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Wsconsrn Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes IPnvacy Law. s 15 04 (1)(m)] Permit Holder's Name City Village Township Jim Annis/sue stiepan TOWN OF CYLON CST BM Elev linsp BM Elev IBM Descriohon TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Dosing 00 Aeration Holding TANK SETBACK INFORMATION % ! l.n'. C TANK TO P/L WELL BL G Vent to BrirIntilki ROAD Septic r 1 Dosing 3, Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Deman GPM Model Number �' TDH Lift Atli oss Systpi.3 Her04 T t Forcemain Lenjti ` is .� Dist to N �," avtt_ AtlaVI(Y I IUN STS FEM ELEVATION DATA l �= I I � .' Ili MMM ' • • :. --� art ! # I :. owl BEDITRENCH Width Lengtpe I No Of es PIT DIMENSIONS No Of Pits Inside Dia Liquid Depth DIMENSIONS SETBACK SYSTE TO P1 BLDG WELL LAKE/STREAM LEACHING Manufacturer. INFORMATION CHAMBER OR T y S stem 6, VVI 7 I UNIT Model Number HeadenM didiId y Distribution 11 Pipe(If x Hole Siz x Hole Spacing 'lent to Art (make Length 1VVl Dia Length Di Spacings — rt Depth Ov �`� ` 0l L Depth Over xx Depth oL xx SeededrSodde xx Mulched Safi'? ch Center - tI d I Bedrtrench Edges Topsoil '11 Yes X- No XYes No I+VMMtN I J: (Include code discrepencies. persons present, etc l Inspectio1n #1. Inspe9Ugn # W"•w' '` t/ Location: 2397 HWY 46 yAif y nY Vg1f1" 1. t{'v�l/yq�,lJ r 1.) Alt BM Description - I RV 2.) Bldg sewer length = 1 C - amount of coverPla= � Use other side f gwred7 Yes j( NO �iN I � . V W V Use other side for additional information. 1 U SBD-6710 (R 3197) ata s or's Signature Cert No ftal % , . � 114A .,t1/- a'""�+, Industry Services Division Jr oun y �P 4822 Madison Yards Way ref a Madison, WI 53705 AUG 112022 P.O. Box7162 Sanitary Permit Number (to be filled in by Co.) st it Application State Transaction Number In accordance wi SF" y CoCode, submission of this form to the ttmenta unit "Code, ®p F 20/t oo C is required prior t ining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Services. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04(I)(m), Slats. Sim L 1. Application Information - Please Print All ]information Property Owner's Name J,:I,t�,tw Parcel # Qab-�ov9-so-lva Property Owner's Mailing Addre Proper Lo atio tb & a � —10 2 35'? ,�/•v . Go;W. City, State Zip Code Phone Number &.Bl r ?Q rL.A Gv LA- 5j 007 6S/- Z yy- 9y92 AW V•�rVa Section .S _ T N R / 4 E o 11. Type of Building (check all that apply) Lot # .I or 2 Family Dwelling - Number of Bedrooms Z _ Subdivision Name ❑ Public/Commercial - Describe Use Block # ❑ City of ❑ Village of _n ❑ State Owned - Describe Use CSM Number 2p . is Z -SS�p J1own of C, [� /e h 111. Type of POWTS Permit: (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C i applicable.) A. ❑ New System :Replacement System ❑ Other Modification to Existing System (explain) ❑ Additional Pretreatment Unit (explain) B. ❑ Holding Tank ❑ In -Ground ❑ At -Grade XMound rf ❑ Individual Site Design ❑ Other Type (explain) (conventional) .412 C. El Renewal Before Expiration El Revision El Change of Plumber ❑ Transfer to New Owner ist Previous Permit Number and Date Issued t 1' �� S� = /� IV. Dispersal/freat ent Area and Tank Information: Q V(` Design Flow (gpd) Design Soil Application Rate(gpd/s `% Dispersal Area Required (sf) Dispersal Area Proposed f) System Elevation 3oU ?50 ?So of rq /o , Tank Information Capacity in Gallons Total Gallons # of Units Manufacturer .� PO1_ / l/O� o $ _u New Tanks Existing Tanks ) U GO rn LL V tl. Septic or Holding Tank b 00 Like CA94 Dosing Chamber 0 "45to V. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached Plana. Plumber's Name (Print) Plu ber's Sign tare MPIMPRS Number Business Phone Number z67F�'s 7�s-u� y��s umber's Address (StreK City, State, Zip Code) 27f03 1204 4-s'p- 1w / a County/Department Use Only Approved ❑ Disapproved ❑ Owner Permit Fee sG 7S ao Date I sue �l 2 Issuing Agenlgnature Given Reason for Denial Conditions of Approval/Rcasons for Disapproval (o�s(1�� qe / SVSTEMOWNER: /1) e ry-f IN/r 1. Septic tank. elflueM filter and tJ A/ JJ �� " dhsperssl call must be wry / Y f [ � ✓Jrt� i t/S V T� � Qi i iink oXe- plan provided by plumber. / l [/l/Mdt:.f-" •J , as per management f 2. All setback requirements must be maintained�•- /_ ,(., /�I'}��,. /h -4�7 4t.f44.9 ' cam -pe as per applicable cope/ordmancts. to 1 X L I'Q l,, lC �t1af,/.O 5 1.11- /b r . Attach to complete plans for the system and submit to the County only on paper not less than 8 102 x 11 ig(hes in si)f SBD-6398 (R. 03121) CHECK BOX AS APPLICABLE. ❑ SOIL EVALUATION SITE MAP PROJECT NAME: Jim Annis CHECK BOX AS APPLICABLE Scale: V =40 0 SYSTEM PAGE 2 OF 6 D 40 60 a0 PLOT PLAN (10 A grid) tD, DESIGN FLOW: 300 GPD Attach design flow Calculations for Commercial plans. PROJECT ADDRESS: 2397 Hwy 46, Deer Park, WI Pipe Material / ASTM Standard (Tables 384.30-3 & 384.30-5) BM Symbol: $ BM Elevation: 100.0 FT N Sanitary Sewer. PVC / ASTM D3034 BM DescdptIon: _ Grade @ fence line comer post Face Main. PVC /ASTM D2665 SlopGradlent Tested dArea:(�) of T 4 Well Symbol (If applicable): Q lndkAne drawing an sm IMPORTANT: Show ground elevation contours at suitable intervals. on the aPCrovdla Ina v Exist. POWTS shall be properly abandoned per SPS 383.33, WAC T I L- ROW of Hwy 46 ti-.IGOPY Fence I \ /oa.87 fer.yi' (o2.6i > 2So' Wisconsin Department of Safety and Professional Services Division of Industry Services 4822 Madison Yards Way PO Box 7302 Madison, WI 53707 August 9, 2022 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 2024-08-09 Plan Review: PWTS-082201808-C MICHAEL J MYERS 2943 130th Ave Glenwood City WI 54013 SITE: Jim Annis 2397 Hwy 46 Town of Cylon St. Croix County NW, NWS5, T31N, R16W Total Amount: $250.00 �. Pbane: 609-266-2112 P Web: hilp" w liL Email: Jsn. awiufimin.gov Tony Evers, Governor ►,.-,.._. „ a4 Dan Hereth, Secretary Con.Nfian�llF APPROVED DEPT. OF SAFETY AND PROF ESSIONA SERVICES OIVISIOB OF INDUSTIIY SERVICES r SEE CORRESPONDENCE FOR: Description: Two Bedroom Mound System 1 Sloping site Mound Component Manual - Version 2.1 (May 2022-202), Pressure Distribution Component Manual Version 2.1 (May 2022-2027), 300 GPD, 18" depth to limiting factor, Maintenance required, Effluent filter, Replacement construction The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. 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: Reminders • A sanitary permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.19, Wis. Stats. • Prior to construction of the dispersal area, check the moisture content of the soil to a depth of 8 inches. Proper soil moisture content can be determined by rolling a soil sample between the hands. If it rolls into a 1/4- inch wire, the site is too wet to prepare. If it crumbles, site preparation can proceed. If the site is too wet to prepare, do not proceed until it dries. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stets. • A state approved effluent filter is required. Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. • A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. Owner Responsibilities The current owner, and each subsequent owner, shall receive a copy of this letter. Owners shall also receive a copy of the appropriate operation and maintenance manual(s) and be responsible for ensuring that POWTS is operated and maintained in accordance with this chapter and the approved management plan under s. SPS 383.54(1). • In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. • The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. In granting this approval the Division of Industry Services 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. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Gerard M Swim POWTS Plan Reviewer WI DSPS - Division of Industry Services (608)789-7892 ierry-swim(ctwi gov PAGE 1 OF 6 Mound Plan Index & Cover Sheet Component Manual Design References: Version 2.0, SBD-10691-P (N.01/01, R. 10/12) & Version 2.0, SBD-10706-P (N.01/01, R. 10/12) Pg 1 of 6 Index & Cover Page Pg 2 of 6 Plot Plan Pg 3 of 6 Mound Cross -Section & Plan View Pg 4 of 6 Distribution Network Specifications Pg 5 of 6 Pump Tank Specifications Pg 6 of 6 Management Plan Attachments: Enclosures: Pump Curve POWTS Application for Review Soil Evaluation Report & Site Map Project Name / Description Jim Annis Owner Name(s): Jim Annis Owner Address: 2397 Hwy 46, Deer Park, WI Phone: 651 _249 _9432 Zip. 54007 Project Address: SAME Govt. Lot: NW 1/4 of NW 1/4, Section 5 T 31 N-R 16 E ❑ or W❑✓ Township: Cylon County: St Croix Project Parcel ID #: 006100950100 Designer Information Designer Name: Michael Myers Designer Address: 2943 130th Ave, Glenwood City, WI E-mail: mcmyers@centurytel.net License Number: 267985 Remarks: Phone: 715 - 265 -4115 bis_a72Z36iVO Zip: 54013 Condlf/onally APPROVED DEPT. OF SAFETY AND PROFESSIONAL SERVICES DIVISION OF INDUSTRY SERVICES SEE CORRESPONDENCE Signature: Date: 7 - ZO-2°ZZ Onginal signature required on each submitted copy. CHECK BOX AS APPLICABLE. CHECK BOX AS APPLICABLE ❑ SOIL EVALUATION o scale: " 40' © SYSTEM PAGE 2 OF 6 60 so SITE MAP I PLOT PLAN PROJECT NAME: (10e01d) tDr DESIGN FLOW: 300 GPD Jim Annis Attach design flow Calculations for commercial plans. PROJECT ADDRESS 2397 Hwy 46, Deer Park, WI Pipe Material / ASTM Standard (Tables 364.30.3 8 384.30.5) BM SymCd: + BM l7evation: 100.0 FT N Sanitary Sewer PVC I ASTM D3034 BM Description: Grade (M fence line Comer post Farce Main: PVC i ASTM D2665 Slope Gradient (%) todkws m" by IMPORTANT: of Tested Area: 4 well Symbd (n appleable): p dreuing an now Show ground elevation contours at suitable intervals, on vie appropme a». T t ROW of Hwy 46 2 Fr41�ls� loos%tee Fence Exist. POWTS shall be properly ZI abandoned per SPS 383.33, WAC pis I I vZ.a7 N ite� W= SINGLE -CELL MOUND DISPERSAL AREA 0.5' TO 2.5' WASHED AGGREGATE D = 18 ft (min. Ur beneath distribution pipe - m1n.2.0' over distribution pipe and covered vft RZ MIN. 6.0' OF TOPSOIL COVER E = 20.9 ft approved synthetic fabric) System Elevation = 1041 ] min. 1.0 ft y.ft ASTM G33 SAND FILL min 5 ft Lateral Invert Elevation = 104.84 it L _ _ CROSS SECTION VIEW 6 fl 1 (No Scale) Plowed Surface Surface Contour 4 % Slope —� Elevation = 102.67 ft (Show force main, manifold, and flush valve locations on plan view) PLAN VIEW (No Scale) 1 1/2 ' 0 Schdl40 PVC Lateral = 7.5 it 8.33 it (typical) OwW1 r r-------- —--------------------------- ------ i- — — — — — — — — + —------------- — ----- 23,9 it — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — J r e = 50 ft 1= 10.4 it K= 10.3 ft crro�) D Bend as necessary to follow contour 0 m DOWNSLOPE TOE W O L = 70.60 It I T Prohibit disturbance and vehicular traffic within 15 feet of downslope toe. LRssot Psg� DISTRIBUTION NETWORK SPECIFICATIONS (No Scale) FLUSH VALVE DETAIL (No Scale) Orifice in — , ` Valve Box Lateral Spacing Center of Threaded Cap S = 3 ft for Head Testing (insulation optional) (optional) / Shield orifices for Ball Valve I \ gravelless applications S (optional) r Lateral Length (P) = 47.6 ft Orifices equally spaced: ` [check a) OR b) below) _ \ a) -Z along bottom of lateral Flush Valve b) n along top of lateral Assembly with every th hole (typical - see detail) _ facing down LATERAL INVERT ELEVATION = 104.84 ft (typical) 2 'O Schdl 40 PVC Force Main (slope to pump tank r— for drain -back) First Orifice (typical) Laterals to be level �--Schdl40 PVC Lateral 0 = 11/2 in (4,*al) Number of Orifices per Lateral = 23 Orifices equally spaced along bottom of lateral v Last Orifice 26 (typical)Onfic(ttypkaarI)lrlg (X) = in OBSERVATION PIPE DETAIL (No Scale) Screw -Type or :�„ Sip Cap �O°�) ` Finished Grade (mulched 8 seeded) 4 O PVC Pipe Topsoil Cover Top of pipe to tannic; (min. 1 foot) at or above frlshed grade (4) i/4@' slots 3�00 Xapart , > Andrairg Device Infiltration Surface Orifice Diameter = -1875 in (typical) First Orifice (ham) [---fix END MANIFOLD ❑ CONNECTION Manifold Check applicable box. First Orifice (riser pipe optional) D (types) i--- x---�--xrz xrzx ----� rn (typical) (tyyp�) ❑ CENTER MANIFOLD -O M�o1d CONNECTION v� (riser pipe optlonal) Orifice Discharge Rate = .66 gpm Number of Laterals = 2 Lateral Discharge Rate = 15.18 gpm TOTAL DISCHARGE RATE = 30.36 GPM PAGE 5OF6 SEPTIC / PUMP TANK SPECIFICATIONS 4'0 Vent Plps (No Scale) >10111rom Building Electron! must comply with 12' On. or 2.0 it above SPS 31a and NEC 300 Established Flood Elevation weelhahPhool Emend manhole riser as necessary. (typical) Approved Junction Box Lod" Menliols IMPORTANT: Vent Cap Approw Mmding l Attached Anchor tank(s) as necessary Cond(typical) pursuant to SPS 383.43(8)(g) rs 4• Mtn. a 2.° n above Established Flood Elevation (typical) �Airtiaht Seal ", Finished Grade CAPACITIES @ 17 gaVin Depth (in) Volume (gal) A 20.9 354.7 B 2.0 34 [C] 5.4 91.3 D 1 10 1 170 *Pump Tank Liquid Level = 38.2 in Force Main Diameter = 2 In Force Main Length = L200 ft Quick l7isconnea J Is* K*m .. a .. . (IYP�) * Weep i Approved Joints with I Hole Approved Plpe 3 tl onto A Solid Ground tk Alarm 6 �_ on t ) Pump a ELEVATION = 88.8 ft I ° Concrete INSIDE BOTTOM el ELEVATION = 88 ft 3' Approved Bedding Material Beneath Tank Force Main Void Volume = 34.8 gal [C] Total Dose Volume (TDV) 86.6 gal/dose/& (5X total lateral void volume <_ TDV s 0.2X design flow) + (force main drainback volume) MIN. PUMP DISCHARGE RATE = 30.36 eassagpm 3 Vertical Head = 1�ft + Min. Supply Head = �ft + FM Friction Loss = 3.88 ft + Fitting Loss' = 1 95 ft '(min. supply head x 0.3) TOTAL DYNAMIC HEAD = 25.08 ft PUMP TANK: SEPTIC TANK(S): Volume = 650 gal Total Volume = 1000 gal Manufacturer. Wieser Conctrete Manufacturer(s): Wieser Concrete Pump Manufacturer. Goulds Install approved effluent filter at the septic tank outlet Pump Model: PE51 P1 (See attached pump cur".) Immediately ul2stream of the 12ump tank Inlet. Controls/Alarm Manufacturer. SJE Rhombus Filter Manufacturer. Polylok Controls/Alarm Model: PSP120V6H150P17A Filter Model: 525 Float switches containingmercury are prohibited. PAGE 6 OF 6 Mound Management Plan IMPORTANT: The owner of this mound system shall be responsible for its perpetual operation and maintenance pursuant to requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this system shall be considered a human health hazard if not maintained in accordance with this approved management plan. Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in accordance with SPS 383.52 (3). Wisc. Admin. Code. Maximum Dispersal Area Operating Limits: Design Flow = 300 gpd; BODS 5 220 mgL"; TSS 5150 mgL"; FOG 5 30 mgL" Inspection Checklist INSPECT EVERY 3 YEARS o type of use o age of system o nuisance factors (i.e. odors, user complaints, etc.) o mechanical malfunction (Le., pumps, valves, switches, floats, etc.) o material fatigue (i.e., leaks, breaks, corrosion, etc.) o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution / drop boxes) o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.) o extent of ponding in distribution cell prior to dosing o dosing irregularities (i.e., pump re -cycling, float switch settings, etc.) o electrical components (i.e., wiring, connections, switches, controls, timers, alarms, etc.) o distribution lateral or lateral orifice plugging (measure lateral distal pressure — compare to design specification) o surface discharge of effluent or sewage back-up into structure served Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary) c Seotic and dose tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis. Slats. when the volume of solids In the tank(s) exceeds one-third (113) the liquid volume of the tank(s) or as required by local ordinance. Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code. o Effluent filter(s) shall be inspected every 3 years and shall be cleaned when necessary to remove any accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12 months. o Distribution laterals shall be flushed once every 3 years or when necessary. System maintenance reports shall be submitted to the proper local government unit in accordance with SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to: Name of individual or company Northland Plumbing Inc Phone: 715-265-4115 Local government unit: St. Croix County Phone: 715-386-4680 Local government unit address: 1101 Carmichael Rd, Hudson, WI Zip: 54016 Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin. Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code. No product for chemical or physical restoration of the POWTS may be used unless approved by the department in accordance with SPS 384, Wisc. Admin. Code. Continuencv Plan In the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to a plan submitted to the appropriate agency for review and approval. A failed mound dispersal component may be re -constructed within the originally approved area after removal of all failed components. System Abandonment If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code. Wisconsin Department of Safety& Professional Services :.i Division of Industry Services SOIL EVALUATION REPORT ` In accordance with SPS 385. Wis. Adm. Code County Attach complete site plan on paper rat less then B 112 x 11 inches in size. Plan must include, is� ' CYof X but not Nmlted to vent W and horizontal roterenoft point (BM), direction and percent slope, Parcel I.D. scab or dimensions, north arrow, and location and distance to nearest road. V O 16 0 0 Please print all Information. Reviewed by PersonN infonnatlon you provide mey be used for secondary purposes (p taw, s. 15.04(1Km)). Property Owner Property Location Page of .3 Date Jim- /606iS Sg'd 94011` Govt. Lot N(w '/. A/w '/. S ,s T 3/ N R E(or Property Owners Melling Address Site Address or CSM and Lot #: 83 City, State, Zip Plane Number ❑ City ❑ \Allege ® Town Nearest Road s a s'/oo 7 c 4 sn s t C P74 ❑ NewCortalnrction Use: [a Residential/Numberofbedrooms Z- Code derived desigriflowrate HOC GPD Replacement ❑ Pudic or comnerdal - Describe: Flood Plan elevation ti applicable fL Parent material %e,U 14'/1 General comments and recommendations: Boring lt []Boring I / I rr ®Ph Ground surface alev e� s R. Depth to limiting fector—ZL_ln, / ebv�/- L 7fl' Horizon Depth In. Dorninant Color Munsell Redox Description Qu. Az. Cont. Color Textu s Structure Gr, Sz. Sh. Consistence Boundary Roots aver rwprcaaam rune GPD/Ft2 'ER#1 'ER#2 a - / 6 YK Y/z Si Zoi:� set/24, , 2 d Ry/ Si/ atGK f. GS -/ 29 "doe Y/# 1 /e YX /& s S/ 1 Se-1 c 'Z4 of K I M r -q -F S — — . !r • ee — .5 .D /- 6 rt f l.S Sri ir+�'i — I'd aBoring # oBoring L RPit Ground surface elev.All o if, Depth to limiting factor 2_ in. / elev.jVF4%. Horizon Depth In. Dominant Color Mur"l Redox Description Ou. Az Cont. Color Texture Structure I Gr. Sz. Sh. ConeiNenoe Boundary Roots a i.•ppnceeunrusts GPD/FN •Eff#1 •Eff#2 o-// o 0eY/2- S.'/ ^24* is► Fr r 1.4/ Z41k MeAd l a o O — - `{ 6 a !/r 'J 7. s Sc M 2rQ6A r P" r— . Z -S b -c CS Nam ( ( nt) Sig CST Number �lrtt r ZG? 85 Address / �` g Date Eva Conducted Telephone Number zo_'= r-Z4S-i///5 Effluent #1 = BOD > 30 s 220 mgrL and TSS > 30 S 150 mg/L ' Effluent 02 - BOD, 5 30 mg/L and TSS s 30 mg1L SBDOW (R03/22) Page 2- of 3 ❑ Bonng © Boring 0 gPit Ground surface elev. /et �1� Depth to limitng factor 20 in. / elev 00. Horizon r Depth In. o—? Dominant Color Munsell 1,6 ,tMz Redox Description Qu. Az Cont Color Texture si Structure Gr. Sz. Sh. mZ 61e Consistence MV — Boundary Cr Roots 2 r., •'4"+ I rwre GPD/Ft2 •EfhY1 •EHA2 , any/ ntvr e G /,o Za e S of r — 'r o rot 5 PJ104A 5-Cl &r �► r — , ❑ Boring k ❑ Boring ❑ Pit Ground surface alev. R. Depth to limitng factor_in. / aW. R. till Boring p ❑ Boring ❑ Pit Ground surface slev. R. Depth to limiting factor in. Effluent #1 x BOO > 30 s 220 mg/L and TSS > 30 9150 M91L ' Effluent N2 - BOD, s 30 MgA. and TSS 9 30 MOIL CHECK BOX M Q'PUCABLE. CHECK BOX AS MPUCABLF. 0 SOIL EVALUATION Scale: '"-4W ❑ SYSTEM PAGE 2 OF SITE MAP eo PLOT PLAN PROJECT NAME: IYZ to n via) i0' DESIGN FLOW: GPo Jim Annis/Sue Stiepan Attach design tlow calalab" for canmeroal plans. PROJECT ADDRESS: 2397 Hm 46, Doer Park Pipe Material I ASTM Standard (Tables 384.303 & 354.30-5) N Switary ssasr oo.o BM Symbd: BM FJovalon: FT Force Mdn: / BU Dracnption: Grade at fence post (oorrw post) S" Gradrr (%) o Waa Symocl (N spplcabb): Q 4 /o erv*" an anw IMPORTANT: Show ground elBvatlon contour at tuthblB kLIBIVeIr. or Tasled Area: on or apvopraa a+a l �,k, IWA I t \ Lit = (b2.02 F33 = /o2.0?2 0 Wastewater METERS FEET 40 35 10 O I 15 F 10 5 0 0 PES1 MODELS: PE31.PE41.PE51 .50 0 GPM 80 0 5 10 15 M3/Fl CAPACITY PERFORMANCE RATINGS PE31 Total Head (feet of Water) GPM 5 52 10 42 15 29 20 16 25 0 PE41 Total Head (feet of water) GPM 8 61 10 57 15 46 20 33 25 16 PE51 Total Head (feet of water) GPM 10 67 15 59 20 50 25 39 30 26 35 8 PAGE 3 S T. Crto UNTY SANITARY SYSTEM Office Use OWNERSHIP/ADDRESS FORM crvawa1 Community Development Department will utilize this information to provide the property owner with information regarding operation and maintenance of your new or replacement sanitary system! This information will be provided as part of our ongoing efforts to protect public health, your well, groundwater, surface water, property values, and county resources. Once approved, this completed form and educational information will be sent to you by email. If you would like to view your issued sanitary permit online, you can do so by using the Property Files Scanned weblink. OWNERIBUYER INFORMATION Owner/Buyer \-�%� 4-hi[15 Mailing Address 2 397 oquP City/State/Zip y-e-cr f Q rf4% t.0 ! Y Do- / Phone Number (required) Email Address (required)._ Parcel Identification Number 04/001540100 (found on the property tax bill) NEW SYSTEM: LEGAL DESCRIPTION Property Location 6r&/'/4 , yjc/ Y, , Sec. _!� , T N R,.1-4r W, Town of T� Subdivision Plat: Lot # 2—' Certified Survey Map # �� Volume 25 . Page #'X;�6 U. Warranty Deed # (before 2006)Volume . Page # Number of bedrooms Spec house G yes)lroo Lot lines identifiable dyes O no New Property Address (Staff Initials) (Date) OFFICE USE ONLY new address required from Community Development Department for new construction.) This form must be submitted with all Private Onsite Water Treatment System (POINTS) applications. New System: Include with this form a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is mode in the warranty deed. Community Development Department— Land Use Division 715-386-4680 St. Croix County Government Center 715-245-4250 Fax cddC)sccwi gov 1101 Carmichael Road, Hudson, WI 54016 www.sccwi.aov t � Q •3 nSt Professional Services Qryt j� Papa 1 of Division r 5� SOIL EVALUATION REPORT n accordance with SPS 385, Wis. Adm. Code minty -T4 , I? rot X Attach complete sit plftrkDft not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to v nd horizontal reference point (BM), direction and percent slope, Parcel I.D. scab or dimensbrre, north arrow, and location and distance to nearest road. U O /C O DO Pleas* print all Information. RevrmDa tel by Personal information you provide may be used for secondary purposes (P taw, s. 15.04(1xm)). I / Property Owner / Properly Location ®_ J/ n4- / 6*ti S SaC S�/. Govt. Lot t�(cu '1A gW % S 'Jr T / N R E (or Property Owner's Malling Address Site Add CSM and 4ot #:55� / Z- D 1 Z 23 S T City, State, Zip Phone Number ❑ City ❑ Village ® Town Nearest Road/ Park,Wf . SV607 (41S!) 2 -12 LC• w 7dV ❑ NewCwMn=Wn Use: B Residential/ Number of bedrooms Code derived designflowrete 302GPD Ig Replacement ❑ Public or commercial — Describe: Flood Plan elevation it appiicable ZU►'4 Y�ft Parent material 561f,!4 Aw General comments and recommendations: /Boring ❑ Boring �/. tT # ® Pit Ground surface slev/ot+7ft. Depth to I lmiting factor�8 in. / el*v/ R Rrmfl Amnrrafion Rate Horizon I Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 'Eff#1 'Eff#2 O - 16 YR J/Z Si rise Zd k petr r •. 2 6 y1t V/Y K y r 4e S / L• 29 /6 YJ /•r 7.5 S/ JJZOA rC( Pit 2aA A( 29-'V 6 YX SNr 1. 5 its/ r�dOT4 aBoring # [-]Boring y pV� 'RPit Ground surface elev.�Z'o ti. Depth to limiting factor 24 in. / elev.ff�R. Snil Annliration Rate Horizon Depth In. Dominant Color Mumell Redox Description Qu. Az. Cont Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/FN 6EMW1 'Eff#2 a -// D X Y/2. S� 24 A -," aS • 4? 2 It- if APAJ sM#5cr c S /.a r - `! 0 YR s f 7, 5 Sc fx 2raLK rrt . Z. .3 CS Name (PI mint-t� S g CST Number �4? 9K5, iytt ` Address 29r1.3 ��A� Date Evaluation Conducted -Z9-2ozz Telephone Number I r5-ZGS-y//s Effluent #1 = SOD > 30 S 220 mg/L and TSS > 30 5150 mg/L ' Effluent #2 = BOD, S 30 mg/L and TSS S 30 mg/L SBD4330 (R03/22) ..• Page 2 of 3 ©❑� Boring # aPil Ground surface elev.AZO* Depth to limiting factor 'Zy in. ! elev 60.JW Soil Annli atim Retw Horizon Depth In. Dominant Color Munsell Redox Description Ou. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ftz •Ef1#1 'Eff#2 40-7 /o JA si/ ow2 6k air✓ r Cs 2 .8 a may/ Cr inr r • G 40 - ZO o ,` 4 Sa &41f - #4 7 vFR s A.+ ZdA 9s S • t2 0 �f .S R-'iP�' in��'i' — S �. o ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. / slev. ft. Soil Aodkation Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 'EM 'Eff#2 ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft Depth to limiting factor in. / elev. ft. Soil Anntiratinn Ratty Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cord. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft' •EMV1 •Ef1#2 Effluent #1 = SOD > 30 s 220 mg/L and TSS > 30 5150 mg/L • Effluent #2 = BOD, 5 30 mg/L and TSS 5 30 mg/L CHECK BOX AS APPUCABLE. CHECK BOX AS APPLICABLE. F71 SOIL EVALUATION Scale: 1" a 40' Ej SYSTEM PAGE 2 OF MAP S° ,o B0 so PLOT PLAN PROJECT NAME: (10e9m) 102 DESIGN FLOW: GPO Jim Annis/Sue Stiepan Attach design flow calculations for commercial plans. PROJECT ADDRESS: 2397 Hwy 46, Deer Park Pipe Meledal / ASTM Standard (Tables 384.30-3 & 384.30-5) BM BM Elevation: 100.0 FT N Sanitary Sewer 1 Forte Main: / SM Descripeom Grade at fenoe post (Comer post) Grauwr x T«� ed �: ( ) 4% Well Symbol (II appYnde): Q tri0lmienormtry W g *n IMPORTANT: Show ground elBVatlOn COntq/6 at suftable Intervals. «d,& appropf"� 62 = faZ•o2. (33 = ioz.oz. �O I I ' I � i-- I t 83 \ I .�y kewto t-- $1. ctoI�( COUNTY� NO., 644785 STATE SANITARY PERMIT ��� ?o.,,,S r7 //W. NG I11TItAMSy�'1�/R�NEiVAl Za.G K OWNER S PLUMBER TOWN OF SEC_ , 51 '4 9 AND/OR LOT Z BLOCK u 07�B5 SUBDIVISION CHAPTER 145.135 (2) WISCONSIN STATUTES (a) The purpose of the sanitary permit is to allow installation of the private sewage system described In the permit. (b) The approval of the sanitary permit is based on regulations In force on the date of approval. (c) The sanitary permit Is valid and may be renewed for a specified period. (d) Changed regulations will not impair the validity of a sanitary permit. (e) Renewal of the sanitary permit will be based on regulations In force at the time renewal is sought, and that changed regulations may impede renewal. (I) The sanitary permit is transferable. History: 1977 c.169; 1979 c. 34,221; 1"1 c. 314 Note: If you wish to renew the permit, or transfer ownership of the permit, please contact the county authority. b AUT OPJIZED ISSUING OFFICER - DATE ZZ PERMIT EXPIRES / 20 UNLESS RENEWED B U THAT DATE POST IN PLAIN VIEW VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION SBD-06499 (R11/20)