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HomeMy WebLinkAbout020-1374-18-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division Sanitary Permit No: INSPECTION REPORT 563847 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)J. Permit Holder's Name: City Village X Township Parcel Tax No: Dragoon, William Hudson, Town of 020-1374-18-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: f d (VA ( 12.29.20.2251 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER i CAPACITY STATION BS HI FS ELEV. Septic f~ Benchmark , 9 la$, 9 f bZ`> v+~iS~~ W 12 ~Z~J 6 Ak. BM QQG+M Aeration Bldg. Sewer R 1vL SZS Holding ~N~~ St/Ht Inlet ILI TANK SETBACK INFORMATION St/Ht Outlet (~•Z3 S 1,6 Z •7 TANK TO P/L WELL ~4 Vent .3 (fir Intake ROAD eHrm 3 lbZ r Sept, Sy 7L 21 24 Dt Bo(e~ I Z56 C' r p Z. 3 DIing _Z1 / 0 I 7 1 ~`~}y, 1 V Header/Man. Aeration 77 0 Dist. Pipe ~o ~JL 4~ e Bot. System Holding rc: PUMP/SIPHON INFORMATION Final Grade -7, b ! Manufacturer Demand St Cover d, tA~ GPM Lo~" o n 1 a TS ~16 Model Number T / 99 clg` ci TDH Li Friction Loss System Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth 13 DIMENSIONS t'M 3 G SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufac urer: INFORMATION CHAMBER OR Z ..J Type ~D Of ~System: JC~~B~~ UNIT Model Number: DISTRIBUTION SYSTEM Saga t,~ - / ~r .3 3 0 Header/Manifol~d . Z Distribution ~t x Hole Size x Hole Spacing Vent to Air Intake S.7114 q Pipe(s) S7 Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center 3. Bed/Trench Edges Topsoil Yes id No -"--\Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: / / Location: 233 Starrwood Hudson , WI 54016 (SE 1/4 SW 1/4 12 T28N R20W) Starr Wood Lot 18 ! Parcel No: 12.29.20.2251 1.) Alt BM Description =e`~ ~'S~ F` LbJc,- C(~•4.; N.~ {mod 2.) Bldg sewer length - amount of cover = L Plan revision Required? FRI Yes No I / Z Use other side for additional information. I J- J Date Insepctor' ignat Cert. No. SBD-6710 (R.3/97) County /,~r~ Safety and Buildings Division cle0l X 201 W. Washington Ave., P.O. Box 7162 Permit Number (to be filled in by CoJ $ I rl Madiso ,53707-7162 a JUG FQ 51,3 $`f Sanitary Permit C Sta tion Number ST C NA- In accordance with SPS 383.21(2), Wis. Adm. Code, sub f thi rm to the appropriate governmental unit. /'1 is required prior to obtaining a sanitary permit. Note: App f s for state-owned POWTS are submitted to ie hi"ress (if different than mailing address) the Department of Safety and Professional Servies. Perso information you provide may be used for secondary 233 5¢~ r{, purposes in accordance with the Privacy Law, s. 15.04 1 m), Stats. S A M c- 1. Application Information - Please Print All Information Property Owner's Name Parcel # Wl"JAM Awn O N DRA60061 ©zO- 137q-/8"000 Property Owner's Mailing Address Property Location Z33 5T Aj~ 12 lid 0 1 E Govt. Lot , Z Z S 1 City, State Zip Code ~n Phone Number y, S yV y,, Section Z. HU o s o l'i \ Y ~r I T © N, R -lE onlo 11. Type of Building (check all that apply) Loot # 1 Subdivision Name X1 or 2 Family Dwelling - Number of Bedroom B STi4 I.Joo a El Public/Commercial -Describe Use ❑ City of CSM Number ❑ Village of El State Owned -Describe Use H U tls ~ n ) 7~ / 1~ Town of {-1 3 U, o E- CeLk-6 (w~ /6 'r 14 4-- IJ LAG- {r! M. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. r p Replacement System ❑ Treatment/Holding Tank Replacement Only Other Modification to Existing System (explain) ❑ New System tef B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. Type of POWTS S stem/Com nent/Device: Check all that apply) 0 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis rsaVl'reatment Area Information: Design Flow (gpd) esign Soil Application Rate(g Dispersal Area Required (sf) Dispersal Area Proposed (s System Elevation / (000 0,4 'A I /So© S©a 9q.D`g8o D VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units New Tanks Existing Tanks //J~ c Y Ne~..J 1 O U ~n rn w C7 0. Septic or Holding Tank Z.5'0 /ZSD Z57W 'L / t 5 t; e Co Dosing Chamber v1 wpestE /'V in-_::: I VIL Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber' ure MP/MPRS Number Business Phone Number ZZ37(d 7~~'7(~D'"D y8 J,9)40 S0414 17-T Plumber's Address (Street, City, State, Zip Code) 14 ~ dI /15-0T11 44 0yvi Eis r sL/o7 s R V Coun /De artment Use Only Approved R=Zven d Permit Fee Date Issued Issuing Ag ignature $ X75 z3 ~3 Reason for Denial M. Condit 9weasons for Disapproval ump"MIK 1 Septic tank,. effluent filth "i dispersal cefl:must all be taerVlsea d ffl& aided as per management pl4n provided by'p,Vt 21 All setback requkements must be, T" as per OPPRC" co ft / O&W%4, Attach to complete plans for the system and submit to the County only on paper not less than S in z 11 inches in sae SBD-6398 (R. 11/11) PLOT PLAN N Project Name: William & Deborah Dragoon Legal Description: SE 1/4, SW1/4, S12, T30N R20W P.I.D: 020-1374-18-000 Subdivision Name: Starr Wood Lot 18 Township: HUDSON Parcel Size: 1.192 Acres SCALE: 1" = 40' County: ST. CROIX System Elevation: T1=99.00' 4 inch Sch 40 -ASTM D2665 Slope: 15% T2=98.00' 4 inch 3034 - ASTM D3034 A BM1 Elevation: 100.00' To of 2" PVC pipe T3=97.00' BM2 Elevation: 105.05' S Dike in oak tree ■ Backhoe Pits: NOTE: Bull Run Valve to be installed. Trenches to be fed from the center. P/L Y6f,o a ~ iU C 14 r 5 NEE i25'0 lExt5%I~vP3 CARA&E`" a + \ S(CP S.i ~J~Dot~C~~ I'Zjc?(_ qL-rL` O \ u 6c De f'1a~15 It ~ ~ S3 li $l o~mz Z i s= X 1S71 IQ L (NZ AII\) i=IELc9 r ; PIL 3310® 0 CONVENTIONAL COMPONENT DESIGN INDEX AND TITLE PAGE Project Name: Dragoon 4 Bedroom Septic System Owners Name: William & Deborah Dragoon Owner's Address 233 Starr Wood Hudson, WI 54016 Legal Description: SE1/4, SW1/4, S12, T29N, R20W Township Hudson County: St. Croix Subdivision Name: Starr Wood Lot Number: 18 Block Number Parcel I.D. Number 020-1374-18-000 Plan Transaction No. Page 1 Index and title Page 2 Plot Plan Page 3 Septic Tank Specifications Page 4 Effluent Filter Information Page 5 Valve Information Page 6 System Sizing & Cross Section Page 7 & 8 EZ Flow Information Page 9 & 10 Management and contingency plan Page 11 Septic Tank Maintenance Agreement Page 12 Warranty Deed Page 13 Plat or CSM Page 14-16 Soil Evaluation Report Designer: John Schmitt Licnese Number: MPRS 223760 Date: 7/18/2013 Phone Number: 715-760-0486 Signature: In round Soil Absorption Component Manual Version 2.0 SBD-10705-P (N. 01/01) Page 1 of 16 PLOT PLAN N Project Name: William & Deborah Dragoon Legal Description: SE 1/4 SW1/4 S12 T30N R20W PAD: 020-1374-18-000 Subdivision Name: Starr Wood Lot 18 Township: HUDSON Parcel Size: 1.192 Acres SCALE: 1"=4W County: ST. CROIX System Elevation: T1=99.00' 4 inch Sch 40 -ASTM D2665 Slope: 15% T2=98.00' 4 inch 3034 - ASTM D3034 A BM1 Elevation: 100.00' To of 2" PVC pipe T3=97.00' BM2 Elevation: 105.05' Spike in oak tree ■ Backhoe Pits: NOTE: Bull Run Valve to be installed. Trenches to be fed from the center. PIL ~V 3-3'xi00 6,7- ~=l Qom/ ~g2 -rkeNcµES ~5' I/. NEW )2.19 i x/5 r io 6ARAG8 5LCP S;r~pozf~~~ t'Z5'0G4L- O \ \ s s S'.T• ~_rrLl y Btoeco HOU5 i= r Tr 133 k.XISi 0N(2 f)2AIA)PIELL) P/L 330' ® ® CRI) to z X V1 72j" 86" z m x 53" z r c m M D N 0 W m v o UP 52" / N 1\ m 4" CAS 4,\ M -i r ° D m 3" 47" O x X D m IT! C0 I m \ N D UP 49" m \ v / 4" CAS N N v m o~jOV C OC ;u D ;v 50" 0<0 z m r O - 0 m y r- D m rn cu z 0r-rm- I O rn > D ~V ~ 0 D m r x~ n D Z 0 m c z-10 0 D r 2 r Z Z p o '5 x -I v v- ~ mi m D X Zmyo ` ODD ~ ~m 5z m z z~~ 0 O>Oz cO 0 Ogz z~ z ~pmo cp px m z vrN p ~ ~np ccnnnp 2p0~0==~ 0rZ CC (A-4 mm ~ m _ N >rnz D MOO mDO f.. Vl > in z cN D X n ANC ~~c r rtzao`i ~ N N zz m N%. c V) _A ° z D=o ~zM ym i.~ rirO:°NN a= A'r (-l =Ik O M -0 r- D ~ D r ,--TI ~ ~ N D r p C >0 Dm N ~N~ N°.. O s~~ - M CD v v °D Z D mM ° Arm- (nMD I m vW~O~s- Z0 N OZ O N < s c OD D a s v v oW o m n v O m° m°m~ Dr N O' a n o o c Q 0 z z O 0 M -1 M to CD O v~ vs r o m z W ~m ; < O ~D Cl) p l-, m OFZ >0 n v H n ;u~ f*Zf C° Z >:kv m D ° -n -4 m D r O r 0 m Z C1 v Q W N Z c v O 1 p'O O O m c) z ;v D 0 m ° X r v = O -1 O N m r ;u D 0 z X C - H 0 O ~ M r~* FA Z M z r m \ cn N11250-MR m DRAWN BY: SME SCAIF1/4 =1'-Cr PRE-POUR: COCCBETE REV. MHER m S ° EPTIC MANUAL DATE: JANUARY 2010 DATE:. POST-POUR: \ z W3716 US HWY 10 MAIDEN ROCK, WI 54750 ° REVISED JAN. 2010 800-325-8456 nLE: 11112 t POLY ~K,~~ INSTALLATION INSTRUCTIONS Innovations Precast Drainage , Zabel' & Wastewater cts Produ A NvicmdPol" Ix PL-525/PL-625 FILTER INSTALLATION INSTRUCTIONS Center filter with opening t~ WE J ~ U:_ Additional pipe or Polylok Extend & Lok° Glue 7 for centering. Step 1: Step 2: Step 3: (A) Locate the outlet of the septic tank. (A) Before installation, place the (A) Glue the filter housing on the (B) Remove tank cover and pump tank filter housing on to the outlet pipe. outlet pipe. if necessary. (B) Make sure that the housing (B) Insert the filter cartridge in the is positioned so the filter can be housing, making sure the filter removed from the tank for cartridge is properly aligned and maintenance and service. completely inserted in the housing. MAINTENANCE INSTRUCTIONS ~ e Step 1: Step 2: Step 3: Locate the outlet of the septic tank. (A) Remove tank cover and pump (A) Insert the filter cartridge back if necessary. into the the housing making sure • NOT USE PLUMBING (B) Pull the filter out of the housing. the filter is properly alighed WHEN FILTER IS R I • ' (C) Hose off the filter over the septic tank and completely inserted. USE RUBBER GLOVES Make sure all solids fall back into the (B) Replace septic tank cover 1 #WM CLEANING FILTER septic tank. ~ } I . ~ ~ i, ATE--'" P TIGHT 0~w 1"P £ ✓%J/j~y ACCESS G P RI SE R CAP ' ADAPTER RI +ER mew TIJ9E 1•iALI E DIRE(:"Tlvi,J HANDLE The Bull Run Valve TM is designed to split flows to septic 4„ S,i JT PCIF;T fields or systems. In addition to the advantages of longer life and easier installation it is the most public {Q TR P''~'RT - _ ' health safe alternating device available for wastewater s disposal applications. The use has absolutely no contact f with wastewater due to the valves leak-proof and n external operating characteristics. The change over from 4" IN PORT one drainage field to another can be accomplished in u less than a minute by simply turning the valve without The Bull Run Valve is available in 4" sch 40 pvc digging or contact with wastewater. and is suitable wherever septic disposal systems are used - in commercial, industrial, and residential applications. I { OPERATING THE VALVE The direction control handle should be rotated FaFid J~~ Fi¢id periodically to direct effluent to one or the other No i i-i'c' 1 144 2 of two septic fields. After removing the screw cap at the top of the riser tube, the valve handle can be turned with the valve key furnished. d14Tr ~ ~ I ~ ~ sil <:1 lttfat'lr4.. a I?ai ~1ta,Tiru ' BULL RUN VALVE on No 1 r I#' Complete Valve Kit fiuri€:;3urt~zg uel Septic rr~tY~ ~ ~;t~a ` pa Contains 1. Bull Run Valve body Taal; Trek; 2. 28" Valve Key 3. Riser Cap Adapter ITEM DESCRIPTION SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT Project Name: William & Deborah Dragoon 3 No. of Cells 10 Per Cell 3 ft Cell Width 30 Total No 1203H 100 ft Cell Length 500 sq ft EISA Per Cell 3 ft Cell Spacing 1500 sq ft Total EISA Manufacturer Model Laying Length EISA Rating Infiltrator EZ1203H-5ft 5.0' 25.0 EZ1203H-10ft 10.0' 50.0 Gravelless Leaching Unit Manufacturer: to Infiltator Gravelless Leaching Unit Model: 1203H Typical Cross Section Finished Grade 100 ft Observation Pipe with approved cap or vent ■ : Soil Backfill 24 in • ~Geotextile Fabric 99.0, 98.0, 97.0 ft Infiltrative Surface 12 in it 96.0, 95.0, 94.0 ft Limiting Factor L >36 in Slotted and Anchored Vent/ Observation Pipe with Cap iR■■■■m■mR■■■■■ ..............................................Room............ Plumber/Designer Signature: License MPRS 223760 Date: 18-Jul-13 11 - Installation Instructions for EZflowo Systems in Wisconsin EZ w PERFORMANCE. @) DOES IT, Wisconsin Department of Commerce, Safety and Buildings Division, 5. The Absorption area (SF) necessary for a given site shall be has reviewed the specifications and/or plans for this product and sized based on maximum daily sewage flow (GPD) and the determined it to be in compliance with chapters Comm 82 through Permeability for the site. If certain criteria is met, the EISA 84, Wisconsin Admin. Code, and Chapters 145 and 160, Wisconsin sizing can be used in Wisconsin, resulting in a 40% smaller Statutes. All sites must meet the Site & Soil Conditions & Locations & Isolation distances as noted in local regulations. drainfield. The approved products are 1203H (3-12" bundles with pipe in cen- 6. Place EZjlow bundle(s) in the EZjCow configuration approved ter bundle in 5' or 10' lengths) and 1203HP (3-12" bundles with pipe by system design permit specified for the particular site. The in each bundle in 5' or 10' lengths, top or center-most bundles containing pipe are joined end to A single pipe bundle contains a four inch perforated pipe surround- end with an internal pipe coupler. Any additional aggregate ed by EPS aggregate and is held together with polyehtylene net- only bundles that may be required, should be butted against ting. A single aggregate bundle contains aggregate only and is held the other aggregate-only bundles and do not require any together with polyethylene netting. type of connection. Materials and Equipment Needed 7. The top of each GEO cylinder contains a filter fabric pre-manu- • EZjlow® Bundles factured in between the netting and aggregate. The fabric • EZjloru Geotextile Fabric is inserted to prevent soil intrusion. The installer shall make • EZjlow Internal Pipe Couplers sure the the GEO is positioned upward and is in contact with • Pipe for Header and Inlet the fabric contained in the adjacent cylinder before backfill- • Backhoe/Excavator ing. Installation instructions 8. The EZjlow Drainfield Systems should be installed in a level The instructions for installation of EZjlow® products are given be- trench in all directions (both across and along the trench low. This product must be installed in accordance with state rules bottom) and should follow the contour of the ground surface defined in chapters Comm 82 through 84, Wisconsin Administrative elevation (uniform depth), with all continuous adjoining Code, and Chapters 145 and 160, Wisconsin Statutes, as well as the 10-foot cylindrical bundles placed end to end, with central local health department's current design manual. bundle distribution pipe interconnected, without any dams, 1. After the local health department has determined sizing, con- stepdowns or other water stops. figuration, and layout for the EZjZmv systems, stake or mark 9. The trench top shall be graded such that water will not pond. with paint the location of trenches and lines. Be careful to set Backfill should be seeded or sodded immediately after correct tank, invert pipe, header line or distribution box and completion to reduce erosion. trench bottom elevations before installation of pipe bundles. 10. Wow EPS bundles are flexible and can fit in curved trenches 2. Remove plastic Wow shipping bags prior to placing bundles as may be necessary to avoid trees, boulders, or other in the trench(es). Remove any plastic bags in the trench be- obstacles. fore system is covered. 11. EPS aggregate is lighter than water, therefore, it might be 3. This product must have geotextile fabric that meets require- expected that natural buoyancy forces would tend to cause ments of s. Comm 84.30 (6) (g), Wis. Adm. Code, installed EZjlow assemblies to float out of ground when ponding oc- directly on top of the product and extending down along the curs. Field experience has shown, however, that this is not a sides of the product to a point at least six inches from the problem when systems have a minimum of 6" of soil cover as bottom of product. recommended by manufacturer. 4. When installed in a trench, the trench should be dug to a 1203H-GEO width of 36 inches. This not only saves labor in excavation, Geotextile but also provides better load-bearing capacity after backfill- BarrierMaterial ing is complete. IT xx~c~~wuufawm( e+~a. PO'EOOUPIfNG 3W Tap Y 0000 EZflow. Ring Industrial Group P: 1-800-649-0253 30 Industrial Park PERFORMANCE. (9) DOES IT.* F: 1-866-279-9203 Oakland, TN 38060 Ringlndustrial.com 1044-101008 0 2006 Ring Industrial Group, LP POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pg.-,f FILE INFORMATION SYSTEM SPECIFICATIONS Owner: William & Deborah Dragoon Tank Manufacturer: Wieser Concrete F NA Permit # it Septic E Dose Holding Volume: 1250 gal DESIGN PARAMETERS Tank Manufacturer: Wieser Concrete r NA Number of Bedrooms: 4 r NA El: Septic E Dose Holding Volume: 1250 al Number of Public Facility Units: AV NA Vertical Distance Tank Bottom (s) to Service Pad: ft Estimated (average) Flow: 400 gal/day Horizontal Distance Tank(s) to Serivce Pad: ft Design (peak) Flow = estimated x 1.5: 600 gal/day Specific servicing mechanics must be provide if vertical is>15 feet or if In Situ Soil Application Rate: 0.4 gal/dayM2 horizontal is > 150 feet. Specific instructions to be provided on back. Standard Domestic Influent/Effluent Monthly average Effluent Filter Manufacturer: Polylok F" NA Fats, Oils & Grease (FOG) :530 mg/L Effluent Filter Model: 525 Biochemical Oxygen Demand (BOD5) <_220mg/L r NA Pump Manufacturer: F7 NA Total Suspended Solids (TSS) 5150mg/L Pump Model: High Strength Influent/Effluent Monthly average Petreatment Unit Fats, Oils & Grease (FOG) 530 mg/L Manufacturer: Biochemical Oxygen Demand (BOD5) 5220mg/L rv-P NA r Mechanical Aeration r Peat Filter NA Total Suspended Solids (TSS) 5150mg/L r Disinfection r Wetland Petreated Effluent Monthly average r Sand/Gravel Filter r other. Biochemical Oxygen Demand (BODs) 530mg/L Soil Absorption System Total Suspended Solids (TSS) 530mg/L r NA IM In-Ground (gravity) r In-Ground (pressure) r NA Fecal Conform (geometric mean) 5104cfu/100m, f At-Grade r Mound Maximum Effluent Particle Size: % in dia. F N r Drip-Line r Other: Other: f Other: F NA MAINTENANCE SCHEDULE Service Event Service Frequency When combined with sludge and scum equals one-third of tank volume Pump out contents of tank(s) When the high water alarm is activated tenth(s) Inspect condition of tank(s) At least once eve : 3 rear(s) (Maximum 3 ears) f- NA r n-"S) Inspect dispersal cell(s) At least once eve : 3 M year(s) Maximum 3 ears) r NA r month(s) Clean effluent filter At least once eve : 1.5 A rear(s) r NA m Ah(s) Inspect filter alarm At least once eve : 1.5 1~ year(s) r NA Flush laterals and pressure test At least once eve : r year(s) NA month(s) Other: At least once every: r year(s) r NA Other: Alternate drainfields annually after 5 year rest of original drainfield MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Insepector; POWTS Maintainer; Septage Servicing Operator (pumper). Tank inspections must include a visual inspeciton 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 a check for any back up or ponding of effluent on 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 indicated a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumualtion of sludge and scum in any treatment tank equals one-third or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Admininistrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, petreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 30 days of completion of any service event. (Rev.2/05) 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, solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During extended power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose and may overload them resulting in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal 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 and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) discharge; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks, pits and other soil absorption systems 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 shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide the opportunity to obtain a sanitary permit for a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as 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: TREATMENT TANKS AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES AND LACK SUFFICIENT OXYGEN TO SUPPORT LIFE. NEVER ENTER A TREATMENT TANK OR HOLDING TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK IS VERY DIFFICULT. ADDITIONAL INFORMATION: POWTS INSTALLER POWTS MAINTAINER Name: John Schmitt Name: John Schmitt Phone: 715-760-0486 Phone: 715-760-0466 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name: Owners Chace Name: St Croix County Zoning Phone: Phone: 715-386-4680 This document is intended to meet minimum requirements of Ch. Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Use of this document does not guarantee the performance of the POWTS. (Rev. 2/05) ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer William & Deborah Dragoon Mailing Address 233 Starr Wood Property Address Same (Verification required from Planning & Zoning Department for new construction.) City/State Hudson, WI Parcel Identification Number 020-1374-18-000 LEGAL DESCRIPTION Property Location SE '/4 , SW '/4 , Sec. 12 , T 29 N R 20 W, Town of Hudson Subdivision Plat: Starr Wood Lot # 18 Certified Survey Map # , Volume , Page # Warranty Deed # (before 2007)Volume , Page # Spec house Dyes Ono Lot lines identifiable Elyes[]no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §SPS. 383.52(1) and in Chapter 1.2 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form Are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty ed recorded in Register of Deeds Office. Number of bedrooms 4 2 07 / 18 / 13 Gt/ SIGNATURE OF )OPOCANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) J 2 1 2 9 P 6 2 6 STATE BAR OF WISCONSIN FORM 2 - 2000 KATHLEEN H. YALSH Document Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., NI This Deed, made between Landsted Homes, Inc., a Wisconsin RECEIVED FOR RECORD Corporation, Grantor, and William R. Dragoon and Deborah H. Dragoon, 02/04/2003 08:30AN husband and wife, as survivorship marital property, Grantee. EXBPT # Grantor, for a valuable consideration, conveys and warrants to Grantee REC FEE : 11.00 the following described real estate in St. Croix County, State of Wisconsin (if TRANS FEE: 417.00 COPY FEE: more space is needed, please attach addendum): CERT COPY FEE: PAGES: 1 Lot 18, Plat of Starr Wood in the Town of Hudson, St. Croix County, Wisconsin Recording Area Name and Return Address. River Valley Abstract & Title, Inc. 1200 Hosford Street Hudson, WI 54016 020-1374-18 Parcel Identification Number (PIN) This is not homestead property (is) (is not) Exceptions to warranties: Easements, covenants, restrictions, and rights-of-way of record, if any. Dated this J S~ day of January ---,2003 LAN =TEDHOS/,fINC. * * By: ark M. Erickson, President AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ) ss. ST. CROIX County ) authenticated this day of - Personally came before me this 3/~ day of January , 2003 the above named Landsted Homes, Inc., by Mark M. Erickson, President TITLE: MEMBER STATE BAR OF WISCO (If not, to me ow to a the person(s) who executed the foregoing authorized by § 706.06, Wis. Slats.) ins me hand cknowledged the e. T THIS INSTRUMENT WAS D B1~~ Lommen, Nelson, Cole Stageberg, P.A. 10 h •9tQS Hudson, Wisconsin Notary Public, State of S7-'C'" t)( My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) f c~ CJV8 ) * Names of persons signing in any capacity must be typed or printed below their signature. INFO-PRO (800)655-2021 www.infoproforms.com STATE BAR OF WISCONSIN WARRANTY DEED FORM No. 2 - 2000 7a og5 SO r? , .,may =eB I MI ACRES (SEE NOTE 8) 12 88.187 50 Fr - -4438`E 368 i 4• . ,.619 ACHES , • MAN MW 18 I 1';92, _ . ~E Noce 8) ovar 684'}8<1 E29E1SEj .c NW4438"E 36D.54 ~ Dc 250.64 10900 1 7 48,SW M 1 lAWACRES (SE6 NM ~ j 84.= 5C1 FT ~ N8B "WE332.96' t.9 M 232.96 104-00 16 / 64,184 50 fT 1.2" ACIDS " Q ~ NDM M r 4P~1f.T6U lYO Department of SOIL EVALUATION REPORT J U L L 2 #1721 . e - Safety and Professional Services in accordance with Comm 85, Wis. Adm. Code Page 1 of 3 ! - ST CROIX COUNTY Schmitt Soil Testing, Inc. m r ~ 4•,.,,.,. " County ' ach complete site plan on paper not less than 8% x 11 inches in size. Plan must St. Croix iMude, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. 020-1374-18-000 Please print all information. Reviewed By Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Dragoon, William & DeborahGovt. Lot SE1/4, SW1/4, S12, T30N, R20W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 233 Starr Wood 18 Starr Wood City State Zip Code Phone Number ❑ City ❑ Village ❑ Town Nearest Road Hudson WI 54016 651-269-5622 Hudson ❑ New Construction Use: Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement ❑ Public or commercial - Describe: Parent material Outwash (PmC Plainfield loamy sand) Flood plain elevation, if applicable NA ft. General comments Replacement area is suitable for a conventional system witha 0.4 gpd/sgft rate. System elevation will be T1=99.0', T2=98.0', T3= and recommendations: 97,0'(Trench No.'s shown on site plan). Slope of area is 15%. 1 Boring # F-1 E Boring Pit Ground surface elev. 100.27 ft. Depth to limiting factor 96+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-7 10yr3/3 none sl 2mgr mvfr as 2m2f 0.6 1.0 2 7-12 10yr4/3 none sl 2msbk mvfr gw 1c2f 0.6 1.0 3 12-22 10yr5/6 none vgrls Osg ml cs if 0.7 1.6 4 22-42 10yr5/6 none ifs Osg ml a 0.5 1.0 5 42-46 7.5yr5/6 none fsl 2msbk mfr cs 0.4 0.8 6 46-63 10yr6/4 none cos Osg ml cs 0.7 1.6 7 63-96 5yr4/4 none sl Om mfi 0.2 0.6 ❑ Boring 2 ]Boring # 0 Pit Ground surface elev. 102.52 ft. Depth to limiting factor 102+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-5 10yr3/3 none sl 2mgr mvfr as 2m2f 0.6 1.0 2 5-20 10yr3/4 none sl 2msbk mvfr gw 1m2f 0.6 1.0 3 20-44 10yr5/6 none Is lcsbk mvfr a if 0.7 1.6 4 44-62 10yr6/4 none fs Osg ml Cs 0.5 1.0 5 62-72 5yr4/4 none sl imsbk mfr cs 0.4 0.7 6 72-102 10yr6/4 none fs Osg ml 0.5 1.0 * Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS s30 mg/L and TSS S.30 mg/L CST Name (Please Print) Signature: CST Number Thomas J. Schmitt 227429 Address Schmitt Soil Testing, Inc. Date Evaluation Conducted Telephone Number 1595 72nd Street New Richmond, WI 54017 6/25/2013 715-760-1978 SBD-8330 (R.07/00) Property Owner Dragoon, William & Deborah Parcel ID # 020-1374-18-000 Page 2 of 3 ❑ Boring F 3+f Boring # Pit Ground surface elev. 98.67' ft. Depth to limiting factor 92+ in, ❑ Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fN in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-6 10yr3/3 none SI 2mgr mvfr Cs 2m2f 0.6 1.0 2 6-20 10yr4/3 none sl 2msbk mvfr gw 2m2f 0.6 1.0 3 20-27 10yr4/4 none grsl 2msbk mvfr gw 2m2f 0.6 1.0 4 27-43 7.5yr5/6 none Ifs lcsbk mvfr gw 2f 0.5 1.0 5 43-92 10yr5/6 none fs Osg ml 0.5 1.0 F-1 ❑ Boring 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/ft2 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 Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *EfW " Effluent #1 = BOD5> 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.07/00) Schmitt Soil Testing, Inc. ag 3 O uc ~ ~-non _ oo-r-~ --_T_ Tho a J. ch ittST 227 2 j 9 j Ac~dre s: 23 Stak r V~ood 15957 cl "I 't i Safe, - ~p Huso y, Wt l Phone: 1 60197 PI 020-1314-18-0 - sig ureLO Noh 18~taq Wood Date- .2 _Wr - Ba ho Pit T ns iP, County: Huds_o St. ICro x Count - - ° Be h ark 1 E . 10 .00 To oft" PVC pipe. - -+-}--}---a -_f--- Slo e= 15% _ I r-- f j Pit lev do s: re ch - - - - lev do s: - - - - fi r--- - - Bl: 10(-.2T T2= IAX, B3: 98. 7' T3=97.0' j - T-- i ~ i l r - l~ m o N rE le- _lA 0 r- I I _ I i ~ I i I~ ~ I I I _ I } 7T - ---L - - - I - I I ! I j I I I I ~rr.ark ~r S~afetyand of SOIL EVALUATION REPORT #1721 in accordance with Comm 85, Wis. Adm. Code Page 1 of 3 11P I = Professional Services Schmitt Soil Testing, Inc. County Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. 020-1374-18-000 print all information. 000 Reviewed By Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Dragoon, William & Deborah Govt. Lot SE1/4, SW114, S12, T30N, R20W Property Owner's Mailing Address T Lot # Block # Subd. Name or CSM# 233 Starr Wood 18 Starr Wood City State Zip Code Phone Number - i - 1 City i y Yd u_ 1 1-~ loge Town Nearest Road Hudson WI 54016 651-269-5622 Hudson L_. New Construction Use: Residential / Number of bedrooms _ 4 Code derived design flow rate 600 GPD Replacement Public or commercial - Describe: Parent material Outwash (PmC Plainfield loamy sand) Flood plain elevation, if applicable NA ft. General comments Replacement area is suitable for a conventional system witha 0.4 gpd/sgft rate. System elevation will be T1=99.0', T2=98.0, T3= and recommendations: 97.0'(Trench No.'s shown on site plan). Slope of area is 15%. 1F1 # F -1 D,/ 1 Boring Pit Ground surface elev. 100.27 _ ft. Depth to limiting factor 96+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fe in. MunseH Qu. Sz. Cont. Color Gr. Sz. Sh. '0101 •Efr#2 1 0-7 10yr3/3 none sl 2mgr mvfr as 2m2f 0.6 1.0 2 7-12 10yr4/3 none sl 2msbk mvfr gw 1c2f 0.6 1.0 3 12-22 10yr5/6 none vgrls Osg ml Cs if 0.7 1.6 4 22-42 10yr5/6 none Ifs Osg ml Cs 0.5 1.0 5 42-46 7.5yr5/6 none fSl 2msbk mfr CS 0.4 0.8 6 46-63 10yr6/4 none Cos Osg ml Cs 0.7 1.6 7 63-96 5yr4/4 none sl Om mfi 0.2 0.6 2 ] F Boring Boring ~l ! , 3 # 7 tU Pit Ground surface elev. 102.52 ft. Dept to limiting factor 102+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 1 0-5 10yr3/3 none sl 2mgr mvfr as 2m2f 0.6 1.0 2 5-20 10yr3/4 none sl 2msbk mvfr gw 1m2f 0.6 1.0 3 20-44 10yr5/6 none Is lcsbk mvfr CS if 0.7 1.6 4 44-62 10yr6/4 none fs Osg ml Cs 0.5 1.0 5 62-72 5yr4/4 none sl lmsbk mfr Cs 0.4 0.7 6 72-102 10yr6/4 none fs Osg ml 0.5 1.0 I1 0 Effluent #1 = BOD5> 30 < 220 mg/L and TSS >30< 150 mg/L7' 6q Effluent #2 = BODS <_30 mg/L. and TSS s 3O mg/L CST Name (Please Print) Signature: CST Number Thomas J. Schmitt 227429 Address Schmitt Soil Testing, Inc. Date Evaluation Conducted Telephone Number 1595 72nd Stmt New Richmond, WI 54017 6/25/2013 715-760-1978 SM4330 (R.07/00) Property Owner Dragoon, William & Deborah Parcel ID # 020-1374-18-0 Page 2 of 3 Boring Boring # P8 Ground surface elev. _ 98.67' ft. Depth to limiting factor 92+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. *Efl#1 *Eff#2 1 0-6 10yr3/3 none 5I 2mgr mvfr fs 2m2f 0.6 1.0 2 6-20 10yr4/3 none si 2msbk mvfr gw 2m2f 0.6 1.0 3 20-27 10yr4/4 none grsl 2msbk mvfr gw 2m2f 0.6 1.0 4 27-43 7.5yr5/6 none IN icsbk mvfr gw 21' 0.5 1.0 5 43-92 10yr5/6 none fs 059 m! 0.5 1.0 ❑ Boring # Boring E] 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/fe in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *EM1 *Eff#2 : J Boring Boring # i - 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/ft2 in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. *Effa1 *Eff#2 " Effluent #1 = BOD5> 30 < 220 mg/- and TSS >30 <150 mg/L " Effluent #2 = BODS < 30 mg1L 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 (R07/00) SCflli* Sao T eo9. Inc. Paae 3 of S - iConfuc~ed by: - _ - Coudncted'hor. _William & De6orahDregoon - - _ . Thomas J. Schmitt, CST 227429 Address: 233 Starr Wood _ City, State,' 10: Hudson WI54016 New-Richmond-M-54017 Phone:71 60-1978 / PID: 020-1374-18-000 signak,re Lot No: _ 18 Starr Wood _ ~,I Legal-DescriPttoc►:---SI!Af SWV4-S1t2 T9N-1MW - ® !Backhoe Pit! Township, County: Hudson, St. Croix County r -Bench Mark 1 El. 100.00' Top of 2" PVC pipe. - Ber►ch Mark ;-2-- -405:05 Spike-in-Oak Tree Slope= 15% Pit Elevations: Trench Elevations: B2~A02 52'. .-T2=98.0' B3: 98.67' T3=97.0' - - b - p r IS \ amp p ~~N~EL>fl 0 - - -