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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division - INSPECTION REPORT Sanitary Permit N. 563824 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: j���' Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)]. '4 / Permit Holder's Name: City Village X Township Parcel Tax No: Canada, Robert&Vonda Troy, Town of 040-1318-00-020 861 CST BM Elev: Insp.BM Elev. BM Description: Section/Town/Range/Map No: r () 1 6 T 11.28.19.2095 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER i '.'`y 5 CAPACITY STATION BS HI FS ELEV. 2 • /OZ. g /es b Septic �.. 2 Benchmark NO PG...t) F;.! f.... 3 e /Z50 Z. loo /AZ.to /db Dosing )4.1�,5 3 9 Alt. BM J Bldg.Sewer 1�,.. 8 et 4-- 6 F i1S y.i /07,9 Holding _ St/Ht Inlet 6. ( 7(.. ,7 St/Ht Outlet TANK SETBACK INFORMATION --- TANK TO P/L WELL BLDG. Vent Air Intake ROAD Dt Inlet �_ Septic /0/ ^_ y6 / „� Dt Bottom /6.3 97. ,r, Dosing / 44- 1/.66/ La / Header/Man. Z.1 ?9• 7 D Aeration Dist. Pipe 2.`] 57, ? Holding C Bot.System 3 .(0 99,Z. — PU MP/SIP HON INFORMATION /5\e-- -e,Final Grade / O /, Manufacturer l! 6,,...j___ r a /5DGePmM and St Cover X1.3 11Z, 00._`__, Z .6 /eo. 1 Model Number , / L.r'a , co„.,..4-5 ,...,(---- V.41 1Tr. zV TDH 'Utz Friction Lo•, System Head TDH 3 '�t Forcemain Len ' Dia. 'I Dist.to Well 1� 76 Z A) _ — SOIL ABSORPTION S1ySTEM BED/TRENCH Width Length / No Of Trenc PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth DIMENSIONS 75 ie �, SETBACK SYSTEM TO P/L / BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Of / CHAMBER OR Type tem:Mod i ,, Zb Ahl - /1!� UNIT Model Number: — DISTRIBUTION SYSTEM 11//1" v Header/Manifold/ /I Distribution W /1 / x Hole Size // x Hole Spacing/ Vent it Int Pipe(s) /3Z Z i. Length Dia ' Length -22, Dia z Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only GC.a' Depth Over / Depth Over xx Depth of xx Seeded/ dde xx Mulched Bed/Trench Center / 7 Bed/Trench Edges \ Topsoil f Yes Ei No Yes At No COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: a / 1/ / /3 Inspection#2: / / Location: 480 Summit Rid e H �s_ocn,,.,WI 54016(NE 1/4 NW 1/4 11 T28N R19W) Hills of Troy Lot 20 Pa 0 Parcel No: 11.28.19.2095 1.)Alt BM Description= F' 1 �% C J e'er" // ,�,,�� , 2.)Bldg sewer Description length= C 4 b ha k -amount of cover= !f � di� > 1L a� Plan revision Required? Yes No / f_ - 1 t, 3� Use other side for additional information. 1 (� (� Ity� _ I __ i ___L__.___. SBD-6710(R.3/97) Date / Insepcto(Signature Cert.No. ■ . • . r. , 3. ... • . ,--11 , exiiiii) .. c f-..----4 .. . _ , . _ .. _ _ 1 9EH SERIES SUMP/EFFLUENT PUMP 11.65 .. T— ep ri \?".. C4 8-95 If O t(e4i it . o 0 \li j � Co v / ` J Specifications MODEL CAt. LISTING HP VOLTS SOUDS SIZE RUNNING PERFORMANCE(GPM @ HEAD) SHUTOFF PSl PWR.CRD. WEIGHT DIMENSIONS NO. NO. (Dia.lu.) AMPSIWAITS 5' lip 15' 20' Al IFt.) (Bsd (HAM 9EH-CIM 509330 UUCSA 4/10 115 3/4 13.0 1000 70 64 55 41 32 13.8 20' 24 9.11 x 11.64 x 8.94 9E1-CIM 509340 USA 4/10 230 3/4 6.5 1000 70 64 55 41 32 13.8 20' 24 9.11 x 11.64 x 8.94 984-CIA-RFS 509350 IA/CSA 4/10 115 3/4 13.0 1000 70 64 55 41 32 13.8 20' 27 9.11 x 11.64 x 8.94 9EH-CIA-RFS 509360 UUCSA 4/10 230 3/4 6.5 1000 •70 64 55 41 32 13.8 20' 27 9.11 x 11.64 x 8.94 Continuous Duty Rated—"Little Giant Wastewater pumps are rated continuous duty as long as they are run within the published ratings forthese pumps.' FLOW- LITERS/HOUR Construction 0 1000 2000 3000 Motor Housing Epoxy Coated Cast Iron 1 I 1_ I I_ Impeller Material Poly Carbonate 30 - L.10 Impeller Type Closed Vane _ - - Volute ABS W = =7.5. Power Cord SJTW-A ``20 — W Mechanical Shaft Seal Nitrile with carbon and - f - 5 ceramic faces ° Fasteners Stainless Steel to -- =Shaft —2.s Stainless Steel Bearings Upper Sleeve and Lower 0 = Ball Bearings 1HI III ilia nn IIII nn 1111 III 0 0 20 40 60 80 FLOW- GALLONS/MINUTE PUMP PERFORMANCE CURVE Little Giant Pump x7S7r a% x,R� I15V 60HZ C.O. L. ,j/ _ 111°' PO Box 12010•Oklahoma City,OK 73157 • a „�"'i!: Phone:405.947.2511•Fax:405.228.1550 ,� E-mail:customerservice @littlegiant-com www.LittleGiarttPump.com Form 995235—07/03 PLOT PLAN PROJECT Bob Canada ADDRESS 1820 Aspen Drive Hudson Wi 54016 NE 1/4 NW 1/4S 1 1 /T 28 N/R 19 W TOWN Troy COUNTY ST.CROIX SYSTEM ELEVATION 99.3' 4 BEDROOM CONVENTIONAL AT-GRADE CONVENTIONAL LIFT HOLDING TANK MOUND )00( SEPTIC TANK SIZE1255 gallons DOSE TANK SIZE 765 HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 600 # of chambers none ■ BENCHMARK V.R.P. Top of 1.5" p ipe ASSUME ELEVATION 100' ❑ BOREHOLE O WELL *H.R.P. same as benchmark Property Line 1 Acre Lot Property Line Property Line Tank is to be properly bedded and provided with lockdown Scale = 1 /4" = 1 0 covers with approved warning labels Grading is to be done to divert run-off away from system Area 15' below system is to remain undisturbed 12% Slope B-3 n 95' 97' I 98.3'— 22/113- 1 ° B-2 Huffcutt Combo Tank 9 Pro 4 Bedroom House 41 i Well is to meet all WDNR setbacks Summit Ridge County Industry Services Division I Dy '1400 E Washington Ave AAntary P01717nitNUrn er (to be filled it by Co.) " s f~ k P.O. Box 7162 -&3 K 2-'~ Madison, WI 53707-7162 Sanitary Permit Application Stale Transaction Number In accords c with SPS 383.21(2), Wis. Adm, Code, submission of this form to the appropriate governmental unit Z--:z, O_/ is required prior to obtaining a sanitary permit. Note: Application forms for state-owlied POWTS are submitted to PMeet Address (if iffercnt than maili ig address) the Department of Safety and Professional Servies. Personal information you provide may be used for secandary u SU ` r ones in accordance with the Privacy Law, s. 15.04(1)(m), Stats 1. Application Information-Please Print All Information Property Owner's me Parcel # VI/ ex-f 06~1_ 0~0 Properly owner's Mall~mgAddress tC Property i,ocauor' Govf. Lot City, St to zip Code Phone Num erg} ..D f~/ Section - W ti ~G V f f' it'cle yer I1. T pe of Building (check all that apply) Lot # - - 2 Farr' Dwelling - Number of Bedroom Subdivision Name c r - c Block # ❑ Public/Commercial - ll tribe Use ❑ City of _ ❑ State Owned- Describe Use CSM Number Village of - wrl of 20 111. `T'ype of Permit: (Cheek only one box on line A, Complete line B if applicable) A' New System F1 Re lacelTlent System ❑ Treatment/Holding Tank Replacement Only Other Modification to Existing g Sys ti n (explain) P"' B. ❑ Permit Renewal ennit Revision- ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date slued Before Expiration Owner - - IV. Type of POWTS Systen/Component/Device: (Check all that Non-Pressurized In-Ground U Pressurized In-Ground ❑ At-Grade Mound % )4 in, of SUitabe S011 C] Mound <24 itl of suitable soil ~ ❑ Holding Tank ❑ Other Dispersal Component (explain)__ Pretreatment Device (explain)___ G-IV.-Dispersal/Treat ment Area Ini'urtnation: ' Design Flow(gpd) Design Soil Application Ra gpds Dispersal lea eci sf} Dispersal Area Prot sed (sl} System Elevatlor/ t1iredi f 0 0. -9 /S~ - - - - - _ - - aea1 --.-L - V11. Tank Info acity in Total 9t~_ a 1lt,1ctu r :l Gallons Gallons Units 1 0,o u New Tanks Existing Tulks `v o ~ ~ n b la ri U in w C7 n, - - - - - - - - ~y Septic or Holding Tankr- Dosing C hamber 7~ - - - - - - - VII. Responsibility Statement- 1, the undersigned, assul4 sponsibility_tr installation of the POINTS shown on the attached plans. _ Plumb r' Name (Print)- Plumber' naune - MP/IViPRS Number Business Phone rnb r L5_X 6L--, 13) -10 Plumber's Address (Street, City, State, Zip Co ) N VIII. ount /De artment Use Only Permit Fe Q0 Date Ins letl sung Agent ' gnatur pproved U Disapproved ~ nn U Owner Given Reason for Denial (V 113 I?C, Conditions o1'Approval/Reasons for Disapproval Gt Jf )Ol~ Gv vc cv, - - - Attach to complete plans for the system and submit to the Cousity only on paper not less than 8 112 x t I inches it, size SBD-6398 (80313) a~PAHTnrg~~ DIVISION OF INDUSTRY SERVICES oz~ °1, 141 NW BARSTOW ST FL 4TH WAUKESHA WI 53188-3789 3 Contact Through Relay www.dsps.wi.gov/sb/ www.wisconsin.gov °sscoxALg~ Scott Walker, Governor Dave Ross, Secretary October 24, 2013 OUST ID No. 226900 ATTN. POWTS Inspector SHAUN R BIRD ZONING OFFICE BIRD PLUMBING INC ST CROIX COUNTY SPIA 1432 120TH ST 1101 CARMICHAEL RD NEW RICHMOND WI 54017 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 10/24/2015 Identification Numbers Transaction ID No. 2326091 SITE: Site ID No. 791981 Bob Canada Please refer to both identification numbers, 480 Summit Ridge I above, in all correspondence with the Town of Troy agency. St Croix County NE1/4, NW1/4, S11, T28N, R19W Lot: 20, Subdivision: Hills of Troy FOR. Description: Mound, 4 bedroom Object Type: POWTS Component Manual Regulated Object ID No.: 1433747 Revision; Maintenance required; 600 GPD Flow rate; 24 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01/01, R. 10/12), Pressure Distribution Component Manual - Ver. 2.0, SBD-10706-P (N.01101, R. 10/12); Effluent Filter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s. 145.06, stats. The following conditions shall be met during construction or installation and prior to og~pj ancy or use: This system is to be constructed and located in accordance with the enclosed proved p6i* a i the ound Component Manual for Private Onsite Wastewater Systems VERSION 2.0 0 1-P~01 10 and the "Pressure Distribution Component Manual for Private Onsite Wastewater t Syste `V ,VON 2.0" SBD-10706 P (N.01/01,R 10/12). The building sewer and distribution network piping shall be of material listed in tab' 84.30-3 and 384.30-5, Wis. Adm. Code. In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. In addition, the owner must comply with the operation, maintenance and monitoring duties as described in section VIII of the mound component manual. A copy of this information must be given to the owner upon completion of the project. All holding/treatment tanks are to comply with SPS 384.25(7)(a). SHAUN R BIRD Page 2 10/24/2013 Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. Access to the filter for cleaning must be provided per SPS 384 product approval conditions. A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. Owner Responsibilities: • SPS 383.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. SPS 383.54(1). • SPS 383.52(2) A POWTS that is not maintained in accordance with the approved management plan or as required under s. SPS 383.54(4) shall be considered a human health hazard. • SPS 383.55 The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Si re Fee Required $ 80.00 This Amount Will Be Invoiced. When You Receive That Invoice, Julia Lewis-Osborne Please Include a Copy With Your POWTS Reviewer 2 , Integrated Services Payment Submittal. (262) 397-6005, Fax: (608) 283-7481 WiSMART code: 7633 julia.lewis@wisconsin.gov Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Industry Services (formerly Safety & Buildings) will be modified. Code references with prefixes starting with "Comm" have been replaced with "SPS" to recognize the relocation of the Division of Industry Services from the former Department of Commerce to the Department of Safety & Professional Services. Additionally, all IS (formerly S&B) codes have been renumbered and addressed in a "300" series. For future reference, the Wisconsin Commercial Building Code will be addressed by SPS Chapters 360-366. Cover Page OT)I HN S AuisnGNI EIN L 1 130 Shaun Bird Bird Plumbing Inc. a3AI3038 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 10/ 10/13 Owner:Bob Canada Location:NE1A NW1A S11 T28 N,R19 W 480 Summit Ridge Troy Manuals Used: Mound Component Manual Version 2.0 (01/31) Pressure Distribution Manual Version 2.0 (01/31) Page# 1. Cover Page 2. Mound Plot Plan 3. Mound Cross Section 4. Pipe Cross Section/Pipe Layout 5. Pump Chamber Cross Section 6. Pump Curve 7-8. Maintance and Contigency plan 9-11. Soil test 12. Filter Specific tions an cross section Shaun Bird Signature License number 6900 cf~ e Q I Mound System Cross Section and Plan View - - - - - " " ' - - ` Dimension Feet i B J r D i L •••L L •••Y•K . • •YL •••L•L •r r } r •••L•L Y } r r •••YL r! .•.L.vL..' .r N!}r•}•r r•}•r•f.}•}}r . { L•L L L L L ••v }r { ; • •r.r•N r}'}}•r•r N}•r}f•r.'•{•Nr.r .L.vL ~.L.L.v •L L L{L•L{•.KK.L•} } L L }r .}•r•r.r r. ~ E d ~ 1 L. K{Y{. .4. iK Y }'}rM4~}}~~rL.}}}}r.r.r. .r.Nr.f}r {i{L{L{li ti{Y L.YL L.{.L : ; • ; . . • • • • • • :.}Lfy{{{~{4 '{Y~{•y~kr}r}r}}1.LK•L!R•L}}}}r r }}~}•}J}}}r}}{•}r}{S!}r}!}f}r r•f,r•f,f•f NN}.r Nr I : f•I•f• fL{y'LL•L.LHK•{{{r'{.L./•} L•} }{}'r}} r}ir}r}r}!}}}r}}}r{}}}}'}r}}}r:Rr~+i}}L}}}}}{S}} A L { YLK L•{KKK L L•K4.L i4.L•L•L.L. •L.L.L.L.1•L L{L•L.L.YL L R { L•L•L L• F f•Nf•!•r•f f•~~~f•r fM fb•N Nf r f } f r. f•r•f•rJ•f•N / K•L.L•L•L•'L•L{L{L•L~41L•L. ' .r•r.f.N{•r.r.r.Nr.r.r.}.f•l.f.r.r.r.{•} }.}.r}r.}.r.}}}}r.}•r.r•f r.r}r.r.r.r.r.f.}. r. r.f.}.f : . G W i i Z . C~ H i i i F -7 -S I I J K D r L S,2-- - - - ' W K- 1 B 1 Z Sloe /o 10 - L o% f Qh-A- r-7 77. r' ' = Topsoil = ASTM C-33 • = Clean aggregate = 4 in. sch. 40 pvc yr}•L}} • L{ti L L}•f•}• Ca to 21/z in. dia. 0 observation pipe t i f{~~~ %Z fill P Material sand I 4 - Geotextile G H Fabric {.r.r f•r.f.f f.fM.N. L• . .............•LK•Y LK•Y r{{ti{ ti{ti {:{f{rte S'•. F 06 {M1{ti{ 15{rYtif•}1r1:4{••'. y 3-,Ft t L S•L L } D E Plowed Surface l a Ft Contour Slope Direction GENERAL INSTALLATION: The mound area is staked out along the design contour. Existing vegetation is mowed and raked off the site. The mound basal area (L x W) is plowed with a moldboard or chisel plow. Plowing may not proceed if the soil is wet enough at the plow depth to form a 1/4 inch soil wire when a sample is rolled between the palms of the hands. ASTM C-33 quality sand is placed immediately after plowing. Sand is placed with a tracked machine keeping 12 or more inches of sand under the tracks or is placed overhead by a backhoe. Special care must be used when placing sand of less than one foot thickness to minimize compaction of the plowed surface. After the topsoil cap is placed, the entire mound is seeded and mulched to promote vegetative growth, limit erosion and protect from freezing. The observation pipes are slotted in the lower 6 inches and secured in place with rebar or a closet flange. 10/071gj Page of Pressure Lateral Layout Two Laterals End Manifold .4 Threaded Cleanout Lateral Turn-up ---0 Plug Manifold M X t L Long Force Main Sweep 90 Bend Distribution Network S ecifications Pressure System Construction Lateral Diameter In. Manifold Diameter o In. Laterals are constructed of Schedule 40, PIto Orifice Diameter 5~3 Z In. pipe. Orifices are drilled perpendiculaX Orifice S acin c~ Y In. the pipe with a sharp drill bit and face down. L ateral Len th Ft. Lateral turn-ups terminate with a threaded M Manifold Len th Ft. cleanout plug and are enclosed in a 6-8 inch Force Main Diameter In. diameter lawn sprinkler valve box accessible Ft. from finished grade. Force Main Len th • • • • • Grade ' ' 6-8 Inch Lawn Sprinkler Valve Box Page of 03/05 lgj i Septic-Dose I Tank Cross Section And Pump Performance Specifications Tank Manufacturer ,.c. Manufacturer Tank Model Number ! ~ Pump Model Number S~ - ii S-0 Alarm hyet~~ Uc►-~d 5: Total Tank P tY l a. 5 Alarm Model Number ID Max' Bury Depth Switch Type E ~ Total Dyneaiic Head t;TDI~ -Feet Filter Man'afU%O Elevation Head U Filter Model Number J r)iatal Pressure Network LOSS Minimum Pump }'Worm me Required Force Main Loss C7 FTDH Total GPM Outlet Manhole Njim 4" Above Grade With Manhole Min. 4" Above Grade Locking Device. Inlet Manhole With Locking Device < 6" Below Chide Sealed Watertight Securely -Mounted -p ou I Junction Box Finished Grade Vast min. 12" Disconnect Above Grade Means With Vent Cap Outlet Filter _ _ 2. •Inlet Baffle X. Inlet : and geserve CagacitY :`t~: Weep ' • Switch S Tank Vohlme ° f GPI j Hole B :i~ Volume Gal. Dimension ; Inches ; . S_ . <; (reserve) A off Elevation C {alarm 2 B It Bottom : Elevation (dose) V i/ (dead) D J D g Ft Total ':i ::a'<':: <':::a': 1~.'•~i ~ a's : a~a~i :.'•'1i a>a•i'aoa''a':: <'1 0,0 a'a'a'j s': i a < • • a a s . < a s < s a < a . s a a . and back filled in accordance GEC with the septic/dose tank is bedded not ~ISTAY1 ATYON: The depth of fiQd. by the ~ufactu rtr rnay . r:s urn spproval specifications. Iv oddum bury have an effective locking device (padlock) manufacture l ,or appm~ Manhole covers e~cpa~ to to the tai~k w& watmti8ht fittings, and be exceeded without e, approved material, Conn eovd , bridge the tank installed. Piping at the >n~ and outlet is of The foroo inain~is sleeved with 4 Sch. 40 PVC to UWJAI~ 16.28. Cut setft or with C 300 and Q laid on stable soil to pxav Ekalrical,sorvice comptio excavation and the slemv8. is sew wstertt$• Pageof 02105 I , . .g ~Y r t an 0 SEW SO Series 4/10 hp Submersible Effluent Pump, 3/4" Solids construction Flow - Utera/Minute 0 SO 100 150 200 250 300 Cover Epoxi.-co4ted cast iron 35 11 G 10 , 30 9 Impeller Material Thermoplastic'Elastomer 25 7 Volute Epoxy-coated gist iron ` 20 6 5 15 4 90 MOW dr, echanical Shpft Nitrile with oarbon and x 10 3 x Seal ceramic faces 5 1e 0 Shaft, Steel 41 A 0 0 20 o so so Flow - Galions/Minute i --4` + uis• 1 9.f6` + 6.80" 4.83' 860 SEN-40 SEN-40-AF specifications 0 14 y l 20 :80 TIMKk 87.5 W 5. gQ, 1'4 $0 '70 T 60 g .46-AF: r Franklin Electric 400 East Spring Street, Bluffton, IN 46714 Tel: 260.824.2900 • Fax: 260.824.2909 www frankllwelectric-com Form: 986189 7.11 10 Wisconsin Department of Comme SOIL EVALUATION REPORT Page of Division of Safety and Buildings accordance with Comm 85, Wis. Adm. Code Attach complete site pa not less than 8 1/2 x 11 inches in size. Plan must CounryJ r~ c include, but not limit I and horizontal reference point (BM), direction and Parcel °I percent slope, scale or ensions, north arrow, and location and distance to nearestoj G- / 00 -0 Please print all information. ( JReviewed Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). <'Q f~v Property Owner / Property Locatrorf c ~NC O W r~-6~ et✓ Govt. Lot 01% ju~d14 S T N R E (o Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 0 City St6te Zip Code Phone Number City ❑ Village To Nea t Road ew Construction Usk! Residential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement Public or comme al - Describe: Parent material :Pop /✓h~,STVnX~ Flood Plain elevation if applicable 1f~.~s ft. General comments ~ - 3 0 Z D L ! o J' and recommendations: UU C~2Q )1 j System TypedCL System Elevation M Boring # Boring pit Ground surface elev. ' V ft. 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 t9 -S' d r 34- 7- 5-di r- ply -yd r- Boring # ❑ Boring ® W, Pit Ground surface elev./ '0 ft. Depth to limiting factor - a~z in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in... s)Muns~eylll Qu. Sz. Cont. Color / Gr. Sz. Sh. •Eff#1 'Eff#2 Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 ` Effluent #2 = BOD 130 mg/L and TSS < 30 mg/L CST Name (Please Print) Sig a CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 5401 715-246-4516 Property Owner _ Parcel ID # Page of Boring # ❑ Boring Pit Ground surface elev. Depth to limiting factor in. g;I 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 `Ef(#2 - 1 -Z -a Ax'Zr 0 F-1 Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Coior Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2 ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD5 > 30:s 220 nVL and TSS >30:< 150 mg/L ` Effluent #2 = BOD5 < 30 mg/- and TSS 5 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. SBD4330 (e.6=) Soil Test Plot Pla Project Name Bob Canada S n Bird Address 1820 Aspen Drive Hudson Wi 54016 TM #226900 Lot 20 Subdivision Hills of Troy Da 10/10/13 NE 1/4 N W 1/4S 11 T 28 N/R19 W Township Troy Fj Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of 1.5" pipe System Elevation 99.3' "HRpSameas Benchmark Property Line 1 Acre Lot Property Line Property Line Scale = 1/4" = 10' 12% Slope B-3 95' 97' 98.3'-- 99NB.M.* B-1 B-2 Summit Ridge County /1 f • --vC l T017L - (to be tilled in by Co-) -nbe Industry Services Division Sanifar l'Crr- nit I f' `s 1400 E Washington Ave y IN 1= $ ► Madison. WI 53707--7162 563 g' Z 4 ! " Sate Transsrtctian ----J Sanitary Permit Application Number ZZ In accordance with SPS :183.21(2), Wis. Adm. Code, submission of this form to the appropriate goven _ ~5 is required prior to obtaining a sanitary permit, Note: Application forms for state-owned POWTS are submi ect Address (if dillbrenl than marling address) the Department of Safety and Professional Servies. Personal information you provide may be us fjy secondary purposes in accordance with the Privacy Law, s. 15.04(1)(m) Slats 1. Application Informatto Please Print All Infor ati 0 su ,r Property Owner's Name a l- / Q 1ti Q, a rce! tl `,.COQ®~ a aa 2 a Property Owner's Mailing Address _ V Property Location City, State / Zip Code - Govt. Lot o f~ J Phone Number lit v! 4~ ~~~l l"• Section ~2 -52 cle o Type of Building (check all that ap ) Lot # i = --u-- N, R - E of W I or 2 Family Dwelling - Number of Bedr oms Subdivision Name _ 020 ❑ Public/Commercial - Describe Use 6k- city of' ❑ State Owned- Describe Use~_ CSM Number El Viflage of own own of~- [it' Typ of Pet mit: C iwil'tly one box on line lline I3 if applicable) A. - -A--_ _ _ System ❑ Replacement System ❑ Treatment/Holding Tank Replaceme illy ❑ Of Modilicati xisting System (explain) B. ❑ Permit Renewal e t Revision ❑ Change of Pl rrriit t u ist ous Permit Number and Date issued Before Expiration ter 'o Owne IV. T e of POWTS a_ tetn/Com neut/Dev e: flat % ❑ Non-Pressurized In-Grouid ❑ Pre •urized In- oun -Gra ❑ ound > 24 i _ suit.fble soil ❑ Mound < 24 in ofsuitable soil ❑ Holding Tank ❑ the, Dispersal C ponen expla' ❑ Pretr;rttrnent Device (explain) _ V. Dis ersaUl'rea ent Area Infor tit : - Design Flow (gpd) Design Soil P„ppli Rate(g Dispersal A eyuired (sf) Dispersal Area Proposed (sf System Etevation VI. Tank Info aciry in Total k of Manufacture - - _ allons Gallons Units c v o -o New Taftks Existing Ta b U ea r a v V) rn U. CD a. Septic or Holding Tank - Dosing VII. Responsibility Statement- I, the undersigned, assu r onsibility for installation of the PO WTS shown on the attached plans. Plumber's Name (Print) Plumbe ' i lure MP/MFRS Number Business Phone Nu ber CA- 2Z Phimber's Address (Street, Ci 5, State, Zip Cod Li Z(] VIII, punt /De artment Use Only V01 I'll pproved Disapprove Permit Fee Date fitted Issuiig ntSignatu - - given Reason for Denial 7/3 3 IX. Conditi ; eas go D'sapproval - - tan , e uen~itanti 3~ Cs l ~-t"o+~5 i` f oG dispersal cell-must all baservtcea / malntalt~d as per management plan provided by plunlw, C.-`e-- 2. AW se4back reouirtirment: moat be maintalnid / _ t~ P ~P a oode f ordirlim i. Aaach to complete pfansfor the system and submit to ,-!6 unty only on pa per nut less than 8 l!z x I I inches in size SBD-6398 (R0313) PLOT PLAN PROJECT Bob Canada ADDRESS 1820 Asoen Drive Hudson Wi 54016 NE 1/4 NW 1/4S 11 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX SYSTEM ELEVATION 1042' BEDROOM 4 CONVENTIONAL AT-GRADE XXX CONVENTIONAL LIFT HOLDING TANK 1255 gallons DOSE TANK SIZE 765 MOUND SEPTIC TANK SIZE HOLDING TANK SIZE LOAD RATE .6 ABSORPTION AREA 1000 # of chambers none BENCHMARK V.R.P. Top of survey iron ASSUME ELEVATION 1034.4' ❑ BOREHOLE O WELL *H.R.P. sameasbenchmark Property/ Line Property/ Line Slope % varies, system to be installed along the 1042' Scale = 1 /4° = 10' contour I i ne 1 Acre Lot Area 15' below system is to be undisturbed Summit Ridge 1040' 1042 1044 E Wel l is to meet al I Huffeutt Combo Tank WDNR setbacks B-B Pro 4 Bedroom House Tank is to be properly bedded and provided with lockdown 16% B-C covers with approved warning Slope C3 labels Grading is to be done to divert run-off away from system B.M. Propert Line C 0 B-A ~ Qzg a~vAR DIVISION OF INDUSTRY SERVICES 141 NW BARSTOW ST FL 4TH WAUKESHA WI 53188-3789 3 Contact Through Relay www.dsps.wi.gov/sb/ ` www.wisconsin.gov °ssIONP~s Scott Walker, Oovemor Dave Ross, Secretary June 25, 2013 CUST ID No. 226900 ATTN: POWTSInspector SHAUN R BIRD ZONING OFFICE BIRD PLUMBING INC ST CROIX COUNTY SPIA 1432 120TH ST 1101 CARMICHAEL RD NEW RICHMOND WI 54017 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL E:XPIRFS: 06/2512015 Identification Numbers Transaction ID No. 2259677 SITE: Site ID No. 791981 Bob Canada Please refer to both identification numbers, 480 Summit Ridge above. in all correspondence with the Town of Troy agency. St Croix County NE1/4, NW1/4, S11, T28N, R19W Lot: 20, Subdivision: Hills of Troy FOR: Description: At-Grade, 4 bedroom Object Type: POWTS Component Manual Regulated Object ID No.: 1433747 Maintenance required; 600 GPD Flow rate; 39 in Soil minimum depth to limiting factor from original grade; System(s): At-grade Component Manual, Version 2.0, SBD-10854-P (N.03/07, R. 1/12), Pressure Distribution Component Manual - Ver. 2.0, SBD-10706-P (N.01/01, R. 10/12); Effluent Filter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s. 145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: This system is to be constructed and located in accordance with the enclosed approved plans and with the At-grade Component Manual, Version 2.0, SBD-10854 (N.03/07), and the Pressure Distribution Compt Manual - Version 2.0, sBD-10706-P (N.ol/ol) P DE'A q~~1V/p/TjQ In the event this soil absorption system or any of its component parts malfu nay s a0p It hazard, the property owner must follow the contingency plan as described in the approve I the owner must comply with the operation, maintenance and monitoring duties as described in sec is the at-grade component manual. A copy of this information must be given to the owner upo om tion o e project. Maintenance information must be given to the owner of the tank explaining th eaning of the filter is required. Access to the filter for cleaning must be provided per SPS 384 product conditions. I A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. SHAUN R BIRD Page 2 6/25/2013 Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. Owner Responsibilities: • SPS 383.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. SPS 383.54(1). • SPS 383.52(2) A POWTS that is not maintained in accordance with the approved management plan or as required under s. SPS 383.54(4) shall be considered a human health hazard. • SPS 383.55 The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. :gi~~ F ee Required $ 250.00 _ This Amount Will Be Invoiced. When You Receive That Invoice, Julia Lewis-Osborne Please Include a Copy With Your POWTS Reviewer 2, Integrated Services Payment Submittal. (262) 397-6005, Fax: (608) 283-7481 W1SMART code: 7633 ,wisconsin. gov julia.lewis(d Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Industry Services (formerly Safety & Buildings) will be modified. Code references with prefixes starting with "Comm" have been replaced with "SPS" to recognize the relocation of the Division of Industry Services from the former Department of Commerce to the Department of Safety & Professional Services. Additionally, all IS (formerly S&B) codes have been renumbered and addressed in a "300" series. For future reference, the Wisconsin Commercial Building Code will be addressed by SPS Chapters 360-366. RECEIVED JUN 10 2013 INDLjSfiRY SERVICES Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 6/6/13 Owner: Bob Canada Location:NE1/4 NW1/4 S11 T28 N,R19W 480 Summit Ridge Troy System type: At-Grade Manuals Used: At-Grade Component Manual version 2.0 SBD 10854 (N. 03/07) Pressure Distribution Manual version 2.0 SBD 10706-P(N. 01 /01) Page# 1. Cover Page 2. At-Grade Plot Plan 3. At-Grade Cross Section 4. Pipe Cross Section/Pipe Layout 5. Pump Chamber Cross Section 6. Pump Curve 7-8. Maintance and Contigency plan 9-11. Soil test 12. Filter Specificatio ;q SFr Shaun Bird SFR4N0 Signature c License number 2U900 ICFs ~FSpo/vo FNCF PLOT PLAN PROJECT Bob Canada ADDRESS 1820 Asoen Drive Hudson Wi 54016 NE 1/4 NW 1/4S 11 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX SYSTEM ELEVATION 1042' 4 BEDROOM CONVENTIONAL AT-GRADE XXX CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1255 gallons DOSE TANK SIZE 765 HOLDING TANK SIZE LOAD RATE .6 ABSORPTION AREA 1000 # of chambers none BENCHMARK V.R.P. Top of survey iron ASSUME ELEVATION 1034.4' ❑ BOREHOLE O WELL -H.R.P. same as benchmark Property Line Property Line Slope % varies, system to be installed along the 1042' Scale = 1/4'1 = 10' contour line area 15' below 1 Acre Lot system is to be undisturbed Summit Ridge 1040'1042 1044 tell is to meet all B_B Huffcutt Combo Tank WDNR setbacks Pro 4 Bedroom Ho use Tank is to be properly bedded and provided with lockdown 16% B-C corers with approved warning Slope El labels Grading is to be done to divert run-off away f ro m system B.M.* Propert Line B-A Site Cross Sectit,n and Plan View At-grade System Sloping Dimension l+ect --~°r--.~--•-.-.--.;-r-----~-•'-'•".'.-r"'r"M r,r,j,r,r.rrr•r+ r•r•r•r• Y ~ 2-- ~-'rr-•";,■•~wryi~FiY1.y!L•yrw•w+w•S S•R•L,'L•S•w•L•'L w•L+R•'r`R+SrtrL•R•".•R•S•R•L«~+RrS+R•R+ _ - r~,.R+Rr•r,j,j.r•r•r r r+j•j+j•j+r•r•r+r+j■jYr•r•1'•r r•r• ■ ■ ■ - y Y ~w`r•Yw•wrRrt•I.+w•S•~L•Lrw•w•w•S•w•R•ww+w•S•S•S•R•w•w•w+w•S•L•'L•RrR+L•w•L►w!L+S•S•w+R• Y A. 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"~~5,:~.~ti tirlrti L~'S~• r r r tirrr,r r j.r•r °•-,Kr,r.r+~1".r,r,.~'!,~'wti R w ti■wYR■L■rL,rtir ' uPlov,eA Surface Slope Direction gti GENERAL INIki-TALL,ATION: The at-grade area is staked out along listaked i it a co ntour. plc wedxi Ina x W) is vegetation is mowed arid. raked off the site. The basal area (I. the moldboard or chisel plow. Plowing may not proceed if the soil is wet alms of't enourih at'1 he plow Ldepth to Pali when form a'/a inch sail wire when a sample is rolled between tl covered by clean aggregate deposited overhead by a baokh e. a Special C he topsoil cap is Placed, placing the aggr'..gate: to minimize compac lion of the plowed in n1 ueprote ct the entire at-grade i , seeded and mulched to promote veget~ ex' 6 6 hes animisecured t crosion lower from freezing. .'he observation pipes are, perforated in the of 03/05 tgj Page Pressure Lateral Layout One Lateral End Mani I.-'old cl Th reacted Cleanout Lateral'] urn-up Plug Force .Main J 'K 11r---r----------------------- Sweep cat} Bend Pressure System Construction - Distribution 1Vetw!t S )ecifications ]C,ateral Diameter - Z ln, Laterals are,,,onstructed of Schedule 40 PVC Orifice Diameter Cn pipe. Orifi(es are drilled perpendicular to - J In the pipe with a sharp drill bit and face down, X (Ot'iCice ici Lateral curn~ups terminate with a threaded. - l~ t. eteaxlocrt plug and are enclosed in a b-ft inch Force Main Diameter --Zfir'-- Force diameter lam sprinkler valve boy accessible lVlain I_ent)i U 1 t from !_inishei grade. _ • • • • • • • • • • • • • • • o • • • Grade c7_. , . 6-8 Inch Lawn Sprinkler Valve - Box 03/05 191 Septic-Dose J'anik. Cross Section And Pump Pelrfortnarlce Spect ica•tions rank Manufacturer ' t'urnp lVlar'triactarrar _'1'ar,k lVft)del Number 1,1, Model Number ...~,7,~✓ 'Cotal[ 1'arik Crrpacit;y Alarm [N~.. b anufactvirm Bury Duptl Alarm Model Itunber_. c°.. z.~ S a. , /D._4-- Type HilterlVlaaiuftu;turer +Z'talJ~ynarnu;C~eaul(Cilll) l'a,el Filter Model N•urnl4rer l~leva. kon l-l[.ead f tistai Pressure S [vetrrvork. Loss 4i'nimtrm Pu,-grip ~er[6rmunw Reclurrerl Purce vCatin l.er:31; _1c_._~%s ar'1 Otall Outlet M nrho. e Mien. V' Above Gr+rule With Manhole IC7e~ricaa. Inlet 1VlanhManhole Min. 4" Above (;rruclr; Looking 6" Below GrhrleSealed 'Watertigtrt 800"roly Mounted _ With l.,etirkirtg De;vicc; Itaketio'l Box Finished Grade Yw a" tow Y *10 rr IfWy rl ♦~~-~.....JJ.J.-- . 4k dent f0in. 12" ~ Disconnect kbove Trade Means With YVimt Cal) r vK>.'YTtrt'Y-'r''.~'`r _s'~~r` ".Y..Y°Y_•L'M'•PI~Y'Wa'FWTMT'f'."7'f L , V,L G+ i ,i 1/ 1 Y,Y L L 1 L L Y v4 1 °A HY+1-~L; l,Y ~L+L4 Y,I rl~lal~L aLaL Ylsl Y Ya YYVYr LiY ~Y ~iL 4`YY 1~ ~`iYY riY/44YJYV~•t~1~L~YL Y~~ ' +a fYs Y Inlet 'Cruet Baffle ~ 1 1 switch :lr~tt nt rain R.ese>r ve Capacity Weep I~Y~Y .C'arrk'il'vlur'rrt:9 +Crl"f N mertskar►. Inches Volume Gal. ll l:la~r Off Y'1 ~ ~ 11 . Y n (alarm) B 1[;le atio C - Y a ( a/ YYYV, V (dose) L" 7, 3 017. Aottom t ;Ia (dead) 3 I { '4e L Total Y a ai 1•IrY 411v YY'asY+O s ~ + l['. .I•4a > 1 414 ' J' .~__+w...,...... 111"'I"I-~i"'Y-]'+f~Y-i;Yi_G_S..Y'Y~f~l•~1~T~`t'T-L'Fe-L-i'Y -T'41_.L_s.L~c._s..4-.Y -L-IY r r•. +1 •',++I vitJ tJ1V1lY VV vitl +lr Y Y i i Y Y a41YV/14 Y1•L' y~~ a. 1, Y I Y t I,t,1,IV1 I I i Y 4 I+_tI t 1 1 Y 1 S Y 11,141 Y`Ya! ! !aY 1 L+1 I4> k l L 1144 S 1 4 L a 1 1+V4144 Y'v Yr /'IYa a I Y Ia.V a41'JY1~1 1'J4a ~1,I,a Y 4 vat Y. Y v 1 + 1 ) 1 l J i J i 1 t vYt,4 i l Y l Y Y Y Y YIsYY is a~l4Yr ~S~i1_YJ:lY,IJ-1~Y s_L+J..J ~f~kJ±l_k:Jl►~.a_k1 Y.1,1 • a LL1a..ll.a_Y_LJ_j..k L GENERAL [ll ST'AilLI A.TION: `Me septio/dow t;mk is Ooddad and btwk tilled in accordance with tlir tnaartutavtuivr's prodiact approval speoifiaations.:lvlaxitnum depth of boxy as spwifted by the mit urfacturer anay rkot be exc"ded without. priorr Approval. Ntanholte covens expomad to grade hive an offinl6ve looking devim {padlaclc.} ins'tallad. Piping at the irtle't and outlet is of approved material, conneckid to the tank with watertight fittings, arrld laid on si.able sail to j-Iresvent settling or sagging. The Barre atain is slevvo:f with 4" Sch. 40 PVC to bridge, tale tank oxcavation and the sb iwvo is sealed watartight. Electrical wrvice complies with Na.' 300 and Comm 16.211, 02/05 LI Page Wastoinvat "k a SEM-40 Series 4/10 hp 5ubinersible Effluent Pump, 3/4" Solids r= Con-Araction Flow - Liters/Minute 0 5o 1V0 150 zoo zsu4 X00 Covm Epoxy-coated cast iron 35 11 . io M")I Hpu"lhy EpQ'Xy-goated cast iron` 30 - y Impel er Material Thermoplastic Elastomer 25 Imp©IiecTypo, NonMc14o r 20 - b Volute Epoxy-coated cast iron ' 15 Power Card x S.!* 4 Mech.inical Shaft Nitrile with, carbon and 3 Seal ceramic faces • 5 z .f FastQl lers %a(hiesiveel - 0 - o Shaft Steel 0 20 40 60 so Flow - allons/Minute t3aarlr us U pe Sir7tBred 51eeV9 : and:lotyerooll be4rinn l~L ~ l unU' r--_.-_ N.11V__ • -~L_.......__ - _JF7 _._....b SEN•-40-AF SEN-40 specifications ! ME SENAn 509211 4,10 115 1-11219/920 80 7t1 60 45 25 32 14 20 26.5 1750 4+Q`~1f4 f.~1Si ~~a112!i?T' '9(950' 60 " 14 .~dG 527, 5 1150 SEN-40-AF 509,13 4)10 115 1 1/"" F N F 1i 9/020 80 70 6 46 25 32 14 2a 27.5 1750 ti; 40J~F! 2,50.8, 14'1175 1'7l•_'"=FNPT ~'s W24 80 701'. ~..46 25, 1.1 3Q E!Q,5' 1750~. Franklin Electric 400 East Springy Street, Bluffton, IN 46714 Tel: 260.824.29(FU • Fax: 260.824.2909 Form: 990199 7-11 www_franklin-electric.corrl POWTS OWNER'S MANUAL. & MANAGEMENT PLAN Page,_._ of FILE INFORMATION SYSTEM Sf'ECIFICATJONS Owner Septic Tarr( Capacity f I-I NA Permit # Septic Tar k Manufacturer 11 NA .3 SIGN PARAMETERS Effluent Filler Manufacturer C l NA Number of Bedrooms _ 0 NA Effluent Filter Model 0 NA Number of public Pacility Units ANA Pump Tanlr Capacity ❑ NA Estimated flow (average) L100 al/da Pump Tanl; Manufacturer El NA , I Design now (peals), (Estimill'ed x 1.6) j 616 at/da Pump Mam.rfacturer ~ Cl NA Soil Application Rate tai/day/ft1 Pump Mod :tl 0 NA Standard Influent/Effluent Ctuality Monthly average* Pretreatmeirt Unit VA Fats, Oil & 13reave (FOG) 530 mg/f_ 11 SandlGr:rvel Filter ❑ heat Filter Biochemical Oxygen t]omand (13005) x220 mg/L 0 NA C1 Mechani :,al Aeration I-l Wetland Total Suspendwl Solids (TSS) 5150 m91L 0 Disinfection Cl Other: Pretreated Effluent Quality Monthly average Dispersal Coll(s) IA NA Biochemical Oxygen Demand (BODs) 530 mg/L Cl In-Ground (gravity) 0 In-Ground (pressurized) Total Suspender;! Solids (TS5) :530 mg/L ~ - t••Grade 0 Mound Fecal Colifonrr (ge!:)metrfG mean) 5f U4 cfu/1 Cit)rnl L7 C7rirwLine IJ Other: _ _ - - - - rMaximum Effluent Particle adze in dia. 0 NA Other: 0 NA C)thar° NA Other: CJ NA Values typical for domestic wa;itewater and septic tank effluent. Other. 0 NA IIIAINYENANCE SCHEDULE Service Ewint Service Frequency inspect condition of tank(s) At least once every: 0 month(s) ~,j ears (MaXimum 3 years) C) NA Pump out contents oftank(si When combined sludge and scum er,.uals one4hir'd (X) of tank volulne 11 NA (Inspect dispersal cell(s) At least once every: Cmonth(s) ears (Maximum 3 years) C! NA C,l month(s) Clean effluent filter At least once every: IJ NA ear(s) I rrspect pump, pump controlf & alarm At least once every: 0 month(s) 11 NA year(s) 0 month(s) Plush laterals and pressure V.mt. At least once every: C] NA ~7ther. At least once every, Cf mcsnth(s) El NA l~l year(s) - - L7 NA MAINTENANCE INSTRUCTICI14S rlrrspections of tanks and dispersal cells shall be made by art individual carrying one of the following licenses or certifications: Master (Plumber; Master Plumber Restricted Sewer; POWTS inspector; POWTS Maintainer; Septago Servicing Operator, Tank inspections must include a visual inspection o° 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 tta ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check ft,r any ponding of effluent on the ground surface. 'rho ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the load 1-ogulatory authority. When the combined accumuiation of sludge and scum in any tank equals one-third ('4) ar rnore of the tank volurne, the entire contents of :he tank shall be removed by a Septage Servicing operator and disposed of in accordance wlth chapter NR 113, Wisconsin Administrative Code. 1411 other services, including taut not limited to the servicing of effluent filters, mechaniml or pressurized components, pretreatment units, I nd any servicing at intervals of s'l2 rwnths, shall be performed by a certified POWTS Aaintainer. A service report shall be protided to the local regulatory authority within 10 days of coml rletion of any service event. . Pace.__ _ of START UP AND OPERATE] N are detected t or have there chemicals loftthi of painting may impede the treatment p For new construction, priejr to raress and/or damage the dispersal tcell(s)s) if high cc,rc®nt presence tank(s) removed by a septcge servicing operator prior to use. System start up shall not oimur when soil conditions are frozen at the infiltrative surfa,,3. ll above excess restored s. Whe wastewate disc power outages pump cell(s) kn oneylairge dose, overloading he cell(s)land maynresultin the backup otr surface discharge ofreffluenwill `~discha discharged to the six ce ( } controls toer store no mal levels To avoid this situation ation have a Plumber or POW TS Maintainer to assist in manually oparatnrgrth Operator effluent pump or contact sr within the pump tank. Do riot drive or park vehicles over tanks and dispersal cells. Do not drive or park o•rar, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination r.-f the following from the wastewater stream may improve the performance'adndiprreol`~oann sthetraif fof the P own-;: antibiotics; baby wipes; ::i~gamtte butts; condoms; cotton swabs; degreasers; dentsl floss; (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 propelly and safely abandoned in,.;ompliance with chapter Comm 83.33, Wisconsin Adrninistreitive Code: • All piping to tank;: and pits shall be disconnected and the abandoned pipe orenings sealed. • The contents of --ill tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, will tanks and pits shall be excavated and removed or their covers removed and the void space filled with sllfil, gravel or another, inert .solid material. CONTINGENCY PLAN If the POW TS tails and cannot be repaired the following measures have beet-, or' must be taken, to provide a rode comp i lint replacement system: L"J A suitable replai:.ement area has been evaluated and may be utilized for ti-.e location of a replacement soil absorption systelm. ld riot be requil The replac eA area s strut ur'er, lot lines rand wells.dFailure aiurprot ct the replacement afreagwilill res rltbin the neled setbacks frorri a,+isngi and for a new soil are:i site evaluation to establish a suitable replacement area, Replacement systems must comply with the rule>:I in effect at that tim,,.:. C1 A suitable replacement area is not available due to setback and/or soil limitations. Barrincf advances in POWTS teehnolo9v a holding tank may be installed as a last resort to replace the failed POWTS. beeinst lledlr is u available la holding tank and The site has nol been evaluated to identify placemiet area. If no epiacemeri area failure mu as must be perfumed to locate a suitable re a last resort to r4! place the failed POWTS. rec ound and at-grade l absor tion systems must may bey with struccted in seple lf -.e following removal of the biomat at the infiltra-live SySiOnIs rules in -ct at that / surface. Reco «WARNING>> TANK UNDER ANY AND/OR INSUFFICIENT OXYGEN C EATH MAY RESULT SEPTIC, PUMP AND OTIAERTREATMENT TANKS MAY CONTAIN LETHAL GA3SES ENTER R~ CUE OI A ENTER A SEPTIC, PUMI OR OTHER TREATMENT PERSON FROM THE IN'T'ERIOR OF A WANK MAY BE DIFFICULT OR IMPOSSI'BI..E. ADDITIONAL - - POWTSINSTALLER PO'WTS MAlfl'TAINER i y Name FN 1 b Phorte 11.E - i SEPTAGE SERVICING Oir'ERA"fOR (PUp11PF..R LOCAL REGULATORY AUTHORITY ) ~~r ♦ Damsel ~'Jr~. ~r7u ? _ Name /7'e?~ r-~ ' J4 Phone y Y -l .b.,r Phone o This document was drafted in :.ompllanee with chapter BPS 383.22(2)(h)(1)(d)&(f) and 383.54(1) (2) S (3), Wisconsin Administrative Code. ti ILTIF"R CARTRIDGE INSTRUCATIONS Installation s r'<_ g .I Ol y nit the :fifter' case. onto the enc. 'it tite nutlet: pipe to ,ensure it is Centered under the racces-z opening. It not. than ait'her Insert snore pipe into the tank through the 01.61et or saivent weld (gore) additional pipe onto the otitlel' Pipe. ' CtP A While the case is still dry fitted on the outlet pipe, measure the length of M•.inch pipe needed to brace the filter to the tank end wall if utilizing the optional supplemental ride. support. If side support mel:hod is not utilized, prareed to strop four, S ;VP For instaffat:ions utilizing the optional supplemental side support: solvent weld titre 1/4-inch pipe (Into the filter rase, if side support method is not, utilized, proceed to !:top four. Solvent weld the filter- case onto the outlet pipe.. Insert the filter s Cartridge into the ra:;e, pressing dovun untif the filter lacks into the bottorrr of the case. It a VkS switch is utilized: insert ini o the filter and ioc_k by turning clockwise 901. „ro r? Maintenance 1... The effluent filter should' be: cleaned every time the septic tank Is senrir.erd. 2. open the outlet a,rress [peeing to Inspect the tank and filter, 3. Pump the septic tank vornpletely, making Sure to 1'erriove the. Shidua layer on the bottom of the tank and not jest the sr.:um and effluent'.. 4, once the effluent level has been lowered below the invert of the outlet pipe, firmly pull up nn the filter hanitle to dislodge the cartridge prone the case. 5. Sfide the cartridge up and aut of the case for cleaning. 6. if a VRS switch cannectmi to air alarm is p, esrent, the switch i ` should he removed by turning r_ouritercloeMwrise. 90* and cleaned with water only. r r.. ' M 7. While: holding the vartridge rrn its side {large flat swtace (adrul down) over the access Opening, rinse nff the cartridge with water only, makincl sure all sepl:age material Is rlr•sed back. into the tank. 8. If VRS switch is utilized, replace by irrsertimi into filler and - - - turninq rlockivise 90". 9. Insert the filter cartridge bark into the case, pressing down until the filter locks into the bot!'om of the rase. 1.0, Replace, and secure the access opening oil the tank. www.bearonsite x:oni 877-MLlFIIXIIEtS (653-4583) i ST. CROIX COUNTY SEPTIC TANT{. MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer ~C'~ _ _ - - - Mailing Address Property Address 9 e"- Lt V\X_V\k_4 ~;t'- T cI - - (Verification required from Planning & Zoning D arttne.nt for new construction.) City/State Parcel Identification Ntiniber L) ti~ D LEGAL DESCRIP73014 Property Location'g~ J'/4 T Z N It/ (_W, Town of f , Subdivision Lot# 2_0 Certified Survey Map # _ - - Vol acne _ Page # Warranty Deed # , Volume Page # - Spec house yes I Lot lines dentifiable ~o SYSTEM MAINTE:IVANQ AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its pre=nature failure to handle wastes. Proper maintenance consists of purnping 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 & Zord;ig Department a certification form, signed by the owner and by a master phnnbe'r, 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 113 full of sludge. I/we, the midersigned have read the above requirements and agree to mainiain 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 ^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 ecorded in Register of Deeds Office. Number droo GNA 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 iarranty deed. (REV. 08/05) . W %T6 a wt a qti es ~ fA a 4F as Fj i ~y'~} ~4~p1j~ ~ - 442.00 0 0 ~P r SIP M~F tlE a'O N NN71RP 10Ib b AIM~p p M~ 'l1lOMb NmO~YR IV REEE7p 9PM• Mk7lRII 9R c%j 19 49sW 4W. 04 1,041 ACRES 45,330 S. Fs, ' ' +IP s~~ee N am~~p 9 awpN n amr~yay a ~n~ew a ~ a ~Vr~esrs W ONW1 h * 6 88000, 0017 BAR it q p~~ k A tle gp~pryR 9! ~1170gc 4 dFWhN M IOg%* q q yb A blMpe? Aft 4 B 2u %MISW -W s .322 ACRES 57571 bf a a 4018 ¢A~ WOW g g i [ ate" s v II Illi'I 1111 III 111111 111111 I I State Bar of Wisconsin Form 3-2003 8 0 3 4 3 9 6 QUIT CLAIM DEED Tx ; 4024892 939893 BETH PABST Document Number Document Name REGISTER OF DEEDS ST. CROIX CO., WI NA PM 2011 28 THIS DEED, made between BMO Harris Bank National Association, successor-in- 08/09/ interest to M&I Marshall & Ilsle Bank EXEMPT REC FEE: 30.00 ("Grantor," whether one r more), TRANS FEE: 96.00 and Robert D. Canada and Vonda L. Canada husband and wife PAGES: 1 ("Grantee," whether one or more). Grantor quit claims to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix Recording Area County, State of Wisconsin ("Property") (if more space is needed, please attach Name and Return Ad ess addendum): Robert and Vo anada Lots 20, Plat of Hills of Troy, in the Town of Troy, St. Croix County, Wisconsin. 1628 Hal avV6 Boulevard NewKichmond, WI 54017 Ov 040-1318-00-020 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Dated Jul 2011 BMO Harris Bank National Association, successor-in- interest to M&I M hall &Ilsley Bank K0' (SEAL) (SEAL) * * Qu&-,Vilce President (SEAL) (SEAL) ce President ~~WWWA,, Signature(s) AUTHE~p41111 ACKNOWLEDGMENT STATE OF WISCONSIN ) authenticated on O ) ss. /lop Milwaukee COUNTY ) * ~cr = Personally came before me on July a/ , 2011 , TITLE: MEMBER STA NSIN the above-nam d L L f (If not, authorized by Wis. Stat. § 706.06) to me known to be the erson(s) w executed the foregoing in meet an ckn 1 ged same THIS INSTRUMENT DRAFTED BY:~ Rebecca K. Hamrin Godfrey & Kahn S.C. Notary Public, State of Wisconsin My Commission 6*Vermenew) (expires: L 6642709_1 (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. QUIT CLAIM DEED © 2003 STATE BAR OF WISCONSIN FORM NO. 3-2003 * Type name below signatures. 1 of 1 i ~ 3 Wisconsin Department of Commerce N REPORT Page I of Division of Safety and Buildings in aecordappe with Co m 85, Wis. Adm. Code County ST. CROIX ~iJs Attach complete site plan " n pap's s than 8 1/2 x 11 in es in size. Plan must Parcel I.D. include, but not limited to: Lyyt tlttaJ,r~ference p nt (BM), direction and percent slope, scale or dimensions, ryt rl d-locetio and distance to nearest road. E R iewed y Dat Please print all in ti n. Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Properly Owner Property Location ■ NORTH DAKOTA STATE UNIVERSITY c/o Leo Beskar Govt. Lot NE 1/4 NW 1/4 S I I T 28 N R 19 EE((or) W Property Owner's Mailing Address Lot # Blodc # Subd. ;Name or CSM# Rodli, Beskar, Boles & Krueger SC, 219 N. Main Street 20 Hills of Troy City State ip ode Phone Number City ~ Village wn Nearest Road River Falls, WI 54022 ( 715) 425 - 7281 Coulee Trail 600 GPD New Construction User Residential / Number of bedrooms 4 Code derived design flow rate El Replacement Public or commercial - Describe: Parent material loess over till Flood Plain elevation if applicableA ft - General comments At-grade system 0.6 loading rate LQ, and recommendations: A (If pre-treatment - below ground drip irrigation system 0.8 loading rate) CX~v Boring# 11 Boring ❑ Q Pit Ground surface elev. 1036.02 ft. Depth to limiting factor 42 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *E GPD/ft?Eff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I 0-4 10YR2/1 1 3fgr&abk ds cb 3vf-co 0.6 0.8 I 2f-ma&sbk ds cs 2vf-co 0.6 0.8 2 4-12 10YR2/1 0.8 3 12-19 10YR2/2 sil 2fabk mfr cs 2vf-co 0.6 10YR3/3 sil 2fabk mfr gs 2vf-co 0.6 0.8 4 19-21 sil If--mabk mfr as lvf-co 0.4c 0.6 5 21-42 10YR3/4 6 42-45 10YR3/4 c2f 10YR4/6&10YR6/1 sil Icsbk mfi 0.4c 0.6 $ Boring # Boring 1038.57 39 ❑ ■ pit Ground surface elev. ft. Depth to limiting factor in, Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots xE~GPD/ Eff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 1 0-5 10YR2/1 1 3fgr&abk ds cb 3vf-co 0.6 0.8 2 5-20 10YR2/1 1 2fgr&abk mfr cs 2vf-co 0.6 0.8 3 20-27 10YR3/3 sil 2f-mabk mfr cs 2vf-m 0.6 0.8 4 2f--mabk mfr as lvf-m 0.6 0.8 27-39 l0Y 5 39-42 10YR3/4 Of 10YR4/6 sil lcsbk mfi lvf-f 0.4c 0.6 • Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L *-Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signatur CST Number ~ Ma Jo Hollister 224832 Address Date Evaluation Conducted Telephone Number W9875 690th Avenue, River Falls, WI 54022 07- 11- 05 (715) 426 - 1775 i Property Owner NDSU (Lot 20) Parcel ID # (Pending) Page 2 of 3 ❑ C Boring # Boring 1044.26 40 Q Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-5 10YR2/1 1 3fgr&abk ds cb 3vf-co 0.6 0.8 2 5-13 10YR2/2 1 2fgr&abk ds cs 2vf-co 0.6 0.8 3 13-23 10YR3/3 1 2fabk mvfr cs 2vf-co 0.6 0.8 4 23-40 10YR3/4 sil 3f-mabk mfr as lvf-m 0.6 0.8 5 40-43 10YR4/4 c2f 10YR4/6 sil lfsbk mfr lvf-f 0.4c 0.6 ❑ Boring # LJ Boring Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDAF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ❑ Boring # 0 Boring pit Ground surface elev. ft. 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 * Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 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-8330Test (R.07/00) ' ~ ns_~ ssf___ r__ s`T:11~ ..r'J'~..~• D.r.sn ? Af rwr roan for nuw at 1 ruy ~ P cfj Town of Troy, & Croix County, WIsconsin Lot Zo I" = 40 ft Legal Description nt~~l4 OF mE Ny~1`~f. rzsat, 2 ft. contours ~.a w -row rJ -rRnY _ 1 ^ Backhoe pit 1 \ r - rr r 0 i I. % I 1, r1 r r ~I I rNO C) 1 W V L„ ti~ _ y \ T FLEV 103 1B Ito • h Plot Plan for Hills of Troy Page 3 of 3 Town of Troy, St. Croix County, Wisconsin Lot z-o 1 40 ft. Legal Description tmr-114 OF-The &&Vgi 1 I. TZ5AI 2 ft. contours w = Backhoe pat B-19A 20 V t I ' 1, , 1 /t,qa r~ ~ l ~ C a-2 Zt , OPCj ti1A \ ) F I EIEV,~I roN i I i 'c n i a b ~ - I A I I I F1 11111 lit I III j Cl 71 0 i i ~ =u I i i per- i J li o_ I 11h 41 a 6>782 8 10 89Q o'Y t t a I i law z-rru ti0u~' _ . BT o i o I F-0-1 --r -VFW z .W0 CL =III _ II °c h .0. . 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