(s) (Maximum 3 years) ❑ NA s) At least once every: years) Clean effluent filter t least once every: Z [3 ear(s) s) ❑ NA Inspect pump, pump controls & alarm At least once every: 0 Y ar(s) [3 NA I ❑ month(s) ❑ NA Flush laterals and pressure test At least once every: i ❑ year(s) Other: ❑ month(s) ❑ NA 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) Page Z .bf START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tanks) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high dpncentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the PEAsuitable fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacestem: replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank maybe installed as a last resort to place the failed POWTS. A ( Th Fbe has not been evaluated to i t n f a suitable eplace nt area poailure of the POWTS a soi and site ev must b e ed to to to a su ble lacement ar no replace nt 1s availa e a holding tank m ns 11 s a last sort replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. 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 L 1 POWTS MAIN INER Name „�� a.S f; C �iyyt^f Name C1 ►.4, V_ Phone 7i5' - Z V z Phone 71 - V 7 z _L�/Z� SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name pr,�fic S u� N Name ,Lui X Oa ✓ ,,,� Phone 7W Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)0)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. I 1362 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 fefdre%e p nt direction and percent slope, scale or dimensions, north avow and location and ds ce to nearest road. Parcel 1. D. Q yb - / Z '"� 3 3 �- pendfng Please print�a#10thrmab . Revi D Personal informabon you provide may qb u - 6l 4or secon y vary Law, ;. .04 (1) (m)). J6q Property Owner Location Humbird Land Corporation Lot 1/4 SW 1/4 S 17 T 28 N R 19 W Property Owner's Mailing Address + r CRi}I x {. # Block # Subd. Name or CSM# 332 Minnesota Street, East 140x4 ,,0L 44 n/a Troy Wood Subdivision City State `Zip Code( &4 i _j City J Village y Town Nearest Road Saint Paul I MN I 5Af0.1 1 651,- 5"5 Troy E Cove Rd / Day Farm Road New Construction Use: Residential % N6mbi& of bedrooms 3 Code derived design flow rate 450 GPD f Replacement J Public or commercial - Describe: Parent material outwash plains Flood plain elevation, if applicable n/a General comments and recommendations: Part of 2.0 acres. BM #1= 100.0'. BM #2= 99.9'. Recommend 93.3' system elevation along 96.3' contour. P29 from preliminary boring work done 5 -5 -00. OT / [ P2 - 9] Boring # I Boring S�S7P/N J� 1/ Pit Ground Surface ele-v. 98.1 ft. Depth to limiting actor X in. Sal Application Rate N` Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft *Eff#1 *Eff#2 a� 1 0 -10 10yr3/2 none sil 2msbk mvfr as 2f,1m 0.5 0.8 2 10 -18 ___ jq0A none sil 2msbk mvfr cw if 0.5 0.8 � 3 18 -35 7.5yr416 none gr. Is 1 msbk mvfr cw - I 0.7 1.2 4 35142 10yr5/6 none gr. s 0 sg ml cw - 0.7 1.2 5 42 -75 10yr6/6 none gr.s, s 0 sg ml - - 0.7 1.2 Boring # r l Boring 01 Pit Ground Surface elev. 95.1 ft. Depth to limiting factor >75 in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft *Eff#1 *Eff#2 1 0 -18 7.5yr2/0 none sit 2msbk mvfr as if 0.5 0.8 2 18 -25 10yr3/4 none sit 2msbk mvfr cw 1 f 0.5 0.8 3 25 -33 r4/4 none sit 2msbk mfr cw - 0 0.8 4 33146 10yr4/6 none gr. Is 1 msbk mvfr cw - 0.7 1.2 5 46 -58 10yr5/6 none s 0 sg ml cw - 0.7 1.2 6 58 -75 - I 10yr5 /4 none IS 0 sg ml - - 0.7 1.2 * Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 50 * Effluent #2 = BOD 5 mg/L and TSS <30 mg/L CST Name (Please Print) Signature: CST Number Tom Gustum 227618 Address Gustum Septic Service Date Evaluation Conducted Telephone Number N 13450 937th St., New Auburn, WI 54757 11/21/00 715 -658 -1344 Property Owner Humbird Land Cow ration parcel ID #ending _ Page 2 of 3 2 ] Boring -- # JBoring -- - -- Pit Ground Surfaceel�.._.— 96.3 ft. Depthto limiting factor >75 in. V1 Pit Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots 6PDM. 'Eff#1 •Eff#2 1 0 -15 7.5yr2/0 none SO 2msbk mvfr as 1f 0.5 0.8 2 15 -24 10yr3/4 none sil 2msbk mvfr cw 1f 0.5 0.8 ICA 116V 3 24 -34 10yr4 /6 none sil 2msbk mfr cw - 0.5 0.8 34-41 10yr4 non gr. Is 1 msbk mvfr cw - 0. 7 1.2 5 41 -59 10yr5/6 non s 0 sg ml cw - 0.7 1.2 6 59 -75 10yr5/4 none s 0 sg ml - - 0.7 1.2 1 2, �`✓ - `,� out , s 40 F Boring # I Boring Ala �� g•(, _f Pit Ground Surface elev. _ -___ -- __ - -- ft. Depth to limiting factor in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots _ CiPOIfL •Eff#1 'Eff#2 I t - -- - F Boring # I Boring _j Pd Ground Surface elev. - -_ _ __ –__ ft• Depth to limiting factor in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots __. GPDIftz •Eff#1 •Eff#2 i i �ff ff I ' Effluent #1 = BOD ? 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOD S 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. l a c � ci V� CIO L -Jc .a GL 2 � O � � o o tz- J O :♦ w � � 8 s a. / .i / 000 10 .0 OV xv � 406 / o a f 4 �'i6 o. a - , Q �' i \\ ,y .,, N \ y m oll .01 ool a�\ 000 l oo, � g � 000� \ ® �' °� we lo i 4 ool � �� 4: Wisconsin Qepartrcent of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety 8nd Building Division Sanitary Permit INSPECTION REPORT 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Weyer, John & Taren I Troy Township 040- 1273 -30 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range/Map No: 17.28.19.1520 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark [ n Dosing Alt. BM Aeration Bldg. Sewer Holding SUHt Inlet SUHt Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L JBLDT WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold IDistribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length 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 xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes L� No LJ Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 322 Day Farm Road River Falls, WI 54022 (SW 1/4 SW 1/4 17 T28N R1 9W) Troywood Lot 44 Parcel No: 17.28.19.1520 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? [ Yes ff] No Use other side for additional information. Date Insepctor's Signature Cart. No. SBD -6710 (R.3/97) Safety and Buildings County Cr0 X w W 201 W. Washington Ave., O. Bo �"►r �sconsin Madison, WI 53707 716��v C Perini utnbcr (to be filled in by Co.) Department of Commerce (608) 266 -31 /_ 3 J �� Sanitary Permit Application e lan LD Number In accord with Comm 83.21, Wis. Adm. Code, personal information you ovidesr CR()/ may be used for secondary purposes Privacy Law, sI5.04(1)(m) O x Pb gtAdd s (if different than mailing address) lC 3a & m 2 I. Application Information — Please Print All Information Property Owner's Name Parcel # Lot # Block # + - rA zg A� \.J e- 614 2Y Property Owner's Mailing Address Property Locatro 6 S W ' /., �' /. Section 1 / '7 City, Stale Zip ode Phone Number • � O �v s� 8' S� - _. �"� circle one) T � 9 N; R � r II. Type of Building (check all that all ) ` 3 39 4- n) r ►21pn, I or 2 Family Dwelling - Number of Bed - Y C¢-- wl � Subdivision Name CSM Number Public /Commercial - Describe Use ✓1 0 C Uyt 144, r ra `�- d 0 j Sv / b - j I V/S i' ❑ State Owned -Describe Use A S U4 2_3 _ 0" 3 2 ❑City []Village Township of / ro y III. Type of Permit: (Check only one boa on 6n . Co plete line B if plicable) T A' 14 New System ❑ Replacement System Trcatmem/Holding ank Replacement Only ❑ it M 'fication to Existing S B. ❑ permit Renewal ❑ Permit Revision ❑ C e of ❑ Permit Transfer to New Li 'ou t Wo Before Expiration plum Owner IV. Type of POWTS System: Check all that appl W Non - Pressurized In -Ground ❑ Mound > 24 in. of suitable soil ound < 24 in. of suitable soil 11 At-Grade 13 Single Pass S ilter ❑ Constructed Wetland ❑ Pressurized In -Ground ❑ Holding Tank t Filter ❑ Aerobic Treatment Unit 11 Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter Leaching Chamber 0 Drip a vel -less Pipe ❑ Other ) V. Disp ersal/Treatment Area In rmation: Desi 6 00 w (gpd) Design Soil ApQlicati� I Rate(gpdsf) Dis 1 Area R fired (sf) Dispersal Area (s sys _ o 1 s8 889 VL Tank Info Capacity in Total Number Man Prefab Site P astir Gallons Gallons of Units Concrete Constructed Glass New Eaiating Tanks Tacks Septic or Holding Tank Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement - 1, the undersigned, ess a responsibility for installs of thArOWTS shown on the attached plaas. Plumber's Name (Print) Pl 's Signs Business Phone Number ovoe F reI 2So Cf / 71S -7a 3-8'/86 . P s d (Street, City, fate, t u G✓ e- C i / S L! 9N m ra ✓ &*✓1 ' x a Vay VIII. 9ounty/Department Use O nly X owed El Disa roved Sanitary Pernut Fee �}ncludes Groundw Da sued I— gen ignature (No ps) Surcharge Fee) QJ , U v Q C El Owner Given Reason for Denial fff rrr ` C� 6 IX. Conditions of Approval/Reasons for Disa roval 03 STEM OWNER: S 1 Septic tank, effluent filter and !�+ SGS'lxr2 dispersal cell must all be serviced / aintain d 8� - 7j�1(1, ? �irC, 6�`w�, Cam- -7-97" r an m nt Ian b lumber,- - ^ / ems & a- 2. All setback requirements must be maintained 7'_(ln / cv' S- h as per applicable code /ordinances `�? S . ` ` ` Attach complete plans (to the County only) for the s em on�p peper n less than 81/2 a 1 inches in siu , SBD -6398 (R. 01/03) v; (0/ i 4r i � .... ....... ban _ _ . 0 z. Me n � O 3 01 no • 0 4 - - - - - Al , �1 ti 1 -- - - - r, " l cd ovo o ii bi �.-� i ` •.-+ o V cd ( ". = . •: ��• lap ' Ni l � •_�- � � s -• - a cu i .-•. o P � - cd IN \ n \ V CA 2 rn \ cd 0 11 11 II � GL. tom. V) ca U cis W rcd U cc o Q' 2 -9 SB_CredentialDetail Page 1 of 1 WISC ONSIN � t7a�ararl i s l; f,4 � DepartmeM of ommercc 01 Sk Afics AWA Cornmerce 9utiness Comma lly Into(notionol Petroleum Programs Safety t Wkfings E of Customer Details Name LOUIE F JOLES Contact Info FALL CREEK,WI 54742 Specific contact information is not available for this customer. Credentials listed for JOLES, LOUIE F Black =Ap roved Yellow In Renewal Process Red =Ex fired or Not Valid CE CE Credential Hours Needed Type Expiration Needed By Cross Connection Control Tester 03/02/02 �0 12/01/01 Master Plumber - Restricted Service 03/31!05 �1 12/30/04 POWTS MAINTAINER 02/28/05 11/29/04 Plumbing Learner - Restricted 02/27/06 11/28/05 Appliance Plumbing Learner - Restricted Service 04/21/99 =0 J 01/20/99 http:/ /apps. commerce. state. wi. us /SB_ Credential /SB_CredentialList ?cust id= 250416 10/13/2004 Private On -Site Wastewater Treatment System (POWTS) I�4n11dex and Title Sheet 0A Owner: 5 o 't �Q `J U W Project Name and System Type: Zy b 1`� T � � 6 Location: '� ��,{� L )�rT; Street Address ; s / '7 r Z � , UI Legal Description Township C my Contents: Page 1: p/ / 7 &r7- Page 2: f j A✓' G v s .5 Sec. Page 3: �i f� ✓ Page 4: Page 5: V 0 CV (� LV Pr 1 �grJVk a,r�r'JR. -gar ��3zy�P��' Page 6: Page Page 8: SO 1 I-es Pag 9: Attachments: oaf � / % A o��� Plumber /Designer: 1� Jvlc'S M)ORS Signed: Credential Number: 2 So q16 Date: 149 — 7 — 2 G ac • 7152484730 FRUM St Croix Vally Custom Homes FAX NO. :7152484730 Oct. 07 2004 11:34AM P1 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 2 - Teas -E� t ,�) e �'e � Mailing Address _ 1 -- t IP—A rt.._- 5,4 &�R ( 19 Property Address vp (Verification required ftom Planning Department for new conshuction) City /State & 0e r6V1 -S (/l/ Parcel Identification Number 0 40 - � Q� �.EGAL DESCRIPTION / 4 Property Location -5 ' /s, '/,,Sec. F7 . T -2—$,,,�I - c ? W, Town of Subdivision r� " Lot # Certified Survey Map # Volume . .Page # Warrsa Deed # 3 5 5 3 . volume 2 3 `� S � - �' t __ ____ -. Page # , Spec house 11 yes fil no Lot lines identifiable yes © no &Y&UM MAINTLi`NANCE Improper use and maintenanceof your septic system could result in its pre=wm failure to handle wastes. Proper maintenance consists of pumping out the septic tank ovory 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 wash disposal system, The property owner agrm to submit to St. Croix Zoning Department a certification form, signed by the owner and by a mastprplumim, 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 1/3 full of sludge. Uwe, 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 expire on date. o /U , (/ L S ' ATURB O PLI DATE OWNER C1 It EMATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) tho ownef(s) of the prTe descdbesi above, by virtue of a warranty deed recorded in Register of Deeds Office. X ',/ v 16 r AWRE AP LICA DATE Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Departalent. "Include with tWs application: as --- wacmuty deed tl+om the Register of Deeds office a OW of f3fed survey map if referC w is made in the wammty deed POWTS OWNER'S MANUAL AND MANAGEMENT PLAN FILE INF0PMATI0a SYSTEM SPECIFICATIONS Owner Septic Tank Capacity 12 al C( NA Permit # Septic Tank Manufacturer H v fGv ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer Z ebal ❑ NA Number of Bedrooms 100 d/bedroom ❑ NA Effluent Filter Model elf leeo ❑ NA Number of Commercial Units ®NA Pump Tank Capacity al 2d NA Estimated flow (average)* 00 al /da Pump Tank Manufacturer CK NA Design flow (peak), estimated x 1.5* SQ g al /day Pum Manufacturer NA Pump JZ Model � NA Soil Application Rate , gal /dav ft Pretreatment Unit ;K NA Influent/Effluent Quality (NA❑) Monthly Average ** ❑ Sand/Gravel Filter ❑ Peat Filter Fats. Oil & Grease (FOG) < 30 mg/L ❑ Mechanical Aeration ❑ Wetland Biochemical Oxygen Demand (BODO < 220 mg/L E3 Disinfection El Other: Total Suspended Solids (TSS) Manufacturer: Model: <_ 150 m L Dispersal Cell(s) Pretreated Effluent Quality ❑ Monthly Average * ** In- ground (gravity) ❑ In- ground (pressurized) Biochemical Oxygen Demand (BODO < 30 mg /L At -rade C1 Mound Total Suspended Solids (TSS) ❑ g < 30 mg /L ❑ At- -line ❑ Other: Fecal Coliform (geometric mean) <10 cfu/100m1 ❑ Leachi Ch tuber Manufacturer ✓ ew Maximum Effluent Particle 1/8 inch diameter Model Laying Length /Chamber e S ze *Wastewater Flow Verification and Calculations: Soil Application Rat j gpd /ft Req. �Sf1 tt` (Other than bedroom based) Infiltrative Surface /Chamber -ESIA Rating ft Minimum Number of Chambers ❑ Aggregate Design Flow /Loading Rate= ft min ** Values typical for domestic (non - commercial wastewater Materials: all materials must comply with WI Adm. Code and septic tank effluent. COMM84 and be installed per manufacturers specifications ** *Values typical for pretreated wastewater. and approval letters. DESIGN CRITERIA ❑ "Wisconsin At -grade Soil Absorption System, Siting, Design & Construction Manual" (Converse et.al.1990) ❑ "Wisconsin Mound Soil Absorption System: Siting, Design & Construction Manual" Converse, J.C. and E.J. Tyler. Publication 15.22 ❑ "Design of Pressure Distribution Networks for Septic Tank -Soil Absorption Systems" Publications 9.6 ❑ "Design of Conventional Soil Absorption Trenches and Beds ". R.J. Otis — ASAE Publications 5 -77 and "Design Manual — Onsite Wastewater Treatment and Disposal Systems ". EPA 625/1 -80 -012 October 1980 ❑ SBD — 10570 —P (8.6/99) "At -Grade Component Manual Using Pressure Distribution" ❑ SBD — 10567 —P (8.6/99) "In Ground Absorption Component Manual" l SBD _ 10705 —P (N.01 /01) "In Ground Soil Absorption Component Manual" Version 2.0 - ❑ SBD — 10628 —P (N.6/99) "Recirculating Sand Filter System Component Manual" ❑ SBD— 10656 —P (N.6/99) "Split Bed Recirculating Sand Filter System Component Manual" ❑ SBD - 10572 —P (R.6/99) "Mound Component Manual" ❑ SBD - 10691 —P (N.01/01) "Mound Component Manual" Version 2.0 ❑ SBD - 10595 —P (R.6/99) "Single Pass Sand Filter Component Manual" ❑ SBD - 10657 —P (R.6/99) "Drip -line Effluent Disposal Component Manual" ❑ SBD - 10573 —P (R 6/99) "Pressure Distribution Component Manual" ❑ SBD - 10706 —P (N.01 /01) "Pressure Distribution Component Manual" Version 2.0 ❑ Drip -line Effluent Dispersal Component Manual for Multi -flo Onsite Wastewater Treatment Units MAINTENANCE AND MANAGEMENT MAINTENANCE MONITORING SCHEDULE Service Event Service Frequenc Inspect condition of tank(s) At least once ever ❑ months ear(s) (Maximum 3 s.) Pump out contents of tank(s) When combined sludge and scum equals one -third (1/3) of tank volume Inspect dispersal cell(s) At least once every ❑ months ear(s) (Maximum 3 s.) Clean effluent filter At least once ever ❑months ear(s) Inspect pump um controls & alarm At least once ever ❑ months ❑ ear(s) NA Flush laterals and pressure test At least once every ❑ months ❑ ear(s) ZK NA Valves At least once every ❑ months ❑ ear(s) 9 NA Other: At least once every ❑ months ❑ ear(s) to NA Page of ❑ Mound, At- Grade, In- Ground Pressure The inspection shall include recording the levels of ponding, if any in the observation tubes and a visual inspection for any evidence of surface seepage or discharge. Any discharge to the ground surface must be promptly reported to the regulatory authority_Ronding greater than 75% of the height of the component may indicate overloading or impending hydraulic failure necessitating more frequent monitoring. The pressure distribution system is provided with an opening at the end of each lateral to be used for flushing. The laterals should be flushed at least once every three (3) years. Pressure checks of systems with multiple laterals should be done to ensure that equal distribution of effluent is occurring to promote the longevity of the system. REPORTS Reports for maintenance, inspection, and monitoring shall be submitted in accordance with COMM 83.55 Wisconsin Administrative Code. ABANDONMENT following When the POWTS fails and /or is permanently taken out of service the f o g ste s p shall be taken to ensure that the system is properly and safely abandoned in compliance with Ch. COMM 83.33, Wisconsin Administrative Code. All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or other inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant re lace nt 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 from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replac the failed POWTS. ❑ 4 e s'te as not b evaluated id tify a suita rep cement are . p failure of t a soil and site evaluation us b p rfo d t locate suitable plac ent area. I acement are ailable a holding tank may be installed a a s r to rep e failed POWTS. ❑ Mound 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 CONTIAN 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 M A o" e of f d f vJ x of u4 a ✓f Name X11 A - e , 7 d i lAe r XC 4 ✓T Phone 71f- Phone 71r — p.7 — voic SEPTAGE SERVICING OPERATOR (Pumper) LOCAL REGULATORY AUTHORITY Name Agenc Phone Phone ] — 3y KAWPDATA \EH\POWTS OWNER'S MANUAL.doc Page od— START UP For pew construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. OPERATION The property owner is responsible for the operation and maintenance of the POWTS and submission of required reports. The quantity and quality of the wastewater stream will affect the performance and longevity of your POWTS. The installation of water - saving appliances and fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine or waste from water softeners, iron removal units, other clear water treatment devices and foundation drains should be discharged to the- ground surface whenever possible. Note: this does not include laundry waste, showers, dishwater, etc. This system is designed to handle domestic strength wastewater, however the disposal of food based greases and oils, vegetable /fruit peels and seeds, bones, and food solids such as those produced by a garbage disposal should be minimized. Toilet tissue is the only paper that should be discharged into the system. Other non - biodegradable items such as baby wipes, tampons, sanitary napkins condoms, cigarette butts, dental floss, and cotton swabs should not enter the system. Chemicals such as petroleum products, paint, disinfectants, pesticides, antibiotics, solvents, etc., should not be flushed into the system as they can seriously damage your POWTS and contaminate your drinking water supply. Maintain a regular steady flow by spreading laundry washing throughout the week. Avoid vehicle traffic over all system components. Compaction of snow over the dispersal unit may cause it to freeze up. ❑ Valves Valves shall be operated in the following manner: _ ❑ Alarms Alarms should be tested on a regular basis by the home owner. If an alarm sounds, contact an individual licensed to service POWTS, There is normally a I day reserve under regular operating conditions, however water should be conserved until any problems with the system are corrected to prevent back -up of sewage into the dwelling or surfacing. INSPECTIONS Inspection shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Maintainer or Septage Servicing Operator (per the attached Maintenance Schedule). m Septic Tanks Component Tank inspections must include a visual inspection of the tank to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back--p or ponding of effluent to the ground surface. Access openings used for service or assessment shall be sealed and/or locked upon completion of service. Any defects shall be promptly corrected. Exposed openings greater than 8 inches in diameter shall be secured with an effective locking device to prevent accidental or unauthorized entry into the tank. When the combination of sludge and scum in any tank exceeds one -third (1/3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with Chapter NR113, Wisconsin Administrative Code. The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to manufacturer's specifications. Provisions are to be made to retain solids in the tank. Filter cleaning may be necessary at more frequent intervals than stated in the maintenance schedule to keep the system operating. ❑ Pump Chamber /Treatment Tanks Component The inspection must include a test of all electrical equipment such as pumps, alarms and floats. A visual check must be made for leaks, backups, surfacing, missing or broken security devices and other hardware and the condition of any filters. Any service needs or repairs shall be promptly taken care of. j� In- Ground Gravity Component Dispersal Cells The inspection shall include recording the levels of ponding, if any in the observation tubes and a visual inspection for any evidence of surface seepage or discharge. Any discharge to the ground surface must be promptly reported to the regulatory authority. Ponding at depths greater than 75% of the height of the component may indicate overloading or impending hydraulic failure necessitating more frequent monitoring. Page C7 od— v Parcel #: 040 - 1273 -30 -000 10/13/2004 12:06 PM PAGE 1 OF 1 Alt. Parcel #: 17.28.19.1520 040 - TOWN OF TROY Current 1XI ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): " = Current Owner * JOHN L & TEREN L WEYER WEYER, JOHN L & TEREN L 14514 LOCKSLIE TRL SAVAGE MN 55378 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description ` 322 DAY FARM RD SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 2.000 Plat: 2565 -TROY WOOD 01 SEC 17 T28N R1 9W SW SW LOT 44 TROY WOOD Block/Condo Bldg: LOT 44 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 17- 28N -19W Notes: Parcel History: Date Doc # Vol /Page Type 08/04/2003 735538 2345/527 WD 12/26/2001 666346 1799/595 QC 2004 SUMMARY Bill #: Fair Market Value: Assessed with: 77,900 Valuations: Last Changed: 07/23/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 82,900 0 82,900 NO Totals for 2004: General Property 2.000 82,900 0 82,900 Woodland 0.000 0 0 All 2.000 82,900 0 82,900 Totals for 2003: General Property 2.000 75,000 0 75,000 Woodland 0.000 0 0 Total 2.000 75,000 0 75,000 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 J 2 3 4 5 P 5 2 7 7 3 3 5 3 6 STATE BAR OF WISCONSIN FORM 2 - 1998 KATHLEEN H. WALSH WARRANTY DEED REGISTER OF DEEDS Document Number ST. CROIX CO., MI This Deed, made between Day Farm Investors, LLC, a Minnesota RECEIVED FOR RECORD Limited Liability Company 08/04/2003 10:00AH WARRANTY DEED EXEMPT # Grantor, and John L. Weyer and Taren L. Weyer, husband and wife REC FEE. 11.00 - TRANS FEE: 248.70 COPY FEE: CC FEE: Grantee. PAGES: 1 Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin: Recording Area Name and Return Address Lot 44 Troy Wood, Town of Troy, St. Croix County, Wisconsin �rC-6 040 -1273- 30-000 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 retention,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 an amount not to exceed the consideration expressed herein, that being the stun of $82,900.00. Dated this 18th day of July 2003 Day Farm Investors, LLC . by } . President * . Austin J. Baillon AUTHENTICATION ACKNOWLEDGMENT STATE OF WISCONSIN ) ) SS. Signature(s) Ramsey County. ) Personally came before me this 18th day of authenticated this day of July , 2003 the above named Austin J. Baillon TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the person(s) who executed the foregoing (If not, instrum d acknowledge the same. authorized by § 706.06, Wis. Stats.)_4 Q ■ THIS INSTRUMENT WAS DRAFTED BY Paul A. BaiHon, Attorney at Law ' Paul A. Baillon ' PAULA. BAILLON If Notary Public, State of rcolaassroN EXF8lE31 914on (Signatures may be authenticated or acknowledged. Both are not My Commission is perm necessary) January 31 2005 ) -Names of persons signing in any capacity should be typed or printed below their signatures WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 2 - 1998 INFORMATION PROFESSIONALS COMPANY FOND DU LAC, WI 800. 655 -2021 f 0 do 00 doop doop A* / .� 4Ph 0 OOV� OOOF lo, .001.00, / .0e Ole / lo / • dp i • �o a