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HomeMy WebLinkAbout040-1314-04-000 PP7 . 17 Drartmentof Commerce PRIVATE SEWAGE SYSTEM County: St. Croix .ety and Building Division INSPECTION REPORT Sanitary Permit No: 488187 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information ywu provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Flame: City Village X Township Parcel Tax No: Feyereisen, Greg & Cheryl Troy, Town of 040 - 1314 -04 -000 CST BM Elev: Insp. BM Elev: I BM Description: Section/Town /Range /Map No: (6 2 • / 2 • 1) ✓kl y ,Q wt•ru 33.28.19.2054 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic - Zoo Benchmark Z• '+Z /d`I. � /�� Dosing Alt. BM U Q- 1 •g� /0 6- o / Aeration B dg. ewer Di(l►• 2 L� -0 4e� s �s- 3 Ho ing t Inlet „� 3 X2. 9 TANK SETBACK INFORMATION t O ��� TANKIU FI/L WELL BLDG. V ent o it Intake n e ep is % 2 7(0� 7 `S1 if / 1 0 7 - Bottom S qQ. o y osmg -75 er an. era ion Dist. Pipe o Ing o. b ysfe rn S Z /b 3 tii S 6/_ L� inal Grade PUMP /SIPHON INFORMATION P6 y M anufacturer Demancl st cover r GPM L it 7 r o e um er �� '�,� C Z• tz. /a7 -3 i TI t-riction Loss S Heaa r em in JlLengtn 7.13 i .Loy ��✓ . 9 g.9 I . 01 1 Iellullezi DIMENSIONS NO. V1 rILS 11151ut: LA4. jLIquIU UUP111 SOIL ABSORPTION SYSTEM CCU - DIMENSIONS Q L F, INFORMATION 9 G CH ER OR Mill w ",/d >5e 2t b 24D IT d LJ - I 0 Pipes) 2 / ~ 3 (f ti 1 C Leng Dia Length1_ Dia Spacing x Pressure Systems Only xx Mound Or At -Grade Systems Only AA I Bed/Trench Center Bed/Trench Edges Topsoil Q C _ , w . , e O Yes I wo COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: 4fr / #2: / / Location: 17 Serenity Ct River Falls, WI 54022 (NE 1/4 S%1/4 33 T28N R19W) Serenity Lot 9 G Parcel N9 33.28.19.2054 1.) Alt BM Description j��� `f It 2.) Bldg sewer length ( A_ J � - amount of cover =' ^- f n ' _ — Plan revision Required? Yes o Use other side for additional information. i LBat ePctor`s� SBD -6710 (R.3197) ` Safety and Buildings Division -County 201 W. Washington Ave., P.O. ro t !I cons in Madison, WI >f j Sanitary rmit Number (to be filled in by Co.) Department of Commerce (608)26 -3151 Sanitary Perm h On' gyp`( State Plan Number with Comm 83.21, Ws. Adm. In accor may be used for seco d purposes Per La� ormat4 rovide S� CRO,XC P Q r (if different than mailing address) I. Application Information - Please Print All Information 7 e- y- e..-yy C� Property Owner's Name / Parf el # Block # ID d 4 Property O er's Mailing d ess Property Location 19 S ee- " V E A SW / 1A Section _ City, State r Zip Code Phone Number 1 uGt! a � �d Z 2 ?/s 3o - So 3a T �8 N; R�Eo� (. 265 II. Type of Building (check all that apply) OK moo 6,,6 -, or 2 Family Dwelling Number of Bedrooms f Subdivision Name CSM Number 11 Public/Commercial - Describe Use , _ - Y - 9 -/ I ►I�' �d W ❑ State Owned - Describe Use '8 - 6 o ❑City, ❑Village EXTownship of r III. Type of Permit: (Check only one box on line A. Complete line B if applicable) in V „ _ — A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of 11 Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: Check all that a 1 i ❑ 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 Chamber ❑ Drip Line ❑ Gr avel -less Pipe ❑ Other (explain) 5 r 35 6 V. Disp ersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate Dispersal Area Req ' ed (sf) Dispersal Area Proposed System Elevation 600 , D �Da 500 0 I D 3 4 S f VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass Tanks Tanks Existin �J ' `� ^'� ✓ ( Septic or Holding Tank 0 Al J.;200 Co w wt A f/ Aerobic Treatment Unit V W Dosing Chamber YC70 _ D_ p 1 0 �-- VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) PI ber's Signatur MP PR SNumber Business Phone Number C Plumber's Address (Street, City, State, Zip Code) C 0 alp S t tra A l tca Qa 2 z, V1111. Countv /De artment Use Onl Approved ❑ Sanitary Permit Fee (includes Groundwater D Issued Issuin gent Si to (No ps) S � � weer Surcharge Fee) en Rea r Denial 4550 IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER: 3) Lo+� �� � nS � �• 5�� y �o('ot T✓.Q 1. Septic tank, effluent filter and .tom Q2�rr dispersal cell must all be services / maintained i as per management plan provided by plumber. 2. AN setback requirements must be maintained as per appNcable code / Ordinances. Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 01/03) l I 0 40wo M3TSYE .t ":;fiKt','s14 w>JC3 Y >'.JC.J!�7)6l!K a6 � �I to ' c • �, <•�, 1\,\ o � •� � o ` VAY 4+..�� �dlf�alC s�� F1'TI�PSeT 0 4 e r _ f "ak dy LvJeser C� �, fie. I ce tail C, r L 1 �a so, fCs'f - esrs - BN/ = 9 n g M 1 e v e. oT d or �6r�u.rtC✓ rf_ /p� - � ® ^.rr lor > to Fr. a ,�� t re F. 7 O g A'14 e 1 C- il)vcc ems v 17 / i '-7 7 _ 'q >toe 71 INTY PLAT OF: SERENITY MEADOWS LWARD M/4 OOr, �nj4 O u �, � W. �, �� mOY. STT""a�ca� sesroa43'1 19ee.ee• UNPLATTED LANDS 21 WW I ... .......... .. ..............................$ ......................................................................................................................... ............................... ... . a fro A wruc . ew.eo i i I t OT 3 eesn AIL tt � p�eo.�ue eo. rrJ .. LOT 4 i i t i i �� � � +' • : � I • t , i i t ?A@ A06 S i ed t , �,. OaMOh/i►aaM u�m�r � d�000eom %M. VW PL ae-aq i � t t i �� x 12tl MAIN IV Ir pr �• N0111XN 99 — .— .— .— .— .— .— . —. —.— —. .— .------- .— .— .— .— . —. —..� 3 ................................................ ..............L..............: -w l It t .............. ........ 16T 2 s< y!e r LM AQ VOL 2794 PL 25-0 100 to J r . sca' — aertr �p o�o r oena*N :,s ........... 70 w Jt OUTI.O'T� 1 aror��o�• g �S.r Owm a rw rtJ / ew Safety and Buildings �r PO BOX 7162 commerce .Wl.gov MADISON WI 53707 -7162 E TDD #: (608) 264 -8777 s c o n s i n v�,.commerce.wi.gov /sb/ Department of Commerce www.wisconsin.gov Jim Doyle, Governor Mary P. Burke, Secretary July 26, 2005 CUST ID No.220673 ATTN.• POWTS Inspector CHARLES L WEBSTER ZONING OFFICE WEBSTER EXCAVATING, INC. ST CROIX COUNTY SPIA N5815 770TH ST 1101 CARMICHAEL RD ELLSWORTH WI 54011 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 07/26/2007 Identification Numbers Transaction ID No. 1158689 SITE• Site ID No. 701910 Greg & Cheryl Feyereisen - Dwelling Please refer to both identification numbers, CTH M above, in all correspondence with the agency. Town of Troy, 54022 St Croix County NEIA, SWIA, S33, T28N, R19W Lot: 4, Subdivision: Serenity Meadows FOR: Description: New Mound System / 600 gpd Object Type: POWTS Component Manual Regulated Object ID No.: 1029972 Maintenance required; 600 GPD Flow rate; 20 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual - Version 2.0, SBD- 10691 -P (N.01 /O1), Pressure Distribution Component Manual - Version 2.0, SBD- 10706 -P (N.01 /01); Biofilter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: Co/IeG 1. This system is to be constructed and located in accordance with the approved plans and with the A PI.. r component manuals listed above. DPP s a. DIVISI >,F 2. On page 1, the legal description is incorrect. The correct legal description is shown above. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to SEE CORR1 inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation /operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. CHARLES L WEBSTER Page 2 7/26/2005 The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely Fee Required $ 175.00 Fee Received $ 175.00 /��r Balance Due $ 0.00 --r- �_� eter E Pagel Private Sewage Plan iewer, , Integrated Services WiSMART code: 7633 (608)266-2889, M - F, 0630 - 1500 Hrs pepagel @commerce.state.wi.us cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544 WEBSTER EXCAVATING, INC. N5815 770th St. f� ~ Ellsworth, Wl 54011 (715) 273 -3430 2 O. ` 00 P OWTS index Sheet Page 1 of Mound System for a 4 Bedroom Residence Property Owner/Project Name: Greg & Cheryl Feyerefsen C��RF Lot 4, Serenity Meadows /pN NE yid sw 11 s Tys N R 19 ��FS FpFp Town of Tro County, WI - s Contents Page 1 of 8 Index Sheet Page 2 of 8 Plot Plan Page 3 of 8 Plan View Cross Section Page 4 of 8 Distribution Pipe Layout Page 5 of 8 Pumping Cham her Layout Page h of 8 Pump Perf ur mance Curve Page 7 &8 of 8 Management Plan OHAKn L. WEBSTER � E1eAOe- W 7, O E61.SWORTM ' . w .6 WML • `4r�all .v Component manual used: y Name: Mound Component Manual for POWTS :rraE �Nc Version: 2.0 SBD- 10691 -P Date: January 30, 2001 -SpoN� Name: Pressure Distribution Manual for POWTS Version: 2.0 SBD 10706 -P Date: January 30, 2001 Approved Synthetic Covering Distribution Pipe Medium Sand H G Topsoil - -_ - == =0 F Elev —J I E D - 3 � % Slope Bed Of i -2 %Z Force Main Plowed Aggregate From Pump Layer ha Cross Section Of A Mound System Using E ih. / A Bed For The Absorption Area G d ,r— Ft. A Ft. H Ft. Lir:ear Loading Rate= 9,0 GPD /LN FT B 73 Ft ' Design Loading Rate =a 3- .GPD /SQ FT j _ - Ft. -- �- - C \ Ft. 74 c c c t s box .--� K Ft. 11 t e..t 1 Ft. 7- yP,cj/ llful /tnQ W .30 Ft. L *Observation Pipe K A Distribution Bed Of Pipe Aggregate Observation Pipe,` (anchbr securely) C, Jbr b ge OLsrrvd t %o•e �•�oPS ?`° J1 I e 1i,e/t�5 46c d c�d1�c. t��Lrf � -)/c� X .Ive 7'i' tto/� 6,i. s /ettcd¢ 6 e seca46440 a Plan View Of Mound Uslhg A bed For The Absorption Area Page Of Perforoted Pipe Detail End View Perforated PVC Pipe ; pv� 6 c c Holes Located On Bottom, Set de�'a %l Are Equally Spaced + 2- �P I t Disim5ution ! Pi?e Sce defid , P 7 c Ft. // Distribution Pipe Layout S Ft. ✓ X 3 6 I nches ,- Y Inches Hole Diameter Inch h- r,i�_ys,�. -yi r� S1`C'i'Y C� ® •���` o Z.G_ Lateral " Inch(es) Manifold a Inches Force Main " o� Inches — of holes /pipe � atcCess •� F I t - kked Ad Ph�� Invert Elpvation of Laterals / 0+ t. 4. P , t o e e,- Place lst hole / 8%z4 from do'de3r >'ddi, cam`/ with succe at 3 C , ;x: 4 intervals. 1- Ao le fio �� l A,hc� I�'�ori, es, �d b� � ,cx - G;x C_ Page 5 Of 9 (No Scale) p /.,sr :r re st p.Pe��jo�Y Approved Locking Manhole Covers rte.,., Wi th Warning Labels Attached Weatherproof Approved^ r IN rlke q Junction Box Vent Cap -� "' "a���� ✓ � 7 12" Minimum t 4" Minimum Quick 18" Minimum , Disconnect i 1 /4" Wee 8.,.�v 4pe- 4.).dk tied& 14vot. i p Hole p4/Z- 7.5- Baffle ,�� Payl I A 4 Alarm B On � t'h B�,h�P�e C ee„'tti.: - APPROVED Off 6� 0F Coy e- I. •. JOINTS WITH ? 11VV1 , ` J °c' f APPROVED PIPE ZD 3' ONTO Conc. Block SOLID SOIL 3" of Bedding Under Tank rw* Pu-fp r ct/ea2w.n ah ' r e. p cat "t a ei � c .�•7S Number of Doses: S. / Per Day Gallons Per Day /�of Doses: /t8- Gallons Volume of Back fl Gallons Tank Manufacturer: w� ese< ZL c, Total Dose Volume: ........ _ /S Gallons Tank Si ze -Septi c /Pump : /;t-0 0 16 o O G allons Alarm Manufacturer: Live/ dIdk, Model Number: oz_ V Capacities: A�i nches or � Gallons Switch Type: ft pc / R,3 r + B inches or Gallons Pump Manufacturer: 67o /c-/ + C inches or Is Gallons Model Number: E Po :S' + D i nches or / 7 f3 Gallons Minimum Discharge ate: a. _ � � Total .....= 3 s inches or Gallons vertical Difference Between Pump Off and Distribution Pipe:La- Feet Minimum Required Supply Pressure:. .- .t?...�13jpe +6:5 UO Feet of Force Main x y_g7 Friction Factor /100 Feet: + :5 Feet 02 Inch Diameter Force Main Total Dynamic Head: ...= Feet � internal Tank Dimensions: Length ength / ; Width F i! ( ; Liquid / Depth ?6' �G:lt?fi -= �� /%«�3' vO:!'C C`ie�jybP Cdpde✓ y `° �..Z "�'�,� �!• //eC� tJ E- f y n 387 EPO4 EP05 APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron Specifically designed for the stainless steel. grade turbine oil for for efficient heat transfer, following uses: • Capable of running lubrication and efficient strength, and durability. • Effluent systems dry without damage to heat transfer. ■ Motor Cover: Thermoplas- • Homes components. Available for automatic and tic cover with integral handle Motor and float switch attachment •Farms manual operation. Automatic • EPO4 Single phase: 0.4 HP points. • Heavy duty sump 115 or 230 V, 60 Hz, 1550 � models include. Mechanical • Water transfer Float Switch assembled and ■ Power Cable: Severe duty 9 preset at the factory. • Dewaterin RPM, built in overload with rated oil and water resistant. automatic reset. ■ Bearings: Upper and lower SPECIFICATIONS • EP05 Single phase: 0.5 HP, FEATURES heavy duty ball bearing 115 V, 60 Hz, 1550 RPM, construction. Pump: EPO4 built in overload with ■ EPO4 Impeller: Thermo- • Solids handling capability: automatic reset. plastic Semi -open design 3 /4" maximum. • Power cord: 10 foot with pump out vanes for AGENCY LISTING • Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. CP• Canadian standards association • Total heads: up to 24 feet. with three prong grounding • Discharge size: 1 plug. Optional 20 foot ■ Impeller: Thermo- (GSA listed model numbers • Mechanical seal: carbon - length, 16/3 SJTW with plasstic tic enclosed design for end in "F" or "AC ".) ry three prong grounding plug improved performance. rota /ceramic - stationary, BUNA -N elastomers. (standard on EP05). ■ Casing and Base: Rugged • Temperature: thermoplastic design provides 104 °F (40 0 C) continuous superior strength and 140 °F (60 °C) intermittent. corrosion resistance. • Fasteners: 300 series METERS FEET stainless steel. 10 I ! ! • Capable of running - —� --- dry without damage to s 30 components. Pump: EP05 8- • Solids handling capability: 0 7 25 1 maximum. a -- -- -- Capacities: up to 60 GPM: s 20 -- - -- — — • Total heads: up to 31 feet. • Discharge size: 1IR' NPT. z s — -- -� -- -- • Mechanical seal: carbon } rotary/ceramic - stationary, 4 1 s BUNA -N elastomers. • Temperature: 3 10 104 °F (40 °C) continuous D - fj 140 (6000) intermittent. 2 —— ! 5 0[ 1 � � 0 0 10 20 30 40 50 GPM -L L 0 2 4 6 8 10 12 m /h CAPACITY @ 1995 Goulds Pumps, Inc. Effective May, 1995 83871 pOWTS OWNER'S MANUAL & MANAGEMENT PLAN Page - 7 of FILE INFORMATION SYSTEM SPECIFICATIONS Owner �' F ¢ t°r ea�te ti Septic Tank Capacity i Z o b a l O JNA Permit # Septic Tank Manufacturer Gv car• e o. �e O Effluent Filter Manufacturer 1 00 /vK D DESIGN PARAMETERS ❑ NA E 0 NA Number of Bedrooms Effluent Filter Model .r'.L,� NA Pump Tank Capacity D O al ❑ NA Number of Commercial Units Estimated flow (average) O fl aVda Pump Tank Manufacturer l�i,'c ra►- C ❑ NA Manufacturer �d ❑ NA 9 Desi n flow (peak), (Estimated x 1.5) �D 4 aUda Pump Soil Application Rate (2 aUda /ft2 Pump Model 7/ A- AAb ❑ NA Month average Pretreatment Unit ;K NA Influent/Effluent Quality ry g ❑ Sand/Qravel Filter ❑ Peat Filter Fats, Oil & Grease (FOG) 530 mg /L p Mechanical Aeration O Wetland Biochemical Oxygen Demand (BOD 5220 mg /L ❑ Disinfection ❑ Other Total Suspended Solids (TSS) 5150 m /L Manufacturer Pretreated Effluent Quality ❑ NA Monthly average" Dispersal Cell(s) ❑ In- ground (pressurized) Biochemical Oxygen Demand (BOD 530 m g /L ❑ In- ground (gravity) ❑ At -grade Mound Total Suspended Solids (TSS) 530 mg /L -9 El Other Fecal Coliform (geometric mean) 510 cfu/100m1 ❑ Drip-line Maximum Effluent Particle Size Y. inch diameter values typical for domestic (non- commerclaQ wastewater and septic tank effluent �+ values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every ❑ months 19- year(s) (Maximum 3 yrs.) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y) of tank volume At least once every D months �year(s) (Maximum 3 yrs.) Inspect dispersal cell(s) Clean effluent filter At least once every /.3 ,1y4 months . O year(s) Inspect pump, pump controls & alarm At least once every ❑ months O years NA ,. 1.ie e dot ) ❑ Flush laterals and pressure test At least once every D months ❑ year(s) � NA other. At least once every O months ❑ year(s) '' .NA Other At least once every O' months ❑ year(s) �IS 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, Maste must include t visual S i e spection of the tank(s) t Pdentif any Ma ss sing or broken Se Operator. Tank inspe ctions 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 d dns dispe the g be round s eThe pon ng of effluent e t on the in the observation pipes and to check f y po 9 f effluent 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 ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWT sal be by a certified POWTS Maintainer. less other maintenance or monitoring at intervals of 12 months or A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. START UP AND OPERATION, of the POW use TS check treatment tank(s) for the presence of painting products or o For new construction, prior to ll(s). If high concentrations ar chemicals that may impede the treatment process and /or damag the dispersal cell(s). detected have the contents of the tank(s) removed by a septage servicing operator prior to use. n Page __:C) of 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 s) and may result in wastewater will be discharged to fflu d avoid this this siituation have the con ents of the pu tank removed by a e backup or surface discharge power to the effluent pump or contact a Plumber or POV1rTS Maintainer to Septage Servicing Operator prior to restoring assist in manually operating the pump controls to restore normal levels within the pump tank. rsal cells. Do not drive or park vehicles over tanks anntd and oat -grade s absorption ra park ea.over, or otherwise disturb or compact, the area within 1S feet down slope of any Reduction orelimination of the following from the wastewater stream may improve the eperforma ntal floss; diapers; a life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degre grease; herbicides; meat disinfectants; fat; foundation drain (sump pump) water, fruit and vegetable peelings; g as scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONM When the POWTS fails and/or is permanent ou t �� ch. Comm 83'33, WisconsU'Administrative Code the system is properly and safely abandone d P sealed. All piping to tanks and pits shall be disconnected and the abandoned pipe openings 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: C3 suitable replacement area has v a l sho e uld be p otected u rom d disturbance and compaction and should not e absorption system. The replacement proposed structure, lot lines and wells. Failure to be infringed upon by required setbacks from existing an propo protect the replacement area will result in the need for anew soil ules in at that timetablish a suitable replacement area. Replacement systems must comply V [I A suitable replacement area is not availed as a last re sort to a eplace i the failed POWTSng advances in POWTS technology a holding tank may be insta ❑ The site has not been evaluated to identi e a suitable replacement area. If no replacement area P OWT S avaSablena site evaluation must be performed to to , holding tank may be installed as a last resort to replace the failed POWTS. Mound and at -grade soil absorption systems may be reconstructed in pWaetheloules in effect at that t me m at at the infiltrative surface. Reconstructions of such systems must comply <<WARNING>> SEPTIC, PUMP AND OTHER TREATMENT TANKS TMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY OXY GEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREA RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS Gt y POWTS MAINTAINER Ct-t POWTS INSTALLER Name Name Phone Phone LOCAL REGULATORY AUTHORITY SEPTAGE SERVICING OPERATOR PUMPER (,l.�.kko�..� Agency s' Cr Name Phone 7 /,S =3 — 0 Phone This document was drafted by the staffs of the Green Lake, Marquette and V2a bh3mWis� n Zoning agencies. Administrative Native Code. Use of this document does not the minimum requirements of ch. Comm 83.22(2)(b)(1)(d ) b(t) and 83.54( O O. GMW (2/01) guarantee the performance of the POVVrS. t ! ' t �+ t r Wisconsin Department ofCommer RECEIVFOIL UATIQ�V ORT page 1 of 3 Division of Safety and Buildings [� (� lJ D in accordance with Comm s- ��yy�r(� yy �((�� Qa, St County . Croix Attach complete site plan on pa r not 1�9�tAan 8 1 x`iM Qr'ches i size. Plan must include, but not limited to: vertical nd horizontal reference (B , direction and Parcel I.D. Pending percent slope, scale or dimensio , nortg] r0Wf4 d len end di nce to nearest road. P�e�s FF E R e Date Personal information you provide may be used for secondary purposes (Privacy Law, a. 15.04 (1) (m)). Property Owner Property Location E l Chris Kusilek Govt. Lot NE 1/4 SW 1/4 S 33 T 28 N R 19 E( ) Property Owner's Mailing Address Lot # I Block # Sub;Name or CSM# N8618 1090 Street 4 - Serenity ea City State Zip Code Phone Number ity 0 ViII e own Nearest Road River Falls WI 1 54022 ( 715 - 42 CTH M E ] New Construction Usejq Residential / Number of bedrooms 3 to 4 Code derived design flow rate 450 to 600 GPD 11 Replacement Public or commercial - Describe: Parent material Loess over bedrock Flood Plain elevation if applicable N ft. General comments and recommendations: Bedrock limitation for mo und '70 B/ f� 132 af � - u P 3G Boring # 0 Boring E3 Pit Ground surface eiev. 101.51 ft. Depth to limiting factor 28 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/W in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0 -14 10yr4 /2 sil 2msbk mfr as 2f .6 .8 2 14 -22 10 4/3 sil 2msbk mfr cw if .6 .8 3 22_28 J 10yr4 /4 sicl lmsbk mfr cw - 2 • 4 _ 2 _ Bedrock Brx - - - - a 2 Boring # 0 Boring 101.50 27 El Pit Ground surface elev. ft. Depth to limiting factor in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0 -10 10yr4 /2 sil 2msbk mfr as 2f .6 .8 2 10 -23 l0w416 sicl 2msbk mfr cam' if .4 .6 3 23 -27 10y,4 /6 sicl lmsbk mfr cw _ 2 3 4 - - Bedrock Brx - - - - - - ' Effluent #1 = BOD > 30 220 mgIL and TSS >30 150 ' Effluent #2 = B D < 30 mgIL and TSS < 30 CST Name (Please Print) Signature . CST Number Thomas C Nelson 227387 Address Date Evaluation Conducted Telephone Number 1432 120th Street, New Richmond, WI 11/20/04 715- 246 -2454 nTT nq�n Tn1In / � Y Property Owner K Parcel ID # P ending Page 2 of 3 Boring Boring # E] Pit Ground surface elev. 103.85 ft Depth to limiting factor 20 P] 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 -6 10yr4 /2 - sil 2msbk mfr as 2f .6 .8 2 6-20 1 4/6 - siel 2msbk mfr cw if .4 .6 3 - - Bedrock Brx - - - F-1 Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /}F in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - Eff#1 'Eff#2 F-1 Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. - Eff#1 - Eff#2 * Effluent #1 = BOD,, > 30 < 220 mg/L and TSS >30 < 150 mg/L - Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608- 264 -8777. SBD- 8330Tem (8.07/00) TOM NELSON CST - Lie. # L 1432 120TH STREET ph. # 715 -246 -2454 r NEW RICHMOND WI 64017 r Chris Kusllek Lot #A -- Plat of Serenity Meadows 1/4 OF THE S 1/4 OF SECTION 33, T28N, i R7 9W, TOWN OF TROY, ST. CRODC COUNTY, ,. WISCONSIN. z ® SOIL BORING •�� A BENCHMARK SCALE IN FEET 1' ALTERNATE BENCHMARK 80 FZ NZ zz / /,✓� / / 1053.6 \ ZZ' 1052.6 / X t / 1052.4 'V \ 0 5.65 AC. 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Ci2OIX COUNTY SEPTTC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer �r G / �zi►��11 �✓! — c T Mailing Address Property Address ��� Y t� ? / * v yr7 (r (Verification required from i latining & Zoning F�c talent for new construction.) City /State t `fr_r ra `1 Parcel Identification Number 01/0 - 12 LEGAL DESCRIPTION Property Location I_ ' /a , % , Sec. 33 , `I' N R �W, Town of T r Subdivision A& S ,Lot # Certified Survey Map # _ , Volume .Page #t Warranty Deed # - © ^, Volume � —, Page # � - 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 tale septic rank 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 ceititication form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed purrtper verifying that (1) tine on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if .neces the septic tank is less than 1/3 full of sludge. I/we, 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 c� Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my /our knowledge, I /we anVarc the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. NATURE OF APPLICANT DATE Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.* �'R Include with this application a recorded warranty deed from the Reg ister of Deeds Office and a copy of The certified survey map if reference is made in the warranty deed_ (REV. 08105) U. 2796P 257 /( 7'34039 STATE BAR OF WISCONSIN FORM I - 2000 KATHLEEN H. WALSH DEED Document Number WARRANTY DEED ST. CROIX , WI This Deed, made between F &K Trucking & Excavating, Inc., a RECEIVED FOR RECORD • Wisconsin Corporation 05/04/2005 10:30AH WARRANTY DEED Grantor, and Greg J. Feyereisen and Cheryl A. Feyereisen, Husband and EXEMPT # Wife, as Marital Property with Rights of Survivorship REC FEE: 11.00 TRANS FEE: 450.00 -- COPY FEE: _ CC FEE: Grantee. PAGES: 1 Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (the "Property ") (if more space is needed, please attach addendum): Recording Area Lot 4, Plat of Serenity Meadows in the Town of Troy, St. Croix County, W� Wisconsin. pit Estreen & Ogland fiQ ; 304 Locust Street �tl Hudson, Wt 5,40 Part of: 040- 1124 -95- 000,040 - 1125 -10- 000,040- 125-60 -000 Parcel Identification Number (PIN) This is not homestead property. (pa) (is not) SUBJECT to Declaration of Protective Covenants and Easements for Plat of Serenity Meadows Subdivision recorded in Volume 2790, Page 20, as Document Number 793139, Driveway Easement Agreement recorded in Volume 2790, Page 26, as Document Number 793141, Restrictive Covenant for Shared and Mutual Roadway, recorded in Volume 2790, Page 10, as Document Number 793137, Articles of Incorporation of Serenity Meadows Homeowners Association, Inc., and Bylaws of Serenity Meadows Homeowners Association recorded in Volume 2790, Page 13, as Document Number 793138. • Together with all appurtenant rights, title and interests. Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except Dated t � % day of April 2005 * Chris M. Kusilek, President AUTHENTICATION ACKNOWLEDGMENT Signature(s) of Chris M. Kusilek, President of F&K Excavating, STATE OF ) Inc. ) ss. County ) authenticated this 27th day of A ril 1 2005 Personally came before me this day of the above named * William J. Radosevich TITLE: MEMBER STATE BAR OF WISCONSIN (]f not, to me known to be the person(s) who executed the foregoing authorized by § 706.06, Wis. Stats.) instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY • William J. Radosevich, Attorney at Law Notary Public, State of 502 Second Street, Hudson, WI 54016 My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) ') • Names or persons signing in any capacity must be typed or printed below their signature. WARRANTY DEED STATE BAR OF WISCONSIN INFO -PRO FORM No. I - 2000 (800)855 -2021 www.infoproforms.com r Parcel #: 040 - 1314 -04 -000 05/18/2006 08:51 AM PAGE 1 OF 1 Alt. Parcel M 33.28.19.2054 040 - TOWN OF TROY Current X1 ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 04/25/2005 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner GREG J & CHERYL A FEYEREISEN O - FEYEREISEN, GREG J & CHERYL A W9682 770TH AVE RIVER FALLS WI 54022 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 17 SERENITY CT SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 7.818 Plat: 10/159- SERENITY MEADOWS LOTS 1 -4 040/05 SEC 33 T28N R19W PTS NE SW, SE SW Block/Condo Bldg: LOT 004 SERENITY MEADOWS LOT 4 (CONSERVATION EASEMENT 2754/25) Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) 33- 28N -19W NE SW 33- 28N -19W SE SW Notes: Parcel History: Date Doc # Vol /Page Type 05/04/2005 794039 2796/257 WD 05/04/2005 793991 2796/096 WD 04/25/2005 793135 10/059 PLAT 2006 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 02/24/2006 Description Class Acres Land Improve Total State Reason Totals for 2006: Property roperty 0.000 0 0 0 Woodland 0.000 0 0 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