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HomeMy WebLinkAbout645433 006-1065-50-000Wisconsin 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 ] Permit Holder's Name City Village Township Four Corners Farm LLC TOWN OF CYLON Sec CST BM Elev linsp BM Ele BM Description _ job -� 20 I BD,pr 1`� 20 PUN w-j.Q TANK INFORMATION ELEVATION DATA TYPE n M UFACTUR CAPACITY Septic 12 5-ORP c t q �piESEi2 tY ICSL L T,4.rc, TM Aeration Holding TANK SETBACK INFORMATION TANK TO P!L WELL BLDG. Vent to Air Intake ROAD Septic Do D Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand G 6S GPM Model Number ie;nD l TDH Lift o c^ Friction Loss System Head I DH Ft Io "X,nk) Forcemain Length Dia t r Dist to well SOIL -ABSORPTION SYSTEM county Lo404SS St. Croix Saritary Permit No 645433 Sia!e Plan ID No Parcel Tax No 006-1065-50-000 ge!Map No 29.31.16.453 STATION BS HI FS ELEV. Benchmark Tp ivkb4 7D 2D Alt BM B I d 7 Sewer ( 75 (o iW ---,- 20 sal 9a-Y� 9�•oSr SI/Ht Inlet „may `r6 r q6•�s StfHt Outlet �Sl 96-1s DI Irises Dt Bottom L! 9 7 0 Header/Man �. 30 75, 3(0 Dist. Pipe Bot System rr / Final Grade # i p St Cover op 0,0 Lop- e I L i00- o 1 B E DIMENSIONS Width I Len Trenches NM PIT DIMENSIONS No Of Pits Inside Dia Liquid Deptn SETBACK INFORMATION SYSTEM TO P/L JOLDG WELL LAKE/STREAM LEACHING CHAMBER OR UNIT Manufacturers .�^ �ylhka5r Typo Of System. J j �S / /1 l4 1 f� / (/ / Model Nurn7p �r �i II D DISTRIBUTION SYSTEM HeadedMamfold t( ( Di 'bution P'pe s) x Hole Slze x Hole Spacing-7 ent io it ake Length -` 1 Dia1(!nOKDia Spacing SOIL COVER x Pressure Svstems Only xx Mound Or At -Grade Svstams Ontv Depth Over Depth Over xx Depth of xx Seeded"Sodded xx Mulched 8ed/TrertGt Center BedlTrench Edges Tapso,l Yes No Yes No ,COMMENT 44include code discrepencies. persons present. etc.) Inspection #1: S/lz(2o23 KC,tK.�,� � �he�, 2 v ch-. j sue. G7,o `s� �h r�{s ocat on: 219 WY 63/64 1.) Alt BM Description = 2.) Bldg sewer length = 1> y",,se „.i C.it&- _ Q � "�"�'��`� `, -amount of co r= ac� - I ' jd g•3� ' 3)1,�r�rtl1�'" Plan revision Required? Yes x Noj'��3 l20 2 3 Use other side for additional information. ,. (�_.� SBD-6710 (R.3197) a Insepclor's Signature ^(�P l ar�e�3,D'u&v4P section #2: S� C1eyQt�lns `ID a/3, 97 93rz� �2rt JC t,^ J apANY sp,A Department of Safety itrL County CROIX & Professional Services, Sanitary Permit Number (to be filled in by Co ) i OCT1 1 2022 � Industry, Servi Di io ' f ��3 ' -7 Transaction Number � co t pplication � tate In accordance with SPS 393.21(2), Wis Adm Code, submisswn ofthis form t4►the appropriate governmental unit �. is required pnor to obtaining a sanitary permit Note Application forms for state-oowned POWTS are submitted to the Department of safety Professnona) Services o}ect Address (iORNE arxi Personal information you provide may be used for secondaryu sin accordance with the Privacy Law, s IS 04(I)(mI. Stats2196 HWYf. A licstioa Iaformstioa — Please Print An Wo Property Owner's Name - " *— Parcel N FOUR CORNERS FARMS LL 006-1065-50-000 ` Property Owner's Mailing Address Property Location 2173 CY RD H )rw cost Lot City, State Zip Code Phone Number DEER PARK WI S E SE vsecuon2 9 `I Ty* 01 B„ Nd1I ft (9b0ek AN ) H x ` ,7 0 1 or 2 Family Dwelling- Number ofBedrooms 8 Lot N -1 31 N R 16 E or X Subdivision Name Block N ❑ Public/COmmcrclal - Describe Use ❑ City of iL S LY —` ❑ S Owned -Describe Use ❑ Village of SM Number l 0 Town of CYLON In lam sm" ft ew" or "ilPbtdatttrmC aid alias appNaajk om IMF A. Cbnk art bull nta rand & Complete line C i w A ® !!tjIgm ❑ Replacement System ❑ Other Modification to Existing system (explain) ❑ Additional Pretreatment Unit (explain) B. ❑ HoldingTank In -Ground ❑ At -Grade El ❑ Individual site Design ❑ Other Type (explain) (conventional ) C- ❑ Renewal Before ❑ Revision p I ❑ Change of Plumber ❑ Transfer to Nett 0wrier ist Previous Permit Number and Date Issued Expiration ( abiIiiiriiiiiiUrmtneW Area and Tank Infattmadaat �•• Design Flow (gpd) Design Soil Application Rate(gpd/sf) rsal Area Required s q (f) Dispersal Area pe Proposed ( ystem Elevation 600 .5 1 1200 1 1200 STEP 93.9 94.4 94.9 Tank Information CapZry in Gallons Tool Gallons N Of Units Manufacturer o $ u Nary Tanks Existing Tama 11111111 � uy - ( Septic or Holding Tank 2 2250 2 WIESER Dosing Om"her X 750 SFR /` V. ResponisibUk Statement- L tl a umkraigaed, a"em rupoasiblillty for iadtafatba of tie POWTS diva M drib attaebd Plumber's Name (Pent) Plumber's Sigrid re MP/MPRS Number Business Phone Number PAUL R KOEHLER �� 225410 1715-246-2660 r Plumber's Address (Street, City. State, Zip Code) 321 WISCONSIN DR NEW RICHMOND WI y Approved ❑ Disapproved Permit Fee i Date Issued Issun Agent 5ignatu ❑ en for Denial �� rD� ZO t' 11 Conditions Approv eo121-for-f3tsappiural 8 SYS M OWNER: 3) OCL P-d 1. ptic tank, effluent filter and dispersal cell Lo must be serviced 1 maintained as per rwcp'3 !. nagement plan provided by plumber. j .0 setback requirements be �l S'�-�'° must maintained A eo PLO— f1b, slw —Ism iW subbmV- it to Me C rely� net A a , in site Tc SB 398 7/22) 5A F© L) r C Ornv.cS far ms Pay cc,0 ooG- logs 5C,> s r-� se. -)l T31 N R Ib W To L.) 1-b ri S-Y cro r G Du t� i V 1 &Y\C�Imofk 1 P;+ 3 qs ;9b �InPC- b To p pi loo ToA of a Pv gg,ab K--eti►X-,f a-1s�/0 pis-1y[ - zero 3Z1 ,Sco„S;h Qp•d4- C4-) 1�� m01not LA.)' jJ(C J c3 #,44 ffr", e;43 z190 140r �3�b 645433 CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: FOUR CORNERS FARMS Owners Name: DAVE GOODRICH Owners Address: 2173 COUNTY RD H DEER PARK WI 54007 Legal Description: SE 1 /4 SE 1 /4 SEC 29 T 31 N R 16 W Township: CYLON County: ST CROIX Subdivision Name: Lot Number: Parcel ID Number: Designer/Plumber. Date: 006-1065-50-000 Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing $ Cross -Section Page 4 Fitter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans PAUL R KOEHLER License Number. 225410 10/07/2022 Phone Number (715) 246-2660 Signature Designed pursuant to the In Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01101). Page 1 1 4ztm 11 ,Y ti7� r).rr 'ovSb ---)n(i z � Q C,°l 001 I,^ri , 06-tl 'M f°yaW `1-DI M7M 07?Z -7hy 'SIG 1^Wd qa h��4IS r� 71 N bi. n o� 645433 SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT Page or 1 Project Name: FOUR CORNERS FARMS (DAVE GOOD RICH ) 3 No. of Cells 3 n Cell Width 80 n Cell Length 3 n Cell Spacing 8 Per Cell 24 Total No of 10 50 sq 1t EISA Per Cell 1200 sq n Total EISA Man ufac$IIar YMod I wino I —M CIQA DEM_ Inflb*W Q1203H-5R SAY 25.0 EZ1203H-1oft 10.0' 50.0 Graveliess Leaching Unit Manufacturer EZ FLOW Graveiiess Leaching Unit Model: Finished Grade ft EZ 1203H - 10 Typical Cross Section Observation Pipe with approved cap or vent r,. ■ ` Soil Backfill In ■ 1� : r ra Geotextile Fabric ■ it Infiltrative Surface 12 in Q n Limiting Factor y� �0 Slotted and Anchored Vent! Observation Pipe with Cap ■■■r■a■■•r■rr■■■r■rrwriii�r■■r■rrr■r■■rrr■rr■■■■r■■■■■r■■■rrrr■r■■r■■■rrr Plumber/DesignerSignature: ucense M 225410 Date: OCT 7 2022 �4A5GE 4 OF 5 GRAVITY -DOSED SEPTIC 1 PUMP TANK SPECIFICATIONS „­__.h__ (No Scale) IMPORTANT: X "wu `- Anchor tank(s) as necessary pursuant to SPS 383.43(8)(g) Finished GradeBEENEENER CAPACITIES @ 600 gaifin Depth (in) Volume (gal) A 25 403 B 2.0 32.24 [c] s ao.s D 8 128.96 * T .IA e �Pump Tank Liquid Level 16.12 in Pump 0 Force Main Diameter = 2 in MEN Elwin®I mull comply with SPS 316 and NEC 300 �Weatherprooi Junetbn Boa fAinighl Seal Weep Hole ' _Alarm �off Lconcrate ]� Bkx* Extend manhole ricer as necessary. Approved Locking Manhde with Warning Label Attached (typical) 4' Min. or 2.0 It above EstabYshed Flood Elevation Quick Disc onned 18' Min. (typical) i Approved Joints with Approved Pipe 3 n onto Sold Ground (bail) PUMP -OFF ELEVATION = 88.65 ft Force Main Length = � 40{t 3' Approved Bedding Material Beneath Tank Force Main Void Volume=5�lgal [C] Total Dose Volume (TDV) = 80 gal/dose (` 0.2X design flow + force main void volume) Vertical Lift = 5'25 ft PUMP TANK; Volume = 600 gal Manufacturer. WIESER Pump Manufacturer: GOULDS Pump Model: EP04 (See attached pump curve.) Controls/Alarm Manufacturer. SJ ROMBUS Controls/Alarm Model: PS PATROL Float switches containing mercury are prohibited INSIDE BOTTOM ELEVATION = $7•9 ft SEPTIC TAWS): Total Volume = 2000 gal Manufacturer(s): WIESER Install approved effluent filter at the septic tank outlet immediately tr m f them tank inlet, Filter Manufacturer: POLYLOCK Filter Model: 525 Wastewater TIT METERS FEET 10 9 30 25 7 2 V 6 20 Q 5 © 15 -4 4 ~ 3 10 2 5 1 0 L 0 5 GPM 2211.5 FT -- __ _ EPOS --- --- --- ___ _ EP04 . —_-- - 1 - 10 20 30 40 50 P,pkfi 1 1 / 1 1 1 1 0 2 4 6 8 10 12 ms/h CAPACITY MODEL INFORMATION Order MP Vohs Amps Minimum Circuit Phase Float Switch Cord Discharge Minimum Minimum Minimum Basin Maximum Solids Shipping Weight Number Breaker Style Length Connection On Level Off Level Diameter Site lbs.kg EP0411 .4 115 12 20 Plug / No Switch 10' Manual Manual 20 / 9.1 EP041 1A Piggyback / Wide -Angle 10' 12" 6' 21 / 9.5 EP041 1 F Plug / No Switch 20' Manual Manual 20 / 9.1 EP0411AC Piggyback / 20' 12. 6' 21 / 9.5 1 Wide -Angle 1 2. 15. Y:` 230 6 10 Plug / No Switch 10' Manual Manual 20 / 9.1 [0EP0511F Plug / No Switch 20' Manual Manual 2019.1 .5 115 13 20 Plug/ No Sitch 20' Manual Manual 22110 EP0511AC Piggyback / Wide -Angle 20' 12' 6' 23110.4 EP0512F 230 6.5 :1:01 Plug / No Switch 20' Manual Manual 22110 PAGE 3 645433 nm!! rIm PL-525 Effluent Filter of Pottlok hc. 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. • Alarm accessibility. • Accepts PVC extension handle. PL-525 Installation: Ideal for residential and commercial waste flows up to 10,000 gallons per day (GPD). 1. Locate the outlet of the septic tank. 2. Remove the tank cover and pump tank if necessary. 3. Glue the filter housing to the 4" or 6" outlet pipe. If the filter is not centered under the access opening use a Polylok Extend & Lok or piece of pipe to center filter. 4. Insert the PL-525 filter into its housing. 5. Replace and secure the septic tank cover. PL-525 Maintenance: The PL-525 Effluent Filters will operate efficiently for several years under normal conditions before requiring cleaning. It is recommended that the filter be cleaned every time the tank is pumped, or at least every three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the filter needs servicing. Servicing should be done by a certified septic tank pumper or installer. 1. Locate the outlet of the septic tank. 2. Remove tank cover and pump tank if necessary. 3. Do not use plumbing when filter is removed. 4. Pull PL-525 cartridge out of the housing. 5. Hose off filter over the septic tank. Make sure all solids fall back into septic tank. 6. Insert the filter cartridge back into the housing making sure the filter is properly aligned and completely inserted. 7. Replace and secure septic tank cover. 1/16" Filtration Slots 10,IX10 GPD Accepts 4" & 6" SCHD 40 pipe Outdoor SmartFilter6) Alarm Polylok, Zabel & Best filters accept the SmartFilterl) switch and alarm. Accepts 1" PVC Extension Handle 525 Linear Ft. of 1/16" Filtration Slots Extend & LokTM Easily installs into existing tanks. Polylok, Inc. 3 Fairfield Blvd. Wallingford, CT 06492 Tall Free: 877.765.9565 Fax: 203.284.8514 www.polylok.com W1250/750—MR TANK SPECIFICATIONS a a I 1 2 - 1 " DIMENSIONS: o WALL: 2 1 /2" 4" CAST -A -SEAL 4" CAST -A -SEAL BOTTOM: 3" COVER: 6" __—__====CIS==== MANHOLE: 24" I.D. PRECAST CONCRETE RISER i Iru HEIGHT: 66" rr II II a LENGTH: 12*-11" rr a i i i i WIDTH: 7'-2" i;' �i {P10 �� BELOW INLET: 53" r' r'- Ir'^'� �+ r I LIQUID LEVEL 48" IT WEIGHT: 14,860 LBS. o' �� `_ `• I� \' 71 INLET AND OUTLET: $ r FILTER OR J I I i i ,�� 4" CAST —A —SEAL BOOT OR EQUAL GASKET m BAFFLE i i i i /ter INLET AND OUTLET BAFFLE AND FILTER: w WISCONSIN, SEE DETAIL #10 Znj in o 11 (OTHER STATES SEE CHART) W .9 TOP VIEW LIQUID CAPACITY: 27.66 GAL/IN (SEPTIC) ; 16.12 GAL/IN (PUMP) X ul cD LOADING DESIGN: 8'-0" UNSATURATED SOIL C00 TANK CAN BE USED AS: v o a j SEPTIC/SEPTIC. SEPTIC/SIPHON, 4" VENT OR SEPTIC/SIPHON o � I COVER: MIX DESIGN /8 (NO FIBER) Lu o tD TANK: MIX DESIGN #10 (STRUCTURAL FIBER) _ °O 4 _ _ _ _ _ _ _ _ "JD CUSTOMIZED TANKS: TINLET - _ - _ - _ OUTLET FOR CUSTOM TANKS CONTACT WIESER CONCRETE el I: 'n I m v I II i -`A a cp r U a z lr_ 00 I Ln I l a Ln Elf Q Z to ++ REVIEWED BY p c� PUMP PAD REVIEW DATE 04 a- _o DRAWINGS SUBMITTED 3 v) SIDE VIEW FOR APPROVAL APPROVED BY: SHEET NO. APPROVAL DATE: j lz TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS I. PRODUCTS NEEDED BY: �r 1 4" CAST 0 w as w Ln INLET � =y,r Li) r7 = a 1 I i WLP 1000— M R GREASE INTERCEPTOR TANK SPECIFICATIONS 4" CAST —A —SEAL DIMENSIONS: WALL: 2 1 /2' BOTTOM: 3' COVER: 5" MANHOLE: 24" I.D. PRECAST CONCRETE RISER HEIGHT: 53 1 /4' LENGTH: 8'-8' WIDTH: 7'-2' BELOW INLET. 42' LIQUID LEVEL: 36' WEIGHT. 6,790 LBS. INLET AND OUTLET: 4" CAST -A -SEAL BOOT OR EQUAL GASKET INLET AND OUTLET BAFFLE: AS SHOWN LIQUID CAPACITY: 27.83 GAL/IN LOADING DESIGN: 8'-0' UNSATURATED SOIL TANK CAN BE USED AS: GREASE INTERCEPTOR COVER: MIX DESIGN #8 (NO FIBER) TANK: MIX DESIGN #10 (STRUCTURAL FIBER) CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE } OUTLET Ln 0 _ a Q' ;.� "-PUMP PAD TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 & C-1613 REVIEWED BY REVIEW DATE DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: APPROVAL DATE: PRODUCTS NEEDED BY: cr J � a Z 0 0 U a F a W SHEET NO. OF / 1 645433 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Rage I of Z FiLE INFORMATION Owner FOUR CORNERS FARMS LLC Permit / DESIGN PARAMETERS Number of Bedrooms 8 ❑ NA Number of Public Facility Units ❑ NA Estimated flow (average) 400gal/day Design flow (peak), (Estimated x 1.5) 640 al/de Soil Application Rate •5 al/d /te Standard InflusWEffluent Quality Monthly average* Fats, Oil & Grasse (FOG) 00 mg/L Biochemical Oxygen Demand (BOD,) 5220 mg/L ❑ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BOD6) 530 mg/L Total Suspended Solids (TSS) 530 mg/L ❑ NA Fecal Conform (geometric mean) 5104 cfu/100ml Maximum Effluent Particle Size Y, in die. ❑ NA Other: ❑ NA `Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS Septic Tank Capacity 1250--- 1000 al ❑ NA Septic Tank Manufacturer WIESER ❑ NA Effluent Filter Manufacturer POLY LOCK ❑ NA Effluent litter Model 525 ❑ NA Pump Tank Capacity 750 al ❑ NA Pump Tank Manufacturer WIESER ❑ NA Pump Manufacturer GOULDS ❑ NA Pump Model EP04 ❑ NA Pretreatment Unit ❑ Sand/Gravel Fitter ❑ Peat Filter ❑ Mechanical Aeration ❑ Wetland ❑ Disinfection CK Other: (p NA Dispersal Collis) ❑ NA 0In-Ground (gravity) ❑ in -Ground (pressurized) ❑ At -Grade ❑ Mound ❑ Drip -Line ❑ Other: Other GREASE TRAP FOR ❑ NA Outer: KITCHEN WASTE ❑ NA 1e� ❑ NA Service Event Service icy Inspect condition of tank(s) At least once every: 3 ❑ monthial (Maulmum 3 ears) ❑ (s) y EJ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Ya) of tank volume ❑ NA Inspect dispersal cellls} At least once every: 3 ❑ month(s) (Maidnrunt 3 years) ❑ yearls) ❑ NA Clear] effluent filter At least once every: 1 ❑ months) • (X yearls) ❑ NA Inspect pump, pump controls & alarm At bast once every: 3 ❑ month(s) [39ar(6) ❑ NA Flush laterals and pressure test At least once every: ❑ monthisl ❑ ow(s) ILL NA Other. At least once every: ❑ month(s) ❑ year(s) ❑ NA Other; PUMP GREASE TRAP ONCE A YEAR /OR AS NEEDED ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cells) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a falling condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third %,) 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, shad 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. 645433 START UP AND OPERATION Page _? of 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 celils), 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 calls. 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 safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. 0 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 lines and wails. 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. �� alua e ai P_ Ai V1) 4Z !`J5TRLJC_?i 0 lank �a+�113 rr+>�. 7% ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < < WARNING > > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name COUNTRYSIDE PLUMBING Name PAUL R KOEHLER Phone 715-246-2660 Phone 715-246-2660 SEPTAGE SERVICING OPERATOR IPUMPER) LOCAL 'REGULATORY AUTHORITY Name POWERS SEPTIC Name S"i C ( 2oA f �'0 Phone 715-265-4623 Phone —7/ ; — 3W(Q_ (v ) This document was drafted In compliance with chapter Gomm 83.22(2)(b)(1)Id)&(f) and 83.5401, (2) & (3), Wisconsin Administrative Code. 645433 ST CR0 NTY SANITARY SYSTEM File #: Office OWNERSHIP/ADDRESS FORM 1202T r 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. 0"ER/8UM INPORMMON . F Owner/Buyer FOUR CORNERS FARMS LLC Mailing Address 2173 CTY RD H City/State/Zip DEER PARK WI 54007 Phone Number (required) 715-781-1500 Email Address (required) Parcel Identification Number 006-1065-50-000 (found on the property tax bill) Property Location SE 1/4 , SE y, , Sec. 29 . T 31 N R 16 W, Town of CYLON Subdivision Plat: © + OC-47 Lot # Certified Survey Map # Volume . Page # Warranty Deed # 1 03 C! (before 2006)Volume Page # Number of bedrooms Spe� house 0 yes ■ no Lot lines identifiable res ■ no r l rti n r^ n New Property Address A-Y-4 Z f a 4S, Nerific lion &C4 P im 4 munity Development Departt for new construction.) (Staff Initials) (Date) This form must be submitted with all Private Onsite Water Treatment System (POWTS) applications. New System: Include with this form a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. Community Development Department - Land Use Division 715-386-4680 St. Croix County Government Center 715-245-4250 Fax cdd@sccwi.aov 1101 Carmichael Road, Hudson, WI 54016 www.$ccwi.Qov a GYM O Rot r 'i. RD[ H RE[ r _V LMOon! i NMOM Y�IDOw t � BATHROOM i m BEDROOM 1 — . BEDROOM 2 BEDROOM 9 �----� BEDROOM 4 I I ~ ioaaM t o I A t zr rer �t BEDROOM 5 1I'�l d n t � Rip n l � /--OVF{tN BEDROOM 5 CUSTOMERSIGWTURE: — _ -- -.— s � aw r • ----. BEDROOM 7 BEDROOM 8 I d d qp nwoow � ff 4 Qom GNiRICH tN1VE � f 7.620¢2 O) NEW wCHMOND. 10.32M (TI HOUBtt1G •ur re A 2 W 57-- 2-4 2-2 + Q043 I ssionalServices Page 1of 3 IL EVALUATION REPORT TA O C T 1 1 2022 In aance with SPS 385, Wrs. Adm. Code County CROIX Attach complete sit plan on paper not less than 8 1/inches in size. Plan m inGtit not limited to ve ical ands-W - "#lam po), direction a cen pe. Parcel I.D. scale or dimension n S� "Ato nearest roa D06-1065-50-000 Please print a onrratlon. 'Rep6wed by I Date Personal information you provide may be used for secondary purpo (Privacy aw, s. 1 . (1)(m)►. _eU46" Property Owner ❑ Property Location FOUR CORNERS FARMS LLC Govt. Lot SE v. SE % S 29 T 31 N R 16 E (or) w Property Owners Mailing Address Site Address or CSM and Lot 0: 2173 CTY RD H City, State, Zip Phone Number ❑ City ❑ Village ® Town Nearest Road NEW RICHMOND WI ( ) CYLON (A New Constnuction use. LJ Residential/Numberofbedreoms4 Code derived designflow rate 1200 GPD ❑ Replacement ❑ Public or commercial - Describe: Flood Plan elevation if applicable ft. Parent material GLACIOFLUVIAL DEPOSITS GRAVELY OUTWASH General comments and recommendations- 6) Pori 1 Pon #� ®Pit Ground Ground surface elev. 97•g�n ft, Depth to limiting factor 76 in. / elev. 6•3 ft, Soil Application Rate Horizon Depth In, Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/F12 •Efhr1 'Eff*2 A 0-9 10 YR 3/3 OMSG ML CW 2F .7 1.6 B 9-19 7.5YR4/4 SL 2MGR MFR GW 1 VF .6 1.0 B1 19-31 7.5 4/4 -------_--_ FSG 2MW MFR CS 1 VF .5 1.0 C C1 31-36 36-41 7.5YR4/6 --------- SL SIL 2 M SBK 2 MSBK IML MVFR CS --- -- .6 .6 1.0 C2 10 YR6/3 -------- ---- FSG 0 F SG ML . Boring ar ❑Boring �re/T Z On Ground surface elev. 96.80ft. Depth to limiting factor 102 in. / elev. $.5 ft. Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cone. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots n ry.Mn.. GPD/Ft2 'Eff*1 'ENr12 A 0-20 10 YR 3/3 — LS OMSG ML CW 2 M .7 1.6 B 1 20-27 10 YR 4/6 SL 2 M GR MFR CS 2 M .6 1.0 61 27-34 7.5YR4/6 SL 2 M SBK MFI CS 1 2 F .6 1.0 B2 10 YR 4/6 SG 0 F SG MFI CW 2 F .5 1.0 133 YR 614 SG O F SG ML CW 2 F 5 1.0 134 7.5YR4/4 - SIL 2 ABK MFR 2 F .6 CST Name (Please Print) PAUL R KOEHLER Signa -yG �_ CST Number 225410 321 I ISCONSIN DRIVE NEW RICHMON Vat Evaluation Conducted SEPT 14 2022 Telephone Number 715-246-2660 Effluent #1 - BOD > 305 220 mg/L and TSS > 30 5150 mg/L ' Effluent 02 - BOD, s 30 mg/L and TSS s 30 mg/L SBD-8330 (R03/22) Fa wM 64`43 2 of 3 age — Boring * ❑ Boring ® Pit Ground surface eiev. 95.9 ft. Depth to limiting factor 96 in. / elev. $ ft. Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az, Cont. Color Texture Structure Gr. Sz. Sh, Consistence Boundary Roots GPD/Ft' 'Effs1 'Eff*2 A 0-10 10 YR 3/3 LS 0 M SG ML Cw2 M 1.6 B 10-36 7.5YR 4/4 SL 2 MABK MFR CW 2 F 6 1. B1 36-51 10 YR 4/6 SG Oi_E SG ML CW 1 F .5 1.0 C 51-72 10 YR 6/4 SG OP G ML CS ____ 5 1.0 C1 72-96 7.5 YR 4/4 ----------- SIL 2 M ABK MFR ----- J--O- WES Boring * ❑ Borng ❑ Pit Ground surface elev. ft. Depth to limiting factor in. / elev. ft. Soil Application Rate Horizon Depth In, Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft' `Efi*1 'Eft*2 F7 Boring * ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. / elev. ft. Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr, Sz. Sh. Consistence Boundary Roots GPD/Ft' 'EthR1 I 'Eff*2 Effluent *1 - BOD > 30 S 220 mg/L and TSS > 30 S 150 mg/L ' Effluent *2 - SOD, S 30 mg/L and TSS S 30 mg/L ml �- ) � rod 7N nr a� I b-�was �`� 3 S 3 S cu C� U a U U U) 645433 0 v Ln g ao r 0 0 S C a O r • S —s40k �� Ivwt st'zr4o Hwr� ��.'(gor�c COUNTY•8 �) No. 645433 bey STATF��SANITARY,PERMIT nUU N --- AL PREVIOU�$ NO, - OWNER -k*U PLUMBERQAMI,, K06#w LIC.# 2151J10 TOWN OF rY► wi► SEC , AND/OR LOr _3_LN9 R Ns 10 PERMIT EXPIRES BLOCK SUBDIVISION ISSUING OFFICER - x CHAPTER 145135 (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. (1) 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. DATE Iv/11I202 L UNLESS RENEWED BEFORE THAT DATE POST IN PLAIN VIEW p co VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION c' SBD-06499 (R11/20)