HomeMy WebLinkAbout040-1316-02-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
561027 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
St. Ores, Blake & Carrie Troy, Town of 040-1316-02-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No
GS T 05.28.19.2058
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
% .ti
/ate
Septic / Benchmark 103 4
r', I P c7z Alt. B O 5, 1 / ~ •s4
Aeration Bldg. Sewer
Holding St/Ht Inlet 7.7 C7.5--If-
TANK SETBACK INFORMATION St/Ht outlet $ •6 ~S• Coy
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic 7 / Dt Bottom
Dosing L~ D Header/Man. JAI. 01
Aeration Dist. Pipe Q 211,13
/
too r Fe.CX*%%)k-S
Holding got. S tem /u ,wI 93
PUMP/SIPHON INFORMATION Final Grade 7
9 q8-
Manufacturer DePmand St Cover
Model N r
TDH 'ft Friction Loss System H TDH Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width / Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 9b Z
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: UNIT
~.0' Model Number:
DISTRIBUTION SYSTEM
rj
Header/Manifo/ ld Distribution x Hole Size x Hole S cing Vent to Air IFtake
Length Dia L4 Pipe(s) \ ✓e' ~,TS p
Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only o ems' S
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched
~ Bed/Trench Edges Topsoil
Bed/Trench Center .(~►+J t ~7
~ Yes No es No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 500 Autumn Blaze Trail Hudson, WI 54016 (NE 1/4 NW 1/4 5 T28N/R1119/W) Cedar Woods Lot 2 Parcel No: 05.28.19.2058
1.) Alt BM Description ,na T ~a c~ p
2.) Bldg sewer length =
- amount of cover
/ FS o to o k
Planrevision revision Required? ❑ Yes ~ No rn 3
Use other side for additional information. I~ I 4
SBD-671 0 (R.3/97) Date Insepctor's nature Cert. No.
P
p C
5, . ~$L+o t L Y (~A i vat 1 5
i ~i ~ Sze ~h j'f E
del
FC7
10 G 717 ~ Lid Ql~
3o3Y
1(7 r.7
J~
16
f
83
f02~, ~ ~
Qtnc~ 1►'t ;IL
D2/28/13
BLAKE ST. ORES
500 AUTUMN BLAZE TRAIL f
L
JUDSON, WI 54016
LOT 2 f
VE 1/4 NW 1/4 SEC 5
r28NR19W
SUBDIVISION: CEDAR WOODS
GOWN OF TROY
SCALE: 1"- 40, 1
3ENCHMARK #1 TOP OF PVC PIPE 100'
3ENCHMARK #2 TOP OF PVC PIPE 102.3'
SYSTEM ELEVATION 95.0
iIESER 1250 WITH POLYLOK 525 FILTER
commerce.vvi.gov Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162 ST. CROIX
t~!epartme S-CO n Madison, WI 5 3 707-7 162 Sanitary Permit Number (to be filled in by Co.)
mme ce /6Z
x y, i mit Application State Transaction Number
In accordance with s. Comm.'8 1(2), W' Code, submission of this form to the appropriate govemmetrtal /•V1
unit is required prior to obtaningya ry permit. Note: Application forms for state-owned PO are e dress (if different than mailing address)
submitted to the Department of erce. Personal information you provide may be used for second 0 TUMN BLAZE TRAIL
ur oses in accordance with ac Law, s. 15.04 1 (m), Stats. H ON, WI 54016
1. Application Infor - Please Print All Information
Property Owner's Name / Parcel #
BLAKE ST. ORES 040-1316-02-000
Property Owner's Mailing Address Property Location
10150 CITY WALK DR Govt. Lot 2
City, State Zip Code Phone Number N-F. V., NW Section 5
WOODBURY, MN 55129 N/A (circle one)
28 N; R 19 Eor~'
II. Type of Building (check all that apply) Lot # T
ON or 2 Family Dwelling - Number of Bedrooms Z Subdivision Name
Ok d!a 1 .tL Block # CEDAR WOODS
El Public/Commercial - Describe Use v
N/A ❑ City of
❑ State Owned - Describe Use CSM Number ❑ Village of
Town of TROY
2- 19 N III. Type of Permit: (Check illy one box on line A. Complete line B if applicable)
A. ® New System
❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
List Previous Permit Number and Date Issued
B. ❑ Permit Renewal ❑ Perms[ Revision ❑ Change of Plumber ❑ Permit Transfer to New
Before Expiration Owner yg!
rptti
IV. Type of POWTS S stem/Com onent/Device: Check all that a t
® 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) ❑ Pretreatment Device (explain)
V. Dis ersal/Trea ent Area Information: 11-11
Design Flow (gpd) Design Soil Application Rate( SO Dispersal Area Requir (sf) Dispersal Area Proposed System Elevation
600 .7 858 900 95.0 4-7-
VI. Tank Info Capacity in Total # of Manufacturer
U
Gallons Gallons Units n U
New Tanks Existing Tanks Y
` a U° yr H yr u, c7 a
F
Septic or Holding Tank 1250 0 1250 1 WIESE X
Dosing Chamber N/A
VII. Responsibility Statement- I, the undersigned, assume respons ility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumb ign MP/MPRS Number Business Phone Number
PAUL KOEHLER 225410 715-246-2660
Plumber's Address (Street, City, State, Zip Code)
321 WISCONSIN DRIVE, NEW RICHMOND, WI 54017
VI ount /De artment Use Only
Xpproved rove Permit Fee Date sue [ssuin ent Signature
$ 4 75' 3 J3
O Given Reason Denial
IX. Conditt lpA,gNV. Weasons for Disapproval
1. Si* tank, effltlent ft1ter and
dispersal cell, must all .serv~~!aintainedaintained
a$ per management plan provided by plumber.
i An setback requirements must be maintained
add per appk" code / ordinances.
Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size
SBD-6398 (R. 02/09) Valid thru 02/11
i`
r
r.
~f -
f
G Zl{J$ s/ate O Q T \
W
10
t3t n' t,1. r^n a~ ~ 303 l3
f
8 3 f
~Ln~~. t'►'tcs~jL /
32/28/13
BLAKE ST. ORES
500 AUTUMN BLAZE TRAIL
JUDSON, WI 54016
LOT 2
VE 1/4 NW 1/4 SEC 5
r28NR19W
SUBDIVISION: CEDAR WOODS
TOWN OF TROY
SCALE: 1"- 40'
3ENCHMARK #1 TOP OF PVC PIPE 100'
3ENCHMARK #2 TOP OF PVC PIPE 102.3'
SYSTEM ELEVATION 95.0
iIESER 1250 WITH POLYLOK 525 FILTER
i
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: BLAKE ST. ORES
Owner's Name: BLAKE ST. ORES
Owner's Address: 10150 CITY WALK DRTVF, WOODBURY- MN 99129
PROJECT ADDRESS: 500 AUTUMN BLAZE TRAIL, HUDSON, WI 54016
Legal Description: NE 1/4 NW 1/4 SEC 5 T 28 N R 19 W
Township: TROY
County: ST. CROIX
Subdivision Name: CEDAR WOODS
Lot Number: 2
Parcel 1D Number: 040-1316-02-000
Pagel Index and title
Page 2 Plot Plan
Page 3 System Sizing & Cross-Section
Page 4 Filter Specs
Page 5 Maintenance Information
Page 6 Management Plan
Page 7 St. Croix Cty Septic Tank Maintenance Form
Page 8 Warranty Deed
Page 9 CSM or Plat
Attachments: Soil Test & House Plans
Designer/Plumber: PAUL KOEHLER License Number: 225410
Date: 02/28/13 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.01/01).
Page 1
'4
i - 10 -'D f
is s y;3t~w, ~ 1 G V t9t~ r o~ q ~
X00
` r
0 0
by Q~~ ~ ; <
,y 1~Lhc.l. M04'( L 3o3Y
pvc-
1O of ro p Pelt
r
`
83
toZ~, ~ ~
02/28/13 , 1Q~ fop
BLAKE ST. ORES
500 AUTUMN BLAZE TRAIL i
HUDSON, WI 54016
LOT 2
NE 1/4 NW 1/4 SEC 5 /
T28NR19W /
SUBDIVISION: CEDAR WOODS
TOWN OF TROY
SCALE: 1"- 40'
BENCHMARK #1 TOP OF PVC PIPE 100'
BENCHMARK #2 TOP OF PVC PIPE 102.3'
SYSTEM ELEVATION 95.0
WIESER 1250 WITH POLYLOK 525 FILTER
I
Soil Absorption System Cross Section
4" Schedule 40 /Oa ft.
PVC Vent Pipe with Vent Cap Final Grade
Geotextiie
Barrier Material
12'
f- 9y ft.
3s=
95 ft.
System Elevation
-ft
Soil Absorption System Plan. View
ft
ft ft
Trench 1 ren
Vent or Observation Pipe €zrtow
Chambers
Leaching; Chamber Specifications
Manufacturer and Model
EISA Rating ~a sq. ft. per chamber Soil Application Rate_ /,7 gpd/sq• ft.
00 gpd Design Flow _ 7_ Soil Application Rate _ ~ ElSA = /8 Chambers
2 rows of chambers each
s
EZ_1203H
Ott r .z k~ra~•,r''t r~`rli~ 1 2
lf
rte 1 . s sY
24ff.~
.
4.62511
t ` ~ T,*
W... f
w~ti►itvrr ~vi►Ytf rf► t r.ttr
s~.ttf►ar tn?!tr~t►t ~iEtrrtl i♦ ttRi
~E'7►ri►~rf tir"~fi•
e Bob=
E qq t1 //..y ~
V .troh.ttfc DLA- (ty- ~
cE--- GfcerFace ! s ~14E
VOW Cdficm-t is A tt►'en a 57.4lG. ~R~
O.D. of 4" pips - 4.623 incites Sogwaal (2 swowaft 2s 114
-
Yofd relasoa far ilffW ft 3.14 • 23f2xw
l/ Efi =O.tt7 $p~pgE
l 2-OD
O.D. QrCIU rvYMWW< t2.5 inchiS Total Suit interface Areati S.1<SQ
VON volwafe is a plop r -(3.14'
l f~if/&
0.g: ofvFAt$. e
ProJecEed Tsra~k Area
/old vogaiAaia sus &qyi 2131
t2islEt .574 9Qt fE' M&'Watt EiOWK m [,2 iff: !2 2M Sq.FL
BOOM a 36 for a 3.00 Sq.FL
votfmfe=-bet" ba.*m COW=
iil►
t2'ofI(f t :flk~~ t ~OW5 w Projce dT ead~ A*mw 4w 5g; :
`E'id wttOffe:t s 6uuefa fps (t12 aF valet "#am-henf;cft -Y*604 421!3 12 -030$ As
atsf VOW vatuaoc-0311 0.422.+ 0.901 +9:2tSE+0.10;" 1.763 cable ftltf.
RMoas pet tR 1.763 Xc ?At LIJ s Raert R
. Ag .re-gaffe
Trench Sj+stern . .
EZ1203H
O
WCti-b-xiUsbid Group
lurid Ptak Rd.
Od* nd. TR 30060
t fi~we: tz~taor~- i . Olin t of i i; zT-sr
W
Y LLJ
O a
O a
U)
.0 -1 - =QC N LY 41
e,
o wp cn~-r ~v ¢1
N~ wU mZ°o C=) 'd [3
U-i Q~ Q~C5
W F- 0,.:t F- F- °
H P: of w
17)U O0~ 0m
O Q
U O C14 E
CJ
r CO W M p
M ] u
W
O U M U M U
Cfl N M to
~ M
MN
u u J u
N U
O
~ CG
N
p
LC7 U
tt
N
45 r ~
H
O W
= W Q V
N ~ ~Z f0
Cn ' to p
~ J
Y W Z F
= of H
O Z
m z W
co 0 IL >
j: LO 0
j ~
C
z a
LU 04
J Z LLI
® U U-L Q ~
ZWO LL"M 0-~
Q>M Lo I _
CC a_ LL
Z Z Q
Q0 Lo
ddm20cd
f
. INSTALLATION INSTRUCTIONS
r~~aG
!m toeh~ak t.. PL-525/PL-625 FILTER
IftWiveas±aww "faer Pro""&dr+`~s D` W~` A abel"
~ 4Y
PL-525/PL-625 FEATURES & BENEFITS
Features & Benefits:
s f • Rated for 10,000 GPD
. PL-525 = 525 Linear Feet of 1/18" Filtration
PL-625 = 625 Linear Feet of 1/32" Filtration
PL 525 PL-625 *Accepts 4" and 6" SCHD. 40 pipe
The PL-525/625 Effluent Filter should operate efficiently • Built in Gas Deflector
for several years under normal conditions before .Automatic Shut-Off Ball when Filter is Removed
requiring cleaning. It is recommended that the filter be
cleaned every time the tank is pumped or at least every o Alarm Accessibility
three years. If the installed filter contains an optional
alarm, the owner will be notified by an alarm when the *Accepts PVC Extension Handle
filter needs servicing. Servicing should be done by a
certified septic tank pumper or Installer.
RECOMMENDED PRODUCTS
Polylok PVC Filter
Extension Handle
7 ~h~,ll ,i-
d 1ri
J! wRisers & Riser Covers Extend & Lok- Riser Safety Screens Filter Alarm Panel and
Polylok risers bring: your Polylok Extend & Lokw Polylok safety screens SrnartFllterTm Control.
Switch
septic tank cover to grade. is a simple, easy to use prevent tragic accidents Sol {ok fitter alarm panels
This allows locating and solution that can extend from happening b children Y p
servicing your filter easier the inlet or outlet pipe and and pets falling into open and switehs provid a visual
and time saving by elimi- make filter and/or baffle septic tank entrances. and audible notification of
nating digging to find tank installation a snap. impending filter and tank
entrance. Fits 3" and 4" pipe- servicing.
For a full list of Polylok products please visit our web site at: www.polylok.com
D
Z
X
N
pA 521" AS 84„
REOD
D
Z
c 41°
D Z
0 r
m
v
o I
m UP 40
m
-1 4" CAS \ n
0
;a N
m --I
0 3" 44j" S" D
m
m o
D 36" <
(n rri
D
UP 38" 0
4" CAS m
A
C
m
39" ~
n
N
i
D
I
N
m
D
r
40 z z 0 0 nC Z Z r. D
Om (7 D Z Z D OZ 0 D G~4►D AC~9 r+1=;nm~~ T~ CC
cam- ND O (7C0 C7 O~ sZ grvZ~ZOODO G
gv vx Sao v=N N D D y rrn00 mDOo
~D (/)M \m D r- --I n ~yC ~6C rzco ~(is N _a
9y f~l N
O N C n=' N- g 0D 'I- i3
;7C ZO =N Dr0r~ ~ 1 Z o l 0AFn N N m\
N ~Ik Z Or p y 0 Qp y r*1 Cd D _.j N I -i O r -1 O O\?y ns
n
_0 2 _u Z 8% vD r5* m o j ~ N mD ID ~~jG\0 O
a v U rc/1 GINC Noll Dr 0. W n
a z ° c°i, O n 51 \ z c ~GmO~ri1 O mm_j n Ntn Opp D
r m m -1 W O C __4 N (A D y m 0 D' m
c < -D DO
v° o -Zi nw r*1 O D tN,r mrZ r-4 D O
n ~mrr1 -u z Z DMh O W N Z
m m Z _ Dv 'imr D> O- 0 Z
r ;o O r -4 m 0 V)
O rn ZI N n c v 0 O~~ n
3 ~ m 0 O_f O N m> m
D 0 z ~ r C r~*
H 0 r
O
Z z
r
m
\ m WLP,25°-MR WIENER CODCRETE DRAWN BY. SME SCALE: 1 4"=1 -0" PRE-POUR:
~ SEPTIC MANUAL W3716 US HWY 10 MAIDEN ROCK, WI 54750 DATE: JANUARY 20POST-POUR:
\ ° REVISED JAN. 2010 800-325-8456 FILE: KMM-M
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer ®1'-c
Mailing Address Wk L-L,',
Property Address 4 cy f i -A- I~ L r
(Verifica(ion required from Planning & Zoning Department for new construction.) T-,
City/State (Parcel Identification Number
LEGAL DESCRIPTION .
Property Location ''V4 , b- CWV. , Sec. 15~ , T ?Ab NR_ t~ -VAT, flown of
Subdivision ~l'1.QQ , Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # Volume , Page #
Spec house yes no Lot lines identifiabl K/y'e)s 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. Wbat 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 & Zcanmg Department a ceitfcation 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 andlor (2) after inspection and pumping (if necessary), the septic tank is
less than 113 full of sludge.
Uwe, 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 bas been maintained must be completed and returned to the St. Croix County Planning &
Zoning Department within 30 days of the three year expiration date.
Uwe certify that all statements on s form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the
property described above, by virtue of a rrauty deed recorded in Register of Deeds Office.
Number of bedrooms
IL Z-1
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 ties application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey reap if
reference is made in the warranty deed.
(REV. 08/45)
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 1 of
FILE INFORMATION SYSTEM SPECIFICATIONS _
Owner BLAKE ST.ORES Septic Tank Capacity 1250 gal ❑ NA
Permit #
Septic Tank Manufacturer WIESER ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer POLYLO ❑ NA
Number of Bedrooms 4 qNA Effluent Filter Model ❑ N A - 25
Number of Public Facility Units Pump Tank Capacity gal ❑ N o.
Estimated flow (average) 450 ga/ay Pump Tank Manufacturer ❑ NA
Design flow (peak), (Estimated x 1.5) 600 gal/day Pump Manufacturer ❑ NA
[Slan, Application Rate • 7 al/day/ft2 Pump Model ❑ Na
ard Influent/Effluent Quality Monthly average' Pretreatment Unit ❑ NA
Fats, Oil & Grease (FOG) 530 mg/L E3 Sand/Gravel Filter ❑ Peat Filter
ochemical Oxygen Demand (SODS) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other:
ated Effluent Quality Monthly average Dispersal Cell(s) d N,>;
chemical Oxygen Dem and (BBD,) 530 mg/L 115 in-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound
Fecal Coliform (geometric mean) 510' ofu/100ml A [Nip-Line O Other:
Maximum Effluent Particle Size Ye in dia. ❑ NA Other: ❑ NIX
Other. ❑ NA Other: ❑ N,~
*Values typical for domestic wastewater and septic tank effluent, other: ❑ NJ
MAINTENANCE SCHEDULE
Service Event Service Frequency
0 month(s)
inspect condition of tank(s) At least once every: 3 year(s) (Maximum 3 years) ❑ Nf~
Pump out contents of tank(s) When combined sludge and soum equals one-third (Y,) oft k volume El NA
Inspect dispersal cell(s) At least once every: 3 0 mon(th(s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once ev Q month(s) Q NA
Y= 1. Cl year(s)
Wt
LFIush pump, pump controls & alarm At least once every: N/A ID ❑ year(s) month(s) ❑ W
terals and pressure test At least once every: N/A ❑ month(s) ❑ W.
❑ year(s)
At least once every: ❑ month(s) ❑ Wt
❑ year(s)
E3 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 Sower; 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 cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one-third (Y3) 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 11:3,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units,: and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintanner.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
IQJUV
Z'
START UP AND OPERATION Page Z of
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemic3
that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the content
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 b
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge e
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restorinj
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls t,
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the are:
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; fiat
foundation drain (sump pump) water, fruit. and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; ail;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
AaANDONMENT
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.
• The contents of all tanks and pits shall be removed and properly disposed of by a Semage Servicing Operator.
a 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:
EJ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorptkn
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 Mes and wells. Failure to protect the replacement area vi III
result in the need for a new soli 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
A/ technology a holding tank may be installed as a last resort to replace the failed POWTS.
alua ' -
o arik
r' ik
e ar ~fll'fll l3 rr~. ~o,e.. N CanrS'TRdc~ o>~
❑ Mound and at-grade son 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 NC T
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 INSTALi.ER POWTS MAINTAINER
Name COUNTRYSIDE PLUMBING & HEATING, INC Name PAUL KOEHLER
Phone 715-246-2660
Phone 715-246-2660
SEPTAGE SERVICING OPI_RATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name POWERS LIQUID WASTE MANAGEMENT
Name G( ( 20d l
Phone ';-21,6-5738 Phone -7/f57- 3REo-- q&o
This document was draped in compliance with chapter Comm 83.22(2)(b)(1)(d)&1f) and 83.54(11. (21 & (3), Wisconsin Administrative Code.
II IIIIIIIIIIIIIIIIIIIIIII 1111
I
8134806
State Bar of Wisconsin Form 1-2003 Tx:4109015
WARRANTY DEED 973869
BETH PABST
Document Number Document Name REGISTER OF DEEDS
ST. CROIX CO., WI
02/22/2013 3:40 PM
THIS DEED, made between G & L Land Development, Inc., a Wisconsin EXEMPT#: N/A
corporation REC FEE: 30.00
("Grantor," whether one or more), TRANS FEE: 169.20
and Blake St. Ores and Carrie St. Ores, husband and wife, as survivorship PAGES: 1
marital property
("Grantee," whether one or more).
Grantor, for a valuable consideration, conveys to Grantee the following described real Recording Area
estate, together with the rents, profits, fixtures and other appurtenant interests, in
St. Croix County, State of Wisconsin ("Property") (if more space is Name and Return Address
needed se attach addendum): FSA'ritte Services, ►.LC
Lot 2, edar Woods Subdivision, St. Croix County, Wisconsin. 5645 Memorial Avenue _
Stillwater, MN 55082 +
File No. 1300117
040-1316-02-000
Parcel Identification Number (PIN)
This is not homestead property.
(is) (is not)
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except:
This property is subject to Covenants and Homeowners Association By-Laws.
Dated February 20, 2013
G & L Land Development, Inc.
(SEAL) k.- L"y , R.. (SEAL)
* * Glen M. Wiese, President
(SEAL) / G'td- w`- c (SEAL)
* * Lola M. Wiese, Secretary
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) )
STATE OF MINNESOTA
ss.
authenticated on WASHINGTON COUNTY )
* Personally came before me on February 20, 2013
TITLE: MEMBER S"I'ATF BAR OF WISCONSIN the above-named Glen M. Wiese as President and Lola
M. Wiese, as Secretary of G & L Land Development, Inc.
(If not, to;;tt per wh o executed the foregoing
authorized by Wis. Slat. § 706.06) ina ged the s~ e.
THIS INSTRUMENT DRAFTED BY:
Baiers C. Heeren, FSA Title Services, LLC
5646 Memorial Avenue. Stillwater. MN 55082 Notary Public, State ol'Minnesota \,~t
My Commission (is permanent) (ex ire : 1 `-I )
(Signatures may be authenticated ur acl;nu,wledg 1. ~e n~+)T. DUERR
NOTE: TtIIS IS A STANDARD FOliNi. ANV i~IODIFICA"I'I(INS'II a;l SIl'Oti 1{f~jN~LI' ID1:, 'l1 IIiD.
WARRANTY DEED G 2003 SPATE RAR OF N1 Minnesota F. NI NO. 1-2003
°114~idnamc heh„'si_nau,rr . + ' commiwonExplt69Janu 31,2014
- r
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3
Division of Safety and Buildings In accordance with Comm 85, Wis. Adm. Code -Ak
P ty St. Croix
Attach complete site plan on paper not less than 8 '/z x 11 inches in size. Plan m 1:5 1
Include but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
040-167$=996
Percent slope, scale or dimensions, north arrow, and BM referenced to nearest ro
Please print all information Reviewed DaPersonal information you provide m 'vary Law, s. 15.04 (1) (m)) Property Owner Property Location
G&L Land Development, c. Govt. Lot NE NW 'i4 5 T 8 N R 19W E (or) W
Property Owner's Mailing Address DEC 2005 Lot # Block # Subd. Name or M#
W12491 890 Ave. 2 Cedar Woods {
City State JZip C6de CROIX QTY [I City ❑ Village 0 Town Nearest Road
River Falls WI 71 A4 8 Troy Coulee Trail / FF
0 New Construction Use: 0 Residential / Number of Bedrooms Code derived design flow rate GPD
0 Replacement 0 Public or Commercial - Describe:
Parent Material Flood Plain elevation if applicable ft.
General comments and recommendations: B-1 was completed during the preliminary soil assessment on July 22, 2005. The lot lines were not
clearly marked during completion of the final soil assessment. Sufficient area is available for installation of the POWTS, however the plumber, prior
to installation of the system, must confirm the location of the lot line.
❑1 Boring # OBoring
0 Pit Ground Surface Elevation 100.0 ft. Depth to Limiting factor >I 10 in.
Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-8 10YR3/2 None SIL 1-f-gr dsh as If 0.4 0.6
2 8-17 10YR4/4 None L 1-co-sbk dvh gw 1f 0.4 0.6
3 17-24 10YR4/4 None S 0-sg dl gw 1f 0.7 1.6
4 24-110+ 10YR5/4 None GRS 0-sg dl - 1f 0.7 1.6
1
it
O Boring
2 ]Boring# 0pit Ground Surface Elevation 100.5 ft. Depth to Limiting factor40 & >120 in.
Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-17 10YR2/3 None SIL 2-f-sbk mfr gs 2f 0.6 0.8
2 17-27 10YR3/2 None SIL 2-m-sbk mfr gs if 0.6 0.8
3 27-40 10YR4/3 None SIL 2-m-sbk mfr gs if 0.6 0.8
4 40-54 10YR4/3 f-1-f 10YR4/6 SIL 2-m-sbk mfr aw if 0.6 0.8
5 54-120+ 10YR5/4 None S 0-sg ml - if 0.7 1.6
N ~ b2
• Effluent # 1= BOD5 > 30 220 mg/L and > 150 mg/L ' Effluent #2 = BOD5 30 mg/L and TSS 5 30 mg/L
CST Name (Please Print) Signature CST Number
Mark Iverson - 46672
Address Date Evaluation Conducted Telephone Number
P.O. Box 155 Hammond, WI 54015 December 20, 2005 715-796-5664
G&L Land Development, Inc. 040-1022-70-000 page 2of
Property Owner Parcel 1D# 3 3 ] Boring # 13 Boring
OPit Ground Surface Elevation 102.7 ft. Depth to Limiting factor >120 u1.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDtfe
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-10 10YR3/2 None SIL 2-m-sbk mfr cs 2 f to co 0.6 0.8
2 10-24 10YR3/4 None SIL 2-m-sbk mfr gs 1 f to co 0.6 0.8
3 24-31 10YR3/4 None LS 0-sg ml cs 1 f to co 0.7 1.6
4 3141 7.5YR3/4 None GRXLS 0-sg ml as 1f 0.5 0.5
5 41-120+ 10YR4/4 None S 0-sg ml - None 0.7 1.6
Boring # ❑ Boring
EIPit Ground Surface Elevation ft. Depth to Limiting factor in.
Soil AoDlication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
11 Boring
F I
Boring # HPit Ground Surface Elevation ft. Depth to Limiting factor in.
Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 -Eff#2
* Effluent #1 = BOD5> 30:S 220 mg/L and TSS > 30!S 150 mg/L * Effluent #2 = BOD5 30 mg/L and TSS 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
Need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
Site Diagram Page of 3
s
r
.J I ~ 11 s
r
t $
r
1 ~ fj r ~
LOT 2
I
ILL
r' 99'."
B-1
r ~ 100.Or.
5 !
U ~ A fn l _ + P
a &2 . BOO;,
0
CS 100.5'
-6-0 O7.
Co
lf X02.
2 1027 it r t
1 .3
10,pr''~ o 0 24 ft. 40 ft: 80 ft.
yr r ' _
k o r
Lot Lines
BM# & Description = Bench Mark B-1
Elevation 100, = Boring Location & Elevation House and well location to be determined
Owner: G & L Land Development Inc. Site Information: Completed By: Mark Iverson, PSS #197
W12491 890th Street NE 1/4, NW 1/4, S8, T28N, R19W & 680 Larcom Street
River Falls, WI 54022 SE 1/4, SW 1/4, S5, T28N, R19W Hammond, WI 54015
Town of Troy 715-796-5664
Phone: 715-386-2928 St. Croix County CST# 46672
Parcel 040-1316-02-000 oa/os/loos 10:22 AM
PAGE 1 OF 1
Alt. Parcel 08.28.19.2058 040 - TOWN OF TROY
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
02/03/2006 00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - G & L LAND DEVELOPMENT INC
G & L LAND DEVELOPMENT INC
W12491 890TH AVE
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 500 AUTUMN BLAZE TRL
SC 2611 HUDSON
SP 1700 WITC
Legal Description: Acres: 1.680 Plat: 10-100-CEDAR WOODS 040-06 LOTS 1/17
SEC 5 T28N R1 9W & PT SEC 8 T28N R1 9W PT Block/Condo Bldg: LOT 02
SE SW & PT NE NW CEDAR WOODS ('06) LOT 2
(1.680AC) Tract(s): (Sec-Twn-Rng 401/4 1601/4)
08-28N-19W NE NW
05-28N-19W SE SW
Notes: Parcel History:
Date Doc # Vol/Page Type
02/28/2006 819453 PLAT
02/03/2006 817941 LC
05/11/2005 794704 2801/185 QC
07/23/1997 824/129
2008 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 08/24/2007
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.680 71,500 0 71,500 NO
Totals for 2008:
General Property 1.680 71,500 0 71,500
Woodland 0.000 0 0
I
Totals for 2007:
General Property 1.680 71,500 0 71,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch M
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
49,8
OUTLOT-
L
i ISJ
LOT 3 mi F
i
i N)
55,202 sf. Gn
127. 0 ( ~ LO'
1.50 acres 9'c5 59"E
61,
'0 L30=908.0~,'~ 1.4
o ~ u; Cn S I ' c~
AD-
OD,
/ fro i
LOT 4
64,315 sf. LOT 2
Future Street S
1.48 acres 73,392 sf µ _ --_.S
1, 8 acres edicated to the p
Leo-90
N68-42'1
q) !
,,Pzic~ LOT 1 17
66,603 sf,
1`~ Y'~-~•
1.53 S/ S89'02
CD,
f i