Loading...
HomeMy WebLinkAbout040-1316-14-000 ,n Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix and Building Division Sanitary Permit No: INSPECTION REPORT 556398 0 rENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: rsonal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)]. rmit Holder's Name: City Village X Township Parcel Tax No: Dassow, Jodi & Barbara Troy, Town of 040-1316-14-000 CST BM Elev: Insp.BM Elev: BM Description: Section/Town/Range/Map No: / 00 13/'vl I G`c7T 05.28.19.2070 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER t CAPACITY STATION BS HI FS ELEV. Septic, / Benchmark C /6 .5 /Qes W 1_ -(– G100 • 7 /6?, .5 wP�J�S f 1 L4s3 J Alt. BMF,�� D �/� P We. �zS !" Lo.m..1 Aeration Bldg.Sewer —2.5 // Z Holding St/Ht Inlet / 3. 5 [//Q V St/Ht Outlet TANK SETBACK INFORMATION 3,12, /O 7 TANK TO P/L WELL i BLDG. Vent to Air I taP ke ROAD Dt Inlet Septic �'/ .-'7 / / ��r Dt Bottom ....,. Dosing Header/Man. 4A 4 /'3. G Aeration Dist. Pipe ! S.(36 /d3' fS /,a (445 /6Z• 65� Holding Bot.System to,416 /62- 67 _ /2 7. 115 ,o, , Final Grade �' t /�5. ,/ PUMP/SIPHON INFORMATION `7' Manufacturer Demand St Cover ,...• -- /� �"—� GPM O Jam, V + C /16 . 1 Model N b TDH I Loss Syste ad DH Ft Forcemain Length `--DIa. Dist.to Well SOIL ABSORPTION SYSTEM ( ot,,ciyailt).44 r� 3 etl s)BED/TRENCH Width f Length No.Of Trenches P DIMENSIONS No.Of Pits Inside Dig_ Liquid Depth DIMENSIONS '3 ` 6' Z I/e —� SETBACK SYSTEM TO / P/L BLDG WELL LAKE/STREAM LEACHING Manufact e INFORMATION ' / CHAMBER OR ' ,tN'e,► Type 9f System: 4 41( '13 I . /� UNIT Model Num Cl A oH,u N IriQf..-,iG�_ DISTRIBUTION SYSTEM 17 4.-T-7 1 34 ilkildl Header/Manifold Distributio x Hole Siz� x Hole Spacing Vent to Air In ake Pipe(s) „" e S Length Dia Length Dia Spacing` SOIL COVER Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of,, xx Seeded/Sodded xx M ed Bed/Trench Center 3.S Bed/Trench Edges �R Topsoil ` Ich No es E No COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: .7 / 21 / 13 I pection#2: / / Location: 509 Autumn Blaze Trail Hudson,WI 54016(SE 1/4 SW 1/4 5 T28N7R19W)�Cedar)Woods Lot 14 Parcel No: 05.28.19.2070 1.)Alt BM Description= • 't L% J�� �G.� `�""� �f 5f f�5 / 2.)Bldg sewer length= 3 8 ✓` �',t,ti. -amount of cover= / 00 8sek d.s., � v1 f`L� , fief A) LLa'Plan revision Required? yYes No Z (� 6 �/7,� Use other side for additional information. I /3 Date Insepct s Sign a Cert.No. ID-6710(R.3/97) -Pio Z Mett,•p Alitine 4(3(11.1 if-tits(4)ivtilz, 0 p.ssob.) 37111\ -Bo IA s+ a . te er tcroillison o .c /L. ocRiD istegie **42ittiol '''e,--------T--,k4— 7 34„ • V S(.11`4 b f\I L Fq2k 14.1.2"jQA6,„ I Lk 33'01(4 ait4 t 37 i citatC\ 4,0 .01 .V.'■ al 10S-) 3)k Lp 0 • ..01 -”' ' ' \ . . ID y . rPji OA' 1 1 . (00' \ Pal,(-14V.fi\I'l 420 , • r'Dn.oUbe\ \ T1V h i 0 I I') i I U ..7 OPS iN U1-{ 5 \ ,, Lit 0 i i - \ • ' . I i I •,, I , I i ‘, 1 i' i. I ,„-----m-- __ ,,.. , ---- '';'•:')5, •----_, -. <---, ■ _. v "��A.::,,:, ,,,, a" County Safety and Buildings Division Cizo i' x {��f "`r 2011 W.Washin ton Ave., P.O. Box 7162 #" g Sanitary Permit Number(to be filled in by Co.) � irF °_ Madison, WI 53707-7162 tH n Sanitary Permit • t it 1 ',.,I State Transaction Number v In accordance with SPS 383.21(2),Wis.Adm.Code,sub.r' si 1 f I• ' - (//+'is required prior to obtaining a sanitary permit. Note:A ��' s e appropriate governmental unit the Department of Safety and Professional Servies. Per .Y' inf arms for ned POWTS are submitted to Project Address(if different than mailing address) purposes in accordance with the Privacy Law,s. 15.04(1 (m),Sta you provide mie used for second. ' I. Application Information—Please Print All Information �� ��� d ��� - Property Owner's Name ���� QubS aN �.,'JS G o ® Parcel 4 a Al2bAIWA DAjSS0(,v s Fps. OV0 - ! 3ll,- 1y-000 Property Owner's Mailing Address — < f r C/6 �/� Property Location / 5©9 A4i N D)Sze TA, I °/NCO `.a o'70� City,State Zip Code &a, Govt.Lot ff.11� Phone Number SE %a, l,vTj$D�I V�1�.S�' O1 S W /<, Section 5' (circle one) II.Type of Building(check all that apply) Lot T—°--$N> R _E or W ❑I or 2 Family Dwelling-Number of Bedrooms 41 Subdivision Name Bloc. CepAg. 1Joobs ❑Public/Commercial-Describe Use l f •,' L,/ - �y / ,�v( ❑ City of_ ❑State Owned-Describe Use _ "� �� CSM Number ❑ Village of 2 �r6 - t.�u b ' / a�i ,vM7liS a �� r) ❑ Town of l LO — I III.Type of Permit: (Ch 'v k on y o e ox on line A. Complete line B if applicable) A. NIum, ew System ❑Replacement System ( ❑ Treatment/lioiding Tank Replacement Only ❑ Other Modification to Existing System(explain) B. ❑ Permit Renewal \Permit Revision List Previous Permit Number d D to Issued ❑Change of Plumber ❑Owner Transfer to New Before Expiration I Owner 55/ q f �' IV.Type of POWTS System/Component/Device: (Check all that apply) �o / 1 i 1-1 Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound%24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑ Holding Tank ❑Other Dispersal Component(explain) 0 -�P,` Pretreatment Device(explain) . � 6 . V.Dispersal/Treat ent Area Information: �' _ Design Flow(gpd) Design Soil A lication Rate pdsf) Dispersal Area Required(s Dispersal Area Proposed(s P System Elevation ysd , (0(13 / I ($6) t{- (0 ,1/ L' loo. VI.Tank Info 1 Capacity in Total 4 of � Manufacturer Gallons Units w Gallons New Tanks Existing Tanks '-' ° i 0 U a y I i —w E. 0, Septic or Holding Tank 100 Dosing Chamber ill F We-eV S 1 VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) i m i ' Sign:`e -- r(F`� �O� � . '� I MP/MPRS Number Business Phone Number _._J 1 3 r ., 1 o� ag0. 7 /c-3%‘--9-0 0)0 Plumber's Address(Street,City,State,Zip Code) 1 0'70 - w 3S ,V Ott SUM 6 Y c' VIII.County/Departme Use Only Vim'IJL' ►� Approved ❑ a'_.:. . Permit Fee I /e Pp d $ e� Date Issued I Issuing/cent Signature / IIITNIIIIIIPIP.--nvei -1 Reason o :_ tal _ g�' 11/17 /3 IX.Condi�gg�E /Reasons for Disapproval - �' 1. Septic tank,effluent filter And / r dispersal cell must all be services/maintained / as per management plan provided{by plumber. 2. Allsetback requu'ements must be maintained t_ as per applicable code/ordinances. Attach to complete plans for the system and submit to the County only on paper not less than 8 vz x 11 inches in size SBD-6398(R. 11/11) r7604. t /Woe re, sab, 10, 44r-4241On 44"4.esicerte" B9x)anta. cr 21,41, p; = Io w b.° as a - 3x8 -fiwA s gal Tov a6 3 Bwirtobm 1301%, An Soil Absorption System Cross Section Ns IPIR ft • I n I 4'Schedule 40 Final Grade PVC Vent Pipe With Vent Cap 1---10AS ft Leaching --i` ( ) OLL.A Chamber � _3_ft SYstem Elevation Ni. 4 Soil Absorptlan.System Plan View Lc ft ft IIIIIMiIIIIIIIIIiIIIIIIIIIIIIIIIIIIIIII iiiiiiiiiiii1100iiiiii111111IiihIIc?2IIJJII- IMI . ft Vent Or Observation Pipe Leaching Chambers j I t � o 111111.1IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII113 u 111111 4'Dia. Trench 2 Header • Leaching Chamber Saecificatfo Manufacturer And Model 1N l ii hoot' 1 1 0 EISA Rating_0 sq ft per chamber Soil Application Rate • 1 gpd/sq ft gpd Design Flow.; Soil Application Rate T EISA= Chambers 2 rows of chambers each. % 3 Page of • ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT • AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 1 4 1613 0A L ) MJ A SJUv Mailing Address 5 u 1 to 4 rn N 510 � , Property Address (Verification required from Planning&Zoning Department for new construction.) City/State 1--1 vet)S 614 ' Parcel Identification Number 0'I 0 (3 ( (4,- I Sb 0 LEGAL DESCRIPTION Property Location 5V. 1/4 ,S U 1/4 , Sec. S , T j N R I 1 W, To of Igt)t Subdivision Plat: Ct Ait W OObS , Lot# 14 . Certified Survey Map # // , Volume , Page # Warranty Deed # 1 362 I 0 (before 2007)Volume , Page# Spec house E yes 0 no Lot lines identifiable 0 yes 0 no • SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed,by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §SPS. 383.52(1)and in Chapter 12-St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning&Zoning Department a certification form,signed by the owner and by a master plumber,journeyman plumber,restricted plumber or a licensed pumper verifying that(1)the on-site wastewater disposal system is in proper operating condition and/or(2)after inspection and pumping(if necessary),the septic tank is less than 1/3 full of sludge. I/we,the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth,herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning&Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are e to the best of my/our knowledge. I/we am/are the owner(s)of the property described above,by virtue of a warranty dee recorded in Register of Deeds Office. Number of bedro s c �' ) ii / t / 13 SIGNATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning&Zoning Department. *** Include with this application 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. (REV. 04/12) it:A: • commerce. m . Safety and Buildings Division County ...-L 4 . vOo St ao i A 201 W.Washington Ave.,P.O.Box 7162 lit* ., -, Madison,WI 538*7 lit, Sanitary Permit Number(to be tiled in by Co.) 'scan nvip,,,,-. . 41 5 cb 3f Department of Co ,-...v , --%-2‘\ State Transaction Number ...,.. Sanitar,ytPetmit Application In accordance with s.Comm.83.21(2'3,1is.Adm.Code,submission of this form to the appropriate governmental /1/4VA unit is required prior to obtaining a sanitary permit. Note; Application forms for state-owned POWTS arc Project Address(if different thanmailing address) ,.. submitted to the Department of Commerce. Personal information you provide may be used for secondary -0 nyr-i/fri A../ RZA--.2P, / R. purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. pit/D-5-6 iJ "1/17, I. Application Information—Please Print All Information 1 _ Properly Owiletr's Name . Parcel# SC1A1 (i- 'tqZ1IL\017kriA D6S-S 0 LI,/ 010 Property Owner's Mailing Address Property Location ( 2- _ , ) 5 al k,,,k‘A.,„ 'V i D oz Tit I Govt.Lot ---, , City.State I Zip Coeztoi c Phone Number 5 6 Vt, 5(j v., Section 1-1\hbsoA V1S(... N)t T xi), N; R I yr_____E or W Acircle one) II.Type of Building(check all that apply) Lot# 2P4 or 2 Family Dwelling- Number of Beckon is I I Subdivision Name ti _ Peli h 44.4„--1._ : Block# Cebox (k)ouvi 0 Public/Commercial- escribe Use N A 0 City of 0 State Owned-Describe Use CSM Number 0 Village of __—.... 0 Town of —rgo • . ,r III.Typ,of Permit: (Check only one box on line A. Comple IL- B if applicable • A. .A 12,1erstgrn.---' 0 Replacement System 0 Treatment ing Tank P. "e 7a nly 0 Other Modification to Existing System(explain) • . te B. 0 Permit Renewal 0 Permit Revision 0 Change of Plu -r 0 it Transfer to New List Previous Permit Number and Da Issued Before Expiration wner IV. OWTS-Sstem/Component/Device: (Check all that ap y) , (-7-- n-Pressurized In-Ground) 0 Pressurized In-Ground I, At-Grade 0 MO fsuitab soil, o Mo od<24 in.of sui cleez:Iii_ __R 4:thel , CI Holding Tank 0 Other Dispersal Component(explar / a Pretreat nt De-a x V.Dispersal/Treatment Area Information: 7 - ,cicrrienfAA,07,Fg 4;c— 5;6' riedie, Design Flow(gpd) Design Soil Application Ratc(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation Le 0 b . --L .7 185.6 8( 0 lilq'a.iL OliktskilL.:V.kit, VI.Tank Info Capacity in -Total 8 of Manufacturer Gallons Gallons Units Ft New Tanks Existing Tanks 4,5 Ai 'd 1i li i 14 4-: 0 iz ri r,5 iZ a Septic or Holding Tank f ----, i a G b Dosing Chamber iNv. / - cCi 'K VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plu 's Si_ A e MP/MPRS Number Business Phone N mbe -S-k ..1\ B6(4-wvvAeN„ ,p 11.-- D'a9o\ii vil•Y (.--)0).0 Plumber's Address(Street,City,State,Zip Code) Iblb Atisik, 3S M lAkAosou kl'i ,(i - 0 0 1 1,..,-.-- VII County/Department Use Only Approved 0 Disapproved Permit Fee Date Issued Isy‘Agent Si_ re bex_ri _. 0 Owner Given Reason for Denial 9 i & r.)-- IN.CogfilatrefotiymeRal/Reasons for Disapproval ) iarydiv / 1 1.1 0 i AlZet/11_014,/i247412"-j)/910eild1l 1.Septic tank,effluent filter and rb--( 6.4- ifkill4-1-011,_t_ ,_5- ,/-„64C., ---A -1-ei--)4— — dispersal cell must be servic,ed I maintained , as per management plan provided by plumber. ' .51/A2API Le t9/' 42-t. ---A 2.5 / di-e-i-e435 1--- -ui-4--- 2.All setback requirements must be maintained as per applicable code/ordinances, Attach to complete plans tor the systetn and submit to the Comity only on paper not less than 8 1/2 44 II inches in size SBD-6398(R.01/07)Valid thnt 01/09 L__ i CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: LArJ&f4 , I Owner's Name: ~ I Aft M $SO 1-3 Owner's Address: _ ~,knS ° N n S(,r Legal Description: S ,E 1 S W~ y S S Township: r~(~~► - County: _51- CKO►y Subdivision Name: CQCIA~ GJaop Lot Number: Parcel ID Number: Olo - 131 ~OO~ 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 Attachrne'nts: Soil Test & House Plans Designer/Plumber. J 1 r+n }t~~ -k Ah License Number: Date: Phone Number ~ ~ ~-3SL grab Signature Designed pursuant to th In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01101). Page 1 i P/0 O Pssow Cc:. c eAan I,J pub G~~ ~~„'Q'+~,' gar Y`i1p ~C Tp 0 3S' I~sLlkyb eve p, a~ Top Vol loop 3x ~v ~o j~ -fRl2NC~, I~ 3XSa i a (,D 50 3s' e' 5fi,, wl poly ~~k~~ y Qeortu~r~.~ I~lv ■ ~t)Tu ul-1 s ~R~' WwN IRA*) Soil Absorption S stem Cross. Section ft (a3 l~ ~4`1•'~c, (bS>`~ 4" Schedule 20 Final Grade J PVC Vent Pipe Ilttith Vent Cap ~ of L ft Leaching - Chamber System Elevation 3:t -3 Soil Absorption Systenn lla View ©I ft ff M Hr - 3 Le. chtng ~ Trench 1 Chambers 4" Dia, ewer ~t U trench 2 H Vent Or Observation Pipe Trench ~ ~ - - L.eachtnn Chamber oecificat ons Manufacturer And Model _ ~ 45 L' FISA Rating. _Q((,)_ sq ft per chamber Soil Application Rate .--T gpd/sq ft _ ~u V qpd Design Flow a Soil Application Rate = EISA q3 Chambers rows of chambers each. 13 Page _ of - ~L~ 2S Ef tnc:nt Filter UT1u,eiit Filters Pol.ylo ~w P cIof2 lvsls~fe;,rr>'ti~e!ls!•s;~.',i: ;i RarlylokInc. 3 FAirfnPldSlvd .....................:...ar,.,•.,•,,,,,,:,,,.. 0649 Call Tell Free, St3-765 91ra6,rr>ail. pa#yiok.com You area Here", ~ ProOoot Details + ,r EFFLUENT FILTER i Raising the her in fli r technol+a PL-625 Effluent, Filter Description Ij Effluent Filters Palyiok, inc is pleased to add its new commercial filter to its existing line of quality Offivont l Extend 1-O filters. The PL-523 is rated for over 10,000 GPD (Gallons Par Day) makinq it tine of the largest commercial filters in its class, It has 525 linear feet of 1/116" filtration slots. Like the L Kisere & Ricer CAVers Polylok Pi_-122, the new Polylok PL-625 U8 art automatic shut off bell in-stalled with every + a iiri filter, Iften the filter is removed for cleaning, the bail will float up and temporarily shut off Llistrlbutian Boxes tans n i n(ijfrlll, the sy!Aorn so the effluent wan'i leave the tank. No other filter on the market can make that Accessories Pumps, Beslna, Plump. Crr -ring In armat;«rt Request a Ouate i and p systems ww Rel_attad Products T.~.»» i Gaels !I Features / Gaskets I Baffles, Banilralry Teas Rated for 10,000 GF'D (Gallons Per Day) Deflectors ► 525 linear feet of 1116" filtration Enlarge for details • Accepts 4" and 6" SAHD, 40 pipe RSkrpecsr3 w Built in Ca,as DefleoG pr M ndl" srna 1'~ aw" Automatic shut-o# ball when filter is rramavad o Alarm accessibility * Accepts PVC extension handle The The PL-525 Effhrent Filter should operate efficiently for several years under normal I Laneiecap9 ! Drainage F conditions llpfore requiring elnanm4. it is reaonviaendred that the fjltel' be cleaned every o rmrlslarrf . time the tans( is pumped or at least every three years. If the ins%lied filter contains an optfonal alarm, the owner will he notified by an alarm when the fiit+er. needs servicing, { SUM Sealetht$ Servicing should be done by a certified septir tank pumpar or installer. Cr~rtoretas AceoM;es Maintenance In tr~lcki+ana Pressure Filters 7. Locate the outlet of the septto tank. Lder Crontrol Product 2, Remove tank cover and pump tank if necessary. 3, Do not use plumbing wl~~+n f11mr is removed, i Ret~t~E,ak and G1UM1J 4. Pull PL-525 out of the housing. I AcceAYfues 5. Hose off filter over the septic, tank. Make, :cure all solids fall I?a* into Septic tank. Reber Safety and lie C; 6. Insert the filter cartildge bacK into the housing making sure the filler is properly align9d MCI Gompletely in,Gr1E?cJ. 7. Repface septic tank cover. PL-525 Installation; idsftl for residential and commercial ~f@+ t--live ~'srrdaGe~ waste flows up to 10,000 Gallons Per laey (GAD). • Technfc~al SPA, teaxi~pt InStallAtion instructions: 1. Locat.a the c4irfet of thhA za septic lank- PUMP. Filter and Sun 3. Glue the filter hni.ising tophca "tor 6'fnecessary, i 2 Filter 4° x 1la Riser the access Opening use a Polylok Fxt Utzp~~ if the filter iS not centered undr r J gmaATM dndl an Insert the rL,525 (liter into its housing, of piece of pipe to Cknter filter. Contras I ~i,,,-tG iir,tavlc ~ic•nPX>•r~rte~n~ Tf''1~'t W1:6 OW 'W 13O ve 1 2010 9: 12AM No, 3066 P. 2 ~p m 0 a c 85 -r" jcny- C)>]Ufjl cTa ~ ter„ ~'j ear -el c- tv w n r~ c~ m Z' N 7V 3 ~ ~ r-~ C77 F...I 1 n lip S , a J T" ^-gym h~ _ Y- W 4rA ~ ,G f1S z ull A CD Lu ~rL A 0 r.L C~ d 990 '0N "I'l-4Uiv iu:un AM St. Croix County Plan/Zoning 715.326-4686 1/2 ('iO1r" 'rS Gt11 NER'$ MANUAL & MANA.ElV~~IgT PLAN lase of PILE I14FQAAV(ATit3:N ~v~r~rr GPSCizsit~A"I`I~NIA Owner >ti D s S V 18eptlo "yank Capacity el C! NA Parrzalt # S600 Tank Manufacturer C7 NA ba tq IN PAF AMEI'N" Effluent Filter Manufacturer Pu b EjCl NA Number of f)edrocros >;ffluant Fitter Madat Numer of Public rsollity Unite NA Di NA Pump Tank Capacity >t( hIA Estimated flow (average) ~ j al da Pump Tank Manufacturer (design flow (peak), (Estimated x 1,5) NA L~ awe lump Manufacturer NA Soft Application Rate Pump Modal Pldtly/ft NA Standard Influent/Effluent Quality Monthly averaw Pretreatment Unix Pats, Oil & Grease (11001 X30 MOIL NA iD Sand/gravel Filter CI Peat Filter Biochemical Oxygen Demand (SOD.) X220 mg/l, 0 NA M Mechanical Aeration 0 WaTlsnd Total Suspended Sollds ITSS) 4164 mg/L R Disinfection a Other: Pretreated Effluent Quality ~ Monthly average LqMDrip-Uns al Cell(s) ID NA Blo©heminal Oxygen Demand 1200j) a30 mg/L ound (gravity) Q In»Gmund (pressurized) Total Suspended Solids (TSS) 530 mg/L C3 NA t ade 4 Mound Fecal Colfform (geometric mean) 9104 cfu/100m1 0 tether: Maximum Effluent Particle Size in dl&. q NA Clthen 0 NA Other: Uthar, Cl NA 0NA 'Values typloal for domestic wastewater and septla Tank effluent, Other Q NIA MAINTENANCE- 89!j9DULE Service Event Service Fraqu,ancy Inspect condition of tanlt(sl At least once every, A rxrantri(h) 3 g, ear e) (Mafturn S years) n NA Pump out contents of tank(s) When combined sludge and scum equals one-third (1/) of stank volume A NA Inspect dispersal call(a) At least once every, motels) ears (Maximum 3 years) RNA Glean effluent filter At least once every, montsh(s) RNA Inspect pump, pump controls & alarm At low cnoq every: A s~th(s NA Flush laterals and pressure test At least once every. i1141th)e) othar, D sal s NA At least once every, R mon* (a) other: ID ear e) NA MAINTENANCE INSTtttlDTioNS NA Inspections of tanks and dispersal calls shell be made by an Individual carrying one of the fallowing i oonsee or certificatlons: Master Plumber; Master Plumber Restricted Sswer; POWT$ Inspector; POWTS Malntainar; 8401108 Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any creaks or leaks, measure the volume of combined sludge and scans and to chock for any back up or ponding of effluerit on the ground surface. The dispersal celt(s) shall be visually inspected to check the affluent levels in the absarvatlon pipes End to shack gfor round any surfsoq of effluent on the ground surface. The ponding of effluent on the ground surface may Indioote a failing Condition and requires the Immediate notifioatlon of the local regulatory authority. When the combined accumulation of sludge and scum In Any tank equals olls-third IN) or more of the tank volume, the entire contents of the tank shall be removed by a ssptage Servicing Operator and disposed of in accordance with chapter NFL 113, Wisconsin Adminlatrattva Code. All ashen services, Including but not 11mited gi 2 to the servicing of effluent filters, mechanical or prasaw6ged components, pretreatment volts and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintefoor. A service report shall be provided to the local regulatory authority within 10 days of eompletlon of any service event, GMW (4101) Nov-11-2010 10.455 AM St Croix County Plan/Zoning 715-386-4686 2/2 ' Page - of START UP AND OPERATION For new construction, prior to use of the pOWTS shack treatment tank(s) for the'presenae of painting prwdarrata or ether chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentretlons 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 frown at the Infiltrative surface. During power outsgas pump tanks may fill above normal highwater Itvals. When power Is restored the exasse wastewater will be discharged to the dispersal oall(s) in one large dose, overloading the call(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 slumber or PAINTS 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 arms within 15 fast down slope of any mound or at-grade soft absorption ores. Reduction or elimination of the following from the wastewater stream may improve the perlormance and prolong the Ilfe of the fat POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; dagreas rs; denn ~ le~ loss; diapers, disinfectants; gy all,, foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grossit; painting products; pesticides, sanitary napkins; tampons; and water softener brine, ABANDONMENT When the POWTS falls and/pr is permanently taken out of service the following steps shall ka taken to insure that the system is properly and safely abandoned In compliance with chapter Comm 85.33, Wisconsin Administrative Code: • All piping to tenkg 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 I$eptage Servicing Operator, is After pumping, all tanks and pits ahall be excavated and ramnved or their covers removed and the void space filled with soil, gravel or another Inert solid material, CONTINGENCY PLAN If the POWTS falls and cannot be repaired the following measuras have been, or must be taken, to provide a code compliant re a nt system: 2 Sd l' I ve eo arm suitable replacement area has bean evaluated and may be utilised for the location of a replacement $ail alMorptlon stem. The replacement area should be protected from disturbance and aompaoticn and should not be infringed upon by required satbooks from existing and proposed structure, fat lines and wells. Failure to protect the replacement area will result in the need for a now sail and site eval~jat(on to establish a suitable replacement area, Rsplaraament systems must comply wlth the rules in affect at that time. Ci A suitable replacement area Is not available due to setback and/or soil limitations. Earring advances in POWT6 technology a holding tank may be installed as a last resort to replace the failed POWTS. 0 The site has not been evaluated to Identify a suitable replacement area. Upon failure of the POWTS a Ball and laity evaluation must ba performed to locate a suitable replacement area. If no repfacamant area Is Walistle a holding tank may be installed as a last resort to replace the failed POWTS, 0 Mound and st-grade soil absorption systams may be reconstructed in place fgllavuMg removal of the blramat at the fnfiitrative surFeoa, Reat~nstructir+ns of such aryatams must comply with the rules to e'f'fect at that tima, C < WARNiWG > > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIINT oX.ygAN, 00 NOT ONTER A SEPTIC, 13UMP OR OTHER TREATMENT TANK UNDER ANY CiRCLJM TAN 00. DEATH MAY RESULT. Fif;SCl1l? OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR Il11If'CPbSliBlt;. ADDITIONAL, CC E TS MOWS IN TALLER Hama i,~. 4 w~~ Noma Phony l~'~ o _ Phone 9EPTAQE SERVICING OIPERATtJR (PUMPER LOCAL R•&13WLATb 1 Cy ~y~ E roams rt n ~ i Name cK d)v) k Phone~~~ p ~ l~- This document wag Phone drafted in namplisnGe with Ghaptar Lana a3.22(2)(h)(1)(d)&(f) and 83,54(1), (y) $s (E), vutsnonain Adrtrfnisttative code, kp,..> 2308 Wisconsin Department of Commerce'' SOIL EVALUATIOW"RE t Page 1 of 4 Division of Safety and Buildings dance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations County Altach complete site plan on paper not less than 8% ~ 11,inches in size. Plan must St. Croix include, but not limited to: vertical:andtlo" W04rdnce point (BM), direction and percent slope, scale or dirnlidrirDrtfl arrow, and location and distance to nearest road. Parcel I.D. 040-1316-14-000 Please print all information. evie _ Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Jodi & Barbara Dassow Govt. Lot SE 1/4 SW 1/4 S 5 T 28 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 2201 White Pine Cr. 14 Plat Of Cedar Woods City State Zip Code Phone Number J City I Village 16 Town Nearest Road Hudson WI 54016 Troy 509 Autumn Blaze Trl tJ New Construction Use: 0 Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD J Replacement -j Public or commercial - Describe: Parent material Glacial Outwash Flood plain elevation, if applicable na General comments and recommendations: Site suitable for conventional POWTS dispersal cell with 0.7 gpd/sq.ft./day loading rate. Proposed infiltrative surface elevations to be 4.5'- 5.0' below existing grade. Boring # _I Boring sel Pit Ground Surface elev. 107.46 ft. Depth to limiting factor > 105" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-10 1Oyr3/3 none 1fsl 1fgr mvfr cs 2fm1c 0.2 0.6 2 10-16 1Oyr4/4 none Ivfs Osg ml cs 3fm2c 0.4 0.6 3 16-27 10yr4/6 none Ifs Osg dl cw 2f1 me 0.5 1.0 4 27-32 10yr4/6 none Is 0 sg dl cw lvf 0.7 1.6 5 32-65 7.5yr4/6 none s 0 sg di cw - 0.7 1.6 6 65-105 10yr5/8 none trat s&g Osg dl - - 0.7 1.6 to ~6 o s / 44,n4 WL-~ a Boring # --j Boring 116 Pit Ground Surface elev. 102.64 ft. Depth to limiting factor >102" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GP /W in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-7 1Oyr3/3 none fsl 1fgr mvfr cs 3f,2mc 0.2 0.6 2 7-17 1Oyr4/3 none sil 2fsbk dsh cs 2fmc 0.6 0.8 3 17-37 10yr4/4 none sil 2msbk dsh gw, 2fm1c 0.6 0.8 4 37-43 1Oyr5/4 none sit 1msbk dsh cw 1vf,fm 0.4 0.6 5 43-49 7.5yr4/6 none is 0 sg dl cw - 0.7 1.6 6 49-102 1Oyr5/8 none trat s&g Osg dl - - 0.7 1.6 * Effluent #1 = BOD? 30 < 220 mg and TSS >30 150 mg/L * Effluent #2 = BOD5 <30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signa re: CST Number James K. Thompson s-- 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 11/29/2012 715-248-7767 Property Owner Jodi & Barbara Dassow Parcel ID # 040-1316-14-000 Page 2 of 4 FBoring # J Boring 3 0 Pit Ground Surface elev. 111.06 ft. Depth to limiting factor >106" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-12 10yr3/2 none sil 1fgr mvfr cs j2vf,fM0.5 0.6 2 12-22 10yr4/3 none sil 2fsbk dsh cs 0.8 3 22-34 10yr4/4 none sil 2msbk rdl h gw 0.8 4 34-48 7.5yr4/6 none tfs Osg cw 1.0 5 48-70 10yr5/6 none s 0 sg l cw 1.6 6 70-106 10yr6/4 none strat s&g Osg dl - - 0.7 1.6 F-1 Boring # Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots QPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 *Eff#2 ❑ Boring # Boring J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Y in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD5> 30 < 220 mg/L and TSS >30 < 150 mg/L " Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L T'he Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.07/00) A.C.E. Soil B Site Evaluations 2308 _2_ of 4 PROPERTY OWNER: Lodi & Barbara Dassow SOIL AND SITE EVALUATION Page PARCEL I .D,# 040-1316-14-000 A.C.E. Soil & Site Evaluations REPORT MEMO Site is very heavily wooded & brushy. Additional elevation work may be needed to determine exact system orientation and depth after site is cleared. ♦ Eit~'s~~9 ~roo(t ells` -~--Awkum n ~i~Cc ° ~0C~i (aRr Z&sscw Pr'°/0 j8.93' Tsui l So9Aw.6umrr B/aotTiu.% ~otr'/f~~k~ of Cc~cvu~s, SEyyr~cc7Y -see S, 7..Za4 T , o f 77-oy, SE . Cvix boy -0 being i.iSac~s b U h~ I I t g gars e ~ P~opose,d N 0 9 ; Qes~de,~ee r+ ~ &f t %Po~a~ P~oPesed ~ _ . _ ~ 10 .01 ~ i A- r' z »r . b. : Top d~' 13 w~~jo o{~ `s VO Ad. e .14?e . /off St_rs~e. E/. =io3,S/: ssu~rt~ Qlerf =/G~. c0 1~. S~oFf/ ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer I i a ~a y N A LS d \A/ Mailing Address Z Zv t 1 h e- Property Address t< 6i 1V r r r' r f t . ,~G'I (Verification required from P anning & Zoning Department for new construction.) City/State hIA&VI Parcel Identification Number O ~ 3~ 6' 1 " DDO LEGAL DESCRIPTION TYO Property Location .J '/4 Sec. , T N R ,'G W, Town of ! . Subdivision Plat: ce-A" W p~cCs , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # ` '3 61 6D (before 2007)Volume , Page # Spec house ❑ yes %no Lot lines identifiable J(yes ❑ no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms I~ /27/ I NATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application 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. (REV. 09/07) 8 0 2 8 0 1 2 Tx:4019597 STATE BAR OF WISCONSIN FORM 1 - 2000 936160 Document Number WARRANTY DEED BETH PABST REGISTER OF DEEDS THIS DEED, made between G & L Land Development, Inc. a ST. CROIX CO., WI Wisconsin Corporation, Grantor, and Jodi T. Dassow and Barbara J. 05/12/2011 2:41 PM Dassow, Grantee. EXEMPT#: N/A REC FEE: 30.00 Grantor, for a valuable consideration, conveys to Grantee the following TRANS FEE: 170.70 described real estate in St. Croix County, State of Wisconsin (the PAGES: 1 "Property"): Lot 14, Plat of Cedar Woods in the Town of Troy, St. Croix County, Wisconsin. , The Grantee hereby agrees that the subject premises will be used as a single family residence and will never be sold or rented as a multi-family Recording Area residence. Name and Return Address: Title One # 16421 Together with all appurtenant rights, title and interests. 040-1316-14-000 Parcel Identification Number (PIN) This is not homestead property. Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except Roadways, easements and restrictions of record. Dated this 6th day of May, 2011. G &~~yyL"~Land Development, Inc. a Wisconsin Corporation 9V) . I,l.cA40_ * Glen M. Wiese, President * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ST. CROIX COUNTY. ) ss. authenticated this 6th day of May, 2011 Personally came before me this 6th day of May, 2011 the above named G & L Land Development, Inc. a Wisconsin * Corporation by Glen M. Wiese, President to me known to be TITLE: MEMBER STATE BAR OF WISCONSIN the person(s) who executed the foregoing instrument and (If not, acknowledged the s authorized by § 706.06, Wis. Slats.) THIS INSTRUMENT WAS DRAFTED BY *Jay Penfi Notary Publt , isconsin My commission is permanent. (If not, state expiration date: Michael H. Forecki, Attorney 8/26/2012 ) (Signatures may be authenticated or acknowledged. Both are not necessary.) *Names of persons signing in any capacity must be typed or printed below their signature JaCPe►PyENFIELD ate of WPubltc '~nsln WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 1-2000 1 of 1