HomeMy WebLinkAbout040-1328-10-000Wisconsin 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 [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name:
City Village Township
Adam & Nicole Wilson
TOWN OF TROY
CST BM Elev:
Insp. BM Elev:
BM Description:
P of V
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
We t�rI
Ong
r� I �CJ ti 4� GF/0
t i o n
H&d9a
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
77sO •
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
Model Number
TDH
Lift
Frictio ss
77f,
System Head
TDH Ft
Forcemain
rngth
Dia.
I Dist. to Well
SOIL ABSORPTION SYSTEM
ELEVATION DATA
County: St. Croix
Sanitary Permit No:
651288
State Plan ID No:
Parcel Tax No:
040-1328-10-000
Section/Town/Range/Map No:
15.28.19.2242
STATION
BS
HI
FS
ELEV.
Benchmark
7,
�Q�,
I O Q
Alt. BM
Bldg. Sewer
St/Ht Inlet
�35
St/Ht Outlet
C)�
�O Z
Dt let
D ott
Header/Man.
Dist. Pipe
Bot. System
Final Grade
►
9
%Cover
!�M
i 7S
C
`o ass
1
BED/TRENCH
DIMENSIONS
Width
Length r
1
No. Of Trenches
PIT DIMENSIONS
No. Of Pits
Inside Dia.
Liquid Depth
SETBACK
INFORMATION
SYSTEM TO
P/L
BLDG
WELL LAKE/STREAM
LEACHING
CHAMBER OR
Manufacturer: '14 I1 N-t fj(
Type Of System:
I
�Jnn a�!
�
,
Z�UNIT
Model Number:C�Vfn
DISTRIBUTION SYSTEM
Header/Manifold
Distribution
x Hole Size
x Hole Spacing
Vent to Air Intake
Pipe(s)
Length Dia
Length Dia Spacing
SOIL COVER x Pressure Svstems Only xx Mound Or At -Grade Svstems Only
Depth Over
Depth Over
xx Depth of
xx Seeded/Sodded
xx Mulched
Bed/Trench Center
Bed/Trench Edges
Topsoil
❑ Yes ❑ No
❑ Yes ❑ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 387 BELLA CT
1. Alt BM Description = �` cov2� 5
p 2 C' �� ��- ('(Ses Qn Q� VS �i-l'1� (� (a6 ( a �1 L C�
2.) Bldg sewer length � = �2 V
, ch U �tI4
- amount of cover = A+ lays]— cover
6qvjoj- ZY-6r f-?,i ax 'Z�
Plan revision Required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R.3/97)
[0
/8 2-3
Date I sepctor's Signature Cert. No.
Department of Safety
& Professional Services,
2023 Industry ServAces D1041on
ilk
SAN-2023-213
San i", Pemt Nu mbtr (to be � in by C,o-�
IT
I 2 3 T
Sanitiry. Per *t Application
In accordance. with S PS 391 -21 (2), Wis.Ads - su
bmission of Ns form to the appinpriaic go vaiuncntul unit
is required prior io obin"a"TIR 4 "ailmy permit- NMe: Applicatioa 16rmo for gtzilz-owncd I'OWTS WC s�ubjnftted to Proj=t Addren (i fdifftrrnt thm naffift addrCS3)
the Dcpartment of SafeaDd PruIessio1W Sci vic=s. Pcrson-dj 11-410tfflutjOn YOu PrOvIde may b-z UW fbr secondary
2222Hs'n acc0rdan,cc with the Privacy Uw, s. 15-04(1)(M)o stats.
I. APPlication Information - Ple&W F'n-nt AU Infwaaadolm 18 7 Li 6r
0W='3?qzM'e
A of 4- )VIZ4 i f 0
PMPMY Ownces Maitittig A&rm Thwerry Location
dY.1-4,V GOVI, Lot
City, staft Zip Code Ptb6= Number
' 'A. IV IJJ Y, S=1ion
Z') I 7/wf Yfl o? F5 9 L
H. Type Of Building (A tail that apply) Lot # T R
I or 2 Family Dwelling - Number ofBo&vorm /0 SUMMSMNwre
C1 Pubi ic./CamupmW - Dcmtoe Use, Blo& N z-4-5 0'r "'O"f6 /X
0 City of
C1 Statc Owned - Lk=ribc Use CSM N=ber 0 V I I liaLge Of
19 To of y
M. Ty , pe of PONWS Permit,.
�p�caWe.) . Tbeck either "NewN air "RepU mmir &ad otbw Applkable an One A. Check, ow box an Hm 38L Compim We C
- 1 -1 ---- -
New Symm RcPlacemcTil System
D Other Modiflcarivn to Existing Systm (expLlin) 11 Addi 6 onal Prdrgatmen,t Unit (explain)
IL
Cl HoldTank WmGrmnd At0 Ind ividual Site Dc�sign
Mcr TYPe (expWn)
C. 0 Real. Befhm C] Revision. C1 ChHW nf Number 0 Transfer to New 0 ist Prcvious Permit N=b%-.r and Daft Imurd
EXPilra—fin-n-
FV. D ispa%aV[yufte12tm-and
"TI
aalnl k In
Lfo mgdm--(3pT3 c&q
zq
-1m6vxDCigFloI 11ml Area Required (gf) Dispersal Aria Proposed (so system
/00
/��- /:500 �4;. 91 91y. d9
Cipacity 11) TOW of Manufactum
Tank Infunmdan (12110as Gallons Units
Ncw Twks x "ram SST to 13
�er
iz Z; A* E4
Stpfi C or d...
IoUo 40 ZivoVsex i::�01-4CA
DosiaS MuLber
V, R!T!!!!N#!Y Stit tment- 4 the underzlpwd� mume Mjp=dbft j;Dr
iinstaftfien of the POVM she wo on the g tt%tcb Ed plant.
PILIMbes Name (Pmt) PluMber"s S
*M*0 NT4WW" Number B u si nc&s Ptme NuxnbcT
0111N 4 KAC- 71-5� 6� 72 jr�?d4
Plumber's Addmss f 1" City, State,, Zip Cmde) oo�
OMS Sr. /164.v. W 1d41A4.W 41/.Z Y7Jd
V1. County eat We offily
19 Approved Dis%Vpm ptmift fee Date hmscd IsaLiqg Apm Sigmmm
or I
Conditions ApprolIV PP
SYSTEM OWNER: 3)
1. Septic tank, effluent filter and dispersal cell st D.*C5,PD/G2-
rust beserviced / maintained as per
marl agemeni plan provided by plumber.
2, All setback requirements must be maintained
as per ap p I'Xzk b I e code 1 -11, -J i n a n ces.
11111611111111 br 00 MWIM sad submit to the County wly an poW not I JNW j W 1-9 11,111144" In 9ba
SHI)-15398 (R. OV22)
PLAN
5 7 1 E 4 L A
s C, N Lil /s, 0? S 1vt
0 jr 4kr ACOO
Of
t tive. .5cw, Vo
4 o44 KAI I I.
0 10DR tj
LiTn r- -il
L:Z7 00 r-' r 1.40 r t Lot L J
Z 13 -C A 4L
J91. �l Scr4Acs
101
S Z 1AJXl'c rA -4 ASA 4� 4014 9 JY C W*440'1 4 4F 5 C4 J Y Sj
9
orr "KAlh rAlL
1060
\lD o it
I$ /6fj4,x. lAjs roo i ar 34 z
W-0
0 040 of,#A t4l ioL
If,$ if A
Z-0 T .16
4J1i'4J end U4tf)
—16,6.z
EON$ i400ij
1(4)
Private C)risite Wastewater Treatment System
Index and Title Page
Project Name A PtW � �e�! - 'Y- ��c. ,� c.���.�v �a errs �,d�-�r }
Owner's Name.- f.
Owner's Address.
14uO.fo,0 zCJl fYtll( __
7/5 i�41/_ 25-f 9
Legal Description: dv�
Muta*cipaliry: Tuvm,, V414ftje,
C-4;y of
County
Lot N umber- Block Number:
Subdiv i s -1 o n Name
Parcel I_ . Number.
Page I Index and Title Page
Page 2 Plot Plan with CrOss�Section & Plan View
Page 3 Septic Tank Specifications
Page 4 POWTS Owner"s Manual & Management Plan
Pa 5 POWTS Owner"s Manual & Management Plan
Page 6 Filter Information
Name of Dcsigner: -To"mN
Signature. -
License
Date.- 2043
Desioirie�
._.�d u�rs �t to the followin PoNk7q r S 381-385:
"'In -ground Sol] AbsOrPtion Component Manual for PoNkrTs"' Version 2.1 (May 2022-2027)
Attactunent: Soil Evaluation Report
PLAN
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2.8
U 045 JSJ. JV3 .01er .11
101
af Ar 1AJXlLrA .4 r4arig c W*44ory 5 (,/,.y
9
106
4 4,
\lD Ao it
I$ /Lfj4,x. lAjs roo i ar 3
W-0
; j
OfA A t4 Or Ja
JA 4COL.
Z-0 T .16
10
a
4J1i'4J end U4tf)
TDili
a
- - - -pme. 4- - t
mrlll- i
if 1[
h -- 4 as T --_/;- SEA L
me
T
"ILTER OR
BAFFLE
4" CAST —A— A
-i . ., - � f s+� tea• m-a �.>.v. � �� �,a,�-.. _ � _ � -_ �` _._
lamb—
# !dlillmlls
;
•� -� _.
t T
OUTLET
Lo
le 2j"
g
a
cn
dm
TANKS ARE UANIAVACM19M TM UCTT M W-Yr-rCn Aclu r_i non-7 cwry ��t�r►��k�
WLP1 250—MR A. 3al,
�
T
*
TAUK.5PME ATIONS
i
i
MALL, 2 112#
IRT'. SEPTIC
COVER: 50
1�;..PRECAST CRETERim
HE+T 1 0.
LE C : 120 1 - O.E.
WIDTH: 84" . .
BELOW INLET. 41' _0
WEI �- t 61810 LBS.
INLET ANDOUTLET:
i T— —SEAL BOOT OR EOVAL
3
GASKET, CAST— —SEAL BOOT OR EQUAL
;LE T AND CXJTLET BALE AND nLTER:
`}
WISCONSIN, SEE DE TAIL 010
(OTHER TAT SEE CHART)
LICKAD CAPACITY: 34.81 GAL/INHOLDING
TANK;
�
U T'L.E T HOLE PLUGGED
1
CAPACITY: 1*323 GALLONS
9
LO INO" . 8' 00 UNSATURATED SOIL
n I
TANK CAN BE USED
SEPTIC/HOLDING/ POUP OR SIPHON
COVE *# MIX DESIGN 08 NO FIBER)
co
TANK. MIX E 10 STRUCTURAL FIBER)
CUSTOMIZED TANKS:
FOR CUSTOM TANKS CONTACT WESER E
I �
a.
DRAWINGSITTE
FOR APPROVAL
FILE (NFORNIATION
Owner
6 0 A/
Perinit A
D E SIGN PA PAMETERS
Nunit Bedrooms
-of
Number of Commercial Units
H s d i rated 0 ow (Avc) (100 gpd,-,b edri-x) m)
1(400 gpd
&W flow (DW) estimated x 1. 5
SOil Ai- icafion Ratc
Influent/Effluent Quality (C3 NA)
MonNy Average
Fats. Oil & Grnsc (FOG)
'C 30 mwt
Biochemical Oxygen Demand (130%)
'S 220 niv� - L
Total Suspended soilds (Tss)
S 1.50 ring/L
' Pre tmated Effluent Quality (53 NA)
Monthly Avcrage
BloChemical Ox�.gen Dtrnand (BOD5)
S 30 mg�L
Totil Suspended 111d.% (TSS)
75 30 nWL
Fecal Colifonn (geometric mearl)
5 10 CfU1 I 00ML
Maximurn Effluent particle SJ7C
I IS iTwh di amc ter
Dispersal Unit Mfg./Model Number:
Soil
A lication-&ft—
a , a ft a I OF
SYSTEM SPECIFICAnONS
Septic Tank er�city
zo? J-4 ga
l 0 NA
Septic Tank Manufacturer
DNA
M uent Filter M anufa c turer
0 N
Effluent Fileer Model
0 N A`
Pun�2, Tank
gal 0 NA
Pump Tank Manufacturer
0 NA
P'ump Manufacturer
0 NA
PUMP Model
0 NA
Pretreatmcm Unit (61 N,A)
ff? Saad/Gravel Filter
(3 Feat Fifter
I
0 Mechanical Aermion
C3 Wetland
C3 Disinfection
0 Other
M4anufacturer-
Model:
Soil Absorption Component (11 NA)
10 In -ground (gravidty)
0, At-gmde tk C3 In-g,round (prftsurized)
0 Mound
M Drip -line 0 Other,
Vertical D 1-stance Taak Bouom to Servioc Pad;
Horizontal DisWnce ink(s) to Service Ra& ft
LA),01111- rA.A -r*,& rA_f NA
Dispersal End Cap (D.IrSpersal Unit EISA)
Area Recouir
FISA — r(Trcnch�y�, #Units orToWLenetho Trenchix)
DUSIGN CRITERIA If.sAri --
CY "At -Grade Component Manw], for PoVvTg* (pressure OTC=Aty. Version 3.0 (May 1.022-2027)
1 rks 0 orpt on S
0 "Des, gn of Presswr- Distribution Nerwo for Septic Tank-S d Abs , I ys.(C MS ? U b] 1cation 9.6 (S SWNV Manual
0 44.EZ Flow Mound Colnponftl Manual" Wrsion 12)15/2017 (Ap6,12018-202,3)
DO -Ground Soil,Absotption Component hWual for PONIVTS" Version 2.1 (,\4ay 2022-2027)
0 "Mound Comporimt Manual for POW= Versioa 2.1 (May 2022-2027)
0"Pressum DistributiGn Conip aijelit]Aunuai �br POW TS." Vmion 2.1 (May 2022-2027)
C3 Other.
NIAWTENANCE NIONITORIN-G SCHEDULE - MAINTENANCE AND MANAGEMENT
ServIce Event
- I--- Se ry, ice Freg tie acy
At least once eym, 13 months 9 3 years 0 OtheT,
—Lqspecl PUMP & PU
t MP controls, alarm, pretreatment unft Ale"a
L4 onc-e every. 13 Months n ears
tl RNA
�sh and pm&-;ure u:s,t .1werals At le .ast once months d w.
_.rs 0 NA J
LL�,j
T.VP For new consftclion, prior to usLing the P0%k-7S check treatment tank(s) tbr the presenze of painting
products or other chemicals that may impede the U-catment proom and/or damage the disposal cell(s). If high concentrations are detccted havc
the con tents of the Unk (s) remved by a upuge sery icin g operator prime to use. System start u p sUll zot a ccu r it,
at thC Infiftndte wrfacel, W h*U SOU c0lididow arefro
The PrOperly owner is responsible, for tho operation and mairitenance of the POVM and submission of'required reports. The quantity and
'eam will'affect the perforn-mnee .and Ion gerity of your PO W- r S Th c i n saa I I at i on of Wat ,
quality of the wastewater sti er-saving applianm and
fixtures along with prDillpt repair ()r lesLks redLU.CA:s tl3c vv-aSt(:%h%ter volume. Also the bn'ne or wawa from water softener-q, irt)n temoval units
0111-or ci= water t=Lrnent device and 16cmdation drains should be discharged to the, gmmd surrface whenever bible. 'Note: this do cs not'
include laundry, waste, showeis, dishwater, cw.
6
This system is dcsy6med ►to handle domestic wength wastewater, ljowever, the cjisNsal of food based gress.es., ails, vegetable/fit peeN,
sccds, bones., aad food solids , such as Lhose produccd by a garbage disposal should be rn knim ized. Toilet tissue is the only paper that should
be discharged into the system. Other nor -blodegradable items., such, as baby wipes, tampons, ki
dental floss, and cotton swabs. should not enter the, syg1cm, C11cm-cals, su j, :a.j petrol &=tory nap ins condoms, cigarette butts,
C cum products, Pauli, 1-1
an fi b i tics. so lv e n ts � c tc., should not be fl-tished i n t o th e s y s te, m' d"% F1['tCtant`S
they can scriouslydainagc your POW79 grid con tam it to your
drinking water supply. M ainta in a regular ste ady flow by spreading laundry wash ingth roughout the w1cck. Avoid vehicle traffic over
9k1 is pa ( em componen ts . C OMPKIdOn Ofmlow ovcr the disper-si I unit may cuusc it to fhm" up.
disinfectants, pesficides, an I ibiotics. solivents,, c1c., should not be flushed into the stet-n as they can scaiously damqe your powTS
and contaminate youT drirLkLag water supply.
Mainlain a regular steadyflow by spreading laundry washing throughout the week. Avoid vehicle traffic over all system Components.
COMPaction of snow over the dispersal unit may cause it 1.0 freeze up.
I NSPEC11ON & MAINTEN CE: lnspwfion shall Ix- made by an individual carrying one of th e 1`0 1 ing I icenws or
I f7 cart ications: Masler Plumber, Master Plumbcr Restricted Scwer, POWTS Mainialum- or Septage.Servic"in-1 (Jpcimtor (per the anached
Ma'', iancesaie,duic), rzmk inspectiuns must include a visual inspection of the tank to identify anyg or
missribroken hardwan
I I
fy any cracks or lcaks, measure the VOlume of combined sludge and scum and check for any backup or pundfiig of effluent to the
groUrnd surface and tic all eiectrical equipnient suQh as pumps and alarms. Any defects shall be promptly correctcd. Exposed openin
urgs
reater than 9 inches diarneter shalt secured withe5ective locking devices to prevent accidental or - unauthorized cnrry the tanks.
L7
When the combination of sludge and scum in any tank exceeds one-third (I ' 13) or more of the tank- volume, the cntire cuntents of the
i a n k s h a I I be rmov eed by a Septage Servi cl ng Opem tor and disposed of in ac c ordance w -1 1h C ha p ter N R 113, Wisconsin A dmi n istra t I Ve
Code.
The outlet Filter(s) shall be inswpccted and cleaned tea remove any accumulated solids according, to manufacturer%, s specifications. So I Ids
washcd from the fi Iter ql.-,La I I be retained in ffile, Unk. Filter ciftnifts may be necesNfj rV at More frequent intervals than stated in Lhe
maintenance schcdul-t- to keep the system operating.
A ha s ho u Id be tes te d ors,( - , � - I
I -, _4,u Jar basis s b y the 1) orn e ow ner. I f art contact an individun I h' censed to sere -Cc POWTS,
There is normally as I day 1 i -�dc under regular opc rafing condlifilons, however walcr shou Id be wnsc",ed until any problc= with the
system are corrected to prevent back-up of w wage into the �dwel. ling or surfacing.
ABA'NDONMFN'T-, When ,he POA7-S flails and/or is pem-anently taken out of service the followig steps shall be. 18-ken to ensure
that tkSys lem, is pi-uperly and s;-11,4114']y gibandoncd in compliance with ChPS 381.-11, Wisconsin AdmLinistrative rode.
All pipluty to, tanks and pits.shall, bc disconnected and he abandonciLl pipe openings sealed.
The cun, tents of all tanks and pits shal I be rcMOVL'-.1 and properly disposed of by -,A Septainac Servici g Operator.
.2� ) -
Aftei pumpi F, ali tanks and pits shail CXCaN".,j j Lind removed or their covers k1110 ', Cd A r Id 111C Vid s
soil, gravel or other itien so I id material
(-() NMI 1N![jENCV PL.LXN: it -the POWTS fails and caunot''De repaired the Rillowing measui-es have been, or niu-st be takeu, to provide
a code cornp I i a n t replacement s N� s I c ri.,
-, I 'bsorption syslem.
X " u-table replacement Area has been evaluated and m,,3y he utilized for the location lon of wi I a
J from disturhance and compaction and should not he inffingcd upon by E-c.L1 Ted
replacement area she ',
L 4
_bicks from existing and prom
posed struce, l-ot lines and wells. FaL'Iere to protc!,ct the replacement area render it unusable.
%
e p la cement systems must com p ly w i th the ndes ire effec t a t t h e t I al e () T re a k., C n.1 CM
El A sultabic replacern.ent area is not available duc to setbij:K- and.`or soil limilations. Bar -ring adVanLCS in POWTS techDOIOgy a
holding tank may be installed as; a last resort to replace the failed PONWS.
C3 T 11 C S i i c has not b,ecn evaluated to iden ti fy a su 1 tab le rep Lacem cnt sTea. spun tail ure of th e Pam" a sail an d s i te eva I u a i i o n
must be perfonincd to locate a suitable replacement area. If no replacement area is availabie a holding tank may be in to I led
as a 'last resort to t �:Place the failed PO W Ts,
0 N.-Iound and at -grade soil absorption nysstems may be reconstructcd in place following removal of the biumat at the infiltrative
surface. Reconamcdons of such system roust CO Tl I P, IN 4, . i ill the, ru I es in effect at that ti ni, e
<<WARNING>>
S E PT I Co P UM P A N D OTHER TRE ATIM E N T TA INt M A Y C ON T I A N L ET I i A L GASSES A N D/O R I1 F1 C1 ENT
OX V G E N - D( � NO T E NO R A SEPTIC. P U" 1%1 P OR OTH E R - 1"R FA T N I E:N-T TAN K U N DER ANY C IR C U MSTANCE.S.
DEATH MAY RESU LT. RESCU F. OF A PERSON FROM THE IN"Y EOR [OR OF A TANK MAY BE DIFFICULT OR
DOOSSIRLE.
ADDI"FIONAL COMMENTS
POWTS INSTALLER PO %XrTS..N1 A I N TA I NNF R
'd r- zxe- 10*v- a? 313 V4 Name
P Phoue
-1 715- 4 7o? Phone 7a7- S-244
,E LOCAL _REG [T LATOR jr A 1:111ORITY
S,EPTAG SERVICING OPERA-rOR (Pummuer
Name 4140f0r"A�IrY i/tW14
Phone
`� f
�r
I nstallation Instructions for the GF1 Q Filter
Step 1. Loc,], Ind ronw-v
0"I'l Septic �T%k ( t=wuf, (it)
the audet A tank
Step 4- Glue the filter case orsto
ihecmutlet pipe. inwrt the filter
,r )j0tFLCj5IQ (Make
me I Iw- I'll ter IS com ple tely
in teal it Pilo I he cas e.)
BEST
TEC"NOLOGY
SuDri 2- lmt,111311r-n
�-F me on I o
t i L pi4,t, M. ake stue
: �) Fied so
UIL I t-- r can bu,,--moved
frwr mainte.
Sirp. 3 FQ,- w -, -,rdations that
Fe- Or 'Idditionail
su_1;,-fxt 14 iwld,.Cbnal support Is
nv, gi — 'Iep 41 Glue
f pipe to the
h0ttOM
of w cas ,L) k3cated
oii t4ie slde u, i
Stop 5 Fw lnsta!;Latl s wheie It °.vitl
1; e diffix- LP i t t 93 reach the h a rwXe, 1A .3,c e
I" Sr, hed t. le 40 pipe into 0 e wo oe j t 7 cm
Nindle .4adcxtend it to height thm mi
rndke k -Illy to (e m ov4 t h e 19 Iter
Installati on of an newsystem only the s-eptic tank
e xi i must be pumped prioir to hvi tatiat.un. IStITIg S3VeM,
P am j*M 114-1 am em I so mm" lmw jwj IVA I,'* Lk--] tfff �imf on RU MAA SWJ LVM ad
Maintenance of the GF10 Filte-n
Ah time fie 0% wNch se Ptl C I - , - - - . i , . `, , . - at cF • i A W al codes
tJ1 h mqh they may be. di*f � -iletlivia,10five
yem s, V* wommend i he GF Wer Lw ti;:., i tvu ti.1wi i *Uv_- �tsc i in k I � not maNy
draned and pumped. cw a s n(- -fed
L
WARNING: If the liquid level in the tank is above the top of the
filter, p ui,,np the tank prior to femovi n g the 15 It car t ridge.
Rem ov e 1 0 1 _. I IL' T 1'K C OVC'
mr) the, Fimk i f nct�!ssjry to
to 114XI
vohei,- �,r is to mcmmed,
Stop 1 Pki I Ole 61ttr
�,j rid Iv an I S 11 de the fi, ter
otit of the caw.
Llw - "14k
j rm, I'm 0114 10 IC211 � I
Step 3 INhitcholding the
f i I F. v r ci r tf idcj c, a vrn i h e
A�-M op-QMr�g Cf the ta-k.
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B 'EST
TECHNOLOGY
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ST. CR UNTY SANITARY SYSTEM officeu
OWNERSHIP/ADDRESS FORM Creoteed 2
Community Development Department will ufli-ze this infc)IL-Mation to j_-)rc1v1de the property owner with
information regard ine, coeration and maintenance of your new or replacement sanitary systemi THS
lnfm-mation will be provided as part of out- ongoing efforts to protect publ'c Health, your well, grcundwater,
surface water, property values, and ccunty ii-escurces. Once approved, this completed form and ecilJcational
informatior will be sent to you by email. If you would like to view your issued sanitary permit online, you can
do so by using tathe,P,Lgp I y,F4.es 5c,anned webl'nk.
A ALL 1b
IL
Owner/Buyer Adam and Nicole Wilson
MaiHng Address 466 Dylan Ct
City/State/4 Hudson / W1 / 54016
Phone Number (required) 715-441 -2559
Email Address vequired) willsonatl 222@gmai1xom
Parcel Identification Number 040-1061-20-0000
: 1,i),jnd an *.hc, propv;-ty tax bill)
NEW SYSTEM: LEGAL, DESCRIPTION
Pr operl%/ Lm-ation S 14 , NV\/ 1/4 , Sec- 15�r T 29 N R 19 W.. Tovn of Troy
Subdivision Plat. Vistas of ST Croix
Certified Survey Map #
Warranty Deed # 1166326
Number of bedrooms 4
New Fropertv A(Jdro_,S�
'Staff in'ti 31s)
I Vo, I;j m e
(before 2006)Volume
Spec liouse 0 yes E no
OFFICE USE ONLY
o Lot # 10 ,
0 Page #
Page Or
Lot lines identifiablle 0 yes 13 no
(Verification of new acid rest required from Community Development Department fc)r new construction-)
(Date)
ri) i 1pmitted with oll Prlate Onsite Watei- Trea ttjL-% te
m TOWTS) cippa 1coti(it"Is-
e w System: Include with this form a reccrded worpl-0,11ter deedfrom the Register of Deeds 0ffice ai-)d fj copy of the certified
�orveapifreferent e is mi2de in the
y is
Ccimii-iuniity Development Departi-nent — Land Division
715-386-4680 St. Croly Co ti nty Clover-tilliet-it r,_,et�ter 71 S --)45 -42 SO Fax
Rci,-,id. W11 54016 1101 Caii ichL"
State Bar of Wisconsin Farm 1-2003
WARRANTY DEED
tkmi cot Number It Document Name
TMS DEED, made between AMW Associates, LLC, a Minnesota limited lia bili
2M�y
("Gutor," whedw orm or more), and Adam Wilson and Nicole Wilson, husband
and wife as mvvivorshi marital pE2p!q
(" Grantee," whether one or more).
Grantor for a valuable consideration, conveys to Grantee the following described real
estate, together with the rents, profits, fixtures and other appurtenant interests, in
County, State of Wisconsin (a ") (if more space is
needed, plaice attach addendum):
Lot 10, 'VisMs of St,. Croix, Town of Troy, St. Croix County, Wisconsin
Grantees shall have two (2) years from May 2, 2023, to construct a primary residence
on the subject teal property and Petta Building dt Design, LLC, shall be the sole and
exclusive building.
1166326
BETH PAT
REGISTER OF DEEDS
ST. CROKK CO., WI
RECEIVED FOR RECORD
93/ 02/ 2023 92:19 PM
EXEMPT*:
REC FEE 39.00
TRANS FEE 375.00
PAGES: 1
**The above rmwrding information
verifies that this document has
been electronically recorded
Ak returned to the su bmitter
Am
Name and Return Addma
Lao A. Beekar
Attorney at Law
219 N. Main Street
Rives Falls, W 154022
040-1328-10-000
Parcel tdentificatwn Number (PIN)
This JA not,.,,. homestead property.
(is) (is nod
Grankw warrants that the title to the Propeety is good, indef"mble, in fre simple and fr+ec and clear of encurnbraww except:
easements, restrictions and reservations, if any, of record.
Dated KM e&.
LC
.
(SEAL) (SEAL)
AUTHENTICATION
Sign mue(s)
authenticated on
(SEAL)
mirninniminrmunnmw�Nrrr�.rmr�i�......ww�,wwr-rrrrw�wrrwr
TITLE: MEMBER STATE BAR OF WISCONSIN
(i
authorized by Wis. Stet.1706.06 �
THIS INSTRUMENT DRAFTED BY:
Lev A. Beskar, Attorney at Law, 219 N. Main Street, River
Falls,,
w
ACXNOVVLYJDGMENT
STATE CF W
CUNTY
�
Personally came before me on► "" ►t .rt
the above-nanAd KMw Associates LW$
to
the
mtr=ent and aclodged the same. `.i�vr�l�
Notary Public, State of
my co 'on (' ] (c pires: 063/2026 l
(Siva#nras any be adt`cati owd or mkawwkdted. Both an nei necessary.;
NOTE: TM is A STANDARD FORM. ANY ?40D CATtoN To TRW FORM SHOULD BE CLKARLY tDUMRrD.
WARRANTY DUD 0240 STATR BAR of WWONBIN FORM NO.1.2003
"Typo mono below sivab w. whwwm www.,rw m.=M
St. Croix County 116632E Page 1 of 1
PROPOSEDBUILMNG EtEVATI045 PE,R GRADING PLAN
GA,RAGE FLOOR 940.0
REAR FINISHED GRADE 931.0
L-B.o. 920.0
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f p0l INT
yz'kf.
RFAR
D11MIEN510
LINF TO 0,
I- I .—
1, 1)Uugla.5 J. zahler, WISCOl'isirl
Professional Land Sufveyor, hereby
cert I fy that this Stake -out Plao was
prepared by me or under my direct
-r,tj p ervis Cori a n d 15 co r r e ( t to the best
of my knowledge and beke f.
•M)ucal As J.
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1 54016
LEGEND
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SCALE:
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Wisconsin Deparim Y61t ' o-d6lt�' d P'ro'fessioi-Al Servic S
Division of Industry SC4'�j6e"S-
%
S IL EVALUATION REPORT
IS6 Irvic S S
C with S PS 385 Is Ad C , od c,,
Attach complete site plan o paper i:ot x 11 in�'htp-s in size, Plan must include.
but not limited to, Vertical an hqrizontal,reference point (BM) direction and percent slope,
scale or dimensions, north ar 1hd location and distance to nearest road.
Please print all information.
Personal in formation you provide may be used for, secondary purposes j"rivacy La-jv. s 15 04'1M))
Property Owner Property Loc'ation-
Ash Properties Got Lot
Property Address Lot # Block #
TBD Bella CT
Zip Code Phone Number Villa
-illy State [I city E
Hudson I 1 -540 16 I 1
387 t3e11a ct
county
ST Croix
Reyiev�Aed by /iDatp 31ZI t in 1-711
S E '/,L N W 1/4 S15 1 29 N R 19 W
Subd. Name or CSM#
Vistas of ST Croix
e FE-1 lown Nearest Po-r3d
Troy Bella CT(prop used road)
New Construction Use FEW Residential I Number of bedroonjs 4 0 de derived design flow rate 600 (-:)PD
.I Replacement L] Public or commercial — De-scl-I)e 3 Ilk - 7
Parent material Loess over loamy drift over sandy outwash (Sattre 1) Floodplain elevationf a I ble NA ft ,
General T r cornmen isUrS ofs n* pear..
ts and recommervdations Soiland ,;Ile avaluEit�on for propo--,;FA V
L F -- 660 r a tu ri d sand) I n- g r uu ri d "conventional' trench as ith 0-4,gpdMQ loa ing ra to pos s bl a al 24 d eptin
du LAI �1.0 41 0 1
I i i�oring 100-00 Depth to limiting f'actor 81 ,,1
P9 pit GfOUnd SUrface elev.
03 Armlic-Ation Rate
cy I
F) eq,,, n
Dominant Color
Munsell
Redox Description
Cu. Az. Cont. Color
Text ure
Structure
Gr. Sz. Sh,
Consistence
Boundary
Roots
_.
G P 1) ',F!
"Eff#1
tI ff#2
1 OYR 313
1
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1
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qW
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1 f
0,6
,
08
3 (5% rock)
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1 Vf
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4
38-60
1 OYR 4/4
S11
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5
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6
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cc 5
6S9
loose
0-7a 1, 6a
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saturated :sirid;
no apparent re*
x1morphicfeatures
. . ..........
[i] Boring #
Boring
FS pit Ground surface elev. 95.70 zt Depth to limiting factor 66 in,
I qnjl AnnIlir-afinn Rate
Horizon
Depth
In
Dominant Color
Munsell
Redox Description
Qu. Az- Cont, Colof
Texture
St ructure
Gr. Sz, Sh,
Consistence
Boundary
Roots
GPD/Ft2
"Eff#,l
. MAI^
41
1
0-13
1 OYR 313
2f'4rnsbk
ds
gs
2f-vf
0,6
0°8
2 (5% rock)
13-25
1 OYR 3/6
Sl
2fsbk
mfr
gs
1 f-vf
0.6
1.0
3
4
5
6
25-36
36-49
49-66
66-82
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7,5YR 414
1 OYR 414
7.5YR 314
fl f 1 OYR 4/6
L
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CW
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0.7a
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(;ST Name (Please Print) Signature CB Number
Ryan Bechel SP-1 11500001
Address Date Evaluation Conducted telephone Number,
779 Spring Creek FAD SL, Red Wing. MN 55066 06/15/21 (651) 327-0074
3 Boring #
❑ Boring
n Pit
Ground surface elegy. 102.00 ft
Depth to limiting factor ', 96 in.
Anil ❑nnlir*atinn Rate
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description Texture
Qu. Az. Cont. Color
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPDIFt2
*Eff#1 *Eff#2
1
0-10
1 QYR 3/3
- 1
2fsbk
ds
gs
2f-vf
0.6
o.8
2 (5-10% rock)
10-16
1 QYR 3/4
- 1
2f-mabk
dsh
gs
2f-Vf
0.6
o.8
3 (75-20% gnus!)
16-27
7.5YR 3/4
- grcos
Qsg
loose
cs
'I f-Vf
0.7a
I 1.6a
4
27-43
7.5YR 3/4
- Is
1 csbk-0sg
mvfr
gw
I Vf
0.7a
1.6a
5
43-56
7.5YR 4/4
- Is-sl
lfsbk
mfr-mfi
cw
-
0.4
0.7
6
56-96
1 QYR 5/4
- s-cos
0sg
loose
-
-
0.7a
1.6a
- -------------------
- - -------
I -T-
4 Boring #
❑ Boring
❑ Pit Ground surface elegy. ft. Depth to limiting factor . in.
Coil ❑n#''lliratinn Pnfa
Horizon Depth
In.
Dominant Color
Munsell
Redox Description Texture
Qu. Az. Cont. Color
Structure
Gr. Sz. Sh.
Consistence Boundary
Roots
GPDIFt2
,� *E2
r
Boring #
❑ Boring
❑ Pit Ground surface elegy. ft. Depth to limiting factor in.
Cnil ❑nnlirratinn Rata
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description Texture
Qu. Az. Cont. Color
Structure
Gr. Sz. Sh.
Consistence Boundary
Roots
GPDIFt2
*'Eff#1
*Eff#2
* Effluent #1 = BOD, > 30 :5 220 mg1L and TSS > 30 s 150 mg/L * Effluent #2 = BOD, > 30 :5 220 mg1L and TSS > 30 :5 150 mg/L
Desigrer- Ryon Bechell Apr--,w VF%L 'All propefty linr not Benchrnark
Certified Sail Tester:SP-111500001 A.- v.,A-- C E: U drawn are >100ft frorr, j.%eptic T ank-
Designer of Engineering tame- D 2263-7 Sait Boring
VZPJ system
Oftopp-
mAll+
1 1
20'
01 40,
(z -f aDuve gracie)
BM2 = 92.00 (921.23 MSL)
Top of I"x2 ti stake by
marked woodeti lathe
(5 IP above grade)
*Well to be located >25ft
from septic tok(s) and >50ft
from soil treatment area**
We rfatem has boom. *migred or4 evoivatw 'in oocordinnm wo State aNd
Lowl codes. The w Ir trectnwnt crea mu j- r e n-c red f rorn C11:1ft, bM arkd/or cornpuctiw be(nd
W WARRANTY IS MADE THAT THIS SY57EM WLL 001INMNI.X TO FUNCTX)N IN1911,4MY. Sywtum fl-RAt bu propuffy mofflftkVd. Rw.,:.Ww YCHr rywtem'v rmrogsfrwrt pkn hw 1nfwrrKrVm an pry rare and
rr,ei nter onct.
STA:
Soil and site evaluabon lot ptoposed Visas of ST Crot
plat
-1 n4;Njnd lcomertonar tFmW wfth G 4gidt bac
rste posstO at 241 deph
Z"M to restrictiori = 66" � siki.Faled saiA
-Corillw -- 100 CIO
-Slnpe -- 18%
I ()(.A I ]ON MAP (not to ecde
A51) Properties
T8D Bella CT Site Address:
Hudson, W1 54016
PIDi. 16L) (Pending plat) 1,13 Acres
Legal: Lot 10 Vista!s of ST Croix
SE 1/4 NW 1 /4
S15 T29N R19W
Town of Troy
Scale. I" = 40' Date: 6/15/21
6m&.aA
jUNTY PLA1
VISTAS OF ST CROiX
PRE UMINARY PLAT
HE PJW I Ad OF I HE Nvy too :L rHk p.'l HL 1 kj� -A PAP' C* 144E St 1.-4 E�* F
4 P A R 1 0 HF �W A OF '..P, 1111 Atj I.% OF T 14E h-t lax OF SECTION 15
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41
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--A -A
'h iscon & n 0 e r n-em of Wety and pmfessKrMl i .--31 of
wisIon of Industry Swmms
1 EVALUAT'10N REPORT
1 'his, fTl_ CodeS4& Plan Or] r
Ian 1f2 x I in�.— i rijust inc trv��
but non limited to, vortical and rrzer- � i �fr r7 �w �� . � ��
seam, or �;�finer'sions. o� arr .r r-, If) cation ar` d ...�sM. ��r �� �P �,rr�rtl ��
( 1- 0- 0
y Date
fcrr
Property Owner
_
r
Ash Properties
N R 19 w
F� O 7,11
r
W Bella i _..
..Y.
iiTnq plat
City -tat valage
r
rs af--
CT (propose -I road)
,
N c r7slrukch rl Ease. F ewden- n Fy
1
Replacement 13 P kvic Cg Cr, ,.
Parent riiaterw s ov r loamy dry' . ov � � wF tvv � 1
if app1caNe NA ft
General ewmiew,-
Pit
Sol Apphcarrl,n
Hvizan Depth
*�^�•-vex., .. _. ., .. ..,_. .,—•.^�u a ue: _. ..� •.. .®.
..
�� nr�r �'. )tr�r k6d wuc.1ure , _ .,c
06
kJ
,
r r
60
0 ''R 1.6
�. r� �• o71
e
BonrK
J 4
Pft a rev. Oepin ► la'wlw,g taclot in.
r.,
aa�il�ir1CWHMO*Deapavwn exiovIStructuie
In
au
}
I
r . o .p 1. a•.. E _ ' .._�.•r_.."'.w",,, .
- 1 — ! � �
0- 1 �@ d
'
► '% rock„ 1.3-2!> 1 OY R 3,16
25-36 7.5 YIR 4
s
36-49 7,5YR 04 -
- rift ew
°
4.
1
CST NAmQ Wleaep Prim I
..:+�• �ing�r,:.r. _. �� .oT ,r.,�•i ;''fir _
Ryan e h ei
Addr
es
?79
-d Tstephori*� Sprung Qreo-K R D eo MINI 55-gwl
Scring #
Boring
, 10100
PTI
J,round surface elev.
ft.
Depth to limkin
g f9dor in.
Soil Application to
Horizon
Depth
Domirart Color
Re�dox Necrohm
Textum Slnxture
Cormister�ce
Boundary
Rods
GPW,
In-
Ou. Az. Com Color
Gr, & . . Sh.
F
--
*E 17' 'Eff*2
0-10
1 OYR 3/3
2fsbk
ads
gs
2f- Vf
0.6
(!5-1 n% (Cw*)
10�46
110YR 314
2F-mabk
9S
V-vf
0,6
0.8
g" j
16-27
7.5YR 314
WCOS
loose
1 f-vt
03a
1,6a
.4
27,0
7.5YR 314
IS
mvf r
9w
1vf
Va
1.6a
5
43�56
7-5YR 4J4
IS-SI lfsbk
mfr-mfi
Cw
04
0.7
56-96
1 OY R 51-4
S-Clos Osg
loose
0-7a 1-6a
Soriry E Bor) N
El P Gl-o4,� sLirface elev. ft DePth to limiting factor In
SOW ��Ion Ra T-
Horizon Depth Dominart Cobt Rix Description Teidure af!XtUM Consistenoe Boundary Roots GPD/W
In, Munsell Ou Az, Cont- Cdor fir.. Sz- Sh.
*Effol "Eff#2
Boring 0 13 on ng
PA Ground surfma okw, ft. Depth to 1 im 4. fwtor
Scil APPIKabon Re
Horizon Depth Dominarl Color Redox Descriptmi Textwre Structure Consistence Boundary Roots GPCVFt2
In. Murr Sz mall 'Qu. Az Cont, Wor V.,
G Sh
Tffoi !#2
I *Eff
"Effluent #i = BOO, >30 5 220 MQ& and TSS >.Ati s 150 mg I * Effluent 92 = BOD. :11, 30:9 220 m9A. and TS S � 30 ic 150 nuyL
3es�. Ryw Bechd
.014�.fsed SA Tester. SP-11150DO01
3eupw of Enginminq Systemv D 22637
SCALI
- - -----------
20
40F
17w-j
%
13M i
4z 4
Cri
10
a
Q) D
0
**VVell to be located ;o,2-Sft
frovn 5eptic tank(s) and >5
from soil treatment area"
cl�
Y 1 41
............. P
At
come SEVIOMML 71,M VIwn bw bmr, dMqrtw old &OWUOW in nccordw" wft SM OW WOW Oud" Pba 30M b*utffcm MW ftVwt t4wnw OW/Or MrMPWtW1 WOM Olhd at7tw
NO %YWMO" 15 INORM RHIAJ T FAK SYSTtW V 14 �:XWTOklTe) It F1*7tMW PJOEFV*My�I MAT fm �' rA16 RM4W V"W PW COF ifOOMOGE" Vn OrtIPW C7WV Mr5d
BM 1 100.0,0
TOP Of V PVC pipe
(24" above grade)
BM 2 = 9 2.00 (9 2 1.2 3 MSQ
Top of I PW" stake by
marked vofj,�,dtn lathe
Iie
4
i [sal
o', jrit�
At iAwffi'. A A' jFl-: -
I t1fd
C'Q
LOCATY,
12
lit
1, 13 At
of S - Olc�A
S1
Town of Tro
OWNER I t1tay.- V wsaa........
. .. .. . . . ... ... ..............................................
PLUMBERLIC.# 2313%
TOWN OF T�ov
sr-ju Nq �M
AND/
. ?Me )(
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
OF ZRI-o lJ CrTDTi`77 C�rOl�7 the permit, please contact the cauuty authority.
al)11 /V 1�71 11
Vn Ilk, AUTHORIZED ISSUING OFFICER — DATE
............. a ......... . . . . . . ... .. . .. . .
THI PERMIT EXPIRES IVAzY202f UNLESS RENEWED
. .. . .. ......... . .... . ... .. .............
. ... ... . ...
SBD-06499 (RI 1/20)
7/zSJ2a3