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Home My WebLink About006-1065-50-000 (2)Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County St. Croix Safety and Budding Division INSPECTION REPORT Sanitary Permd No (ATTACH TO PERMIT) 645433 GENERAL INFORMATION Sta'e 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 Township Parcel Tax No Four Corners Farm LLC TOWN OF CYLON 006-1065-50-000 CST SM Elev. Insp. BM Elev BM Descriplion SectronRown/Range/Map No 29.31.16.453 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Au Intake ROAD Septic Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia Dist. to Well SOIL ABSORPTION SYSTEM STATION BS HI FS ELEV. Benchmark Alt BM Bldg. Sewer SUHt Inlet SVHI Outlet DI Intel Dt Bottom Header/Man. Dist. Pipe Bot. System Final Grade St Cover BED/TRENCH Width Length No. 01 Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO IPIL BLDG WELL LAKE/STREAM LEACHING Manufacturer INFORMATION CHAMBER OR UNIT Type Of System. Model Number. I-IIIJI-ALta g"LelZl Akz'ilaiJ Header/Mandold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Die Length Die Spacmq SOIL COVER x Pressure Systems Only xx Mnund Or At -Grads Svstems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bedrrrench Center Bad/Trench Edges Topsoil : J Yes _� No Yes - No COMMENTS: (include code discrepencies. persons present. etc.) Location: 2190 HWY 63164 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? Yes :Dm No Use other side for additional information. Date SBD-6710 (R.3197) Inspection #1: Inspection #2: I Insepdor's Signature Can. No. %.., r r wLr, tat N �°Q vIM OCT 11 2022 Department of Safety & Professional Services, Industry, Servi Di ' io i County ST CROIX Sanitary Permit Number (to be filled in by Co ) 61fs�3 3 v co 't pplication In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form IQthe appropnate governmental unit is required pnor to obtaining a sanitary permit. Note. Application forms for state-owned POWTS are submitted to the Department of Safety and Professional Services. Personal information you provide may be used for secondary s in accordance with the Pnvery law, s. 15.04(1 xm), Stars. -State Transaction Number ^oJibi Address (if diMerj�n than mail i ress / Q lrsa' 4 S).-� 2196 HWY �64 -� r cy+ a tine teiu Property Owner's Name FOUR CORNERS FARMS LL + #Z ' Parcel N 006-1065-50-000 Property Owner's Mailing Address Property Location r 2173 CY RD H Govt Lot S E ,, SE ,, Section2 9 T 31 N R 16 E or X City, State Zip Code DEER PARK WI H. Type of Building (check all that apply) 0 1 or 2 Family Dwelling- Number of Bedrooms ❑ Public/Commereial - Describe Use Phone Number Lot N Subdivision Name lock N ❑City of ❑S Owned - Describe UxSM �N6X ❑ Village of BTowno( CYLON Number 11111,Type of POWTS Permit: erv^ or "Replacement" and other applicable on line A. Check one box on line B. Complete line C i Applieabk. " ', ®New S ❑ Replacement System ❑ Other Modification to Existing System (explain) ❑ Additional Pretreatment Unit (explain) Sconventional) B. ❑ Holding Tank In-Gnd rou ❑ At -Grade ❑ Mound ❑ Individual Site Design ❑ Other Type (explain) p r C. ❑ Renewal Before Expiration ❑ Revision ❑ Change of Number ❑ Transfer to New Owner r. List Previous Permit Number and Date Issued rv. rsavirraimeet Ara and Tank llebrmatisn: X Design Flow (gpd) 600 Design Soil Application Rate(gpdtsf) .5 Dr5persal Area Required (sq 1200 Dispersal Area Proposed ( 1200 ystem Elevation STEP 93.9 94.4 94.9 Tank Information Capacity in Gallons Total Gallons N of Units Manufacturer (i /. ' .� C P -- g, 3 2 0 'g v� New Tanks Existing Tanks Septic orHoldinsTank 2 2250 2 WIESER Dosing Chamber X 750 1 WIESER X V. Responsibility Statement- I, the undersigned, assume responsibility for imWaYae of the POWTS shown oa the attached plans. Plumber's Name (Prom) Plumber's Sigrna4uc PAUL R KOEHLER .00 MP'AWRS \umber 225410 Business Phone Number 1715-246-2660 r Plumber's Address (Strut, City, State, Zip Code) 321 WISCONSIN DR NEW RICHMOND WI 1 Vl. con. vn GWIY (� Approved ❑ Disapproved ❑ en j4UW for Denial Permit Fee Date Issued Issuin Agent Signatur y 1. rianagement !.A Conditions qApprov snnsfor f3isappruM SYST M OWNER: pfic tank, effluent filter and dispersal cell cy: (,� (lV�� w t�� 6.e_. must be serviced / maintained as per plan provided by plumber. setback requirements must be maintained r _. —r r..—�._ --A 11"ee�h rl►•a Ge ske maeniad� C� aat`uwl fe�1 r 12si -- �Iet ae—`_(/•,y�(`JI� C CtIG'/G_ k/_ice SB 39 0 nz j StQoo / ho"2 ►%...ap�— J P"'t'��d�� t�A�c�a�- s a s� �9/g9 AC -xvi I�uQ q40 SO oSL UIV �I.2Y �y� �-9 GrnH �`1'11 r" Jr%%ow tip, w ^''N "P.00 w4SuozoS.'m Ilt 077Z -7hti -Slt- of/7S.tt r1143,-x I'lld Oh 9,h'dQIS r c-� u rn of rn 71 � N 1U b-C.'�s k-I 4 3 �, 3 S `�100`05- S94( -w4 Vn Ibd sw.AW4 5Jay.'$oJ , 0oA Project Name: Owners Name: Owners Address: Legal Description: Township: County: Subdivision Name: Lot Number: Parcel ID Number. DesigneNPlumber: Date: CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE FOUR CORNERS FARMS DAVE GOODRICH 2173 COUNTY RD H DEER PARK W1 54007 SE 1/4 SE1/4 SEC 29 T 31 N R 16W CYLON ST CROIX 006-1065-50-000 Page 1 Page 2 Page 3 Index and title Plot Plan System Sizing & Cross -Section Page 4 Fitter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans PAUL R KOEHLER License Number: 10/07/2022 Phone Number Signature 225410 (715)246-2660 Designed pursuant to the In Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 Fo u t C 0eWecS far mS PAr C, l ooG- logs So-oc)c� Sec,10j Y31A/ R I L W Tow, C�Lor SrtCro;tie cI>Li �3ev,�a1,. f'nK 1 TolzaT w411I Ibo I is Mari Z fc"ef a' pUC, Ig,2D P; + 96,$a p;t 3 �S,qa Slbp�`I ob Scctic 1'-104 p��l K�tilt.. a15�1� 32� 4J.;SGonS.n Qilli{' Moh,, LN Nw7 0 3OTc,- 3Tcc..c T r , m � oo• S p o i � QC.4raar-, gt0io� s . p .�� i i Y � SOIL ABSORPTION SYSTEM DETAIL I GRAVELLESS LEACHING UNIT Page of 1 Project Name: FOUR CORNERS FARMS (DAVE GOOD RICH ) 3 No. of Cells 8 Per Cell 3 r. Cell Width 24 Total No of 10 80 n Cell Length 50 sq n EISA Per Cell 3 n Cell Spacing 1200 sq n Total EISA Infiltraw EZ1203H-51`1 5.0' 25.0 FZ12031-t-10R 10.0' 50.0 Graveiless Leaching Unit Manufacturer: EZ FLOW Gravelless Leaching Unit Model: EZ 1203H - 10 Finished Grade in . .'.�.f :\Y:: 12 in y-� in Typical Cross Section Observation Pipe with approved cap or vent Soil Backfill Fabric n Infiltrative Surface O I / ' n Limiting Factor ' Slotted and Anchored Vent/ Observation Pipe with Cap ................................................ Plumber/Designer Signature: J� License #: 225410 Date: OCT 7 2022 PAGE 4OF5 GRAVITY -DOSED SEPTIC / PUMP TANK SPECIFICATIONS (No Scale) IMPORTANT: ` "wna Anchor tank(s) as necessary pursuant to SPS 383.43(8)(g) Finished Grade CAPACITIES aQ 600 gaUin Depth (in) Volume (gel) A 25 403 B 2.0 32.24 [C] 5 80.6 D 8 128.96 i' .. 4 2 in *Pump Tank Liquid Level = 16.12 in Force Main Diameter = Force Main Length = Electrical must comply vAth SPS 376 and NEC 300 Wealherpaol J undbn Box y.. *T weep Hole B Alarm On Pump Oft Extend manhole daer as necessary Approved Lodtktp MaNwk with Warning Label Ntached v Min. or 2.0 n above IT�Established Flood FJevalbn (trp+m) 3' Approved Bedding Material Beneath Tank Force Main Vold Volume ==gal [C] Total Dose Volume TDV = 80 gal/dose (< 0.2X design flow + force main void volume) Vertical Lift = 5.25 ft I `Approved Jamb with Approved Pipe 3 R onb Sold Ground (Arpical) PUMP -OFF ELEVATION = 88.65 ft INSIDE BOTTOM ELEVATION = 87•9 ft PUMP TANK: SEPTIC TANK(S): Volume = 600 gal Total Volume = 2000 gal Manufacturer. WIESER Manufacturer(s): WIESER Pump Manufacturer. GOULDS Install approved effluent filter at the septic tank outlet Pump Model: EP04 (See attadied pump curIMMENSENESS ve,) immediately uP m streaof the pump tank inlet. Controls/Alarm Manufacturer. SJ ROMBUS Filter Manufacturer: POLYLOCK Controls/Alarm Model: PS PATROL Filter Model: 525 Float switches containing mercury are prohibited Wastewater !'1 METERS 10 9 n T; FEET 30 8 2E 7 6 2C 5 15 4 3 1C 2 5 1 0L C I 5GPM *2.5 i --- - - - -- -- - - -- EPOS - -- 10 20 30 40 50 GPM 0 2 4 6 8 10 12 m'/h CAPACITY MODEL INFORMATION Order HP Volts Amps Minimum Circuk Phase Float Switch �� Discharge Minimum Minimum Minimum Basin Maximum Solids Shipping Weight Number Breaker Style length Connection On level OH level Diameter Size Ibs.kg EP0411 .4 115 12 20 1 P/ No Switch S 10' 1'h' Manual Manual 15' '/.' 20/9.1 EP0411 A Piggyback / Wide -Angle 10' 12' 6' 21 / 9.5 EP0411 F Plug Switch No S 20' Manual Manual 20/9.1 EP0411 AC Piggyback / Wide -Angle 20' 12. 6' 21 / 9.5 EP0412 230 6 10 Plug / No Switch 10' Manual Manual 20/9.1 EP0412F Plug No Switch 20' Manual Manual 20/9.1 EP0511 F .5 115 13 20 Plug / No Switch 20' Manual Manual 22110 EP0511AC Piggyback / Wide -Angle 20' 12' 6' 23 / 10.4 EP0512F 230 6.5 10 Plugt No Switch 20' Manual Manual 22110 PAGE 3 PaL rInc. Innorsom in Prrast Dukup �' Zabel' 6 Wannwfer Prodwu v A I)Msion of P*iok Inc. PL-525 Filter PL-525 Effluent Filter The PL-525 Filter is rated for 10,000 GPD (gallons per day) making it one of the largest filters in its class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok PL-122, the Polylok PL-525 has an automatic shut-off ball installed with every filter. When the filter is removed for cleaning, the ball will float up and temporarily shut off the system so the effluent won't leave the tank. I - Features: • Rated for 10,000 GPD (gallons per day). • 525 linear feet of 1/16" filtration. • Accepts 4" and 6" SCHD 40 pipe. • Built in gas deflector. • Automatic shut-off ball when filter is removed. • Alarm accessibility. • Accepts PVC extension handle. PL-525 Installation: Ideal for residential and commercial waste flows up to 10,000 gallons per day (GPD). 1. Locate the outlet of the septic tank. 2. Remove the tank cover and pump tank if necessary. 3. Glue the filter housing to the 4" or 6" outlet pipe. if the filter is not centered under the access opening use a Polylok Extend & Lok or piece of pipe to center filter. 4. Insert the PL-525 filter into its housing. 5. Replace and secure the septic tank cover. PL-525 Maintenance: The PL-525 Effluent Filters will operate efficiently for several years under normal conditions before requiring cleaning. It is recommended that the filter be cleaned every time the tank is pumped, or at least every three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the filter needs servicing. Servicing should be done by a certified septic tank pumper or installer. 1. Locate the outlet of the septic tank. 2. Remove tank cover and pump tank if necessary. 3. Do not use plumbing when filter is removed. 4. Pull PL-525 cartridge out of the housing. 5. Hose off filter over the septic tank. Make sure all solids fall back into septic tank. 6. Insert the filter cartridge back into the housing making sure the filter is properly aligned and completely inserted. 7. Replace and secure septic tank cover. 1/16" Filtration Slots 10,000 GPD Accepts 4" & 6" SCHD 40 pipe NSF Outdoor Smart Filter® Alarm Polylok, Zabel & Best filters accept the SmartFilter® switch and alarm. Alarm Switch (Optional) Accepts 1" PVC Extension Handle Rated for 10,000 GPD 525 Linear Ft. of 1/16" Filtration Slots CertMled to NSF/ANSI Standard 46 Gas Deflector Automatic Shut -Off Ball Extend & LokrM Easily installs into existing tanks. Polylok, Inc. 3 Fairfield Blvd. Wallingford, CT 06492 Toll Free: 877.765.9565 Fax: 203.284.8514 www.polylok.com IT W1250/750-MR TANK SPECIFICATIONS _ a I 12 -11 DIMENSIONS: ~ rc o WALL' 2 1/2" 4" CAST -A -SEAL 4" CAST -A -SEAL BOTTOM: 3" COVER: 6" ===CIF==y= MANHOLE: 24" I.D. PRECAST CONCRETE RISER i HEIGHT. 66" o i� II II a `�� LENGTH: 12'-11" ii 11110 WIDTH: 7'-2" A 1111. ii/,_,\ 42� II ��- ��BELOW INLET: 53" N i� 10 LIQUID LEVEL- 48" 1 E a WEIGHT. 14.860 LBS.)IT 7) INLET AND OUTLET: 24$ ' \" FILTER OR i i i i �� 4" CAST -A -SEAL BOOT OR EQUAL GASKET m 8 i BAFFLE INLET AND OUTLET BAFFLE AND FILTER: WISCONSIN, SEE DETAIL /10 (OTHER STATES SEE CHART) W .9 TOP VIEW UOUID CAPACITY: 27.66 GAL/IN (SEPTIC) ~ Lu 16.12 GAL/IN (PUMP) LOADING DESIGN: 8'-0" UNSATURATED SOIL 0 Ln TANK CAN BE USED AS: G.1' o I N SEPTIC/SEPTIC, SEPTIC/SIPHON. < N a w 4" VENT OR SEPTIC/SIPHON o n W o to TANK: MIX DESIGN /10 (STRUCTURAL FIBER) _ °D ---- -- __ _ W CUSTOMIZED TANKS: INLET - FOR CUSTOM TANKS CONTACT WIESER CONCRETE n OUTLET ; U I I I I =r U 1 II= i7 a I m a U I • : N 1 I J I I j Q '' I c z c I I REVIEWED BY I c� n PUMP PAD REVIEW DATE N d DRAWINGS SUBMITTED SIDE VIEW FOR APPROVAL APPROVED BY: SHEET NO. APPROVAL DATE: j Z PRODUCTS NEEDED BY: of VKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS 1 4" CAST INLET _ " a a. i 2} OR EXCEED In n WLP 1000— MR GREASE INTERCEPTOR TANK SPECIFICATIONS 4' CAST -A -SEAL DIMENSIONS- WALL- 2 1/2- BOTTOM: 3" COVER: 5" MANHOLE: 24" I.D. PRECAST CONCRETE RISER HEIGHT: 53 1/4- LENGTH: 8'-8" WIDTH: 7'-2" BELOW INLET. 42" LIQUID LEVEL: 36" WEIGHT. 6,790 LBS. INLET AND OUTLET: 4" CAST -A -SEAL BOOT OR EOUAL GASKET INLET AND OUTLET BAFFLE: AS SHOWN LIQUID CAPACITY: 27.83 GAL/IN LOADING DESIGN: 8'-0" UNSATURATED SOIL TANK CAN BE USED AS: GREASEINTERCEPTOR COVER: MIX DESIGN /8 (NO FIBER) TANK: MIX DESIGN #10 (STRUCTURAL FIBER) CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE i =-a OUTLET :.. c a a , o, PUMP PAD & C-1613 K Q I Z om o U REVIEWED BY REVIEW DATE a. DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: SHEET NO. APPROVAL DATE: j z PRODUCTS NEEDED BY: OF 1 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pape I of Z FILE INFORMATION owner FOUR CORNERS FARMS LLC Permit l DESIGN PARAMETERS Number of Bedrooms 8 ❑ NA Number of Public Facility Units ❑ NA Estimated flow (average) 400 gal/day Design flow (peak), (Estimated x 1.5) 600 gal/day Soil Application Rate .5 al/d /ft' Standard Influent/Effluent Quality Monthly average' Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODO) 5220 mg/L ❑ NA Total Suspended Solids ffSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODO) S30 mg/L Total Suspended Solids (TSS) 00 mg/L ❑ NA Fecal Col'Iform (geometric mean) 5104 cfu/100ml Maximum Effluent Particle Size Y. in die. ❑ NA Other: ❑ NA 'Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS Septic Tank Capacity 1250---1000 al ❑ NA Septic Tank Manufacturer WIESER ❑ NA Effluent Filter Manufacturer POLY LOCK ❑ NA Effluent Fitter Model rr2rr DU ❑ NA Pump Tank Capacity 750 al ❑ NA Pump Tank Manufacturer WIESER ❑ NA Pump Manufacturer GOULDS ❑ NA Pump Model EP04 ❑ NA Pretreatment Unit ❑ Sand/Gravel Fitter ❑ Peat Fitter ❑ Mechanical Aeration ❑ Wetland ❑ Disinfection A Other: ❑ NA Dispersal Collis) ❑ NA X In -Ground (gravity) ❑ In -Ground (pressurized) ❑ At -Grade ❑ Mound ❑ Drip-Une ❑ Other: Other. GREASE TRAP FOR ❑ NA Od' KITCHEN WASTE ❑ NA Other. ❑ NA Service Event Service Frequency Inspect condition of tank(s) At least once every: 3 ❑ months) (Maximum 3 ❑ year(s) Yom) ❑ NA Pump out contents of tank(*) When combined sludge and scum equals one-third (Ya) of tank volume ❑ NA Inspect dispersal cellls) At bast once every: 3 ❑ month(s) (Maximum 3 yam) ❑ ear(s) ❑ NA Clean effluent filter At least once every: 1 ❑ months) . ( JQ YWB) ❑ NA Inspect pump, pump controls & alarm At best once every: 3 ❑ months) ❑ earls) ❑ NA Flush laterals and pressure test At isast once every: ❑ month(s) '3 earls) C[ NA Other: At least once every: ❑ morrthla) ❑ yearls) ❑ NA Other. PUMP GREASE TRAP ONCE A YEAR /OR AS NEEDED ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector, POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cells) 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 falling 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 OPEFIAT10N pop Z of Z 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 tankls) 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 cells) 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 tags. 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 isump pumpl 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 snd 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 webs. 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 sob limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. slue ' e a. . 1�ZDNIt r in. s�z a&JS XdCn O Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name COUNTRYSIDE PLUMBING Name PAUL R KOEHLER Phone 715-246-2660 Phone 715-246-2660 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name POWERS SEPTIC Name ST. l 20AIIAJ Phone 715-265-4623 Phone This document was drafted in compliance with chapter Comm 83.2212)(b)(1)(d)h(f) and 63.54(1), (2) h (3), Wisconsin Administrative Code ST._S:SjPj6PVNTY. SANITARY SYSTEM File #: NTY OWNERSHIP/ADDRESS FORM � 1��ty 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. OVMLV UYER INFORMATION Owner/Buyer FOUR CORNERS FARMS LLC Mailing Address 2173 CTY RD H City/State/Zip DEER PARK WI 54007 Phone Number (required) 715-781-1500 Email Address (required) Parcel Identification Number 006-1065-50-000 (found on the property tax bill) NEW SYSI'M LEGAL DESCRIPTION Property Location SE y� , SE 1�4 , Sec. 29 T 31 N R 16 W, Town of CYLON Subdivision Plat: A�0 4- ac.R�S Lot # Certified Survey Map # Volume . Page # Warranty Deed # 103 COj �o !j (before 2006)Volume Page # Number of bedrooms Spf house CI yes ■ no Lot lines identifiable yes ■ no t- t I T un New Property Address \ pJ Z t) Y W (Verific ion munity Development Depa t for new construction.) Dl Z. (Staff Initials) (Date This form must be submitted with all Private Onsite Water Treatment System (POWTS) 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 made in the warranty deed. Community Development Department - Land Use Division 715-386-4680 St Croix County Government Center 715-245-4250 Fax cdd@sccwi.aov 1101 Carmichael Road, Hudson, WI 54016 wwwsccwi.aov CJ f-Irs �, sgr i wmr woaw Yi.1� I BATHROOM r� BEDROOM R - — BEDROOM 2 BEDROOM 3--.-�7 BEDROOM rR I �I I ww c! I 1T I I�^ BEDROOM 6 ;, j BEDROOM e BEDROOM? �� BEDROOM B -7;�I' �l a n� MWOMER SMUTW - wwe TAX �e2o .0 m a2� A a G 5r- 26 22 - 2 3-7 Mi 7and,4prLzpM*j1 fessional Services Page 1 of 3 SOIL EVALUATION REPORT 022 in aecgrdance with SPS 385. Wis. Adm. Code C ROIx Attach complete than 8 1/2 x 11 inches in size. Plan m indbut not limited to point BM)dirtiction a ce pe, Parcel I.D. scale or dimensiVwAst to nearest roa 006-1065-50-000 Pleaw prlM ormatlon. a by I Date Personal information you provide may be used for secondary purpo (Privacy aw, s. 1 . (1)(m)). PA LAA Property Owner Property Location ❑ FOUR CORNERS FARMS LLC Govt. Lot SE ,' SE X S 29 T 31 N R 16 E (or) W Property Owners Mailing Address Site Address or CSM and Lot *: 2173 CTY RD H City, State, Zip Phone Number ❑ City ❑ Village 13 Town Nearest Road NEW RICHMOND WI I ( ) CYLON LN New Construction Use: LJ Residential/Numberofbedroorns4 ❑ Replacement ❑ Public or commercial - Describe: Parent material GLACIOFLUVIAL DEPOSITS GRAVELY OUTWASH General comments and recommendations: F Boring 0 ❑ Boring 97.9n ®pit Ground surface elev. tit. Code derived dasignflow rate 1LW GPD Flood Plan elevation if applicable fl. ---( M"- -- -- - Depth to limiting factor 76 in. / elev. 6.3 fl. Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 'Effr><1 'Etffi2 A 0-9 10 YR 3/3 OMSG ML W 2F .7 1.6 B 9-19 7.5YR4/4 SL 2MGR MFR GW 1 VF •6 1.0 B1 19-31 7.5 4/4 ---- FSG 2MW 0 MFR CS 1 VF .5 1.0 C C1 31-36 36-4175YR4/4SIL 7.5YR4/6 ----- SL 2 M SBK 2 MSBK ML MVFR CS -- -- •6 .6 1.0 1,9� C2 10 YR6/3 — ----- FSG 0 F SG IML afi Boring s ❑Boring 'S`i� /- 2- ®Pit Ground surface elev.2•80111. Depth to limiting factor 102 in. / elev. 8.5 ft. Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 'Efh11 •E1fi2 A 0-20 10 YR 3/3 LS OMSG ML CW 2 M .7 1.6 B 20-27 10 YR 4/6 SL 2MGR MFR CS 2 M 6 0 Bi 27-34 7.5YR ro SL 2 M SBK MFI CS 2 F 6 . 1.0 82 10 YR 4/6 SG 0 F SG MFI CW 2 F .5 B3 SG 1 0 F SG ML CW 12 F .5 64 7.5YR4/4 SIL 2M ABK MFR 12 F .6 1r CST Name (Please Print) PAUL R KOEHLER Signets / `.q/ �G �_ CST Number 225410 32211 1�ISCONSIN DRIVE NEW RICHMON pate Evaluation conducted WI 2022 Telephone 5-246- Number 715-246-2660 Effluent #1 - BOD > 30:5 220 mg/L and TSS > 30 5150 mg& Effluent t2 - BOD, s 30 mg/L and TSS s 30 mg/L SBD-8330 (R03/22) s Page 2 of 3 FBoring • ❑ Boring 959 ® Pit Ground . Ground surface el ev. ft. Depth to limiting factor 96 in. / elev. 8 ft. Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Ou. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft' 'Eff*l I 'EftR2 A 0-10 10 YR 3/3 LS 0 M SG ML Cw 2 M 1.6 B 10-36 7.5YR 4/4 SL 2 MABK MFR CW 2 F 6 1. B1 36 1 10 YR 4/6 SG O-E SG ML CW 1 F .5 1.0 C 51-72 10 YR 6/4 SG 0 SG ML CS _ .5 1.0 C1 72-96 7.5 YR 4/4 SIL 2 M ABK MFR - - yg- 7-Lt(610 ❑ Boringrt ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. / elev. ft. Soil Application Rate ❑ Boring • ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. / elev. ft. Soil Application Rate MMO, M.- Redox Description Qu. Az. Cont. Color Effluent 01 - BOD > 305 220 mg& and TSS > 30 s 150 mg/L • Effluent i2 - BOD, s 30 mg/L and TSS s 30 mg/L N e Cocr,e,cs farms Doi- ws ^SO-Dcc5 1� &ec--1q i31N RIL W Town. CtLon S-rCiro, Nt GDunt� P,1 N a P, k ti eras. Mti�i� 1. T,, oq I00 O�rc� pUq$,2 L n Mal or P,t q�,�a P;t 3 q$ ,qc, SIbP�`�'o ?!s-1yL- 1G(D 3�1 41,SconS:n (�srrJt- IVAw Q,CA moMll LAJ Nw� 63 nn. Y1 t : Y • ! My Iy► �� ' � ' y •1. SCC ArcGIS Web Map 1011812022, 9:59:53 AM 1:4,514 ♦ 0 0.03 0.06 0.11 mi Sks Addrm Points Lot Tax Parcels Shmshod Overtry DWVkg ® ~0 DrWnswEasement Lw*w Common Spom or Park 0 ossr Sub*mi cw Bsdariss 75 FT SefbeCk —�, r�— 0 0.04 O.D9 0.09 0.17 kris Pubk ROW Private Rk tot -Wry 0 300 FT River/SI a VAXM. scc coo. Scc coo r,e scc ryrfwGV O"t scc cop. FEMOk. scc cm WN! ApOkftw Iw rasa SM COD I WOW SM= I Wr D%lt of MkxW%wwm pAmw at Www I WcC00 wtl SM I Vmy ant I%EWl SM c0pICp0 wd WS I NowW ow*o ft%wm A♦wwy OKLq pw 9Ub Lm"w, EwlI IX couNTv �•8 !) No. 645433 STATF�4SAN ITARY�PERMIT t ziQ*WA"9 bq AL PREVIOU�%NO, OWNER k$ IA ut. PLUMBERQAtL �WC LIC.# 2251410 TOWN OF SEC _,T_? _N, R tp IM AND/OPI LOT BLOCK a — SUBDIVISION CHAPTER 145.135 (2) WISCONSIN STATUTES (a) The purpose of the sanitary permit is to Wow installation of the private sewage system described in the permit. (b) The approval of the unitary permit is based on regulations in force on the date of approval. (c) The unitary 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 unitary permit will be based on regulations in force at the time renewal is sought, and that changed regulations may impede renewal. (I) The unitary permit is transferable. History: 1977 c.168; 1979 c. 34,221; 1981 c. 314 Note: If you wish to renew the permit, or transfer ownership of the permit, please contact the county authority. UTRIfED ISSUING OFFICER - DATEHIS PERMIT EXPIRES �� UNLESS RENEWED BEFORE THAT DATE POST IN PLAIN VIEW VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION SBD-06499 (RI 1/20)