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040-1258-20-000 (2)
YVuconsin Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you Provide may be used for secondary purposes IPnvacy Law, 3.15.04 (1)(m)I Permit Helders iv.m. � 1 �v . y TANK INFORMATION PUMP/SIPHON INFORMATfn►u code discrepancies, persons present. etc.) TOWN OF TROY ELEVATION DATA 1.1 Alt BM Description = r 2.) Bldg sewer length = .. - amount of cover = q2 go+ 3, 1.0 f %.Sn &^ S •T: W&Wim.� �Ct w :l.l 6rt644nzerQ..f 0 ay.- p.T ^" Plan revision Required? El Yes �' No L L, % b � Gi lgjyy�,Q e Use other side for additional information. �� `W48710 (R.097) Q L3 apdofs Signature �j'Cert No 9A Sma.l ._ Z.oe J Q 1 Industry S Di ion Cry • I i �%V 4822 Madison Yards Way Madison, WI 53705 T, L"40/ Permit Number be filled in by Co.) . _�: P �:; Sanitary (to Q �f 2�72` P.O. Box 716 Madison, Wl 37 / fp 2 �tQ ' S Pet pphcatio State Transaction Number In accordance with S 3g3.Z1yiplaV tssion of this forth to lire govemrnentnl unit Project Addrra (if diflev than mailing address) is required prix b Note: ApPI cation terms for ■tatco POWYS are submitted b the Department of Sa 1 Services. Personal ialbrmation you provide my be used for secondary purposes in accord&= with the Privacy Law, A 15.D4(1 m), Stars. 3 y`/ //a•o Ssy 1. Application information- Please Print All Information Property Owner's Name Parcel # 7 Lorr lXh-A 5 OY40- e75,8'0?0-000 Property Owner's Mailing Address Property Location 74 4)d i f19 TfSric E/cNrS alll. Covt. Lot '�—y���� City, State Zip Code Phone Number uSSEX Cti S3o89 3/? 422-7/73 T 0?8 N P. e?O 11. Type of Building check all that apply) Lot # Subdivision Name R� RR l or 2 Family Dwelling - Number Q � ` t1µ -A-Q / 51 Bloc[ # .4-- i:I;il /1 ublic/Commercial - Describe � AoY U/c, 3 — 0. Cityof [IState Owned - Describe Use loof CSM Number Town of Fine Y M. Type of POWTS Permit: (Cheek either "New" or "Replacement" and other applicable on line A. Check one box oa Ilne B. Complete line C If applicable.) A. cw Sysltan aeplace ent System LX ❑Oder Modification to Existing System (explain) Additional Prtnntment Unit (explain) B ❑Holding Tank In -Ground ❑4t-Grade Mound Individual Site Design Other Type (explain) C. Renewal Before ❑Revision ge of Plumber ❑Transfer to New Owner Prevtotu Permit Number and Date Isarrrd Expiration r IV. Dispersal/Treatment Ara and Took iaformotion Design Flow (gpd) Design Soil Application Rate(gpd/s ispersal Area Requi (sf) Dispersal Area Proposed ( System Elevetioa 00 7 8s8 893.E 9s.8/ Tank Information Capoeity in Gam Total Gnllotn # of Units Manufiasry �' N*-r e c ° " 14- gksr-f—UF-ro g 2 New Tads F�c _$t Tads Septic or Holding Tads JS� - �.t.SO 1 � 1 N/ES E.e /A,dl.. Donag Chunbcr 750 1— 756 ! Ca rfae V. Responsibility Statement- 1. the atiderslgoed, aswme respetedhatty for losnYadon or the POWTS shorro OR tee attxhed phn. Plumber's Name (Print) Plumber's re MP/1r13'!:9 Number Business Phone Number /1'N Nzxr.?3/3fG /S G7J-sicG Pltmtb%:6 Address (Sttcd. City, State, Zip Ctldc) N C,?98 Sr. S /,/OA,4d4 l)-r S!l73 Conn artment Use Only rVt. Iq Approvrd ❑Disapproved Perm�i't FCC Date ]ssu 1 in Agent Signature 5 /�i ( �^ Y / ZZ ❑ t n for Denial Conditions Pf Approv isawjl F 0�1tZ SYSTEM O / / f 1. Septic tank, effluent filter and y\ P:�rµ {,�� � Y��_ 5 imely I dispersal cell must a n/ir�d J }(n ` �` � _ by errs. plum t plumber: � as per management plan provided 2. All setback requirements must be maintained as per applicable codelo0inances. Abatis to tawptab = fir dw system and aubadt to the Cwaty Only an paver no Was lane 1 to a 11 laebas In sin SBD-6398 (li. 03t2l) a Kevin Grabau Subject: 642260-- Pei ke--Jeffers Location: Town of Troy --"RED" Start: Mon 8/22/2022 2:00 PM End: Mon 8/22/2022 3:00 PM Recurrence: (none) Organizer: Kevin Grabau Categories: POWTS f 344 Lindsay Rd 040-1258-20-000 24.28.20.1374 Scheduled on phone with Jackie 8-17-22—"RED" Rescheduled to Friday at 2 pm on 8-18-22—RED Rescheduled to Monday at 2 pm on 8-18-22—"RED" SLorr •-e/ccres- 3Yy llisoY gyp- Lo r //Y, i Aor U/c. 3"' A.D. N[✓, s E, , d8/1/, oTo tJ r or rA.0 Sr, Z C,3, ' 6, n , 1/o O ,to' YO /0 ALdf Lnf All. 5 PS 38343 szradc,rf /rEr 1 I c,Juf 1 rya/s[0 , �IEcc ® t J L/�DSDY QD. N 0 rrcur tJF. t 46/J!a) LIDS (7) ,� >/J"/w• scl. yo II tl II tt f r Lico.ff- SE[r[w Coo Jl,"t Usf /�FicrcA ray pr.ruc /% LHR�/!a5 C/i x jf V6,.? d.2 Yll L/iAI[QfaJ �ra rlt� / Ego LA/s 5Y x 3°3 FrZ= 883.E > /rZL/TarAc /`l// /tEo• Gdp= ,7- 83-1Fr1 /y�X• /� f rAtL. ,OE/T/�- r: 9 r ,6ELOrJ G�AAF r /'N✓. / 1 s rfu OE/rN %a .7 t.d. = 'Y aF[o✓ I�AD£ ,Bv,(rfD /JT/cr riC3 f _ - � - g•'y • %/.cS r./ R/JJ Of %�Ne✓f JfJ. Wr.. Ec.I UMr r 90 f 3 Er l "/rc Scp. !'o a, 5.-4LID. ///EJC.2) y UENr ,o/PCJ ��� // ,i°3f GIAN UlEw ("b J[yfC� END LA/S Page I of 7 Private Onsite Wastewater Treatment System Index and Title Page Project Name: SGorr J6fffL3- 'Y-!fA144A*U.+o11un/ Aaurs Owner's Name: Owner's Address: /1/7661.E36'l'/ iJ,gJ'Esric hl/ "vrs %tgn ,sc�SsEx� L.lr S3o89 3/; C,J,?- 7/73 Legal Description: NlJ S E�� o� 8 �►', .?o �J _ Municipality: Town, Vi ne, Eityof %adY County: .S r Lao.x Lot Number: //`/ Block Number: CSM Number: Subdivision Name: Y lilt 3 6-' AaA - 31111 Z .05AY Qy _ Parcel I.D. Number. O y0-/,?S8-170 -oea Page I Index and Title Page Page 2 Plot Plan with Cross -Section & Plan View Page 3 Septic Tank / Pump Chamber Cross -Section & Specifications Page 4 Pump Performance Curve Page 5 POWTS Owner's Manual & Management Plan Page 6 POWTS Owner's Manual & Management Plan Page 7 Name of Designer: Signature: Filter Information "In -ground Soil Attachment: Soil Evaluation Report License #: IV- o? 3 / 3 y' Date: /,7-,?9-,702! Component Manual" Version 2.0 A. ,7 ,, 7 SLorr TEf<Fis - ivy Zor //y iA.OY ult. Ny, S E, a v,, wid, e70 w j. eF rte yl Sr. LAegr Le. Ao' ye AQ/rS/ �o A44C LaT I A[c SPs 383.y3 SLrr6Acrcs ,rir jI I 1 1 wu•I I Ppeles[o lit a/etcO ' ® /i-/fe. /RISE. l✓/CJEA /1So/7S0 /L - �1 GO MRe rAJC 1 y"/oc Scx.YO �"/uc Scd• Yo r Ie/esfe f,Rct /ye+w�Sol G o 9uucuer / � a r - L•8 � r �d sty. Ef 1/pp.e i 3 _ PL 0:/IJ 6uArlo /lilt, rrta r,r/Rrc r.l ,ty��Ec.r rArf 11,o NtNr dF.,r CMa(7) i IiC Y 11 U 11 I� I r 4i.8 LAeff- SCLrmw (Ale J[RL/) uSf /✓ficrcArec 4p&,4x // INA,v/tAS y fclA LAAS ^ > Bpi 2 fr t(iarAc� /1AX. /AJsrAtt, r06/r4- (9rrdELeN LAAA! ,/t/ne/ fae..7 L.L. = �Y JEcoa LA/•F r 90 I 3 uENr /Ma��) AhN VIEW (Ab SLA/C) �E.V/L//s (V) Page 3 Di 7 COMNAaTION SF_PTiC/DQ,§E TANK CROSS4ECTION twtivu T fo�A FINAL GRADE MANHOLE RISER S: COVER W" ground surface amey from l (Per SPS device. & v(r) i (9). approved �'�n9 devke, a label: E=derW alan1r01a(s) for proper drama drainage) vas ne nlanllale dear a necessary.) 4' MkL Scd. 40 PVC TV* Va„ I 4' Ww. Set 40 Pve Tank vent ELECTRICAL located or 24, � BUILDING SEINER bc*ed,2'above grade or24' JUNCTION SO. above R�� {par SPS 9e2.30(1 t)} about Regional Frooll 21evaUarl (comply Eh SPS 319 t anNEC N300) / ' 1 FORCE / -- MAIN "Z OPTIONS � Ise' cover � $ ! . .. Mill 11 � I rtwn aOrMM OF tMt.-a'f (mvrt wa:Nap Foal Tree— ! AIM I I I /l tam .0 AUel Few a•Dear We a=Mvad 0kard Fees ,p an now ON ab9" sL FNwida Sea Pawed onOt" ON ram ...................................... ...................•.-.-..•. • MINIMUM OF Y OF SUITABLE BEDDING- BENEATH TANK S MAXIMUM BURY DEPTH OF W Anchoring of lank may be required per SPS 3a3.43(agg) Tank Manufacturer Gi/6SE2 COn1GRET6 Septic/Pump Size: /.7So /7SO cations Alai, Manufacturer. ST. e /w,0ffQas Model Number. r4.ix Azirer I Switch Type A/4-t,✓A✓/C/L Effluent Pump Manufacturer Z6EUE,E Model slumber. /$I Minimum Discharge Rate: c10 GPM Verdcat lift (pump off to lateral invert)............ 9 S ft System head (distal pressure ;c 1.3 ft): — ft SO ,t Forte main x /. o /100 friction factor . S ft terfdctionE�i�loss..................................... — ft Daily t=llastewater Flow (DUVF): 4106 GPD Number of daily doses: .5•l i /R / 20 Force main volume- SO i x , /43 gel{( = 8•,� gal Actual dose volume: /,7?. S gat - A 2 gal = /L 3 gal (total dose volume - volume of force main) DOSE ± A N 9 i:� FAQIi;FS: Reserve above alarm 34.'/ in = 0 0 gal (D) Alarm float above on float g_ in = 32.2 gal (C) On/Off float measurement 7./ in = /aa S gal (g) Of above tank bottom o— in = /a 9 gal (A) DOSE TANK DIMENSIONS: Length /5S. In Total Dynamic Head (TDH): /40.3 ft Outlet height _-Y8 in Width 86 In Galions/lnch 4C. /,a w PUMP PERFORMANCE CURVE MODEL 1511152/153 56 14 46 153 -.. ti 4D - p 35 S 1e_ 112- - 30 " 25 4 , 15- 10 :{ 54t _ -� o-I- O-L 04ugEs 304o Io m ro rA w uv UrFA5- —4Tm6 :6 m-bo io 2W MO Ss FLOW PS VRAM 014 CONSUL? FACTORY VOR SPECIAL APPLICATIONS. • Timed dosing panels available. • Electrical alternators, for duplex systems, are available and supplied with an alarm. • Variable level control switches are available for controlling single phase systems. • Double piggyback variable level float switches are available for variable level long and short cycle controls. • Sealed Owik-Box available for outdoor installations. See FM1420. • Over 130OF (540C) special quotation required. 151115N153 MODELS control SdK§M Modell Vobs•Ph Mode Aops N151 115 1 Non 9.0 ..Sk11pN31;._bupkx 7 2 or 7 BN151 - 115 i Milo to k¢4d6d 2or3 E151 230 1 Non _ 3.2 _ -1 1 2or3 BE151 230 1 _ Auki - 3.2 - Wood 2 or 3 NW 115 1 - Non 85 1 2or3 BN152 115 1 Aub -- 115 kckdN '- 2or3 E152 230 1-- -- Non 43 1 _ _2v3 _ 6E 152 230 1 Aub 4.3 k U bled 2or 3 N153�7 - --. _ 115 1 --Mon- -- 10.5 1 2or3 BN153 � ' 115 1 - - - Au1p -�- 10.5 - k1G1dltl -'- - 2or3 E153 236 1- Non 5.3 t 2ar3 _ SE 153 230 1 Auld 5.3 kKkrded 2or3 1. Single piggyback variable level float switch or double piggyback variable level float switch. Refer to FM0477. 2 See FMC712 for correct model of Eiectri-A Allemaky E-Pak 3. Variable level control switch 10-0743 used as a control activator, specify duplex (3) or (4) float system. A CAUTION TOTAL DYNAMIC HEAD/FLOW PER MINUTE EFFLUENT AND DEWATERING MODEL F4er klows _ 5 1_5 1 3.0 (1-0 4.6 151 Gr lion 50 1e9_ 4 170 �- 38 144 152 G"I. lb 69 261 -61- -251 53 201 -- 153 Cw _ 77 tin 291 70 - 61 265 231 20 6.1 29 16 110 61 44 w 52 197 25 i 7.5 34 23 _ -�- 120 .. ET ... 42 .33 159 30 9 1 I - - - _ 125 42 >5 107 i -_ - 1 22 11 40 122 Snufon llea0. 30 R. t91m1 38k (116m) _ 449113.4m) Model 151 e rsx / 3re I 37.8 �jylA I t �: .a•I '1 tE I 51IN41 0145M Models 1521153 67.ii Sim 0 � S/M 1 r�, Ina "Zw - 1 4'� `tit �M? s34 F 1 �Cl,aa- JL 1 5K300• - 'Easy assembly" tyro a thdlerpe Poe nor ilcklded.I \ Reduces potential dogging by debris. Replaces rocks or bricks under the pump. Made of durable, noncorrosive ABS. Raises pump 2" off bottom of basin. Provides the ability to raise intake by adding sections of 1 V or 2' PVC piping. Attaches securely to pump. Accommodates sump, dewatering and effluent applications. NOTE: Make sure float is free from obstruction. For unusual conditions a reserve safety factor Is engineered into the design of every Zoeller pump. 0 Copyright 2008 Zoeller Co All rights reserved POWTS OWNER'S MANUAL AND MANAGEMENT PLAN FILE INFORMATION Owner .SGorr Tf ffoe5 i Permit # nveini r n. n A aate, ,..,,. Number of Commercial Units Estimated flow (average) Yd0 l Design flow (DWF), estimated x 1.5 Goo Soil Application Rate niluent/Et}luent Quality (❑ NA) Monthly Average Fats. OR & Grease (FOG) 5 30 mg/L Biochemical Oxygen Demand (BODs) Total Suspended Solids (TSS) 5 220 mg/L _S I50 m¢/L Pretreated Effluent Quality (® NA) Monthly Avenge Biochemical Oxygen Demand (BODs) 5 30 mg/L Total Suspended Solids (TSS) Fecal Coliform (geometric mean) 5 ^30 mg/L iiai SYSTEM SPRINVIrsTrnt tc Septic Tank Capacity .0 al ❑ NA Septic Tank Manufacturer lJ/Es Ce,acs.Q NA Effluent Filter Manufacturer f9 f7 ❑ NA Effluent Filter Model F- G ❑ NA Pump Tank Capacity O Rall 0 NA Pump Tank Manufacturer A-' fsa.t. Co,ua. ❑ NA Pump Manufacturer Zofuet ❑ NA Pump Model 3/ ❑ NA Pretreatment Unit TO NA) ❑ Sand/Gravel Filter ❑ Peat Filter ❑ Mechanical Aeration ❑ Wetland ❑ Disinfection ❑ Other. Manufacturer: Model: Soil Absorption Component (❑ NA) ® In -ground (gravity) ❑ In -ground (pressurized) ❑ At -grade ❑ Mound Drip -line 171 Other: ® Dispersal Units ---- Manufacturer _ /.ffii rww r�. ❑ Aggregate Cell(s) Model u cx Soil Dispersal End Cap (Dispersal Unit E1SA) or QW ARWkA921L= = Area Required - EISA T (Trench Width) _ # Units or Total Length ofT(c) 7 = 8S8 - jqJ• 3) _ 070. 0 fr a = _ S"� fi✓,yrtus C89.i Fr') IESIGN CRITERIA /3 2 sr ❑ "Design of Pressure Distribution Networks for Septic Tank -Soil Absorption Systems" Publication 9.6 (SSWMP Manual) ❑ "ICC Flowtech Mound Component Manual" Version 1.2 ❑ "EzFlow Mound Component Manual" Version 12/15/2017 ❑ SBD - 10854-P (R.1/12) "At -Grade Component Manual Using Pressure Distribution" Vcrsion 2.0 ® SBD - 10705-P (N.01/01) "In Ground Soil Absorption Component Manual" Version 2.0 ❑ SBD - 10691-P (N.01/01) "Mound Component Manual" Version 2.0 ❑ SBD - 10657-P (R.6/99) "Drip -line Effluent Disposal Component Manual" ❑ SBD - 10706-P (N.01/01) "Pressure Distribution Component Manual" Version 2.0 ' r, — START UP AND OPERATION: 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. The property owner is responsible for the operation and maintenance of the POWTS and submission of required reports. The quantity and quality of the wastewater stream will affect the performance and longevity of your POWTS. The installation of water -saving appliances and fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine or waste from water softeners, iron removal units, other clear water treatment devices and foundation drains should be discharged to the ground surface whenever possible. Note: this does not include laundry waste, showers, dishwater, etc. This system is designed to handle domestic strength wastewater, however the disposal of food based greases and oils, vegetable/fruit peels and seeds, bones, and food solids such as those produced by a garbage disposal should be minimized. Toilet tissue is the only paper that should be discharged into the system. Other non -biodegradable items such as baby wipes, tampons, sanitary napkins condoms, cigarette butts, dental floss, and cotton swabs should not enter the system. Chemicals such as petroleum products, paint, Page —Iof L disinfectants, pesticides, antibiotics, solvents, etc., should not be flushed into the system as they can seriously damage your POWTS and contaminate your drinking water supply. Maintain a regular steady flow by spreading laundry washing throughout the week. Avoid vehicle traffic over all system components. Compaction of snow over the dispersal unit may cause it to freeze up. INSPECTIONS & MAINTENANCE: Inspection shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Maintainer or Septage Servicing Operator (per the attached Maintenance Schedule). Tank inspections must include a visual inspection of the tank to identify any missing or broken hardware, identify any cracks or leaks, treasure the volume of combined sludge and scum and check for any backup or ponding of effluent to the ground surface and test all electrical equipment such as pumps and alarms. Any defects shall be promptly corrected. Exposed openings greater than 8 inches in diameter shall be secured with effective locking devices to prevent accidental or unauthorized entry the tanks. When the combination of sludge and scum in any tank exceeds one-third (1,13) 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 NR113, Wisconsin Administrative Code. The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to manufacturer's specifications. Solids washed from the filter shall be retained in the tank. Filter cleaning may be necessary at more frequent intervals than stated in the maintenance schedule to keep the system operating. Alarms should be tested on a regular basis by the home owner. If an alarm sounds, contact an individual licensed to service POWTS, There is normally a 1 day reserve under regular operating conditions, however water should be conserved until any problems wi th the system are corrected to prevent back-up of sewage into the dwelling or surfacing. ABANDONMENT: When the POWTS fails and/or is permanently taken out of service the fallowing steps shall be taken to ensure that the system is properly and safely abandoned in compliance with Ch. SPS 383.33, Wisconsin Administrative Code. - All piping to tanks and pits shall be disconnected and the abandoned pipe openings scaled. - The contents of all tanks and pits shall be removed and properly disposed of by a Septagc 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 other 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: 10 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 render it unusable. Replacement systems must comply with the rules in effect at the time of replacement. ❑ 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 CONTIAN 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 TopN 097EtEE r/P->3/3yG Name EtKE turd/dt Phone 7/5' 472-S74[ rPhorc _ T/S 47,9-6-.741 SEPTAGE SERVICING OPERATOR (Pumper) LOCAL REGULATORY AUTHORITY Name Agency $T. ldfi4owPr Phone Phone 7/s dIl- f esd 1 Page 4 of 7 e Installation Instructions for the GF10 Filter Maintenance of the GF10 Filter a Shp 1: Locate and remove the septic tank cover, on the outlet side of lank. n4;0'AVr rt�A Step 4: Glue the filter case onto the outlet pipe. Insert the filter CarWdge Into the rase. (Make sure the filter Is completely Inserted Into the case.) F-�w BEST Step 2: Before Installation, Place the filter case on to the outlet pipe. Make sure the case Is positioned so the filter can be removed from the tank for mainte- nance and service I � Step3: For Installations [hat require or desire additional support (If additional support Is not needed, ga to Step 4) Glue a section of 1' Sch.40 pope to the two huts located on the bottom of the case and the hub located on the side of the case. i Stap 5: For Installations where it will be difficult to reach the handle, place l *Schedule 40 pipe Into the tee on the handle and extend It to height that will make It easy to remove the filter. I...r r.r ,:. ,..: re c, ; rr: r-r s✓s M, r,r rw vo «Er nor rrti {•J{ `I hl i,E Installation of an rI Same as a new system only the Sepik tank y Y existing system. must bepueepedprior toInstallation. A time frame In which septictanks areserviced is so by state and local codes. Although they may be different, most regulatory agencies suggest two to fiat years We recommend the GF 10 Neer he cleansed when the septic tank Is normally cleaned and psanped, or as needed. WARNING: If the liquid level in the tank is above the top of the filter, pump the tank prior to removing the filter cartridge. 0 CAUTION: USE RUBBER GLOVES WHEN HANDLING FILTERS! Step 1: Remove the septic tank cover and pump the tank R necessary to Prevent any solids from escaping to the held when the filter Is removed. L l•l ll Step 2: Pull the filter handle and "the filter out of the case. L31 Step 3; While holding the fiber cartridge over the access opening of the tank, rinse thecartridge off with fresh water. Take care to make sure all solid material falls backlnto the tank �'ec�o�ocr 3 FakBeld Blvd, Wallingford. Cr 09492 1-1177-N9.99ati Fax: M-284-0514 Stop 4: Insert the cartridge back Into the case n%"gi sure that it Is properly aligned and completely Inserted Into the case, Iwconsin Department of Safety and Professional Services aye lot j r64on of Industry Services OIL EVALUATION REPORT �ro,aancewimSPS385.Ws Adm Code I L,ounty _-n comorete site oan on paper not Tess man o I e x i I Incnes In sae vien mug Intauoe. - ^ea to vemcal Ono nonzontai remianix pww rorvit, atauron ana percem mope. zmranisions. noun arrow, ana location anro orstance to nearest roao I 'iaase prim all rmORylation. ..evieweo oy I ate "_:;,cnat information you provide may be used for sacomary purposes tPnvaty Law, s 15 04(1)(m)), I I __ 1 'iooerty Owner Property Location. I 3cnr, Jeffers iBuveri i (iovt Lot KW . SE i. S 24 T 28 N M 20 W Property Address Lot 0 Block P Subo Name or CSMIt -dd I ny,env Rf1 1114 j Troy Village Thiro Addition -rty owte Zip ewe Pivne Number 1 ❑ City ❑ Village Q Town Nearest Road I W16 i j Troy Lindsay RD N'".Construction Use © Residential/Number of bedrooms 4 Code denveaaes,gnflow rate e00 GPD Replacement ❑ Public or commercial - Describe I parent material Loess over sandy and gravelly outwash tPillot sill Fippdplain elevation if applicable NA R .3eneral comments and recommendations Pa nNilnd In•i rWnd -r:onytrn0otlaf neridies M 44- mnmjm .1@rxfl wen wen 0 7aQ0dM2 1096r10 rap - ris* oeeenra �ttelxr I I I r-t i"1 ?^nng 1 { 1 I Boring a Q Pit Ground surface elev 101 00 ft Depth to linking factor >to5 In I Soil Application Rate worizon I Depth j In Dominant Color Redox Description Texture Munsell Qu Az Cont Color Structure Gr Sz, Sh Consistence Boundary Roots GPD1Ft' ERr1 EfM2 I 0-11 I 7.5YR 2.5i2 j sll 2mgr ds gs 2f-vl 0.6 0.8 2 11-19 7.5YR3/2 se 1mpl ds cS 1f-vf 0.4c 0.6 ' 19-40 7.5YR414 sd 2mabk mfr Cw 1vf 0.6 0.8 j 4 40-56 7.5YR 416 cos Osg ml cw 0.7a 1.6 5 56-93 7.5YR 5/4 s Osg ml gw - 0.7a 1.6a 6 93-105 7.5YR 6/4 s Dsg ml 0.7a 1.6a -MoAZon3ahohad10YRV29illcDats nBoning N ❑ Bonng Q Pit Ground surface elev 99 75 ft Depth',o limiting factor 'i09 in -arson I Depth I Dominant Color 'n I Munseu I Redox Description I Texture Qu Az Cont Color I j Structure I Gr Sz Sh Consistence Boundary Roots �a ADoucation Male GPD/Ft' 'E1M1 'ErtN2 r 0-9 1 10YR 212 sd 3mor ds cs 2c-vf 0.6 0.8 2 j 9.21 1 10YR 212 sil zfat* j ash C5 1C-Vf 0.6 0.8 ?'-34 1 7.5YR3/3 I 2mabk ash aw 1c-vf 0.6 0.8 v-•w 7.5YR 414 sl 1 msbk ash Cw 11-vf 0.4 0.7 5 44-51 7.5YR 416 s-cos Ong di cw if-vf 0.7a 1.6a 6 51-76 7.5YR 5/4 s Osg dl gw 0.7a 1.6a 7 (5Wo rock) 76-109 7.5YR 614 s Osg ml 0.7a 1.6a ' Effluent Mt - BOD. > 30 s 220 m L and TSS > 3o s 150 mail - Effluent M2 = BOD. > 30 s 220 L and TSS > 30 s 150 m 1 CST Name (Please Print) "van Bechal Signature CST Number SP-111500001 '•doress Date Evaluation Conducted -�- Scring Creek RD S. Red Wed, MN 55W 08/23121 I Telephone Number 118511 327-W74 r:u 83301 /1 Si I I 3 Boring 0 ❑ Boring ® Pit Ground surface e)ev 100 00 R Depth to IaMwrg factor 't05 in Soil Application Rate =onzon I Depth ! Dominant Color I Radox Description I `-'unsell I Qu. Az. Cont. Color I Texture I structure Gr. Sa. Sh. I Conamience Boundary I Roots GPDfFt' 'c"I •EM2 '.SYR 2.512 I I sn I 3mgr 1 as I cs I 2c-vf 0.6 0.8 t-33 1 7.5YR 4/4 1 I sit I 2mebk deh I cs 2o-vf 0.6 0.8 33-46 1 7.5YR 416 - 3-CO3 1 Osg ml cw If-vf 0.7a 1.6a 4 46-79 7.5YR 614 - s Osg ml gw 0.7a 1.6a 15% rock) I 79-105 7.SYR 6/4 - s Osg ml 0.7a 1.6a Boring Boring e ❑ �_ ❑Pit Ground surface ekv ft Depth to lunfirrg factor _ in Sod AVOication Rate N^.nzon i Depth ! Dominant Color Radox Description . Texture Structure I Consistence ! Boundary I Roots GPD/FI' n Munsell Go. Az. Cont. Color I I Gr. Sz. Sh I •Eltet I •ERa2 J Boring ❑ Pit Ground surface ekv fl Depth to imding factor _ in. Sod Application Rate Horizon Depth In. Dominant Color Muntaell Radox Description Qu. Az. Cant Color Texture Structure Gr. Sz Sh ConsaYence Boundary Roots GPD1Ft= ERNt EtiN2 i I i i - Effluent 91 = BOD > 30 s 220 mq,L and TSS > 3C s 150 mgyL • Effluent M2 = BOD > 30 s 220 MWL and TSS > 30 s I50 m9 L Designer. Rym fBoj,4 Certiled*fr Sol groweMw. Sp - 11trrnr D ADVANCED •a' r: l'etir Ine> not �� 13entfin>ar4 Oesigler of Engineering Systems D 2263-7 jp SCA Burly SI'A1.F 20, LOT 105 0' 40' "Well to be located >50ft LOT 27 from system components** ELEVATIONS: �a BM1 = 100.00 Top nail in 24" Elm LOT 106 LOT 114 tree V above grade / Top of phone L pedestal 4a s �• / q O SKI 301 Z \ C LOT 113 I area `•`\ ��� m Sl SIF]4MIIF\ l'.Peic "I •ek Pmn P T,.k %[ A: Pm,ww urd n yrun4'rmrer•.d W cl.e a 4C +.Reai fires.e 101110 1 grraf IM"I•k �InblBiMcan `iP_•IMsn.anGle Crtm a Ion a �rq. A M%Irlbulkm- Ooelrt enlar.I;,,nar E. tounoN KV (rrl to soon) PNFruttn FM ` s ` ° f, Scott )filer: \� `. \ �r Site Adarese: vw una4ay RD Hudson, 1M sale PIID:D: 0904Pi25e•20-000 1.0 Acre Legal: Lot 114 Troy Vllege 3RD / Addition NW 1 /4 SE 1 /4 OwMd s.e.,..c llru y.eur, ry e..o a.. q mra w o..e In ice d. ,..ro, M.L. 014 In••1 mdm le• .or s.ov . a m neel .ar per a.• eem areaw S24 T28N R20W w 00*11tr a wa mar n°s 9MM wu murw.c m rL CnM 04DUw ¢r sy.t.. u.wt w mV. m.�r., bwwe Mw rr Town of Troy Prrp•rb rrde•YI•LL IYdw 1•r pwwr/• arwlwrre Mm ror ewrrrew m prow owe mW Sc ale: I' = 40 OAS: 9R3/I1 - a �. aawr s•. "711Le5e"'y�.. w r�.�c.Ria�va°xo ate' wu s's}aaw o.�w n 4w.we.aae. OO awmaw 0 ELEVPATION ate. FRONT ELEVATION REAR ELEVATION � W. ra 1« _ !-r °m _ } � i Q�Q B n 8lll y it NEW RESIDENCE FOR SCOTr AND BRENDA JEFFERS rMIJEJ HUDS O MN $ ! 1 WUwtoLivanb m� IJ S'.l13S a ic NEW RESIDENCE FOR SCOiT AND BRENDA JEFFERS la a Al -> r i 1 o� �B ------------ ---------------- I El F , E e NEW RESIDENCE FOR SCOTf AND BRENDA JEFFERS � § xxxxxzx>Ucxzx j g0 LW 14 HUDSON, MN ST. CR NTY SANITARY SYSTEM File#' � oylce use o�ry �� OWNERSHIP/ADDRESS FORM c z/zoar 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. OWNER/BUYER INFORMATION Owner/Buyer `J �10 f F dr d re ,-dam fc CiCe Mailing Address h` L W a 31044 (� I eSfic— �-i-e_t City/State/Zip _� k �j L 5 3Q 2e G Phone Number (required) 31 Email Address (required) SeO+f Crnai j . [orvrn Parcel Identification Number _ n y 1315 ;found on the property tax bill) NEW SYSTEM: LEGAL DESCRIPTION Property Location I'L A , � •. Sec. oZ T � R j;Lw.Townof -Fr-c — T Si L(�n4%:{�1 Subdivision Plat: ' ll ri Tik,/ , , d,6Lot # �i� t ift/) 1 i� n� Certified Survey Map # — Volume Page # Warranty Deed 0 W 1 g Z- (before 2006)Voiume . Page 4 Number of bedrooms Spec house O yes gLno Lot lines identifiable 0 yes O no New Property Address k.lfr— (St Ini als) OFFICE USE ONLY �{ !,i/V OSAV Ro . o2new ess reQu,'eC trcm Community Develupmen Depart ent for new construction ) 20 ZZ— This form must be submitted with all Private Onsite Water Treatment System (POWTS) applications. New system: include with this form o recorded wormnty deed from the Register of Deeds Office and a copy of the certified survey mop if reference is mode to the warranty deed. Community Development Department - I and I )an Divis;on 715-386-4680 St. Croix County Government Center 715-245.4250 Fax cddosccwi.aov 1101 Carmichael Road, Hudson, WI 54016 wwwscoai.00v State Bar of Wisconsin Form 7-2003 TRUSTEE'S DEED Document Number I Document Name THIS DEED, made between David A. Holt, as Trustee of the David A. and Barbara A. Holt Joint Revocable Trust Agreement dated November 7, 2012 ("Grantor," whether one or more), and Scott Jeffs ("Grantee," whether one or more). Grantor conveys to ran ee, wilhoul warranty, the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in Saint Croix County, State of Wisconsin ("Property") (if more space is needed, please attach addendum) See Exhibit A Dateedd� Auoust 30, 2021 SEAL) David A. Holt, Trustee THIS INSTRUMENT DRAFTED BY: Attorney Ams Sketrud P.O. Box 361 New Richmond, WI 54017 1138182 BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 09 / 01 / 2021 10:06 AM EXEMPT*: REC FEE 30.00 TRANS FEE 510.00 PAGES: 2 "The above recording information verifies that this document has been electronically recorded & returned to the submitter Recording Area Name and Return A(Xres PartnersTille 401 2nd Street, Suite 100 Hudson, WI 54016 04D-1 z5a-20-000 Parcel Identification Number(PIN) This is not homestead property SEAL) ACKNOWLEDGEMENT State of Wisconsin SS. County of s Personally came before me on .?D% the above nam avl , as Trustee of the David A. and Barba A. Holt Joint R ocable Trust Agreement dated Nov 012 to a known to be the person who ocu th oregoing and acknow ad the dam Notary Publig(5tate of ,5x P. i (Signatures may be authenticated or acknowledged. Both NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM TRUSTEE'S DEED 2003 STATE BAR OF WISCONSIN Type nerve below slgnstures Foe No.%M647s4 BE 2,1 3 Y I NTIFIED. FORM NO 7.2000 Page 1 of 1 St. Croix County 1138182 Page 1 of 2 EXHIBITA W 164794 Lot 114 f the Plat of Troy Village Third Addition In the Town of Troy, St. Croix County, Wisconsin. St. Croix County 1138182 Page 2 of 2 G Sr, Za1- 332 HE � v �D � Page lo(2 Wisconsin Dep rtment of Safety and Professional ry ces Division of Indu try ServiA G 3 0 2021 SOIL EVALUATION REPORT St. Croix County In a rdance with SPS 385, Ws. Adm. Code County ST Croix Attach complete sit 11 inches in size. Plan must include. Parcel I.D. but not limited to: vertical and horizontal reference point (BM). direction and percent slope. 040-1258-20.000 scale or dimensions, north arrow, and location and distance to nearest road. Please print all Information. Re wed by n Property Owner Property Location: Scott Jeffers (Buyer) Govt- Lot: NW ''A SE % S 24 T 28 N R 20 W Property Address Lot # Block # Subd. Name or CSM# 344 Lindsay RD 114 Troy Village Third Addition State Zip Code Ph -::one Number ❑ City ❑Village M Town Nearest Road :�::: City Troy Lindsay RD Hudson IWI 154016 0 New Construction Use: [@ Residential/Number of bedrooms 4 Code derived design flow rate 600 GPD ❑ Replacement ❑ Public or Commercial — Describe: Parent material Loess over sandy and gravelly outwash (Pillot sil) V Floodplain elevation if applicable NA tt. General comments and recommendations: RmwO inyrourdco -wWonN' w at 44' minimum depth with wile +0 7ap Iwdinp e rate. LF - los- lob"mmwn extent) P� 1❑ oring Boring # Pit Ground surface elev. tt Depth to limiting factor >105 in. r— Horizon Depth Dominant Color Redox Description In. Munsell Qu. Az. Cont. Color 1 0-11 7.5YR 2.5/2 2 11-19 7.5YR 3/2 3 1941 7.5YR 4/4 4 40.9 7.SYR 4/6 5 56-93 7.5YR 5/4 6 93_105 7.5YR 6!4 •Horizon 3 e had IOYR 2 silt costs ❑ Boring Boring # Q Pit Horizon Depth In.unsell nant Color Redox Description Qu. Az. Cont. Color 1 0-9YR 212 L77 2 9-21YR 2/2 3 21-34YR 313 4 3444 7.5YR 4/4 5 44-51 7.5YR 416 6 51-76 7.5YR 514 7 (5% rock) 76-109 7.5YR 6/4 Effluent #1 = NOD, 30 5 220 n CST Name (Please Print) Ryan Bechel Address 779 Spring Creek RD S, Red Wing, MN 55066 Signature Texture Structure Gr. Sz. Sh. Consistence Boundary Roots L;rurrr Eff#1 'Eff*2 sit 2mgr cis gs 2f-vf 0.6 0.8 Sill 1m cis cs 1t-vf 0.4c 0.6 sil 2mabk mfr cw 1vf 0.6 0.8 cos Gsg mill cw 0.7a 1.6 s 0sg ml gw 0.7a 1.6a s Osg ml 0.7a 1.6a ►/4(�•7 '109 ourxt surface elev. 99.75 fl th to limiting factor _ in. Texture Structure Gr. Sz.Sh. ConsistetBoundaryRoots GPUIht- •Eff#1 'Elf#2 sil 3mgr ds2c-vf 0.6 0.8 sil 2fabk dsh1c-vf 0.6 0.8 2mabk ds1c-vf 0.6 0.8 sl 1msbk dsh if-vf 0.4 0.7 s-cos 0Sg dl cw if-vf 0.7a 1.6a s 05g dl gw 0.7a 1.6a s 0sg ml M 0.7a 1.6a Date Evaluation Conducted 08f2321 CST Number SP-111500001 Telephone Number (6511327-0074 ❑3 Boring # ❑ Boring 0 Pit Ground surface elev. 100.00 f, Depth to limiting factor >105 in. Horizon 1 2 Depth In. 0-11 11-33 Dominant Color Munsell 7.5YR 2.5/2 7.5YR 4/4 Redox Description Clu. Az. Cont. Color Texture sil sit Structure Gr. Sz. Sh. 3mgr 2mabk Consistence ds dsh Bourxlary cs cs Roots 2c-vf 2c-vf Soil lication Rate GPD/FIB 'EfF#1 0.6 0.6 'Eff#2 0.8 0.8 3 33-46 7.5YR 416 s-cos Osg ml cw 1/-vf 0.7a 1.6a 4 5 (5% rock) 46-79 79-105 7.5YR 5/4 7.5YR 6/4 s s Osg Osg ml ml gw 0.7a 0.7a 1.6a 1.6a J Boring # ❑ Boring ❑ Pit Ground surface elev Depth to limiting factor _ in Horizon Depth In. Dominant Color Munsell Redox Description Du. Az. Cont. Color Texture Structure Gr. Sz. Sh Consistence Boundary Roots Soil lication Rate GPD/Fl2 'Eff#1 'Eff#2 ❑5 Boring # ❑ Boring ❑ Pit Ground surface elev. Depth to limiting factor _ in. Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont Color Texture Structure Gr Sz. Sh. Consistence Boundary Roots Soil Application Rate GPD/Ft2 Eff#1 I 'Eff#2 Effluent #1 = BOD. > 30 5 220 mg/L and TSS > 30 5 150 mg/L ' Effluent #2 = BOD. > 30:5 220 mg/L and TSS > 30 5 150 mg/L ❑3 Boring # ❑ Boring 0 Pit Ground surface elev.100.00 ft. Depth to limiting factor >105 in. Horizon Depth In.u. edox Descriptlon Az Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots Soil APPIlcation Rate GPD/Ftt •Etf#1 •Eft#2 1 0-11 U7.5YR4/6 sit 3mgr ds cs 2c-vf 0.6 0.8 2 1133 sil 2mabk dsh cs 2c-vf 0.6 0.8 3 33-46 a -cos Osg ml rw 1f-vf 0.7a 1.6a 4 46-79 7.5YR 5/4 s Osg ml gw 0.7a 1.6a 5 (5% rock) 79-105 7.SYR 6/4 s Osg ml 0.7a 1.6a Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor _ in. Horizon Depth In. Dominant Color Munseil Redox Description Qu. Az. Cont Color.Sh. T�.G ure Consistence Boundary Roots Jolt Application Rate GPD/Ft' •Eff#1 •Efl#2 5] Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor _ in. Effluent 01 = BOD, > 30 5 220 mg/L and TSS > 30 5150 mg/L • Effluent #2 = BOD, > 30:5 220 rrg/L and TSS > 30 5 150 mg/L Designer: Ryon Bechd �AII progeny Enos not SYSTFAI NOTES Certified oil Tesler. sP-1„5p000, ADVANCED o BenohmarM Designer of Engineering Systems D 2263-7 system Seprla-T.nk: - system 1 Soil Boring I ,i SC'AI.F: \ a C 1 r LOT 105 L 01 2 40 e\ **Well to be located >5Oft LOT 27 Pump Tank: from system components** E VATIONS: B = 100.00 \ as Top nail in 24" Elm LOT 114 tree V above grade LOT 106 STA: BM2 = 101.65 A«d'"eW4n¢tuflill'94V Top of phone �d"YO wM 07p* totaling late 11" to Te9nd1011= 11W (oesawtW erial) `1 ) �Calat = 10100 �`+a pedestal^ts � � Slope 3% i I //\\ O \ 301 Q \ / 'IX / 1 \ Eeo, it LOT 113 ! ti s„r q ��� �. Well.i e °� �` '/ i0 r x I Cal I Certatmd SnuOmrrwrt: This gaNm had, Ern demlyrwa and aaMrotmd in dctadmdm with State and Ladd awdw. TM me treatment area at .mndn prdeced frcm AeWrOonn and/or oorr�1 11 EMam and ate, aawtrutydn. No wNetWN 6 MADE 11NT TINS SYSTEM WILL WmeaJE TO FUNCTION MCIMTELT. 9At" met r preprty nx***Nd testa YaV symem'm rmemdpmmnemt pNam b inlarmweon do MW dam and Mmkk nw. tNmtrlbu0dn: C4&* d1dri iem porsLk LOCATION MAP �y (rot to mode) PREPARED FOR: Scott Jeffers Ste Address: 344 Lindsay RD Hudson, WI SM16 PID: 040-12511-20-000 1.0 Acre Legal: Lot 114 Troy village 3RD Addition NW 1/4 SE 1/4 S24 T28N R20W Town of Troy Scale: 1' = 40' Date: 8123/21 CSI� 28 105 y 1.201 ACRES f , 52.328 SF. / oti � , /� e ems• � 2741 YQ . Q' 106 / 1,243 ACRES 54,128 S.F.114 9° 1.000 ACRES �. 4,., 2 ,y 43,562 SF./ 107 Ati0 ' 1.300 ACRES ,$ / qc' 56.649 S.F. ° �• J o° .od n A ' '0•�0 �„ 113 . -S� °psJ. w - n 1.02V CRES / q�, ` �� NE —SE 44.674 S.F / Jr. 108 ti 66. / % by / LEGI 1.385 ACRES ?Jg°p np„ •' / ' / 60,310 S.F.z?' 112 191 RES +m �o�, g 1.059 ACRES , 1 6 F. 2>,. �b•• w _42 6-12S.E_ -- - - -- - - \ I P � 9• N OHO J6B9 Og.. / ,9REs- 4 S.F. 1.009 ACRES /r Q 1 16 hm 43,946 S.F / / h^ O'T 1 184 ACRES . w 51,592 S.F. OU'LOT_ 9 "6Z. h / i TROY VILLAC 0~ 110 1.000 ACRES, ti 43 581 S F. TOP CE I" NON VNE — ELEVATION-88506 _ 2 ' Sao 1 17 - i COUNTY NOS, 642260 STA�E SANITARY PERMIT �394 uvasnY Re. OWNER pTT 'S PLUMB TOWN 1 AND/OR PERMIT EXPIRES PREVIOUS NO, kra CHAPTER 145.135 (2) SCONSIN STATUTES BLOCK 0 • SUBDIVISION OFFICER - (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 maybe renewed fora specified period. (d) Changed regulations will not impair the validity of ■ 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. 168; 1979 c. 34,221; 1981 c. 314 Note: If you wish to renew the permit, or transfer ownership of the pelt, please contact tte county authority. DATE Val MAU RENEWED BEFORE THAT DATE POST IN PLAIN VIEW VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION SBD-06499 (R11/20)