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HomeMy WebLinkAbout040-1292-30-000 r Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safe anu"`Building Division INSPECTION REPORT Sanitary Permit No: 515152 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: Ellis, James & Ronna I Troy, Town of 040- 1292 -30 -000 CST BM Elev: Insp. BM Elev: IBM Description: Section/Town /Range /Map No: %f/ I &P✓ . V�/eS�' � 24.28.20.1670 TANK INFOR A ION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic / _ \ Benchmark '0 � q 9L I Do ' Alt. BM Aeration Bldg. Sewer , `3 F l0 P OK 3 3 , Holding St/Ht Inlet ��� 4� St/)4.tOutl_t' 4' TANK SETBACK INFORMATION �/ l0 TANK TO P//L WELL BLDG. Vent to Air Intake ROAD Septic Dosing l r ` 5/ Heade /MaAn U Aeration I Distpw VV Holding Bot. S Final Grade PUMP /SIPHON INFORMATION S 5 0 Manufacturer GPM Demand St Cover Model Number Z TDH Lift Friction Loss stem Head TDH Ft d h Forcemain Length ia. to Well -er SOIL ABSORPTION SYSTEM - 'e j " QJUL.A. Q BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS o. Of Pits Inside Dia. Liquid Depth DIMENSIONS 31 i d / 2 SETBACK SYSTEM TO P/ BLD WEL LAKE /STREAM LEACHIN Man�acturer INFORMATION f System: / b CHAMBER OR Model Numb V-- Typ IBUTION SYSTEM p� the ✓ Heade anifol 11__nn �y ution x Hole Size x Hole Spacin Vent to Air Intake Length W t ia 1r Length Dia Spacing / SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only s Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center /. Bed/Trench Edges Topsoil E Yes El N o ❑ Yes [ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / 1 / /a Inspection #2: / / Location: 307 Lindsay Rd Hudson, WI 54016 (SE 11/4 SE 1/4 24 T28N R2 Troy Village 5ttP Addi / tion Lot 42 , �Parcel No: 24.28.20.1670 1.) Alt BM Description = Tf of -4-1 AI A - ���� U ��' 2.) Bldg sewer length = S /— �f 7/No 1k, -/v � j (� V Q !l tf Q'7 t CN /' - amount of cover = � a bP �, C, &m-169 ,Sl�r Plan revision Required? ❑ Ye --- ---- Use other side for additional information. E/( 13 Date Insepctor's Signa re Cert. No. SBD -6710 (R.3/97) Y commerce.wl.gov Safety and Build isit2n County 201 W. Washington A ., P.O. Box _ I i sco n s i n Madison, WI 53707- Sanitary Permit Number (to be filled in by Co.) Department of Commerce 51 /5 Sanitary Permit Application State Transaction Number In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental J+ unit is required prior to obtaining a sanitary permit. Note: Application forms for s POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information you pfq"Ar for secondary purp in accordance with the Privacy Law, s. 15.04 1 m Stats. KG I. Application Information - Please Print All Informatio i MA zez Prope Owner's Name ,e Parcel P Z' # to �v utytr ICE d Zr� — 12 '— ^ '�Q Property Owner's Mailing Address PNtNG $Z Property Location // _ 7(D Govt. Lot ` � ZCit�,e Zip Code Phone Number ye_ '/4, Section .1�2 JZ — D (circle one II. Type of Building (check all that apply) Lot # T N; R ,: . :© E orV 1 or 2 Family Dwelling - Number of Bedrooms _ Subdivision Name ❑ Public /Commercial - Describe Use 1a �- ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village of 0 Town of III. Type of Permit: (Chec only one box on line A. Complete line B if applicable) A ' New System y ❑Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System (explain) B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner ZA•/ ,�r4�� IV. Type of POWTS System/Component/Device: Check all that appl Non - Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treat ent Area Information: Design Flow (gpd) Design Soil Application Rate,(pdsf) Dispersal Area Required ( Dispersal Area Proposed (sf) System Elevation VI. Tank Info Capacity in Total Of # of Manufacturer Gallons Gallons Units o n New Tanks Existing Tanks c d Y R Septic or Holding Tank Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume respons' lity for install t(on of the POWTS shown on the attached plans. Plumbe s ame (Pri Plumber's MP/MPRS Number Business Phone Number �7 Plumber's Ad (Street , C , State, Zip Code) VIII. Coun /De artment Use Onl >i::�pproved ❑ epprere Permit Fee Date su Issuing nt Signature ven Reason for al $ A1767. Gd / Z / O_ IX. Condit"Olweasons for Disapproval 1. Septic tank, effluent filter and dispersal cell must all be services / maintakned as per management plan provided by plumber. 2. All setback requirements must be maintained Attach to complete plans for the system and submit to the County only on paper not less than 81/1 x 11 inches in size SBD -6398 (R. 02/09) Valid thru 02/11 �c z ok qo ;]COPY • `3 d 3 YD v �C Wisconaln Deparbnent of commerce SOIL EVALUATION REPORT Pape _ 1, of 3 phMbn of safety and Buildings In accordance with Comm 85, Wla. Adm. Code County ST cRO�x Attach complete site plan on paper not less than 8112 x 11 Inches In size. Plan must include, but not IMNted to: vertical and horizontal reference point (BM), direction and Pared I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all Information Reviews y Date psreonet Intormstion you provide rney be wed for saw. defy purposes (Prtveoy tow, S. 15.04 f 1(m)1• Property 0­r Property location 0� T✓i !; t1 N C�1NT1 D�V �tO�°ML —.►JT trOKp NF-- 114 SC 114 S 24 T Z8 N R Z )W Property Owner's Mailing Address =lo M Subd. Name or CSMM \oo A1C�ERDEEn1 SC, n1 E. -sunE �tp Mo -IRON VtL(E- T 7DW 'TN l\). City State s Number C) City El Village Co Town Nearest Road 5 44 (�3 s7 -1s� T y LA ND'SLI TQA Eq New Construction Use:i( Residendal I Number of bed n ed d flow rate (o 0 D _ GPO C] Replacement ❑ Public or commercial - Novi Parent material _ 0 'A'T WA S Flood Plelr�lq�tion it �plicabie N •-A General co mlents �1 1 � and recommendations: (ONVENTIDn1At- - tW-eA It 1Y N ROIX GOU E C 1C ZON\NG O Boring Q Baring # 19 pi Ground surface elev. _ l y , 4 ft. Depth to limiting factor __ _ In Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots 91 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh, 'Eff#1 'EW2 1 0 -l� 1U�1t2.� L z� -mal, Y 1 0,5 0 I- Z�- 0­ 34-a ,5 0 3 15 IOu.'f(l ":5 1 LS'oy 0.5 - 4,Z 0,3 34-Lo�, 5 V f� -- s 4 !" 0, - 7 1, 2- 5 l0-¢i 4D 123�b 5 1 -- 0.7 I, Z- t2 H a� ire ® eoriry # C] Boring D Ja Pit Ground surface elev. 9 K. Depth to HmItng factor In. Soil ApplIcatloit Bete Horizon Depth QOominant Redox Description Texture Structure Consistence Boundary Roots GPDM in. Qu. Sz. Cont. Color Gr. Sz.'Sh. 'Eff#1 'Eft #2 y 6W � 0,S 0, z tZ t l sb 5 Z DI 013 3 to-tis ?,5VR3 5 1 W lv�- 0,1 1, -5 Ot� 1r Effluent #t - BOO > 30 _< 220 mg1L and TSS >30 c 150 mg/L ' Effluent #2 a BOD < 30 mg/L and TSS 30 nWL CST Name (Please Print) gnature CST Number .�0 H LU STF- ZZ 83Z Address Date Evaluation Conducted Telephone Nurnber W98 ?5 bon + '�AVk. RtvE F, FAU-S �,JT 5402 Z 09 -0 -bz - 7t5 L41 Z_ Wtarxx,aln DepaftrMnt of Corrvnerce SOIL EVALUATION REPORT Pape i of 3 Ohl4tbn of Safely and 6uildirga to accordance with Comm 85, Wis. Adm. Code C oun t y Attach composts site plan on paper not test than 81/2 x 11 Miehes In Giza. Pton must • Cf201 bnduds. but not limited to: vertical and horizontal reference point (W. dkoctlon and Parcel I.D. parcent slope, scale or dimensions, north arrow, and location and distance to nearest road. 0 q0 - 1 Z 9 Z - y0 - 000 Plense prinf el! Information Reviewed by Date emonen nnfemsban you vrvmda nwy be vaad for second" pvowea (rrNraay Law. a. 18.01 1+) (n+)1• PNOPsrty owner Property Location Sf Vv o c 7k ,* my CO/JTWeM - rA L- DbVt=LOP CO"' ' n1L- 114 5E 114 S 2 T 1 N R 2p W ft"dy Owners Mdflng - Add... Lot M alocit 0 Subd. Name or CSW I t4 00 A3P-CM Si. N 6 ' Te I op ltt'S 1 11RD\I City State 23P code Phone Nurnber City ❑ Walls XTovm Nearest Road GA 54y 9 7 - ICON{ i L WD5A`1 'P ODD V.:Naw Construction Use: Residential / Number of bedrooms Code derived design now rats 1, On ,- ._ _ ._ GPO ❑ Replec moM ❑ "Ic or corrxnerdsf - Describe: Parent material _ tT r, p' CA Flood Pialn elevation It applicable N,A Garlsr/1 comments and recommendatlons: C uN U E AJT r 0 A)A L- 1 K E AfC 0* -S � W� N Q t3orinp ® Pp Ground surface elev. _ 5, 2 ft. Depth to limiting factor _ 7z tn. Soil ApplIcation Rate r Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P /ff In. Munseil Ou. Sr. Cont. Color Gr. Sz. Sh. 'Efta1 '092 l 0 -7 I - 4 - 0.2 0,3 2 7 -m t 1 -L A s tq 0, 2 - 3 13 - 1 v 0, 1 ,2- (1'� �>;�ZOn �}LR gprnE G ref S tol R 3 s , r► a sorirv* ° SodN Pit Ground surface elev. 5 Yq( e . 9 R. Depth to Ilmtdng raga �! _ In. llpn Rate Horizon Depth Dominant Color Redox Dasroiplion Texture Structure Consist Bourdary Roots GPD/ff in. Munsell Ou. Sz. Conl. Cola Gr. Sz. Sh. '0011 'E11s74 L- 24 -L-ab ti 14 - 01 0.9 2 1 0 `I 51 m 0.5 .2 0,:5 XZF 3 23 - W �3 I y 0416 t s yf�{r 0• Z 0. 0 . LI +7 Ice 5 33 -b tour �>Ilo S rn C5 0,'7 1, (� - l avfey� Gs — tl, �,2 C�pR�2Dt� }1Dr5 Sorr t'c 0C 5 DF 1 `l2 b 5 01�1w le At-M T 54A A-A O , ) Effluont 111 - 1100 > 30 1220 mgk and TSS >30 ;150 mok ' Effluent 02 a SOD -< 30 nV& and TSS 130 nVIL CST Name fPtaasr Print) A g poture CST Number Jo H L.t_ s ZZ 83� Date Evelustion Conducted Tetsphone Number t+J9 ?S `4p +►• Ads, R vE f US WT 59022 09--03 2- '71S y16 -1-175 PLOf PLAN 9 e w : RTYOVdU: COAMNENTAL B AA cut Co T TROY Y - P =<M P /PES ,s r se' s>' Yl A a Tz44r R2aQ lk 0 - Sox. Doi&% wi DACM NO COMM 8P 5EfDAa F'RODl.EM5 i / 14M a 42/14 1 955.2 A : 143 s o 0 0 r f., 19 ,1 42A .4 i 9 ! ca MOLM 141 9ckl �94A / ,41A X 51Gf w or je 2zyg3z D�fE: -03 OZ. Hu man Rel ations 09partment of gel ations bons g Industry SOIL AND SITE EVALUATION REPORT P I of 3 and Hu _ ,swi of Safety & Buildings Vyis:, "� in accord with ILHR 83.05, Adlm Code COUNTY ff ST • GZ a lk Attach complete site plan on paper not less than 8 1/2 x 11 inches in size fPlart must into o* but , not limited to vertical and horizontal reference point (BM), direction and °� of slope, scale or PARCEL I.D. # P�tj 1.N 6 dimensioned, north arrow, and location and distance to nearest road. ' APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REV150DBY _ DATE PROPERTY OWNER: PROP ION 133_ wz CO U f-1 r1 T CZ sa (7 . F, S& , 1/ 'SZ4 T Zb ,N,R ZA E (or& PROPERTY OWNER':S MAILING ADDRESS • I M " BLOCK # SUBD,:NAME OR CSM # - Oy UIL�.Pt6E 4 4 �1 CITY, STATE ZIP CODE PHONE NUMBER CITY ❑VILLAGE ®TOWN ' NEAREST ROAD e \-P2 u �z , P-L fv SS 4S ( ) T t� -o`( t ryp S pr-1 Itt r} p [XI New Construction Use ( aq Residential / Number of bedrooms y [ J Addition to existing building [ ] Replacement [ ] Public or commercial describe Code derived daily flow Gov gpd Recommended design loading rate --- _bed, gpd /ft t trench, gpdt t Absorption area required '8 bed, ft2 "1 S o trench, 11 Maximum design loading rate • - 1 bed, gpd /ft trench, gpd/ft Recommended infiltration surface elevation(s) 88 - )-0 - 8865 - 886.15 ft (as referred to site plan benchmark) Additional design / site considerations 5 tEL—. Nr,`f't; Ta f Aj STf't•(_e2 0),j PIP Ce 3 Parent material Lo ASS OV eft S L_ A f L WrL i R S H Flood plain elevation, if applicable tJ A� It S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FlLL HOLDING TANK U =Unsuitable fors stem ®S OU CAS ❑U ®S 0 ( 19 S ❑U 21 S ❑U ❑S OU SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure Boring # Horizon Texture Consistence Bourxfaly Roots GPD /ft �3 in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. I g� re xfi o_\Z le`ttz - si1 2 S b�C �'F'h el - s •6 S i 1 Zms�k x��Fi- �-s • S Ground 3 4q -110 - I•S`tR 31y - S OS9 M l - •� •g elev. 8 92_ Z ft Depth to limiting factor Remarks: Boring # so "'W_ o�� ery . Z. ':.3 Z" " k CS — • S 3 zz..3b tort tZ 3LL - sty) Zw, s b bc s�� � s — � • s Ground elev. 16 - 1 10 Li IZ 3!(, — 1 S`t 5/6 ';)d W SMt OL S . Z `. 3 % llib.0 Depth to S 41 =S - 1 - S — sl ��sb12 wi�i �S 1 •q •S limiting ( st_\'1S -•S't 3! — S 6h 00- y„,� — ,-\ •moo T_ f l I N4 f Remarks: T Name:— Please Print Phone: Arthur L. We erer 715- 425 -0165 e Soil Testing & Design Service -P.O. Box 74 River.Falls,WI. 54022 Signature .o! 21 _ Z,4 7 _ �3 ` Date: CST Number:. ll - 3p_gq 220254 PROPERTY OWNER CUKClt 'Z)�Zkj . SOIL DESCRIPTION REPORT Page?9of, PARCEL I.D. # _ tie X-oD) Iv G Col l C i Depth Dominant Color Mottles Consistence on g # Sz Cont in. Munsell QuHorizon Texture Structure GPDfft �3 �' . . or Gr. Sz. Sh. Y Roots .:?`Z Bed Trench c s i t 1 sl�lz 1� ew - z . Z �z_�z I u �Z 3� 6 r�'fh Ground 3 Z -11S - 1 .S Ll R I elev. b %.5 ft. Depth to limiting . i factor �11S Remarks: B KKing # lu`!2 Ground 3 t8 lZ I'S `tR 31y S 6t- aS9 , elev. �aZ.8 ft. Depth to limiting factor y It Remarks: Bc�fi�q # 0 -11 �o�-t 2 3IZ ::.... •��x I s l l lw, �-Vk h cg _ . Z. (• 3 Z 11 -4$ !t)`1 _ Yn -s'b CS � 'S Ground Ye 31 yr - S d G6 O a5 vq elev. Sa . S t. Depth to limiting factor >V36 Remarks: 3oring # around ;lev. it. )eplh to imiting actor Remarks: __ PLOT PLAN Page 3 of 3 SCALE 1 "= 50 ' db anti . F3*'1 �L_ 847.�l9 OKI 1liz" plp@ 112..Lsv crag � � b so ` N1lD. @84.5' k 11 . Vpp"ii T" -. 881.0 l.oT �3z �4 R-L flq 1. zp 0 1 Rt7hl l� l P � y LOT V nor X30 Z 2A Z. S `f ( 715 ) 425 -n n5 CST Signature Date Signed Telephone No. CST # Wisconsin a e Relations ntoflndustry Hu Labor and Human SOIL AND SITE EVALUATION REPORT Page I of : Division of safety a Buildings I � in accord with ILHR 83.05, Wis. Adm. Code ` COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D.;3 pka qty t,u r dimensioned, north arrow, and location and distance to nearest road. ' APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION REVIEWED BY _ DATE PROPERTY OWNER: PROPERTY LOCATION N `- S E 1'vn./p COQ -raJ vc�C'1,O� y .� -�- (20P- P ^GV;. 6G . S Q 1/4 SE 1 /4,SZY T ,N,R ZQ E ( W PROPERTY OWNER':S MAILING ADDRESS. LOT # BLOCK # SUBD. NAME OR CSM 3 J�Uji Q.N, . Zap va, - TTtO U l ll.ft6E F'1DD . CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE [MOWN ' NEAREST ROAD B urn,N e, wt ry SS 4 , 1y () TQ t rvp g [}CJ New Construction Use Residential / Number of bedrooms y [ ] AdditiQn to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow boy gpd Recommended design loading rate - bed, gpd/ft2 — trench, gpd/ft Absorption area required E S % bed, ft2 -1 0 trench, ft Maximum design loading rate • - 1 bed, gpd /0 trench, gpd/ft Recommended infiltration surface elevation(s) 88 - 7-0 - g865 - 886.0 ft (as referred to site plan benchmark) Additional design / site considerations 5 -. N r,"f'I; 'M f. A! 5'T-{ -t„ t� pj-,j QP,c - 3 Parent material Ow GL 1'--L f t_ pyYw ft 3 N ' Flood plain elevation, if applicable k--) f\ It S = Suitable for system CONVONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem ®S ENTI U I ®S ❑ U I ® S E] U I 2S ❑ U ( 0S ❑ U 0S O U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color I Mottles I Structure I GPD /ft in. Munsell Qu. Sz. Cont Color Texture Consistence Bo rclary I Roots Gr. Sz. Sh. Bed rerx�t f� ) o -� lb `'!IL 3 LZ - si Z sblz w►' e.w - s .6 l0 `12 316 _ Sit �,mAl2�l^ Ground 3 4 y -1 [D -j • S `t i2 31 y S9 rho - . •$ elev. Depth to limiting factor ? L[O Remarks: Boring # Z \2�Z lO`l R Z[1 11 3 z�.sb to�t� 3LC - sty Ground Z�+n • S elev. p 36 -y 1 I D `1 R 316 -1 S`t SLg s I CI W1 Sbk wt'Fi q S - - Z ft. p Vl6 - s1 �e �b1z " .,;;�'Fi � •q De .S th to limiting (o St- \19 -• S 't 2 3! - S 6F• S9 - , - � - "o factor Remarks: T Name Print Phone: Arthur L. We erer 715- 425 -0165 e Testing & Design Service -P.O'. Box 74 River.Falls,WI. 54022 Signature: q' 4 _ Z 9 -7 - t3 Date: CST Number: . t I- 3p 2202 54 - — 1 PRO �1M1tJ � "J PRO PERTY �M'L• �kV • SOIL DESCRIPTION REPORT Page of 3 PARCEL I.D. # V -4 X !V G �ori # Horizon Depth Dominant Color Mottles Structure GPD /ft 3� in. Munsell Texture Gr. Sz. Sh. Consistence Roots Qu. Sz. Cont. Color Y Bed Trends L o ` l tZ 3 Z S t 1 `M S1r� 12 �� — • Z 7 Z �z_�z l u tZ 3! 6 s Z w, s bk �,'F 0 0 _ -S to Ground 3 2 -IIS I L y elev. - Z9 it. Depth to limiting factor I *7 Remarks: Bring # >< L0`12 2-7 Z SO 1'm g bk , 3 Ground R 31 U Sg M I 1 elev. Depth to — limiting factor Remarks: B i # �Qr nQ •� ..,:...:.� ) o� l l t bl-t R 3 I Z - s l 1 �:,,, �,bk o� h CS _" , z I •3 hni C v e '31y - S 6�. 035 Ground elev. 800 • S t. Depth to limiting factor 1 13 6 : Remarks: 3oring # Si around ?lev. it. )epth to imiting actor -L - F Remarks: __ > r PLOT PLAN Page 3 of 3 SCALE 1 "= 50 ' e g' 5 OK3 1�`I%L+j Ptp@ G �- 5 Z� $ so ' I r L 8L 6.0 g.t3� 1, ' pn •� 4!L $86.5 loT WL — PM • eq L. zo tilt 'LCL 1 PIPN �1 q zzoZ.sy ( 715 ) 42.5 - 01 65 CST Signature Date Signed Telephone No. CST # Soil Absorption System Cross Section ft 4" Schedule 40 *Fina Grade PVC Vent Pipe With Vent Cap ft Leaching --► Chamber System Elevation ft a ft Soil Absorption System Plan View ft ft { 1 Leaching Trench 1 - ft Vent Or Observation Pipe Chambers 4" Dia. Trench 2 Header �eachina Cham / Specifications Manufacturer And Model 4 -5�In EISA Rating � sq ft per chamber Soil Application Rate ^ gpd /sq ft gpd Design Flow . , � Soil Application Rate � EISA = ,s Chambers 2 rows of _ chambers each. Page of POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page � of FiLE INFORMATION SYSTEM SPECIFICATIONS Owner S Septic Tank Capacity ga l ❑ NA Permit # Septic Tank Manufacturer 14J S ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA J Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units ,i1 NA Pump Tank Capacity gal .0 NA Estimated flow (average) gal /day Pump Tank Manufacturer JXNA Design flow (peak), (Estimated x 1.5) gal /day Pump Manufacturer J9 NA Soil Application Rate gal /day /ftz Pump Model -Iff NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit J 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) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L Ci(In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L 5d NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size % 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 eve ❑ month(s) ry' � ear(s) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one -third (%) of tank volume ❑ NA !aspect dispersal cel!(s) At least once every: Cl month(s) (Maximum 3 ears) ❑ NA J9 year(s) y Clean effluent filter At least once every: ❑ month(s) ❑ NA Oyear(sl 'aspect pump, pump controls & alarm At least once every: ❑ month(s) ,® NA ❑ year(s) FI(ish l ate-als and pressure test At least once every: ❑ month(s) ANA ❑ year(s) At least once every: ❑ month(s) year(s) year(s) ❑ NA Otfier' ❑ NA VIAINTENANCE 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 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. 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. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ 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 INSTAL R POWTS MAINTAINER me Na me = Na Phone S_` — SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHOR" Name Name Phone Phone This document was dra -e-t - = lance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. STARTUP AND OPERATION Page'. of For new 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. 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. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ 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 INS" POWTS MAINTAINER Name Name Phone �/ 5`� � �_ - 791 - 7 1 Phone ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM j . Owner/Buyer Mailing Address (P Property Address 3 ©s1 Ll 1tJ S t�1�CJ� W� S �} O (Verification required from Pl 'ng & Zoning Department for new construction.) City/State L) �) s� N . C'jS Parcel Identification Number 0 ib • 12- 5; Z 3 D - C00 i� 76 LEGAL DESCRIPTION Property Location S� t /a , t /4 , Sec. aq , T Zg N R W, Town of 72Qq0­1_ Subdivision —! �O 1 t CAA I -�- , Lot # Lq _ 14 — Certified Survey Map # , Volume , Page # Warranty Deed # , Volume , Page # Spec house yes <3D 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. 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 & 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 am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms e J ow, SIGNATURE OF APPLICANT(S) 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. 08/05) �� � d Ri € p g a � b r N �d e p @_Q as 8 a R S i NI NI . i "I t I II 1 1 ^ I I 3a�R 9 1 - - - - - - 6 dy pi 4 bti4QQ'� r I nau,enr tubno�Ynn AOdl cross .�xi•? � � Y�� ��[� � .rdl�� aasa aa b I J - ---- . I f C yb !� �I ! ab g 5 @« . @ 6 : y i L II o f - 1- - -r i i A 13.ab 5iis §i pia t 11 bR! �� -- --N R �I�I � pil I • L �I�I 4a '. J11Y M. w u N ®aor ewe N o ; WW � W2 NIC51 ; ' s'2. 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STATE BAR OF WISCONSIN FORM 2 - 1998 i iI�II� I�III �Iiil �I�II Ii��' I��II I�i �IIIII IIII IN WARRANTY DEED * 9 0 4 4 7 9 1 * Document Number _ 904479 BETH PABST This Deed made between Troy Development Corporation REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 09/28/2009 10:55AM _ Grantor. WARRANTY DEED and James C. Ellis and Ro nne S. Elli Hu sband a nd Wife as JO i nt Tenants - -- — EXEMPT REC FEE: 11.00 TRANS FEE: 405.00 Grantee. PAGES: 7 Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin: ' R�crntia,g fv'a3 r Lot 142 of the Plat of T g ` - - - - -- Troy Village a e 5th Addition i n the Town of Name and Return Address >rroy, St. Croix County, Wisconsin. Subject to the Declaration of Covenants, Conditions and Restricti James and Ronna Ellis for Troy Villa in 622 Gilbert Road and the DeclaratiDeclaration Golf Course Covenants, Conditions and Easements, Hudson, WI 54016 recorded in Vol. 1241, Page 301, as Doc. No. 559969, all as appearing in the office of the Register of Deeds for St. Croix County, Wisconsin, and such other easements, restrictions and reservations of record, 040 - 1 or in use, and the "Buyer" obligations and conditions contained in 000 Parcel 292-30- 292 - 30- Number (PIN) the Purchase Agreement for this lot and any addendtun thereto between Grantor and Grantee herein, which includes, without 1 i mi tati on, This i s not homestead property requirements for approval of plans by an Architectural Review (is) (is not) Comsmittee, approval of hone builder by Grantor, carpliance with Grantor's approved builder requirements, payment of the Developer Service Fee and ctxmencerent of construction deadlines together with related rights of redetptio, all of which shall survive closing and conveyance of this property and shall be binding upon Grantee, and his /her /their successors and assigns. la Exceptions to warranties: i� Dated this 31 St day of Au 2009 :i (SEAL) _ -- (SEAL) is Courtnie Kirvela * y, is Preside * Troy Development Corporation ?' (SEAL) (SEAL) fi AUTHENTICATION ACKNOWLEDGMENT Minnesota Signature(s) - --_' State of 0KX 1� 55. f Anoka County. fj authenticated this day of Personally came before me this 31st day of _August the above named Cour_tnie.Kirvelay, vice Pr Psiden' Troy Devel oliment Corr Q ti nn ?� TITLE: MEMBER STATE BAR OF WISCONSIN to it i (If not, me known to be the person who executed the foregoing authorized by §706.06, Wis. Stats.) instrument and acknowledge the same. j� THIS INSTRUMENT WAS DRAFTED BYt�dt i� Troy Developmt Corporation * David Lamers Notary Public, State of %&V& Ki rinesota I Charles S. Cook, President My commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not Jarlllary 31 2014 ) necessary.) Names of persons signing In any capacity must be typed or pr th printed below eir algnature. _ — ` �q STATE BAR OF WISCON IIOTAl1V'� nsh Legal Blank Go Inc. ii WARRI&TY D�D FORM Na. 2 — 1998 whlwaiikee w +s'