HomeMy WebLinkAbout040-1303-00-011
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No,
561075
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)]. j
Permit Holder's Name: City Village X Township Parcel Tax No:
Oeverin Homes LLC, aka Oeverin Pro ertie Troy, Town of 040-1303-00-011
CST BM Elev: Insp. BM Elev: BM Desc ' tion: / Section/Town/Range/Map No:
~ t) ' D r~ l ~ t j X 22.28.19.1746
d.
TANK INFORMATION ELEVATI N DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark rt t L-~ J i> / a b
v J
Dosing f~ , r Alt. M t
Aeration Bldg. Sewer
Holding St/Ht Inlet %h
St/Ht Outlet
TANK SETBACK INFORMATION c% 6/_ F36
TANK TO P/L WELD,/ BLDG. Vent to it Intake ROAD Dt Inlet
Septic Z ® t - -~„V'tG Dt Bottom /
Dosing
Aeration C4nAA -u Dis ~ b~ S• it G V 2Holding Bot. ystem T _ l q.o I ,
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer Demand St Cover
GPM I r s=2 +d
m
Model Number C J wv~
TDH Lift Friction System Hea TDH Ft T
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length Igo. Of Trenches PIT DIMENSION No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LA ST AM ACHING Mtu Y
INFORMATION T pa Of System- CHAMBER 0
y t /S UNIT Model Number:
N
DISTRIBUTION SYSTEM Q J, 19r, X
Head anifold istri x ole ize x Hole acing 1ent jr Intake
i- ipe(s) / -
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over J Depth Over xx Depth of Seeded/Sodded xx Mulched
Bedfrrench Center Bedfrrench Edges Topsoil r Ej Yes No a Yes J No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ,;`Inspection #2:
Location: 664 Tradition Trail River FAls, WI 54022 ( E 1/4 SE 1/4 22 T29N R1 9W) Walnut Hill Farm aka The Tribute Lo Parcel No: 22.28.19.1746
1.) Alt BM Description = / 0 k' ma'VI,
2.) Bldg sewer length = 3'0 /
- amount of cover =
Plan revision Required? ❑ Yes SA/0
Use other side for additional information. s- 6, _ - J
/
SBD-6710 (R.3/97) Date Insepctor's ignature Cert. No.
Soil Test and System PLOT PLAN
PROJECT Oeverina Homes LLC ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017
SE ' 1/4 SE 1/4s 22 /T 2 /N/R 19 W TOWN Troy COUNTY ST. CROIX
10/9/13 3
MPRS Shaun Bird 226900 DATE BEDROOM
CONVENTIONAL XXX IN-CIS UND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE ABSORPTION AREA 931 # of chambers 46
, BENCHMARK V.R.P. Top of steel fence post ASSUME ELEVATION 100' Filter BEAR Filter
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
SYSTEM ELEVATION 91.2/91.0 F below qrade
Property Line
All piping shall be SDR 30/34, within 10'
of tank, piping shall be Schedule 40.
Well is to meet all
setbacks required by
WDNR
Scale is 1" = 40'
150' unless otherwise
B-3 94~ noted
B.M.*
95'
40' Ven s 2-3' X 94' Cells with >3' spacing
20 ~Y6,
IOLJAW-- 50' PIN 50'
1B-1 10' B-2b
S
ZL
Pro 3 Vent
Bedroo
House >6„ Quick4 Standard
of Cover Leaching Chamber
with 20.0 ft2 of Area
5.6ft^2/pair of end caps
12"
4' Long
Grade at System Elevation
34"
Tradition Trail
ty
aan - - Coun S
a
industry Services Division
a.
1400 E Washington Ave Sanitary I'errnrt Number (to be filled in by Co ) P H P.O. Box 7162
rti s Madison, WI 53707-7162 I _
~s .
16 75
xar
Number
- - State Transactioi
a ry Perrriit Application
in accordance with SPS 3 I(2), Wis. Adrn. Code, submission of this form to the appropriate governmental unit
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POW'I'S are submitted to Prqject Address (if different than mailing ddress)
the Department of'Safety and Professional SUMS. Personal information you provide may broil for secondary purposes
in accordance with the Privacy Law, s. 15.04(I)(m), Stats_- - Ta ~
1. Application 'Information -Please Print All Inform
n l
- - Property Owner's Name Parcel H
I -
- al
D / ~d
I 'I
-
- , ~T---I roperty L.-ucafion
Pro Perr Owner's Mailing Ad 's
Y
R
,,oo Govt. l,ot
Z
City, State ~ Zip Code Phone Number Section
/0-cle on
# - -
y) -
11. Type of Building (check all that appl Lot
Subdivision Name
I or 2 Family Dwelling- Number of Bedroo
A lo,
❑Public/Commercial-DescribeUsc___,--._ City of
V` - -
CSM Number Village of _
❑ State Owned --Describe Use
wn of
_113 Z3a - - C-
2-
111. Type of Permit: (Check only, onfe box ou line A. Complete hue B if applicable)
New System ❑ Replacement System ❑ l reatment/1lolding Tank Replacement Only ❑ Other Modification to Existing System (explain)
List Previous Perrnit'Nurnberand Date Is' red -
B. ❑ PenYiit Rcnewr 'ennit Revision ❑ Change of Piwnber ❑ Permit 1 r tnsfei to New
Before Expiration Owner r'
IV. T e ofPOWTS system/component/Device. Check all that a tl j - ' -
Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ AL-Grade 11 Mound >.24 in, of'suitablc soil Mound <24 in. of sunabl soil
jl Holding 7 a~cher Dispersal Component (explain)_._ Pretreatment Device (explain)
- -
_V. Dispersal/Treatment Area Information:
/
Dell n Sail A hcation Rate(gpd Dispersal Area Requiruf (sf) 1)ispertal .Area Proposed yste n L'.levat II
Design Flow (gpd) g PP - - -
7-]n VI. TCapacity in Manufactcarer
U Gallons Gallons nits 0
n New Tanks Exisling'ietnks
o n k
DOSing Chamber
VII.. Responsibility Staterrre t- 1, the undersigned, assu re possibility for installation ofthe POWTS shown oil the attached plans,
M
Phu s Narne (Print) Plumber' i lure P/MMPPRS Numbeer~ BBuussiness Phone Nu fiber
Plumber's Address (Street, City, State, Zip Code t
Vll :ouut /Department Use Only
Permit Fee Date I. ued Issuir@, m Signature
Approved ❑ $
en r . a~ I b l
6,7
Reason for Denial
~rlwr-ft~
IX, CondifWtixTt NQM easons for Disapproval
1. Septic tank, efftuentfiltKwtd B✓tr5 i av` rtl`. Aff -,J ~J6
dispersal cell must all be v I
as per management plan protq d by * rOJ .'COP
tie
pr appNcitt taotite / orioK:
Attach to cmnplete plans for the system and submit to th County only on paper nut I ess th:: A 112 x 11 inches ru tlr~j A - d3-1 Ct~~
~1 prv.2~Ow t.cJ t V [~~t~~
f
S13D-6398 (R0313) f'M~
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County
~
f 'x
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel LD. X
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. *11Y6 d - Ql
Please print all information. Revie by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
Govt. Lot 5 e 1/4 1/4 T Z F N V N R E (o W
Property Owner's Mailing Ad ss Lot # Block # Subd. CSNW
A/3 3 f fit/
City State Zip Code Phone Number ❑ City ❑ Village QTown Nearest R pd
ocz
d-New Construction Use=esidential / Number of bedrooms Code derived design flow rate y-ty GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material ll,.e LJ Flood Plain elevation if applicable /1/ 1 rT ft.
General comments
and recommendations: `
System Type y'n/ J System Elevation-C~ /D
Boring # Boring
F-11 Rpit Ground surface elev. Depth to limiting factor l 1 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
s - l S 0 s / A1,4 , S v
11
►l
F0 I
6
Boring # Q Boring
E]rn
® 1i51. Pit Ground surface elevft. Depth to limiting factor //-r in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Z -
IS Zo-
IL,
.z .t
it
b
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 nAV ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) re CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date Evaluation Conducted Telephone Number
1008 192nd Ave, New Richmond, WI 54017 ~O~ _ 715-246-4516
Property Owner _ Parcel ID # Page of
F Boring # ❑ Boring
6• pit Ground surface elevA Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2
F-1 Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Boring
Boring # Ground surface elev. ft. Depth to limiting factor in.
F-1 ❑ Pit Soil Application Rate
Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPDAf
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
I
Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
SBD-8330 (R.W00)
Soil Test and System PLOT PLAN
PROJECT Oeverina Homes LLC ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017
SE , 1/4 SE 1/4S 22 /T 2 N/R 19 W TOWN Troy COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 10/9/13 BEDROOM 3
CONVENTIONAL XXX IN- UND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE ABSORPTION AREA 931 # of chambers 46
BENCHMARK V.R.P. Top of steel fence post ASSUME ELEVATION 100' Filter BEAR Filter
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
SYSTEM ELEVATION 91.2/91.0 5' below qrade
Property
All piping shall be SDR 30/34, within 10'
of tank, piping shall be Schedule 40.
Well is to meet all
setbacks required by
WDNR
Scale is 1" = 40'
150' unless otherwise
B-3 94' noted
B.M.
95'
09 40' 2-3' X 94' Cells with >3' spacing
Vents 96'
15' B-1 50 50 10' B-2
ST
Pro 3 30' Bedroom
House ic. Quick4 Standard
eaching Chamber
ith 20.0 ft2 of Area
.6ft^2/pair of end c aps
Grade at System Elevation
34Tradition Trail
County
'8 Safety and Buildings Division
201 W. Washington Ave., P.O. Box 7162 Sanity permit Number (to be filled in by Co.)
ot~q Madison, W 53707-7162
4 -'"-HJ1pNA1
Sanitary S (o1 a7 5
r_'pn Number O
t).Oi l state TTf/~~JL'
In accordance with SPS 383.22(2), Wis. Adm, su
is required prior to obtainin a sanit n of this form to the appropriate go'Mrnmental unit 0
the Department of 8 permit. Note; Application forrrn for state-owned are submitted to
Safety and Professional Servies. Personal information you provide rna Project Address (if different than mailing addres )
_purposes in accordance with the Privacy Law s. 15.04 1 (m , Stats. y r'secondary
I, A lication Information - Please Print All Information
Property Owner's Name
f ) Parcel N
t? ~~~n l,L_ L. sr~ ~~1' UFO -/30
Property Owner's Mailing Address 3 - Q f r
Propert
CD y Location
City, state Govt. Lot / (o
Zip Code Phone Number
'/a, Section
Cc% 1-17
11 ype of Building (check all that apply) Lot 4 T Z crrcE on
r of Bedro
or 2 Family DwelPA/ - Nu e . .
o
- Subdivrsrvn Name
MaL Block
❑ Public/Commercial - Descri e Use ❑ City Of -
El State Owned -:Describe Use CSM Number ❑ Village of
2
a - Xxown of
III. T pe Permit: (Check only ne box on li A. Com ete fine B if applicable) -
New System ❑ Replacement Sys: ❑ Trea ~ntlHolding Tank Replacame O 1
y ❑ Other Modification to Existing System (explain)
11. ❑ Permit Renewal ❑ Permit Revision ❑ Chang of Plumber ❑ t t r fer to New
List Previous Permit Number and Date Issued
Before Expiration 0 e
IV. T e of POWTS S stem/Com onenVDe heck 1 that a
Non-Pressurized In-Ground ❑ Pressurized In-G and ❑ A Grade `
❑ ou d > 24 in. of suitable soil Mound < 24 in. of suitable soil
L~ Holding Tank ❑ Other Dispersal Component (exp irt)
❑ Pretreatment Device (explain)
is ersaUTreatment Area Information:
Design Flow (gpd) / Design Soil Application Raya(gpds1} ispersal Area Re uired f
✓ ✓ 4 ) Aispersai Area Proposes sf) System Elevation
2 3j'2 X0 55,3
( 1. Tank Info Capacity in Total 4 of Manufacturer
Gallons Gallons Units
New Tanks Existing Tanks
w t>D ~d f. w U ~l E ~
S ptic or Holding Tank y u (7 p r lei
Dosing Chamber lD
VII. Responsibility Statement- I, the untlersigned, ass a responsibility for installation Of the PO'pWTS shown on the attached plans. -
Plumber's Name (Print) plumber. r afore
MP/MFRS Number Business Phone Nuitfnberl
Plumber's Address (Street, City, State, zip Code) J - ~L)-3 /
/`1 z l z.L2
V OUR /Ae artmeat Use Only
Approved ❑ Permit Fee Date Issued issuing ent Signatur
_ =7iven <R,,.1rf,r Menial 175
Ix. Cond tsasons tbr Disapproval nt)'`/~
h , 3 1J lfla-.. !~a ne &j dvn-#-e
tifapers~ 100111must d be.sseftes tmalMalrsad ,e
~ ~ t errant plan provided by plumber. L4.) d9. e,.A.dVc tz /A PC ~
t t 4uirwwts.must baAmintab*4
~ t~Ods ! Ors
Attseb to complate plans for the system and submit to the County only on paper not less than 8 in x 11 inches iu 61Y4
SBD-6398 (R_ 11/11)
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi 54017
715-246-4516
Date: 4/30/13
Owner:Oevering Homes
Location: SE1A SE1A S22 T28 N,R19W lot 11 Walnut Hill Farm Troy
System type: In-ground absorbtion system (conventional)
Manuals Used: In-ground absorbtion system (version 2.0)
Page#
1. Cover Page
2. Plot Plan
3. Chamber Cross Section
4-6. Maintanance and Contingency Plan
7. Filter Specifications Phpet
Signature Z / /
License nu er #226900
PLOT PLAN
PROJECT Oeverina Homes LLC ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017
SE 1/4 SE 1/4s 22 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 4/30/13 BEDROOM 3
CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE ABSORPTION AREA 931 # of chambers 46
BENCHMARK V.R.P. 1/2" steel conduit ASSUME ELEVATION 1009 Filter BEAR Filter
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
SYSTEM ELEVATION 96.0/95.3 4.4' below qrade
All piping shall be SDR 30/34, within 10'
of tank, piping shall be Schedule 40.
Please note: soils in this area
are a FS not a S and the Well is to meet all
system is to be sized setbacks required by
accordingly, also test area lies WDNR
right in the middle of the
building site, further testing
will be done to fix this
problem Scale is 1" = 40'
Pro 3
Bedroom unless otherwise
House noted
5'
B-3 99'
3% SLope S
5'
0'
B.M
100'
10'B-1 45' 45' B-2
2-3' X 94' cells with >3' spacing
Vent
>6„ Quick4 Standard
Leaching Chamber
100 of Cover
with 20.0 ft2 of Area
5.6ft^2/pair of end caps
4' Long 12"
Grade at System Elevation
3 4"
Town Road
Cross Section of Infiltrator Quick 4 Leaching Chamber
Typical cross section for 2 of 2 cells
Quick 4 Standard Leaching Chamber
with 20.0 ft2 of Area per Chamber To be >1' above grade
5.6ft 2 pair of end plates
Finish grade elevation
Typical Installation 100.4'
Vent Grade Vent
3' 4" 3'
,A;~30/34 Septic Tank
5' Long 1 99 5' S' Long 1 19 3699 Grade at System Elevation Grade at System Elevation
Spacing 5'
2-3' X 94' Cells
Same on other end Observation tubeNent
At end of cell
A
B
23 chambers per cell
System elevations:
A-96.0'
B 95.3'
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
-Owner P n Septic Tank Capacity 10r_ro al ❑ NA
Permit # Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA
Number of Bedrooms - ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units -)6.NA Pump Tank Capacity al NA
Estimated flow (average) gal/day Pump Tank Manufacturer 11 NA
Design flow (peak), (Estimated x 1.5) '9-"J_0 gal/day Pump Manufacturer NA
i Soil Application Rate - al/da lftZ Pump Model NA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit NA
Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BODs) 5220 mg/L ❑ NA D Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other.
i- -
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BODE) 530 mg/L -Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound
Fecal Coliform (geometric mean) 5104 cfu/100ml ❑ Drip-Line ❑ Other:
iMaximum Effluent Particle Size 36 in dia, ❑ NA Other: NA
Other O NA Other: LNA
`Values typical for domestic wastewater and septic tank effluent. Other: MAINTENANCE SCHEDULE
Service Event Service Frequency
1' mont s) y
(Inspect condition of tank(s) At least once every: r s (Maximum 3 ears) ❑ NA
(Pump out contents of tank(s) When combined sludge and scum equals one-third (X) of tank volume ❑ NA
!inspect dispersal cell(s) At least once every: _ y C ear(s(s) (Maximum 3 years) ❑ NA
ear s
Cl onth(s)
Paean effluent filter At least once every: ar(s) ❑ NA
Inspect pump, pump controls & alarm At least once every: p months) NA
1=lush laterals and pressure test At least once every: ❑ month(s) NA
❑ year(s)
month(s) NA
5ther: At least once every: ❑ D year s)
ether.
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; POINTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must
iinclude 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 an 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 (4) 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
14dministrative Code.
III other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units,
iand any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
Ik service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals thElt
may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of thl3
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 ble
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluenit.
normal levels
effluent void this s ontac a s Plumber contents or POWTS Maintaitank remove ner to assstin manualy operatni he pump the controls to restoring
pump or contact
within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within
15 feet down slope of any mound or at-grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance
fatf fo of the oOn dr :1in
diapers; d sinrolo n the
antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; pes
(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 propejty
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 Septage Servicing Operator.
After pumping, all tanks and pits shalt be excavated and removed or their covers removed and the void space filled with sci►il,
gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS falls and cannot be repaired the following measures have been, or must be taken, to provide a code compliipn
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 requhled
setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result In the neled
for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rule:[ in
effect at that time.
❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technologN a
holding tank may be installed as a last resort to replace the failed POWTS. evaluaillon C] The site peeto locate a suitable replacement area. replacement
available POWTS a soil and
replacement area failure of the
g tank may beeInstalled as
must be performed
a last resort to replace the failed POWTS.
❑ 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 NIOT
DEATH MAY RESULT. RESCUE OI A
ENTER A SEPTIC, PUMP O OTHER A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
PERSON FROM THE INTERIOR
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name E Name
Phone Phone
SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTH_ ORITY
Name 17f Name
Phone 7 Phone
This document was drafted In compliance with chapter SIPS 383.22(2)(b)(%d)&(f) and 383.54(1), (2) & (3), Wisconsin Administrative Code,
lok
TER CARTRIDGE INSTRUCTIONS
~~r~lrr~l,rrinl~, •
s'rtp i bry lit the iririer cw- ►WV the lord of t:hr olltlrtt pipe, trt ensure it is
te+titered under tiee +a auar npwning. If not, 044" richer int;ert move 0104 into titw
tank through the outlet or eoiumst weds{ (glna) additlunal plpe phtu the outlet
pipe-
: +pts 2 While the case is still dry fitted on Cori outlet pipe, rnuasure the iewgth
of st4-b4ch pipe needed to bract., the niter to tite tank end wall if utilt
*j 9 " tf►e
rtptionaal supplerretrttol Wde support, If side support trttethod. Is nvt utificed,
proceed to step foul-
: `"o x For ittstagatiatrss utiliairlly thv ol►tlQndl SUppielYtental side support-
SCIVObt weld the %-ihch pipe Mato. the Cl"r Cage, If rpide summit Method is ivot
utiiiiad, proceed to step four.
-Solvent w*W cartridge into the cavepreasiinl down until the filter lacks into the buttvtr, of
I{
tiro C2ltiti. , p ,
If a VRS switch is utifivgRd_ insert into too filter. and luck Iry turnitlg
clockwise 900,
1. The emijent Niter should be tieanad every time the tpaptic tank 15
serviced.
1. opeh the outlet access opoWng to Inspect the tank dtid I'tltttr, "
s. l'urlip tFte septic tank corrrplotelyr making .yero to retnttile rho slodyiLi
layer on the bottom of this baYrlk acrd not ,inter tire scuirt and efflutint. ,u
4- once fire otNuant level has bue n Iowered below the invert r►f the
outlet pipe, firmly pull up oh the Niter handle to dlalodgd the
cartridge halo tho erase, '
S. Slide: the rartrltiw tip and or a of the case: fnr cleaning, pig
G, tY a VRS switch cunhe ctad to ;err alarm 1!5 ordsent, the swtlitL"h
should be removed by tvl*411 p r=ountarclvCkWlsa 901 bind twilled
With water only. a. •9 c'„
i. While huldlnly the relrtfidge on its tide (large fiat Wr4re f scbru + Y t+ir,,,
down) over the acce" opening, ritto off the catridge With WAne
only, criakitrg sure as s to!)et-:
•p roeaterlal is rtrisad back Into the tttui;_ ~ •5,~m,; • t
u. if VRS twitch Is utiiizedx replace by Inaertlhy into lifter and
turning clockwise 90".
9, ittsmrt tam filter cartridge back into the cai*o fired hig down' Until Y v l
the filter locks into the bottom of tow cake.
417 •,K,
ip.Replace and secure the au:cesio utiehlow an the tanlL
are:••one. v.;...+rt °yx; ;gxl,$;JTSrd •lru,. ,y r:.~tlrat'41~sVailr~6tx"'.
rn►wiW:~tTVUlri~i»lc,tt►xtt
RjjFmjw low -q.-qm-
tASEMV4T
Or
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lop
1 50161 S. F.
1.15 Ac.
L go
10
46237 S.F.
96 1.06 AC.
S, F. LBO 9630
I -qw-Ac.-
40
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TO MEMO
dLYS 9k OW .9A: 9~
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer ____6'1t0u!~LLy -
Mailing Address c2t~nn~s~-~.-suel%~
Property Address ---,~U IT(N
Verification re aired from Planning Zoning Department for new constniction.)
C.ii:y/State I V (,%~~-,/V yT Parcel. Identi Ccation Number Uf 3 O ~j / _
LEGAL DESCRIPTION
Property Location Y,, Sec. Z , T Z8 N .RJ0 W, Town of Subdivision Lot #
Certified Survey Map # Volume Page
Warranty Deed # Volume Page #
Spec house yes no Lot lines identifiable es 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 §Comrn. 83.52(1) and in Chapter 12 St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St:. Croix County Planning &Z.oning Department a certification form, signed by the
owner and by a master plumber, ;journeyman plumber, restricted plumber or a licensed pumper verifying that (l.) the on-sits
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
Toning Department within 30 days of the three year expiration date.
lAve 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 ed recorded in It egister of Deeds Office.
Number of bedrooms-----) _ _ Y1.301
~IGN- AT - OF-APPLICANT(S) DATE
***Any information that is misrepresented may result in die 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. 118/05)
i iall'llll'il iilillilll~lifi
8155083
Tx;4126480
STATE BAR OF WISCONSIN FORM 3 - 2000 978629
Document Number QUIT CLAIM DEED BETH PABST
REGISTER OF DEEDS
THIS DEED, made between Citizens State Bank, Grantor, and Oevering ST. CROIX CO., WI
Homes LLC, Grantee. 05/15/2013 12:28 PM
Grantor quit claims to Grantee the following described real estate in St. EXEMPT#: NA
Croix County, State of Wisconsin (the "Property"): REC FEE: 30.00
TRANS FEE: 57.50
PAGES: 2
Property is sold `as is'.
SEE ATTACHED EXHIBIT A
Recording Arca
Name and Return Address:
Title One
File #19322
y
Together with all appurtenant rights, title and interests. 040-1303-00-011
Parcel Identification Number (PIN)
This is not homestead property.
Dated this 1 st day of May, 2013.
Citizens Stat
e Bank p
L"~-
* Gene Haberman, Vice Chairman
* *
AUTHENTICATION ACKNOWLEDGMENT
STATE OF WISCONSIN )
Signature(s) ST CROIX COUNTY. ) ss.
authenticated this 1 st day of May, 2013 Personally came before me this 1 st day of May, 2013 the
above named Citizens State Bank to me known to be the
* person(s) who executed the foregoing instrument and
TITLE: MEMBER STATE BAR OF WISCONSIN ackno edged t De same.
(If not,
authorized by 4 706.06, Wis. Stats.) '
* /velyn Jaeger
THIS INSTRUMENT WAS DRAFTED BY Notary Public, State of Wisconsin
' " P. My commission is permanent. (If not, state expiration date:
12/11/2016 )
Michael H Forecki, Attorne ;
Y
(Signatures may be authenticated or acknowledged. Both Zie ngtPU ft4aJ-
*Names of persons signing in any capacity must be typed or priritec le 1h " •ature
• pF .
1 of 2 QUITCLAIM DEED STATE BAR OF WISCONSIN FORM No. 3-2000
EXHIBIT A
Lot II of Walnut Hill Farm, All in the Town of Troy, St. Croix County, Wisconsin.
Roadways, Easements and Restrictions of Record
~I
2 of 2
Parcel 040-1303-00-011 05/07/2013 08:45 AM
PAGE 1 OF 1
Alt. Parcel 22.28.19.1746 040 - TOWN OF TROY
Current 0 ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
00 0
Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner
0 - CITIZENS STATE BANK
CITIZENS STATE BANK
375 STAGELINE RD PO BOX 247
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 664 TRADITION TRL
SC 4893 SCH DIST RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 1.150 Plat: 09-092-WALNUT HILL FARM 1/75 040-03
SEC 22 T28N R19W PT NW SE WALNUT HILL Block/Condo Bldg: LOT 011
FARM LOT 11 (1.150AC) Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
22-28N-19W NW SE
Notes: Parcel History:
Date Doc # Vol/Page Type
03/05/2010 912825 SD
12/10/2003 748766 2471/591 WD
11/19/2003 747018 9/92 PLAT
2013 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 08/20/2012
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.150 27,500 0 27,500 NO
Totals for 2013:
General Property 1.150 27,500 0 27,500
Woodland 0.000 0 0
Totals for 2012:
General Property 1.150 27,500 0 27,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page ~ of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County 57-- G,e o/ )L- r
Attach complete site plan on paper not less than 8112 x 11 inches in size. Plan must ` v T ~N H
include. but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. p itl~lJ~
Please print all information. viewed Date
Personal krrorm txm you provide may be used for seoondary purposes (Privacy Law. s.15.04 (1) (m)l. I 'l G / 6 3 y~
1
Property owner t^ TOpp Property Location 0 0 Q
T-0 CID 133ERSTe7pT- /v 41M;'' YK GovL Lot AlI Vf( S~114 SZL TZL N R /f / E(or)W
Property owner's Mailing Address Lot/#/ Block A! Subd. Nana or CSfM
(Pot5 CA WiL1- Ave. • 6vAivor Kill FARM '~t
city --CM R State Zip Code Phone Number ❑ city ❑ Village CA Town Nearest Road
b~oV~ 1iT3: MN SSOW, ( &S!) Z5/8• toff TRoy so. CirtovER
0
New Construction Use: C § Residential 1 Number of bedrooms Code derived design flow rate r O a GPD
❑ Replacement ❑ Public or commercial - Describe- - to
Parent material 1,0&5.5' 011.- SAV D y 14 &f Z~/fcam/ N Flood Plain elevation If applicable
General comments
and recorrrrnardations. , pert 72?1r0 sa; r VE- jo ~v /tiy.Pov~a o• cv. s L
P. 44 6 4,
N
Boring y r
- tL Depth to limiting factor in.
o # o ® Pit Ground surface elev. 65
Sol licabon Rate
Horizon Depth Dominant Redox Description Texture StrudLxe Consistence Boundary Roots GPDff
in. Mumsen Qu. Sz. Court. Color Gr. Sz. Sh. 1 *M *Eff#2
C
3 Y~- G
L s ~
/o R 313 I 1a~ S w
7- 16-17 110VA 3 51 L- /fs s i Z• 3 ~A
3 17- 3 /or yi s~ ate, sh • s • 0
/o yve s/ S D s P •
~ n
1 a Boring 8
1 e« +g # ® Pit Ground surface elev. /O o • 8. Depth to limiting factor. > in. Sol Applic"on Rate
Horizon Depth Dominant Color Redgx Description Texture Structure Consistence Boundary Roots GPD ff
In. Mumsen t1u. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Etf#2 IN
0 • o yR 3/3 L S Tk- dSA w 3 -)P- . `1 N
z 2l /AO5 dA s
• Effluent #1 = BOD > V :S =0 mg& and T S96:3-0 < 50 mglL • Effluent #2 = BOO 30 mglL and TSS 130 mglL
igr'attme , . G L
I Name (Please In, , .u LB R ! G ~n 1 S
G 37 5;
nddrm Ulbricht & Assgciates Data Evaluation Con fed i ~ Telephone 3 Number
0 7S
Private sy Z
" T y
2812 10th Ave.
Spring Valley, WI 54767
PINS FOR 4 PRO x . 2- yo
. ~ ~ oyD • /ors • so • t~
. . dyp • /O~G • .zo • o~
Oyd-/o~lo• ~D•~
0 ~oe /0 70
o ~'D
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Cv~~v V T"" ffi//r~iP~-1
TOD/7 ~E S TED7-
Prop" Parcel ID # L o f POP z d 3
n3 Boftlp SG
t,/,9 Ground surface elm ft- Depth to testing factor irz
Sod 12ate
Fforixun Depth ant color Redox Description Texture Struc~txe Consistence Bounc#aryt Roots GPDM
seff Qu. Sz Cont. Color Gr. Sz. Sh. `121191 'EfF#2
~'L ~~'SLi~ w 2 • y
z D is 3 S~ c. ~ s ti . Z . 3
3 G• 3 /l' Sl L 2 n1t s v c S . S
4-2
F-] a
B,,V ❑ pit Ground surface elev ft. Depth to lsn sting factor in. Sol art Rate
Horizon Depth Dornin Redox Description Texture Skucure Consistence Boundary Roots GPDff
trr. Munsetl Qu. Sz. Corti Color Q% Sz Sh. 'Ef1#t °1211#2
# Baring ,
❑ Pit Ground surface elev. tt. Depth trrratntg factor in
Soil Application Rate
Horizon Depth Dominant Color Redox Description- Texture a Consistence Boutxfary Roots
in. Munseff Qu. Sz Cunt Color tsj. Sz Sh. `Eff#1 'Etf#2
a+
4
E 8vring # ❑ Bating
Groutsd surface elev. ft. Depth to limiting factor In.
❑ P":t Sod Appikation Rate
Horizon Depth Dominant Color Redox besalplior~ Texture Structute Consistence Boundary Roaas t puff
its. Munseff Qu, Sz. Cork Gr. Sz. Sh. 'Eff#1 'Eii#2
Eflfuent #1 = BODs > 30 < 220 mg& and T >30 < 150 mgfL • Effluent #2 = BOD$ < 30 nx t. and TSS < 30 mg1t.
The Department of Commerce is an squat appo nity service provider and employer. If you need assistance to access services or
need material in an alternate format, g ease contact the department at 608-266-3151 or TTY 608-264-8777.
sea-esractzs+ea?
i
TDp~ T3 .~E ~ S T~D7`
Property owner Parcel lU # Page Z of 3
~ L) Boring
F3-1 ~jo
I Ground surface elev. / 0 . 5(" ft_ Depth to limiting factor in.
_ Solt Application Rate
Ffosfzon depth Dominant or Redox Description Texture Structure Consistence Boundary Roots GPDM
irr Munsell QU. Sa. Cont. Color Gr. Sz. Sh, `Eff#1 -Etf#2
Z D /e
3 G 3 /0f s« z s v ~S s
a
" B,dng # Ll Boling
pit Ground surface elev. ft. Depth to limiting factor Fn. Soil on Rate
f-loOM Depth t7otninanf Color Redox Description Texture ShO" Consistence Bmw dart' (toots GPIM
In. Mtmself Qu. Sz. Copt Color Gr. Sz. Sh. 'Eff#1 '092
Boling Boring
pit Ground surface elev. ff. Depth limiting factor in.
A Ilr~tion gate
horizon Depth Dominant Color Redox Description- Texture tauctwe Consistence Boundary Roots GPD,tf?
In. MurrseN Qu. Sz. Cont Color Gr, Sz. Sh. `Eff#i 'Eff#2
Baring
Boling
Q pit Ground surface elev. ft. Depth to limiting factor in.
Horizon Depth Dominant Color Redox Descrtpti - Texture Structure consistence Boundary Roots In. Munsell Qu. Sz. cod. cd Gr. Sz. Sh. e
M*Efffr#1*'EEffff##22te'
' EftiueM #1 - BOD, > 30 < 220 mc, L and T >30c 150 nigh. ° Effluent #2 - B006 :S 30 mg/4 and TSS < 30 nVIL
The Department of Commerce is an equal oppo pity service provider and employer. If you creed assistance to access services or
need material in an alternate format, p ease contact the department at 608-266-3151 or TTY 608-264-9777.
s®u-eiwsreoT
PLOT PLAN WALNUT HILLS FARM. LOT # Pg. 3 of 3
Contour elevation lines.
t = Backhoe Soil pits.
0 = Benchmarks set, maRKED WITH FLAGGED
lathes. 1/2" steel conduit pipes.
0
SCALE: 1" _ l
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ka~
Ica
f3 3
o 98.60
x d 9q 0
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