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020-1430-20-000
Wisconsin 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 [Privacy Law, s.15.04 (1)(m)J. 'ermit Holder's Name: City Village Township L� W1t1TAC_F_E Two aF "e.04 ST BM Elev: Insp. BM Elev: BM Description: -f-P -f 44FIDoan•M.en— ANtI INr'UKIVIA I IUN TYPE MANUFACTURER CAPACITY Septic Dosing Aer� Holding TANK SETBACK INFORMATION PUMP/SIPHON INFORMATION Ma ufacturer and GPM Model mber TDH Lift ction Loss System Head TDH F For am Length ta. Dist, to Well SOIL ABSORPTION SYSTEM tLtVA I IUN UA I A County: St. Croix Sanitary Per_mit�lo: 77 State Plan ID No: c�— Parcel Tax No: 020— I'{3t) —if) —600 Section/Town/Range/Map No: 20.29, 14.2&QI Ridg. Sewer E WMIM 114 r 2 MSA A I MO 'St/Ht Outlet ___AL __a& - _=_ 14 4WAJILENCH DIMENSIONS Width Length ! /O D No. Of Trenches 3\ PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth SETBACK INFORMATION SYSTEM TO P/L B✓LDG IWELL LAKE/STREAM LEACHING CHAMBER OR UNIT Manufacturer - ' Type Of System: i -'.35' —Z1f `911 Model Num er: FLDW U1.1- I KItIU I IUN 7bY51 tM I, ---% rL -) Header/Manifold t� Distribution Pipe x H�oleSlze x Hole Spacing Vent to Air Intake/ Lengtr' �� Dia Length Dia Spacing JUIL GUVtK x Pressure Svstems Only xx Mound Or At -Grade SVStem,, Oniv Depth Over 2fl �-t d ! Bed/Trench Center ti 7 Depth Over Bed/Trench xx Depth of xx Seeded/Sodded xx Mulched Edges Topsoil Yes ❑ No Yes � No r, ) s�sz- COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: (� 2DL3 �.� Inspection #2: `APzo2_3 r-Firn►4L. Location: 1595 32ND ST 1.) Alt BM Description 2.) Bldg sewer length = ��o. j�y�J�✓� amount of cover = i S ( 6, *Tr. = 110. 94.'iS 3} ., 35', _b/��3 Plan revision Required? 0 Yes �<No Use other side for additional information. Date Insepctor's Signature Cart. No. S/jB1D-6710 (R.3/97) q /� /1 1 n n !/ ° (J/ piers i✓v �� �r, aw.1I1PRQ¢f avbls(rS,c..� "z DL/y •I-re-1J1 . n XIARs 0-mW vwr .' 00PPe fE�) I E ri= n o n ra r� j,KI•,'; Department of Safety & Professional county ST CROIX sAAI-20.25-00( JUN 01 2023 Services, Industry Sanitary Permit Number to be filled in b Co. ( y ) Services Division Comm un it Application State Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit —� is required prior to obtaining 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(1)(m), Stats. Gt-4A,\-t-- 1. Application information - Please Print All information Property Owner's Name Parcel # LANCE AND CARRIE WHITACRE 020-1430-20-000 Property Owner's Mailing Address Property Location 431 WREN LANE Govt. Lot City, State Zip Code Phone Number HUDSON WI 54016 SE ,NW ��., Section 2 0 T 29 N R 19 E or WX iI. Type of Building (check all that apply) Lot # Subdivision Name ® 1 or 2 Family Dwelling -Number ofBedrooms 4 87 ❑ Public/Commercial -Describe Use THE GLEN Block # ❑ City of ❑ State Owned - Describe Use ❑ Village of CSM Number �- ®Town of HUDSON Ili. 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 ❑ Mound ❑ Individual Site Design ❑ Other Type (explain) c nv C. ❑ Renewal Before Expiration ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date Issued I 3 D Z ! 2I zoo 3 IV. Uispersal/rreatment Area and 'Tank Information: 3 `X(a0 -AP tZ Flow Design Flow (gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation 600 .7 857 900 94:4S Capacity in Total # of Manufacturer , Tank Information Gallons Gallons Units r �2.6 r+l, f P6° �tCr�nf�1O :? U o o " U y r New Tanks Existing Tanks EL A /o0 1 / fi U on Septic or Holding Tank X 1250 1 WI ESER X Dosing Chamber N/A r--- I V. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number PAUL R KOEHLER ��� 225410 715 246 2660 Plumber's Address (Street, City, State, Zip Code) 321 WISCONSIN DR NEW RICHMOND 54017 V 1. Coun"-/Department Use Only Approved ❑ Dis Given R �forDe Permit Fee Date Issued Issuing Agent Signature er I Conditions A prova M OWNER: DvLS t C wl P;QLAIA..IaJ2-r/CS i 1. Septic tank, effluent filter and dispersal cell �4elaex- Sts < must be serviced ! maintained as per e�Q- L.r r p-�d-+etn management plan provided by plumber. ���" " `� "' q.e-D r S �,'Q�, 2. All setback requirements must be maintained . : �v-L4AJ--¢e w�� Y4. � S ��-�-(,i S�� aLkQ- el as per applicable code / ordinances. E 1 e-as w, u 6,z- w;. Gg , YLe- QaLa Z s" q.o'+ Attach to co plete plans fo the system a`fid s b it to the County pnly on pipernoi less than 8 1/2 x 11 inches in size Qrt SDK tut( oZ u.'�E+/�(t �� t /e�p .� �iY , ,__ ^ y ` o_ W/ik 62 yL 6, - 7 tA, 'Sei�CatjEr�� `�SBD-6398 ((R.�03/2� �u -- S>'� Der ra,r� S Ce w�-� %AS �ra�a,�e:G �,, ems, n sseedd�ll " w� w. w � t� �esay is ' l �-VW�� te�¢^^s4i -, Q CLAt cl�wa ' s - t ,,,� or�a,+�Q -�n ova �� t- y� t ro �. COPY 'V ),ftj 0.gt L� -(pr 10to COPY CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Lance and Carrie Whitacre Owner's Name: Owner's Address: 431 Wren lane Hudson wi 54016 Legal Description: Se 1 /4 nw 1 /4 sec 20 t 29 r 19 w Township: Hudson County: St Croix Subdivision Name: The Glen Lot Number 87 Parcel ID Number: 020-1430-30-000 Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross -Section Page 4 Filter 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 Designer/Plumber /!Z411 License Number: e7 Z Date: 0*�,4. % 202Q Phone Number Signature 000 � Designed pursuant to the In -Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 2 a,2,J SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT Page of r Project Name: �q h e- iC. ����o "� w G /lot, No. of Celts Per Cell ft Cell Width /04;r Total No of Arz-odv 19 ft Cell Length D sq ft EISA Per Cell ft Cell Spacing sq ft Total EISA Mani farfilrar unrinl 1 -1-- 1 s....46% G10A Infiltrator EZ1203H-5ft 5.0' 25.0 EZ1203HADIt 10.0' 50.0 Graveliess Leaching Unit Manufacturer: Gravelless Leaching Unit Model: Typical Cross Section Finished Grade ft rlbservation Pipe with pproved cap or vent l ■ :;...... :;;:•:::.::::;:•::: Soil Backfitl ::::''`:: in Geotextile Fabric R: �tt Infiltrative Surface 12 in 0 _ft Limiting Factor 3 C� In Slotted and Anchored Vent/ ------------ Observation Pipe with Cap ■a•■...saRR■■■r■..■■■ea■■ra■a■■■r■a..a.r■■a.■.a..■...a..■...ar...araa.■.a Plumber/Designer Signature: License #: .2 Z 0'r Date: ofto.' �3 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Lance and Carrie Whitacre Permit # DESIGN PARAMETERS Number of Bedrooms 4 ❑ 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 .7 al/da /ft2 Standard Influent/Effluent Quality Monthly average's Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BOD6) 5220 mg/L ❑ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODS) 530 mg/L Total Suspended Solids (TSS) 530 mg/L ❑ NA Fecal Coliform (geometric mean) 5104 cfu/100m1 Maximum Effluent Particle Size Y8 in dia. ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDtll E Septic Tank Capacity 1250 gal ❑ NA Septic Tank Manufacturer WIESER ❑ NA Effluent Filter Manufacturer POLY LOCK ❑ NA Effluent Filter Model 525 ❑ NA Pump Tank Capacity gal ❑(NA Pump Tank Manufacturer 154 NA Pump Manufacturer 0 NA Pump Model IR NA Pretreatment Unit Q NA ❑ Sand/Gravel Filter ❑ Peat Filter ❑ Mechanical Aeration ❑ Wetland ❑ Disinfection ❑ Other: Dispersal Cell(s) ❑ NA IR In -Ground (gravity) ❑ In -Ground (pressurized) ❑ At -Grade ❑ Mound ❑ Drip -Line ❑ Other: Other: ❑ NA Other: ❑ NA Other: ❑ NA Service Event Service Frequency Inspect condition of tank(s) At least once every: 3 ❑ month(s) (Maximum 3 years) Qk ear(s) .❑ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cells) At least once every: 3 ❑ month(s) (Maximum 3 years) year(g) ❑ NA Clean effluent filter At least once every: 1 • ❑ year(s) ❑ month(s) year ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ year(s) IA NA Flush laterals and pressure test At least once every: ❑ month(s) ❑ year(s) E NA Other: At least once every: ❑ month(s) ❑ year(s) LfJY4A Other: QC 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 tanks) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ' ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y.) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. Page 71 of 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. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit_ and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safety abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or: must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot fines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. T afuati a o ding�ank be i e ai e . °'R Df4l'6ir5L�, FD P �J&-�%j Q5"5'TK( C--A 0 ❑ 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 Name COUNTRYSIDE PLUMBING Phone 715 246 2660 POWTS MAINTAINER Name Phone 715 246 2660 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name appostel Septic Phone Name S'"(`, I\-() l (9 U N 2o/V CA Phone (O'YD This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(fj and 83.54(1), (2) & (3), Wisconsin Administrative Code. P40LYj440X I['. Inc. Innovations in Precast Drainage Zabel' & Wastewater Products V A Division of PoMok Inc, PL-525 Effluent Filter PL-525 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. 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. r I • 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 i 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. f i 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. t 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 Alarm Switch ` (10,000 GPD (Optional) Accepts 4" & 6" SCHD 40. pipe Accepts 1" PVC Extension Handle Rated for 10,000 GPD 525 Linear Ft. of 1/16" Filtration Slots *- Certified to NSF/ANSI Standard 46 Gas Deflector Automatic Shut -Off Ball Outdoor SmartFiltere- Alarm Extend & Lok"'" Polylok, Zabel & Best filters accept Easily installs the SmartFilter© switch and alarm. into existing tanks. Polylok, Inc. 3 Fairfield Blvd. Wallingford, CT 06492 Toll Free: 877.765.9565 Fax: 203.284.8514 www.polylok.com �EpARTMEN 3 S PS °ssloNAtis August 6, 2018 REVISED COPY INFILTRATOR WATER TECHNOLOGIES LLC JONATHAN KAISER 4 BUSINESS PARK RD PO BOX 768 OLD SAYBROOK CT 06475 SAFETY AND BUILDINGS DIVISION Plumbing Product Review P.O. Box 7302 Madison, Wisconsin 53701-2658 TTY: Contact Through Relay Governor Scott Walker Laura Gutierrez, Secretary Re: Description: LEACHING SYSTEM, POLYSTYRENE AGGREGATE Manufacturer: INFILTRATOR WATER TECHNOLOGIES LLC Product Name: (trans id 3138939) EZFLOW DRAINAGE SYSTEMS Model Number(s): EZ1203H (3 to 12-in. bundles with pipe in center bundle in 5 ft. or 10 ft. lengths). EZ1203HP (3 to 12-in. bundles with pipe in each bundle in 5 ft. or 10 ft. lengths). EZ1201 P (1 to 12-inch bundles with pipe in 5 ft. or 10 ft. lengths), EZ1201 A (1 to12-inch bundles containing aggregate only). EZ0701 A (1 to 7-inch bundles containing polystyrene aggregate only in 5 ft. or 10 ft. lengths). EZ1203H-GEO (1 to 12-inch bundle with non -woven geotextile fabric installed at 180' on the upper side of the bundle, pipe in 5 ft. or 10 ft. lengths). (EISA of EZ1203 H, EZ1203H-GEO or EZ1203HP in 5 ft. lengths = 25.0 ft.2/product, EISA of EZ1203 H; EZ1203H-GEO; EZ1203HP in 10 ft. lengths = 50.0 ft.2/product, Width = 36 inches, Height = 12 inches, max. depth of bury = 8 ft.). Product File No: 20180186 The specifications and/or plans for this plumbing product have been reviewed and determined to be in compliance with chapters SPS 382 through 384, Wisconsin Administrative Code, and Chapters 145 and 160, Wisconsin Statutes. The Department hereby issues an alternate approval to s. SPS 383.44 (4) (a) 1. a.; 384.30 (6) (k) based on the Wisconsin Statutes and the Wisconsin Administrative Code. This approval is valid until the end of August 2023. This approval supersedes the approval issued on October 11, 2013 under product file number 20130145. This alternate approval is contingent upon compliance with the following stipulation(s): • This product must be installed in accordance with the manufacturer's printed instructions, product approval, and plan approval. If there is a conflict between the manufacturer's instructions and the product approval and/or plan approval, the product approval and/or plan approval will take precedence. • When this product is installed in a dispersal cell that is sized based on the EISA rating stated in the regarding block of the product approval letter, this product must receive wastewater having a BOD5 value less than or equal to 220 mg/L, a TSS value less than or equal to 150 mg/L and a FOG value less than or equal to 30 mg/L on a monthly average. • When this product is installed in a dispersal cell that is sized based on the EISA rating stated in the regarding block of the product approval letter, this product must be installed in individual excavations that create a dispersal cell that is horizontally separated from other dispersal cells in other excavations by at least 3 feet. The 3-foot measurement is measured between the closest outside edges of the product listed in the regarding block of the product approval letter. • When this product is installed in a dispersal cell that is sized based on the EISA rating stated in the regarding block of the product approval letter, this product must be installed in a dispersal system, which has the top of the dispersal cell at or below original grade of in situ soil. SBD-10564-E (N.10/97) File Ref: 18018602.DOC Infiltrator Water Technologies Inc. August 6, 2018 Page 2 of 3 Product File No.: 20180186 • This product must have geotextile fabric that meets requirements of s. SPS 384.30 (6) (g), Wis. Adm. Code, installed directly on top of the product and extending down along the sides of the product to a point at least 6 inches from the bottom of the product. • This product may be installed in dispersal cells in place of stone aggregate specified in approved POWTS Component Manuals or Department approved systems. When the distribution cell is not sized based on the EISA rating, the dispersal cell area must be >_ the area required for stone aggregate. • This product may be installed at a depth that exceeds the maximum depth stated in the regarding block of this approval, when the manufacturer provides in writing that the proposed installation depth is acceptable for the individual installation. • The following stipulations apply only to the EZ1203H-GEO, 1 to 12 in. and 3 to 12 in. bundles with non -woven geotextile fabric installed at 180' on the upper side of the bundle, pipe in 5 ft. or 10 ft. lengths: 1. When installing EZ1203H-GEO in 5 ft. or 10 ft. lengths, the product must be installed with the geotextile fabric facing upward. 2. When installing the 3 to 12 in. bundles, trenches must be excavated no wider than 42 in., with a 36 to 40 in. trench width preferred. (Although EZ1203H-GEO is not, to date, recognized in the EZFLOW Mound Component Manual.) 3. Geotextile fabric meeting the requirements of s. SPS 384.30 (6) (g), installed directly on top of the product and extending down along the sides of the product to a point at least 6 inches from the bottom of the product. When installing model EZ1203H-GEO, the fabric width shall be at least 5 feet wide. 4. When installing the 3 to12 in. bundles, bands used in transport must remain intact during installation. 5. Pipe connectors are necessary for the transition between differing pipe materials (e.g., polyethylene corrugated piping and PVC pipe), meeting s. SPS 384.40, and must be used to assure piping does not separate during construction and backfilling. (Example: Include pipe connector such as AC-VCOUPLER-4 for both Schedule 40 and 3034 PVC 4 in. pipe.) For gravity distribution of wastewater, the distribution cell piping shall meet the following conditions: 1. The cell units (bundles) shall be 12 inches in diameter± 1 inch. 2. The cell units (bundles) shall be manufactured in 5 and 10-foot lengths sections, ±2 inches. 3. The 4-inch pipe within the bundle shall be certified as complying with ASTM F 405, Standard Specifications for Corrugated Polyethylene (PE) Tubing and fittings. 4. The 4-inch pipe shall be offset from the center towards the top of the bundle whereby 5 to 6 inches of aggregate is located between the bottom of the pipe and the bottom of the bundle, and 2 inches of aggregate is located between the top of the pipe and the top of the bundle. 5. The 4-inch pipe shall be connected by an internal coupling device to allow continuous connection from one bundle section to the next. 6. The end -to -end gap distance between pipe containing bundle sections, as measured from the straps fixing the netting to the pipe or from the face edges of aggregate on adjoining bundles, shall be no greater than 3 inches. 7. The header or manifold pipe connected to the 4-inch pipe within the bundle shall be at least 6 inches above the infiltrative surface of the distribution cell, or the 4-inch pipe within the bundle shall be connected to the header or manifold pipe using an adapter that raises the invert to at least 6 inches above the infiltrative surface. • The EISA rating reduction may be used in dispersal cells < 36 inches wide. 1. The maximum excavation width of the dispersal cell is 42 inches for a 33 to 36-inch bundle. • Otherwise as permitted in this Alternate Approval, the stipulations of the In -Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems (Version 2.0) October 2012, [SBD-10705-P (N. 01 /01; R. 10/12)] apply. See Product File No. 20170147: httos://verification.dsns.wi.ciov/1 ndustry-Service-Searches/ProductResuIts?Descrl D=POWTSM#2733 Infiltrator Water Technologies Inc. August 6, 2018 Page 3 of 3 Product File No.: 20180186 • A copy of the manufacturers' installation instructions shall be onsite and available at the time of installation. • A copy of this alternate approval shall be onsite and available at the time of installation. The department is in no way endorsing this product or any advertising and is not responsible for any situation which may result from its use. Sincerely, Brad Johnson POWTS Program Supervisor 2331 San Luis PI #150 Green Bay, WI 54304 920-492-5605 Phone Bradley.Johnson@Wisconsin.gov Email File #: ST CRC LINTY SANITARY SYSTEM � 'rst°jrr.vri, Office Use Only OWNERSHIP/ADDRESS FORM created 2/2o21 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. Owner/Buyer OWNER/BUYER INFORMATION Lance and Carrie Whitacre Mailing Address 431 wren lane City/State/zip hudson wi 54016 Phone Number (requi 715-222-5734 Email. Address (required)_ 4cloile -1 S--CAd7 & fffir' Z /'0.Z*4 / f1 Parcel Identification Number 020-1430-30-000 (found on the property tax bill) NEW SYSTEM: LEGAL DESCRIPTION Property Location Se �/a , nw 1/a , Sec. 20 , T 29 N R 19 W, Town of hudson Subdivision Plat: The Glen , Lot # 87 . Certified Survey Map # Volume , Page # jS cw cf CL A-E Nn Wafmn ;•� Deed # t o �f 903� (before 2006)Volume , Page # Number of bedrooms 4 Spec house 0 yes o no Lot lines identifiable 0 yes 0 no OFFICE USE ONLY IJ � New Property Address `7 3 < <� eCN L a4414U (Verification of new address required from Community Development Department for new construction.) WOO/ #O-Z--5 (Staffit Is) (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.clov 1101 Carmichael Road, Hudson, WI 54016 www.sccwi.aov QUITCLAIM DEED Document Name Document Number THIS DEED, made between LANCE L. WHITACRE and CARRIE S. WHITACRE ("Grantor" whether one or more), and LANCE L. WHITACRE and CARRIE S. WHITACRE, Co -Trustees of the LANCE L. WHITACRE & CARRIE S. WHITACRE REVOCABLE TRUST, dated the 7th day of June, 2017 ("Grantee" whether one or more). Grantor quitclaims to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property"): SEE ATTACHED EXHIBIT A. aaass ix:131i9i6 1049038 BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI 06/09/2017 11:34 AM EXEMPT#: 16 REC FEE: 30.00 PAGES: 2 Recording area Name and Return Address: Ryan C. Cari , Esq. HEYWOOD CARI & ANDERSON SC 816 Dominion Drive, Suite 100 Hudson, WI 54016 020-1430-30-000 Parcel Identification Number (PIN) This IS homestead property. Dated the 7th day of June, 2017. (SEAL) (SEAL) LANCE L. WHITACRE CARRIE S. WHITA RE AUTHENTICATION ACKNOWLEDGMENT Signature of LANCE HITAC ndCARRIE S. STATE OF WISCONSIN ) WHITAC tic don ) ss. i ST. CROIX COUNTY ) Ryan C. i, q. Personally came before me on the above -named LANCE L. WHITACRE and CARRIE S. TITLE: MEMBER STATE BAR OF WISCONSIN WHITACRE to me known to be the persons who executed the (If not, authorized by foregoing instrument and acknowledged the same. Wis. Stat. § 706.06) THIS INSTRUMENT DRAFTED BY: Ryan C. Cari, Esq. HEYWOOD CARI & ANDERSON SC 816 Dominion Drive, Suite 100, Hudson WI 54016 Signature: Print or type name: Notary Public, State of Wisconsin My Commission (is permanent) (expires: St. Croix County 1049038 Page 1 of 2 EXHIBIT "A" Legal Description: Lot 87, Block 9, Plat of the Glen in the Town of Hudson, St. Croix County, Wisconsin. St. Croix County 1049038 Page 2 of 2 I a ,11 /. ! 1 ; �rr+l t` fl • rl r I �f i J I II (I f ' 1: 11 rtit lil 1 5 ,I I II II i I 9liI 45Z cozi I II II 1 I 1 ,1t 1_ir I� t , I r• j,5 r rl r l r p. 1 1, 1 t , ,OVA I � 1� t t I II � I Itt,•�4ai' 1.1•t f ( ! � flrrlJl r o a I � I �,jr ( II I II � I 1 1 �♦ 1 1! ! r ! 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I I Iry (t.062 AC.) I I I -= — SBL SBL i to la SBL S$l- 1 1 t t 1 1 1i 1 l i t i 1 1 1 1 t 86 475880S.F. (1.092 AC.) SBL 1 I 1 1 1 1 1 I t I 1 1 I I 1 t I I SEE SHEET 5 4E 0. i 1103 Wisconsin Department of Commerce SOIL EVALUATION REPORT page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, W is. Adm. Code Steel Sol Service Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County St. Croix include, but not limited to: vertical and horizontal reference pant (13M). direction and Parse! I.D. , percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Please print all information. .• �3 /y3� mg _,,. f' "—� R Date Personal ir>icxrrretion you provide may be rWomy , s.15. (1) (m)). - U r.. Property Owner Proerty Location Sienna Corporation ,� 6 ZG�JCV.-ity SE 19 NWIA S 20 T 29 N R 29 W Property Owner's Mailing Address, �� '� lock # Subd. Narne or CSM# 4940 Viking Dr, Suke 608 ��T``'' 1 ,`.��,, �;� na The Glen City Stale Zip mane lu ejy�g�y Village JS Town Nearest Road MN 554 —20oY Hudson Carmichael Rd. M New Construction Use: Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD jj Replacement Public or commercial - Describe: Parent material Pitted outwash Flood plain elevation, if applic" na General commerft and recommendations: System elevation 99.79ft, des spaced and depth to code 5.16ft below grade '1 Boring Boring Pit Ground Surface elev. 104.95 ft. Depth to limiting factor 98 in. soil Applicatim Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Bocxrdary Roots GPDMe -Eff#1 I *Eff#2 1 0-12 10yrM none sr1 2msbk n* gw 1f .5 .8 2 12 28 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 281 7.Syr41i6 none ms ms ml na na .7 1.2 / Boring # is Ong u M Pit Ground Surface elev. 104.95 ft. Depth to Smiting factor 9ti in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fe -Eff#1 I -Eff#2 1 0-27 10yr3/3 none so 2msbk n* gw 1 C .5 .8 2 27- 10yr4/4 none sic 2msbk mfr Cs 1 f .4 .6 50-98 7.5yr4/6 none ms ms ml na na .7 1.2 "2, " Effluent #1 = BOD ? 30 < 220 mo/L and TSS >30 < ISO mn& • Ff itimA 27 = Rr)n < 3n mn/r aM T5M < -In mnA CST Name (Please Print) Signature: CST Number David J. Steel 248956 Address Steel Soil Service Date Evaluation Conducted Telephone Number 1564 CR GG, New Richmond, W1 540 9/7/2002 715-246-5085 Property owner , Sienna Corporation 3] Boring # Boring IK Pit 1 0-24 10yr3/3 2 24-46 1Oyr4/4 3 4� 7.5yr4/6 t�/ Parcel ID # pending Ground Surface elev. 100.75 ft. Depth to limiting factor none sil 2msbk mfr none sicl 2msbk mfr none ms ms ml Page 2 of 3 98 in. Sal Application Rate iundary Roots GPD/ft' 'Eff#1 'Eff#2 gw 1 c .5 .8 cs 1f .4 .6 na na 0 1.2 Boring # Boring eP ft. Depth to limiting factor in, Pii Ground Surface elev, 9 Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/W "Eff#1 'Eff#2 F-I Boring# fit+ Boring ft. Depth to limiting factor Pit Ground Surface elev. in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft: 'Eff#1 'Eff#2 ' Effluent #1 = BOD s> 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD5 <30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or Wk;tSS @ AL. lJC! e- Ale AAav j 'V ,,. y Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division of r INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Sienna Corp.Hudson Townshi CST BM Elev: Insp. BM Elev: BM Description: i 41 co . t5 Ca r j f t-t* 1 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic , • � Dosing ��, s tam Aeration Holding TANX SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ! i !J o Dosing Aeration Holding PUMP16PHON INFORMATION Manufac urer Demand GPM Model Numb , TDH Lift I oss System Head TDH Ft Force fn Length Dia. t. to Well SOIL ABSORPTION SYSTEM County: St. Croix Sanitary Permit No: 430249 0 State Plan ID No: Parcel Tax No: 020-1430-30-000 Sectionrrown/Range/Map No: 20.29.19.2681 STATION BS HI FS ELEV. Benchmark $.i3o /og .s Alt. BM Bldg. Sewer tf U j y I Q V St/Ht Inlet �(.4K St/Ht Outlet y1 Dt Inlet Dt Bottom Header/Man. to, 31 q$.ytl Dist. Pipe Bot. System 97.3 Final Grade 310 St Cover BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS % F° `? S- ( " SETBACK INFORMATION SYSTEM TO P/L JBLDG WELL LAKE/STREAM LEACHING CHAMBER OR NIT !r! rr,-CI- Manufacturer: Type Of System: ef-ak)U�QA 0y t �� r "zI N c� T yr� Model Number: .T DI UTION SYSTEM Header/Mani Id Length -= Dia (^i Distribution Length Dia Spaci x Hole Size 11 I• x Hole Spacing Vent to Air Intake n, SOIL COVER . _ t 1 — ,,,„ J x Rcessxtre Svstems Only xx Mound Or At -Grade Svstems Oniv Depth Over ! epth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bedrrrench Edges Topsoil . Yes L,] No �s I4� No COMMENTS. (int�iude code Disc pi e ties, persons present, etc.) Inspection #1: �o l / l a3 inspection #2: Location: 431 Wren Lane Hudson, WI 54016 (SE 1/4 NW 1/4 20 T29N R19W) The Glen Lot 87 Parcel No: 20.49,19.2681 G� / 1.) Alt BM Description = /a P l tf f3� ! l0 2.) Bldg sewer length = / j r j�- ^'''� / -amount of cover = .�5 +r �c� ,),>rtst �b 4C"', \ti,pZrQ �rj lU/1Ly�7�� Plan revision Required? Yes ,` _ No II' 1 03 Use other side for additional infor Ion. i d �_ L.__J —7 C ---- �— Date Insepctor's SiWature Ceft. No. SBD-6710 (R.3/97) J 0 ,- %G V'' ► f 1 S t 9 ,(1 n G y�`1y"//� ,j % if/✓UaL ear ,,,E %/, 7 O 7 A "�- ~)J Safety and Buildings Division / 201 W. Washington Ave., P.O. Box 7162 Madison, WI 53707 - 7162 County 5 ��V-0 C - Sanitary Permit Number (to be filled in by Co.) ,�onsin (�8) 266 3151 �2 De artment of Commerce AID State Plan i.D. Number Sanitary Permit Application In accord with Comm 83.21, Wis. Adm. Code, personal information you pro may be used for secondary purposes Privacy Law, gi5-04(1)(m). Project Address (i different than mailing address) Information I. Application Information - Please Print All Property Owner's Na me Parcel # Bioek N �, '� ���� � Property Owner's M ailing Address�� Property Location o / yli 4'i�kr �/ SGIi' G �i G o t4,� (�i14,Section o'1 circle o T � N; RE or C. Giity, state / - �% Zip Code J�J� Phone Number q�$ �33 �o2l�d II. Type of Building (check all that apply) / Subdivision Name CSM Number 51 or 2 Family Dwelling - Number of Bedrooms ❑Public/Commercial -Describe Use ❑Ciry�ClVillage Township of �Gti ❑ State Owned - Describe Use III. Type of Permit: (Check only one box on line A. Complete line B if applicable) ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System Ftem enewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issuediration Piumher Owner iV. Type of POWTS System: (Check all that apply) Non -Pressurized In -Ground ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In -Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculatin Synthetic Media Filter ching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (ox lain 4-M YS V. D rsal/Treatment Area Infor atlon: (s Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (so Dispersal Area Proposed System Elevation 'C Q a'O [ 7 �J 21' VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass o o Now Existing Tanks Tanks Septic or Holding Tank 9 er Aerobic Treatment Unit Dosing Chamber 2XJ I- -L G VII:'Responslbillty Statement- I, the undersigned, assume responsibility for allation of the POWTS shown on the attached plans. Plumber's No me (Print) Plumber's Si gnature M PRS Number Business Phone Number ` �a a , 7 99d /5-3SG Plumber's Addre ss (Street, City, State, Zip Code) �I 7 e �O! s 'o VIII, 0ounty/Deriatment Use Only Sanitary Permit Pee (includes Groundwater Da Isar Issuing A nt Si tur ( mpg) Approved 0 Disapproved Surcharge Fee) ❑ Owner Given Reason for Denial 1ou . Conditions of Approval/Reasons for Disapproval _ n • , _. Ort.�`U�', �t I D vim _.,._ ._._.._ __ .,,,.e..,nr i"a ihun nlr2 x 11 Inches in size .,.. - -__ .P2_ 1� q Ornpla{e 1 l ty onlyy).Ruut wwo wyn.cw On r4r ..... _ (i(/iv7/+^. ,. 4S- 43V(RPL�_103) N00C couNry NO. G,HR4�-9 STATE SANITARY PERMIT T j _PREVIOUS NO. q 3o -2 47 i C^Ka.tE War t�r•�ceE rl4Df,ik� LIC.# 22Sy/0 TOWN L' J ?.o 9 19 AND/OR LOT BLOCK SUBDIVISION VOR . 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. (f) 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 permit, please contact the county authority. t--AUTHORIZED ISSUING OFFICER - DATE THIS PERMIT EXPIRES �IL �2& L5 UNLESS RENEWED BEFORE THAT DATE SBD-06499 (R11/20)