HomeMy WebLinkAbout040-1260-40-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division Sanitary Permit No: t
INSPECTION REPORT 487946
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provid may be used for, econdary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Bailey, Terry & Jean Troy, Town of 040 - 1260 -40 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range /Map No:
j��• Z ��-. G(V\II. 18.28.19.1393
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic { � Benchmark 3
Alt. BM &A % �`7T �ry •� 9?• is
Aeration Bldg. Sewer
Holding St/Ht Inlet Z5 /bc
TANK SETBACK INFORMATION St/Ht Outlet `n 7(,
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet G'--, Septic 7 / , [� ZI Dt Bottom ` \
Dosing �VIC( _ __ Header /Man.
Aeration ` Dist. Pipe
-7,77 / - D S'
ID
Bot. System . ' S. 5S 97. CAK,
Final Grade 4 7� 61, 6_Z-
PUMP /SIPHON INFORMATION 1
Manufacturer Demand St Cover icy �Z•
GPM
Model Num
TDH Lift Friction Loss jSysteT TDH
Force main Le Oi Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 47 •�
SETBACK SYSTEM TO / P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer. Ez r" �V
INFORMATION Type Of System:, / / A ,A �� CHA UN OR Model Number. 64 —
- I - JZ DISTRIBUTION SYSTEM — ITeIII . 1T f%4ZQ
Header /Manifold IDistributio x Hole Size x Hole Spaci Intake
Pipe(s) f ez
Length Dia_ Length Dia l Spacing 1
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded/ odded xx Mulched
Bed/Trench Center 3 Bedlrrench Edges Topsoil Yes i No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 390 Deer Valley Drive Hudson, WI 54016 (NE 1/4 NE 1/4 18 T28N R1 9W) Deer Valley Lot 14 Parcel No: 18.28.19.1393
1.) Alt BM Description = ✓"� �� +� �� O �_
2.) Bldg sewer length= 3o
- amount of cover = i
3 _
--
Plan revision Required? - 1 Yes - )?40 1 11 ' L6
Use other side for additional information. _- __ __ —
Date Insepctors Si ature Cert. No.
SBD -6710 (R.3/97)
Safety and Buildings Division r
201 W Washington Ave., P.O. Box 7162 County nn
Madison, WI 53707 - 7162 V r
De artrnent of Commence (608) 266 -3151 Sanitary Permit Number (to be filled in by Co.)
In
Sanitary permit Applica State Plan I. . Num ?
accord with Comm 83.2 1 Wis. Adm. Code, Personal information you provide
may be used for secondary purposes Privacy Law, $I
I. Application Information - Please Print All Information Jes -Gums (if different than mailing address)
n
Pro er's Name `10 b.<" VC I lay .
Prope o ct` o.`, N OV 2005 P ilf ots l B �k ► r
wner's Mai ng Address _ N
00 �' ST. CROIX COUNTY P pe Locauon ��
CitState m ' �� ZONING OFFICE
i ipCode One Number 't. NEf,, Section_
i S two S So
II. Type of Building (check al that appl T N; R (c o irclep�)
L L .
1 or 2 Family Dwelling - Number of Bedrooms
- 3
0 Pubhc/COmmercial - Describe Use r ' Subdivision Name CSM Number
O State Owned - Des Use f+
III, T OCity ❑Village�fo ship of f�
T ype of Permit: (Check only one box on I• e
A. ' O
Com to lice B if applicable)
N ew System 0 Replacement S stem
y 11 Treaunent(Holding Tank Replacement Only ❑ Other Modification to Existing System
B• ❑Permit Renewal
Permit Revision ❑Chan a of List Previous Permit Number and Date sued
Before Expiration g List Transfer to New
Plumber Owner y
IV. T of POAVTS S stem: Check all that apply)
A - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil
Constructed Wetland Press - Mound 124 in. of suitable soil El At-Grade 0 Single Pass Sand Filter
urized In- Ground 0 Holding Tank 0 Peat Filter 0 Aerobic Treatment Unit 0 Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter 0 Leaching Chamber 0 Drip Line r
V. Dis rsjt .b„- t_1,�Q p 0
Vr tment Area Information: (expla n)
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area R uired s ty
. / �s e4 f) Di al Area Propos sf) System Elevation
VI, nk I
✓
co ✓ 7
Tatnfo Capacity in Total Number
Gallons Gallons Of Units Manufacturer Prefab Site
Steel Fiber Plastic
Septic Holding Tank
New Existing Concrete Constructed Glass
Tanks Tanks
Aerobic Treatment Unit � �Jv t rE%s v F
Dosing Chamber
VII. Responsibility Statement - 1, the enders a 1
Plu her's Name (Print ' assume TS sho
PI her's Si ature asibility for in the POWwn on the attached plans
IMPRS tuber Business Phone Number
t
Plum is A ass (Street, City, State, Zip Code) CI
i9 IgS Lp N- t �s
Coua /De artment Use On
Approved Disapproved Sanitary Permit Fee includes Groundwater
Surcharge Fee) Date ssu Issuing t Signs re S
0 Owne en Reason for De 66
IX. Conditions o pproval/Reasons for Disapproval
SYSTEM OWNER: 3) key j
1. 'Septic tank, effluent fiker and f v •
dispersal cell must all be services / maintain.,d
as per management plan provided by plumber.
2. All setback requirernerrts must be maintakW
as Par *P11cable code / ordinances.
Attach eompkte plans (to the County only) ror the a tam on a t sot
Ys p pe kss thaw 8t2 a l t lathes is size
SBD -6398 (R. 01/03)
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Wisconsin Department of Commerce SOI 485,Wis. Page I of 3
Division of Safety and Buildings
ante with Codm. Code Cou St. Croix
Attach complete site plan on paper n ss th x 11 inch m�is1J � include, but not limited to: vertical and h tal r en int and Pa I I.D. 0401070 -10
percent slope, scale or dimensions, north a and an MressttOUd N X Nr Re iewed Date
by Please print all in ation. G OFFICE
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m
Property Owner Property Location
Terry and Jean Bailey Govt. Lot NE 1/4 NE 1/4 S 18 T 28 N R 19 E (or) )W W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
30085 Norway Ave 14 1 1 Deer Valley
City State Zip Code Phone Number []City rjVillage Town Nearest Road
Lindstrom MN 1 55045 ( lroy I Deer Valley Drive
Q New Construction Use(E Residential / Number of bedrooms 3 to 4 Code derived design flow rate 450 to 600 GPD
Replacement Public or commercial - Describe:
Parent material Flood Plain elevation if applicable NA ft.
General comments This soil test has been completed so as to move the "permitted system" area to the other side of the house. The site
and recommendations: that was tested has been graded prior to the evaluation with surface soil being removed. At the time of instillation
0 additional grading may be completed that would replace top soil and alter surface elevations. All tested soils are
0 natural (not disturbed) with vertical and horizontal measurements being accurate.
FTI Boring # �D Boring /'-
ID Pit Ground surface elev. 99.30 ft. Depth to limiting factor >96 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -5 IOyr4 /3 sil 2msbk mfr as 2f .6 .8
2 5 -15 7.5 r4/3 is O ml gw If .7 1.6
3 15 -50 7.5yr5/4 s Osg ml gw - ,7 1.6
4 50 -65 7.5yr4/4 cos Osg in] 9w - .7 1.6
5 65 -96 7.5yr6/4 II s Osg ml - - .7 1.6
J
Boring # Boring 101.00 > 100 ✓ F 0 pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2
1 0 -12 1Oyr6 /4 s Osg m gs - .7 1.6
2 12-50 10 r5/4 cos Osg ml gw _ .7 1.6
3 50 -100 1Oyr6 /4 s Osg ml - _ .7 1.6
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature CST Number
Thomas C Nelson "�■ 227387
Address Date Evaluation Conducted Telephone Number
1432 120th Street, New Richmond, Wl 11-03-05 715- 246 -2454
Property Owner Bailey Parcel ID # 0401070 -10 / Page 2 of 3
❑ Ong # pit Ground Ground surface elev. 100.40 ft. Depth to limiting factor 105
Sofl Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2
1 0 -28 7.5yr4/4 - s Osg ml gw - .7 1.6
2 28 -72 7.5 5/4 - Cos Osg ml gw - .7 1.6
3 72 -78 7.5yr6/4 - s Osg ml ew _ .7 1.6
4 78 -105 7.5yr5/4 - Cos Osg ml - - .7 1.6
j lj '
2"
Boring # Boring
Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
F-1 Boring # Boring
u Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg1L * 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.
CnTI- R4'irtt'rcr lR mmm
Terry & Jean Ba iley
Lot 14
N OI
tot tine
Arbitrary line between two lot line points
for the purpose of measurements
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168' 102'
81'
132 R
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61 2% n
� ■ slope e
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183'
BM2
10
120' Lot 14
63
76'
100'
53'
BM1
/4%
lope
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t tine a 98 ,
388' —�
SE lot corner
Lot
t 100'
1 Scale 1" = 30'
BM1 Top of "T" on "T" post base 100.00'
6 BM2 Top of poored concrete footing 103.20'
B1 99.30'
82101.00'
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' e Bottom
36
12 -1/2" DIA. (typ.)
Void Volume SQ{ Interface Areso 11.14 Ft
Void Coefficient in Aggregate given at 57,4%. Sidewall (2 Sidewalls) 2 * 18.84tn =
O.D. of 4" pipe - 4.625 inches
l2in 3.14
IR
= 3.14
Void volume per linear
2.3 125iu l Bottom 2.00
ft. • ( J • Ift = 0.117 ft>
l l2in /ft )
O.D, of txteter cytiteder =T2.5 inches Total Soil Interface Area 5,14 SQ.FT
Void volume in a ( 6,23in 2.3123ia
ggregate of center cylinder =3.14.1 l2in / ft,. - 3.14' ( 12m / ft) � ' -574 = ,422 ft
O.D. of outside cylinders .= 12 inches l /// Projected Trench Area
Void volume in outside cylinders - 2.3.1 6m ' 574-.901 ft> Sidewal I Height = 12 in. •2 = 2.00 Sq.Ft.
�12in /ftJ
Bottom = 36 in. = 3.00 Sq.Ft.
Void volume at bottom between cylinders - I NWIR 24in bin 6m
q� 0.215 ft Projected Treacle Area = 5.00 5 Ft.
y 12 in /ft) - `12intft) )I _ > q-
Void volume at outside bottom comers (1R of void volume between cylinders) 0.215 ! 2 = 0.108 ft>
Total void volume-0.1 17 +0.422 +0.901 + +0-108- 1.763 cubic ft t ft
Gallons per R - 1.763 X 7.48 - 13.2 gallons Per linear ft.
EPS Aggregate
Trench System
EZ1203H
Ring"- Industrial Group
65 Industrial Park Rd.
Oakland, TM 18060
sc�u1 nLE tutus ¢12031+ -ve1 sNW. t al , „ -z7 -o,
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner -r'_ 1
Permit # G `� Septic Tank Capacity S V gal ❑ NA
7- Septic Tank Manufacturer s ❑ NA
�;s
DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model
❑ NA
Number of Public Facility Units ❑ NA Pump Tank Capacity al ❑ NA
Estimated flow ( average)
( gel
D� gal/day Pump Tank Manufacturer ❑ NA
Design flow (peak), (Estimated x 1.5) C)��gal /day Pump Manufacturer ❑ NA
Soil Application Rate ' 7 a) /day /ft Pump Model
❑ NA
Standard influent /Effluent Quality Monthly average* Pretreatment Unit ❑ NA
Fats, Oil & Grease (FOG) _ <30 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) ❑ 14A
Biochemical Oxygen Demand (BOD 530 mg /L Kin- Ground (gravity) ❑ In- Ground 1pressurized)
Total Suspended Solids (TSS) <_30 mg /L ❑ NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) 510 cfu /100ml ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA
Other:
❑ NA Other. ❑ NA
* Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3
ear(s) years) O NA
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume El NA
Inspect dispersal cell(s) At least once every: ❑ month(s)
ear(s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: months)
• years) ❑ NA
Inspect pump, pump controls & alarm At least once every: ❑ month(s)
❑ year(s) D NA
Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA
Other: ❑ year(s)
At least once every: ❑ month(s) ❑ year(s) ❑ NA
rher:
❑ 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.
START UP AND OPERATION Page of
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of aintin `
that may impede the treatment process and /or damage the dispersal cell(s). if high concentrations are detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; tat;
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 i e openings p p p gs sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performer} 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.
WTS.
❑ 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 POWTS MAINTAINER
Name Name
W
Phone s a ( Phone El E
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name i
Phone Phone —7
This document was drafted in compliance with chapter Comm 83.22(2)(b)(IIM &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
` ety and Buildings Division
,�� d, R
� ZUI 5 County
,�Q BOX 7162
De artmertt of Commerce `>;
26 ; ` C, nary Permit Number (to be filled in by Co.)
Sanitary Permit Appli S e Pian LD,
In accord with Comm 83.21, Wis. Adm. Code, 10 d.. UiiibCf
final
may be used for secondary , s You Provide
ry purposes Privacy Law, S.t�(
1x I GOV I 1ect Address Or different than mailing address
L Application Information — Please Print All Information }
Pro ICE .
Owner's Name 3 L o V C A 1'A p k
R ` J Parcel # Lot # Block H
Property Owner's ailing A ess V� a 'Q
3 O ro Location O U O tJ
City, State WG� �V E M 3
Zip Code
� Phone Number Y � � ' /,, Section
H. T ��0
Ype of Buikting (check all that a y) (circ
I or 2 Family Dwellin ! f 3 1 3p- L.L ;r T N; R.�E orr
g — Number of Bedroo } ,
PublielCommercial — Describe Use Subdivision Name CSM N�
❑ State Owned — cribe Use
III. T ype of Per OCity ❑Village ifowns ip of r _ C>
A. ms ( heck only one box on line A. omplete line B if Applicable)
New System ❑Replacement System ❑ T
tment(Holding Tank,l%ePlacement Only ❑ Other Modification to Existing System
B. ❑ Permit Renewal
❑ Permit Revision f ❑Chan
Before Expiration g O Permit Transfer to New List Previous Permit Number and Date Issued
Plumber Owner
IV. T of PO S S stem: Check all that a 1
Non — Pressurized In- Ground ❑ Mound > 24 in, of suitable soil ❑ Hto d <24 in. of s
Constructed Wand [] Pressurized In- Ground El Holdin Tank unable soil ❑ At -Grade ❑Single Pass Sand Filter E] g �] Peat er ❑ Aerobic Treatment Unit
❑ Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter ❑Leaching Chamber
V. Dis rsal/Treatment Area Information: ❑ Line veI -less ❑Other (explain)
Design Flow (gpd) Design Soil Application Rat
e(B Dis
0 l 4'' persal Area Requi f) is rsal � � � Ar Proposed (sfj D
New System Elevation
VI. Tank Info Capacity in Total Number o O ,/ - 7 a ✓
Gallons Gallons of units Manufacture Prefab Site
Steel Fiber Plastic
Tanks Existing Glass
Tanks Concrete Constructed
Sept or Holding Tank 11
erobic Treatment Unit
it
Dosing Chamber
;j
VII• Responsibility Statement - 1, the on
tuber's Na t) t
Plu espoasibility for instal of the POWTS sho on the attached plans,
ber Si ature
RS umber Business Phone Number
Plumber's Address i et, City, State, Zip j 5C 3S
oun !D S Q
t'tment Use On
Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater
Surcharge Fee) Date I sued I gent S cure
❑ Owner Given Reaso for Denial s)
M Conditions o ff�A for Dina * 3 0 D, Di r O 9 d
SYSTEM OW tR. pproval
ep Ic ank, effluent filter and
dispersal cell must all be serviced / maintained
as per management plan Provided by lumber.
2. All setback requirements must be maintained
as per applicable code /ordinances.
Attach com to
Ple pram (to the Co" only) feu the system om paper not ksa than 81/Z s 11 inches is size
SBD -6398 (R. 01/03)
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Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor and Human Relations
Division of,;afety & 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 St. Croix
not limited to vertical and horizontal reference point (B \ 'qd % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distan �, _e
APPLICANT 040 1070 -10
APPLICANT INFORMATION - PLEASE P Nf LL I V OVATION(\ RE IEWEDBY a DATE
PROPERTY OWNER: �'p r `099PERTY LOCATION
Derrick Construction Inc. 4� `���� LOT NE 1/4 NE 1/4,S 18 T 28 N,R 19 fdor) W
PROPERTY OWNER':S MAILING ADDRESS
* ` t0 # BLOCK # SUBD. NAME OR CSM #
_u� sr � ��
1505 Hwy #65 y na Deer Valley
CITY, STATE ZIP CODE >'RHO ITY ❑VILLAGE x❑rOWN NEAREST ROAD
New &g"LQd I WI. 4 ( ,1 X",' Troy E. Cove Rd.
New Construction Usekd Residential/ Numbsc,bf bd drbo' W " 4 [ ] Addition to existing building
I ] Replacement [ ] Public or commercial describe
Code derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd /ft .8 trench, gpd /ft
Absorption area required 858 bed, ft 750 trench, ft Maximum design loading rate .7 bed, gpd /ft .8 trench, gpd /ft
Recommended infiltration surface elevation(s) A= 98.70 -B =97.25 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem KI S ❑ U EIS ❑ U [IS ❑ U ®S ❑ U ® S ❑ U O S ® U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
..................
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
.................
..................
.................
1 1 0 -19 10 r 2/2 none 1 2msbk mfr 9W 2f .5 1.6
2 19 -35 10 r 4 4 none sil 2csbk mfr gw 2f .5 .6
Ground 3 35 -90 7.5 r 4/4 none cos osg ml na na .7 .8
elev.
10 ft.
Depth to
limiting
factor B,10 ok ot 36
a -Oyt i o
+A
Remarks:
Boring #
1 0 -11 10 r 2/2 none 1 2msbk mfr gw 2f .5 .6
2 11 -20 10 r 4/4 none sil 2csbk mfr qw 2f .5 .6
Ground 3 20 -90 7.5 r 4/4 none cos os ml na na .7 .8
elev.
1 02.5 ft.
Depth to
limiting S �(•�
factor
+90
Remarks:
CST Name: -- Please Print Ciary L. Steel Phone: 715 -246 -6200
Address: 1554 200th. Av . w Richmondl Wl 54017
Signature: - Date: 6 - 4 - 99 CST Number: m02298
PROPERTY OWNER Derrick Cons tru cti orS OIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D. # -- Q40-1070-10
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bax>dary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
3.:. 1 0 -15 1 .6
" ;A -30 10 r 4/4 none sil 2csbk mfr 9w 2f .5 .6
Ground 3 30 -90 7.5 r 4/4 none cos osg ml na na .7 .8
elev.
101.
Depth to
limiting
factor - -qg,�„ 2 -
+90"
36 /� z 5 • `(
Remarks:
Boring #
1 0 -25 10 r 2/2 none 1 2msbk mfr gw 2f .5 .6
4 i
2 25 -46 10 r 4/4 none sil 2csbk mfr gw 2f .5 ' .6
3 46 -90 7.5yr 4/4 none cos osg ml na na .7 .8
Ground
elev.
101.Q0
Depth to 4 2
limiting 4r
factor
+90
Remarks:
Boring #
1 0 -18 10 r 2/2 none 1 2msbk mfr gw 2f .5 . 6
2 18 -38 10 r 4/4 none sil 2csbk mfr gw 2f .5; .6
Ground 3 38 -90 7.5 r 4/4 none cos osg ml na na .7 ' .8
elev.
1 00.5 ft.
Depth to
limiting 9 s'
factor
— 17 +90
Remarks:
Boring #
Ground
elev. j
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 Derrick Construction, Inc.
NE4NE4 S18- T28N -R19w New Richmond, WI 54017
MPRSW -3254 town of Troy ( 715 ) 246 -6200
lot #14 -Deer Valley
This soil evaluation was conducted to satisfy a zoning requirement, it may or may
not be suitable for your use. The location of the test may or may not be as shown
as permanent lot lines were not established at the time the test was conducted.
N
1 =40'
BM. 4 top of 1" pvc pipe C el. 100.00'
Al t. BM.= top of 1" pvc pipe C el. 99.40'
to
fd
i
�lG
A
15° ti
oil
Y
Gary L. Steel
6 -4 -99
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer J ��Lf 1-$A1 L- Address '�4 0 � d►�/ r4vc L t4 A 5pzv M, /;f&1 5 s o g S
Property Address -2 2 \4 L-LSY 1 0 44 Vc'
(Verification required from Planning & Zoning Department for new construction.)
City /State A d S 0 &t ("/ Parcel Identification Number O V'0 - /) � - �O d 4 Q
LEGAL DESCRIPTION
� /�S (' X3 93)
Property Location 1 k /4 , / a , Sec. , T 7 .� N R `� W, Town of _
Subdivision Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # `� O S 7 , Volume 2 $ , Page # l g
Spec house yes no Lot lines identifiable yes no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
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 Planning &
Zoning Department within 30 days of the three year expiration date.
Uwe certify that all statements on this form are true to the best of my /our knowledge. I/we am/are the owner(s) of the
property described above, by virtue o a warranty deed recorded in Register of Deeds Office.
Number of bedrooms
l
SI TURE OF APPLICANT( DATE
** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * **
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 08105)
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of 7�
FILE INFORMATION
Owner SYSTEM SPECIFICATIONS
� � . t
Permit # `Q Septic Tank Capacity al ❑ NA
7�f Septic Tank Manufacturer W ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA
Number of Bedrooms
❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units ❑ NA Pump Tank Capacity
al NA 7�
[,Estimated flow (average) �j Pump Tank Manufacturer
..g al/day ❑ NA
Design flow (peak), (Estimated x 1.5) 0 0 al /day Pump Manufacturer
❑ NA
Soil Application Rate al /day /ft2 Pump Model
❑ NA
Standard influent /Effluent Quality Monthly average* Pretreatment Unit
A
Fats, Oil & Grease (FOG) <30 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 (ROD <30 mg /L � 'In- G round (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) <30 mg /L A ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) 51 ° 100ml ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y in dia. 13 NA Other:
❑ NA
Other; Other:
❑ NA ❑ 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
ear {s) years) ❑ NA
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) years) (Maximum 3 yearns) ❑ NA
Clean effluent filtd°r At least once every: 0 month(s) ❑ NA
years)
Inspect pump, pump controls & alarm At least once every: ❑ month(s)
❑ year(s) ❑ NA
Flush laterals and pressure test At least once every: ❑ month(s)
Other: ❑ year(s) ❑ NA
At least once every: ❑ month(s) ❑ NA'
Other: ❑ year {s)
❑ 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,
k Wisconsin Administrative Code.
l other services, including but not limited to the servicing of effluent filters m echanical or pressurized components, pretreatment
its, and any servicing at intervals of <12 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within t0 days of completion of any service event.
1,
START UP AND OPERATION Page of
For new construction, prior to use of
the POWTS check treatment tank(s) for the presence of paintin
that may impede the treatment process and /or damage the dispersal p al cell 9 Products h other chemicals
. I
of the tank(s) removed by a septage servicing operator prior to use. (s ) f high concentrations are detected have the contents
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 POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
Th site a not b �eva luated t r tify a s�ita re ement area pon ilure of the TS a soil a d e at ust ed t ocata cement no
replace nt ar s avai ble a a t site ank
ay be i sta as to replace the faiWTS.
❑ Mound a nd 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 t
Name
Phone S Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name Slt. 0 c 'BDl
Phone Phone tS
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.5411), (2) & (3), Wisconsin Administrative Code.
7 c3ISIZS-Z+ f 1
U 2 S 1 0 P 1 8A KATHLEEN H. WALSH
Doctirmant Number WARRANTY EED REGISTER OF DEEDS
ST. CROIX CO., WI
THIS DEED made between Deer Valley Partners ( "Grantor ") RECEIVED FOR RECORD
and Terry R. Bailey and Jean L. Bailey, Trustees, or their successors 05/27/2005 10: 40AN
in trust, under the Bailey Living Trust, dated March 15, 2000 and any
amendments thereto. ( "Grantee "), WARRANTY DEED
WITNESSETH, that the said Grantor, for valuable consideration EXEMPT #
conveys to Grantee the following described real estate in St. Croix
County, State of Wisconsin: REC FEE: 11.00
TRANS FEE: 280.50
COPY FEE:
Recording Area Cr FRR •
Lot 14 (fourteen), Plat of Deer Valley in the Town of Troy Name and Retup : 1
St. Croix County, Wisconsin
Deer Valley Partners
PO Box 445
New Richmond, WI 54017
040 - 1260 -40 -000
(Parcel Identification Number)
This is not homestead property.
Grantor, Deer Valley partners, a Wisconsin Limited Liability Partnership, is an affiliate of Derrick Homes, LLC, a
Wisconsin Limited Liability Corporation. Grantor develops land and Derrick Homes, LLC is a home construction
contractor. Grantor agrees to sell this lot to Grantee on the condition that Derrick Homes, LLC will be the builder
of the home for Grantee. If Grantee does not commence construction With Derrick Homes, LLC as the
contractor /builder within two (2) years of the date of sale of this lot to Grantee, Grantee gives Grantor the
irrevocable right to re- purchase the lot for the same price as Grantee paid Grantor for it when Grantee bought it
from Grantor. If Grantee desires to sell the lot to another purchaser before constructing a home upon this lot,
Grantee gives Grantor the right of first refusal to re- purchase the lot for the same price as Grantee paid Grantor
for it when Grantee bought it from Grantor.
Dated this 25th day of itchy, 2005.
�a
" d L. Derric
ichael R. St yens
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
ST. CROIX COUNTY
Personally came before me this = day of uj�i y, 20Q5, the
authenticated this _ day of 20_ above named Michael R. Stevens and Ronald L. Derrick,
,!s-pa Deer Valley Partners to me known to be the
Lackno%ye erso s who cut the foregoing instrument and
signature d ge same.
PAN
type or print name
TITLE: MEMBER STATE BAR OF WISCONSIN signature ELA . RUTLEDQE
(If not, type or print nam m Note PubUc
40 authorized by' 706.06, Wis. Slats.) Notary Public St. Croix County, Wisconsin. Qtnt9 O Wltll msln
My Commission Expires: September 27 , 2008
THIS INSTRUMENT WAS DRAFTED BY *Names of ersons signing in an c should be
Deer Valle Partners p g y p b typed or
Y printed below their signat
PO Box 445
New Richmond, WI 54017
DEER VALLEY
Located in the NE of the NE1 /4, Part of the SE of the NE1 /4,,Part of the SWIM of the NE1 /4,
and part of the NW1/4 of the NEi /4, of Section 18, T28N, Ill 9W, TOWN OF TROY, ST. CROIX
COUNTY, WISCONSIN
LOT 12
2.3 Acres LOT 11
2.7 Acres
N LOT 13
4.8 Acres
Z
LOT 10
2.7 Acres
LOT 14
J 3-2 Acres
IL LOT 9
Q j 3.3 Apes
Z LOT 15
UNPLATTED LANDS LOT 16 2.3
p 2.3 Acres LOT 8
t Acres 3.4 Ades
Q
J
a
D LOT 17
O
2_4 Acres
LOT 18 LOT 23 LOT 7
LOT 28 2.5 Ades 2.6 4.7 Acres
2.9 Acres LOT 22 Acres
29 2_T
LOT
Acres
e 6 8 Ades
� LOT L0T 6
O LOT 19 4 2.7 Apes
2.3 Apes A
LOT 20
C 3-4 Acres
7
U LOT 5
2.7 Apes
LOT 4
LOT 25 4-S Acres
2-3
Acres
LOT 2 LOT 3
2-8 Acre 3.7 Acres
s
LOT 26
3_3
Acres
LOT 27 \
2.7 Acres LOT 1
2.3 Acres
Existing
Mouse
East Cove Aoad