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040-1318-00-057
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 563884 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Creative Homes Construction, LLC Troy, Town of 040-1318-00-057 CST BM Elev: Insp.BM Elev: BM Descriptio}: Section/Town/Range/Map No: /Do 6 v14 I GSA 11.28.19.2132 TANK INFORMATION ELEVATION DATA TYPE illiiiiiiiiMI CAPACITY STATION BS HI FS ELEV. 7 35 /67. 43 Adel Septic Benchmark , pinllIllgjMl /Z5a /3.4 //3.,( lest , Dosing / �, 7 56 Alt. BC I L Ld wt.. Aeration MIMI Bldg.Sewer z 9 11 6 • 1.5 Holding St/Ht Inlet //, / /6Z 3 W� ,,gay ;ti St/Ht Outlet TANK SETBACK INFORMATION I \- TANK TO P/L'` WELL BLDG. 40o Air Intake ROAD Dt Inlet ` �\ DID J Y-L, d Septic 5/ / 7/65 603/ Dt Bottom /G. 1 -77, 3 Dosing 5 I J 7/t,5 (,3 72 _ Header/Man. / 5 /,r.c Aeration Dist. Pipe Holding Best.System C 7.35 3 Al Final Grade PUMP/SIPHON INFORMATION O . (05 /64 . 7 a,k Manufacturer Demand St Cover Zp e( GPM r'IL C 6 JfA.. co. Z /t, 7• Z Model Number 8 , ` /C ( 3 TDH ILj65 Friction Loss System Head TDH Ft 8.75 3.3 /Z.Co • Forcemain Lenga Dia.� I/ Dist Well 7 /08 SOIL ABSORPTION S'cSTEM BED/TRENCH Width Length / No.0 8nche PIT DIMENSIONS No.Of Pill.„ Inside Dia. Liquid`h DIMENSIONS `7 g I 7 _ I/ SETBACK SYSTEM TO IP/L BLDG WELL 4, LAKE/STREAM LEACHING Manufacturer: INFORMATION l CHAMBER OR Typeq(S�p ; 5/ //Oz. -7 /zS / /J/Jet- UNIT Model Number: DISTRIBUTION SYSTEM c Y� ot ".' 1STEEM Header/Manifold �/ I/ Distribution �/` // f /I x Hole Size // x Hole Spaying Ven rpe Pipe(s) z 7 ,5 7 3 Length 3 7 Dia Length 3 Dia Spacing 3 �� 3 SOIL COVER x Pressure Systems Only At-Grade rad Systems Only y s y xx Mound Or t G a ys s 0 y ec....•.• Depth Over Depth Over xx Depth of xx Seede Sodded Sy. -�'�C Mulched Bed/Trench Center Bed/Trench Ed es Topsoil 9 p 'V � \� � Yes E3 No No COMMENTS: (Include code discrepencies, persons present,etc.) Inspection#1: /O/ /1/ /3 r' Inspection#2: / / Location: 470 Prominence Drive Hudson,WI 54016(SW 1/4 NW 1/4 11 T28N R1/9W) Hills of Troy Lot 57 4:.°64F---. Parcel No: 11.28.19.2132 1.)Alt BM Description= l ';'I Go Jer CI 4,(A,5 4— L-6 c .% c v-� 2.)Bldg sewer length= / 3 C'f .6GI f/0 -amount of cover= �O Q �I 1r�, Y c'v - et -ILL ! 60 a' . 0 4'. Plan revision Required? Ir: Yes No Use other side for additional informati n. % A-- - Date . SBD-6710(R.3/97) Insepcbf s Signatury Cert.No. kt n \Io t..t.4. . .. 1! . ti.) N.! t.)! L. ! 0 1.. 7__ __ _________, ! ., 1 ab h L, i e S v b b I, I ,V NI \∎ !k / 0 1 ,o `k ,h r ex- O M ;� � _i 0 L 1 I. ! i W 1I • � a � I 4■1 t° l'? )‘'; ? 1 rV) 1 to n � t 1k j / 4 v b •vl - /-----.IMI— �h v\ v o o \ Q c \ o / Q 1 i\ 1 o I o , '0 � ' i r X % 1:. 4\ 4 %i ,.._ , , „ , „ ,,,‘ %; *k 0, N., -ki . .._,.. ,, , -_ N. ,tn" ,‘,.i ki ,h Industry Services Division p` 1400 E Washington Ave Sanitary Permit Number (to be filled in by Co.) p# P.O. Box 7162 St Madison, WI 53707-7162 S/ 3 ~Q l~ U Sanitary Permit Application State Transat io Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriat ovemmental unit is required prior to obtaining a sanitary permit. Nofe: Ap h "on forms for state-owned POW ubmitted to Project Address (if different than mailing address) the Department of Safety and Professional Servi P n olmation you provide may be usondary purposes in accordance with the Privacy L 1. Application -information - QWsej!Kj~nformajjon 70 14 oM/ En11c6 ,7110E Property Owner's Name ST 9< Parcel # Of ~~E fig oryc~ ~,✓s Aac r~o,r t:R 6yo - /.~i8 -oo -os7 Property Owner's Mailing Address COIN Property Location 7e7 Co ~-a E' ,11.0E _5~o/TE $//o Lot l Z.I 3 City, State tp Code Phone Number 41, ~114/ y. /VA/ Section G~/ooDQu/CY circle one T pT8 N; REob 11. Type of Building (check all that apply) Lot # I or 2 Family Dwelling - Number of Bedrooms 7 Subdivision Name r lj.Qi Qk of Block# J 1LS Gf /1fOy ❑ Public/Commercial - Describe Use of - 7 / CSM Number ❑ State Owned - Describe Use 7 g~ / 7 fflo J,n 6 Town of Tao y 111. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. XNew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision List Previous Permit Number and Date issued ' ❑ Change of Plumber ❑ Permit Transfer to New Before Expiration Owner IV. Type of POWTS Sys tem/Comonent/Device: Check all that a I ,h- O ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil /f ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) )Z V. Dis ersal/Trea ent Area Information: Design Flow (gpd) Design Soil Application (gpdsf) Dispersal Area Required ( Dispersal Area Pro d 00 11 ation Goo D 6.5 G6o / Z"~ Goo. G $ /oS.o or /rya oa,,no- V1. Tank Info Capacity in Total of Manufacturer Gallons Gallons Units o u New Tanks Existing Tanks v c G.J e5~- ~F I a U t;s H to w a CL. Septic or ijW4-g-T-k o ~.Jro / /E O,tl t arsE ✓ Dosing Chamber 75-0 1 /11 .41 V11. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's ature MP[hf2*i Number Business Phone Number ~f ors~.v Et,~E f ~?.3/3yG 7~s G7.7- :W4 Plumber's Address (Street, City, State, Zip Code) /6/ L? 98 Sr. c.11Y. ,?S lvultA ~O L.J.r Sy7_3G Vlil. Coun /De artment Use Only Approved _ Permit Fee Date ssued issuing A t Signature 0 eason for Denial IX. Condit*VlIIl$IEJp49I> t gsons for Disapproval 3) n~+~ /I ~~fo ~wt /~er.3 p 1. Septic tank, effluent filter and J (7 dki~ l t n -dispersal cell must all be servkes I maintained W g E di• - r A r w!, as per management plan provided by plumber. 2. AO so"' ck requeemettts must be )YI!auttain8d n applic" cads rorl~nances: .as per Attach to complete plans for the system and suti it to the County only, on per not less than l8 in llinchesinsi41 Lam- '71 PC_r-.. SBD-6398 (R0313) DIVISION OF INDUSTRY SERVICES oV&.RllT ANT 10541 N RANCH ROAD r HAYWARD WI 54843 4 ' Contact Through Relay 3 i DS K www.dsps.wi.gov/sb/ P S y www.wisconsin.gov O-ssl°NAti S~ Scott Walker, Governor Dave Ross, Secretary August 14, 2013 CUST ID No. 231346 ATTN. pOWTS Inspector JOHN HERBERT PELKE ZONING OFFICE PELKE PLUMBING ST CROIX COUNTY SPIA N 6298 ST HWY 25 1101 CARMICHAEL RD DURAND WI 54736 HUDSON WI 54016 CONDITIONAL APPROVAL Identification Numbers PLAN APPROVAL EXPIRES: 08/14/2015 Transaction ID No. 2292611 Site ID No. 794028 SITE: Please refer to both identification numbers, Creative Homes above, in all cones ondence with the a enc . Prominence Dr COW),T~~N Town of Troy AppEtOV St Croix County ~Ep t of SO SWl/4, NW1/4, S11, T28N, R19W ~SS10% Lot: 57, Subdivision: Hills of Troy PR~~ O~ pV FOR: ~N Description: Mound, 4 bedroom residence DIVISOR Object Type: POWTS Component Manual Regulated Object ID No.: 1442724 S System Maintenance required; 600 GPD Flow rate; 25 in Soil minimum depth to limiting factor from original grade; y. . O~ Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01101, R. 10/12), Pressure Distribution Component Manu Ver. 2.0, SBD-10706-P (N.01101, R. 10/12); Effluent Filter ~jEE 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: Key Item(s) • 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 insure that the operation, maintenance and monitoring duties as described in section VIII of the mound component manual are complied with. A copy of this information must be given to the owner upon completion of the project. Reminder • The orientation of the mound system must be such that the longest dimension is oriented along the surface contour per SPS 383.44(6)(a)2. • Limit activities in the area 15' beyond the down slope edge of the mound per Mound Component Manual. • Surface water drainage shall be diverted away from the system area per Mound Component Manual. • Materials shall conform to the requirements of SPS 384.10. No fixture, appliance, appurtenance, material, . device or product may be sold for use in a plumbing system or may be installed in a plumbing system, unless it JOHN HERBERT PELKE Page 2 8/14/2013 is of a type conforming to the standards or specifications of chs. SPS 382 and 383 and this chapter and ch. 145, Stats. • Maintain well and waterline set backs per SPS 383.43(8)(i). Consult the Department of Natural Resources for well setbacks and other regulations and exceptions. 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. Sincerely, Fee Required $ 250.00 Fee Received $ 250.00 Balance Due $ 0.00 j Patricia `POWTS Plan Revie r , In grated Services ! WiSMART code: 7633 (715),034-7810, Fax (71 634-5150 , M - F 8:00 a.m. - 4:45 p.m. pat.shandorf@wisconsm.gov j. cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm *J ..t t teffective 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. JOHN HERBERT PELKE Page 2 8/1412013 is of a type conforming to the standards or specifications of chs. SPS 382 and 383 and this chapter and ch. 145, Stats. • Maintain well and waterline set backs per SPS 383.43(8)(i). Consult the Department of Natural Resources for well setbacks and other regulations and exceptions. 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. Sincerely, Fee Required $ 250.00 Fee Received $ 250.00 Balance Due $ 0.00 Patricia and - - `'PbNTS Plan Revie r , In grated Services WiSMART code: 7633 <715_), 634-7810, Fax (71 634-5150 , M - F 8:00 a.m. - 4:45 p.m. ,~.9handorf@Visconsm.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm ~ffective 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. private Omite Wastewater Treatment System Index and Tide Page P"fect Name: C,< ,F.4 /yau"JOD l~ocr rS Ownees Name: ~ilE,~ rivE ~~s-s odl.trA 0 -C r-0.4 owner°s Address: 7,07 '001 re WY/o ~ooD,Qu,~Y /Yi1/ SS/.tS' L LePI Desen-pdow f a/ a78 9 Mmnctpsli#p: T-- w~a e~ GitY Of County: • .oaNa~'5'7,- Lot : Number<<ro~/x BiockN, - l Pagel, LD_ Number. e5 Page I Page 2 DLo r ~J~.v.~ Z Pale 3 Gloss c r~o.J t ~,ov l/i~w o f ~.~o Page 4 D/PE lA LEErrt 4Ya4,7- P 5 SE.orrc --flyx/DU.~P L~s/Ary6E G/tOSS- ~EGt/o~J ~~EGS Page ~G/M/~"EiLFoit~fAacf. ~~/fo Pagel Do0 rs ot✓aEit s .✓u'~~ t /lowJL~rv •i~ Qls,✓ Page 8 Page 9 rE2 /.✓Fo.~.yorie.✓ Name ofDesignea: Tay, -z er License Number: 1r~-a?.~/.~'f~L S:gnatUM -A PlAq Daft: 7 ,~s- •~0/3 Designed PmZiant to the Following POWTS Component Manuai and 0 s P s 81-85: JIOGwJ® ~a.yPa.veryr ~.Jait tlEits~„~ J.O Sid-/DC 9/-~ ~~•G//a/~ /QTrAG/f/yEN~S : ~D/L Ev,61uAT/o,~ ~E~o~t1'~ n ~ h b ~ ~ 0 1 o~ o 04 ~ Q Q 1 0 ~.T . o b v a ~ Hof a Ilk ~ ao o°°' ~ 1 0 , ~ b a v v of ~ r~ - - v OL A! - O oP4 V b01~ v► U is o - 1 a ^ W n ct n 1 ` w a O - • 14 W t \ • • . - • • c. . - V 3 I IV n e = o tz 0 o. a ^ L n Z hh~ ~ a ~ Q a ~ • w j'1t~ ~w ~V v ~o wy `•ro y~ tt ~ h Y 14 HHH}-l W - H u u u u A O~~ W W W W:~HU ~ ~ - ra H Z OG S''1 x rd-~ W A4 Page S Of q ;SEPTIC TANK &•PUMP CHAMBER CROSS SECTIOW AND SPECIFICATIONS 4" Cl VENT PIPE 12" MIN. ABOVE GRADE WEATHERPROOF /a' FROM DOOR, WINDOW OR JUNCTION SOX APPROVED FRESH AIR INTAKE WITH CONDUIT MANHOLE COVER 'aszow W/ PADLOCK 8 y4A~oE WARNING LABEL 4" MIN. INLET WATER TIGHT SEALS ~£sr GAS- TIGHT[ o \/APPROVED APPROVED - Fia r~~r SEAL ~ i ALM JOINTS WITH ' PIPE 3' g APPROVED PIPE ONTO SOLID ON S31 OLID SOIL SOIL' C PUMP OFF ELEV. 97.0 FT. ~ OFF RISER EXIT D PERMITTED ONL: IF TANK MANUFACTURER HAS APPROVAL 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS SEPTIC./ DOSE TANK MANUFACTURER: ~jE'SEit Zo.j5gj-rr N`JMB£R DOSES PER DAY: X1 (.7ova) TANK SIZES: SEPTIC ,?So GAL. DOSE VOLUME INCLUDING 117 3.3 = DOSE Tso GAL.. FLOWBACK: /,7.o8 GAL. ALARM MANUFACTURER: CAPACITIES: A = 20. S' INCHES = .1 GAL. MODEL NUMBER: LEar, SWITCH TYPE: «/y.✓icA~ B = _2r INCHES = GAL. /G. / GAtS. PUMP MANUFACTURER: C = 75, INCHES = ,~6 8 GAL. MODEL NUMBER : SWITCH TYPE: /'9~c y.9a o,oc D = 8 4 INCHES = 8 GAL. REQUIRED DISCHARGE RATE GPM PUMP 9 ALARM WIRING AS PER ILHR 16;23 WAC VERTICAL'DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE . S. G FEET + MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . . . . . . . . . . 3 FEET + ao FEET FORCEMAIN`X ?.S FT/100 FT. FRICTION FACTOR . s- FEET TOTAL. DYNAMIC HEAD = ~~FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH Ssl WIDTH &0 DIAMETER LIQUID DEPTH y~ PUMP PERFORMANCE CURVE TOTAL DYNAMIC HEAD/FLOW . ~ LL MINUTE MODEL 151/1521153 PER EFFLUENT AND DEWATERING 14- 45 153 4p MODEL 151 152 153 1z Feet Meters Gal. Liters Gal. Liters Gal. liters Ip 35 1152 5 1.5 50 189 69 261 77 291 30 _ 10 3.0 45 170 61 231 70 265 15 4.6 38 144 53 201 61 231 c 8 25 15t _ 20 6.1 29 110 44 167 52 197 25 7.6 16 61 34 129 42 159 6 20 - ( 30 9.1 - - 387 33 125 15 35 10.7 - - - - 22 85 4 - j ' 40 12.2 - - - - 11 42 10 i _ Shut-off Head: 30 ft. (9.1mj 38 ft. (11.6m) 44 ft. (13.4m) 2 0145088 5 ,p 36 4U 70 80 9p 10o Model 151 Models 1521153 GALLONS- 6 7132 6 7132 -y LITERS 0 40 80 120 180 200 240 280 320 380 3718 - - - 4 518 3 718 45,'8 -may FLOW PER MINUTE 014508A I -j- 3718 37/8 4 -3718 37/8 • Timed dosing panels available. • Electrical alternators, for duplex systems, are available and i Oil supplied with an alarm. ! f • Variable level control switches are available for controlling _ single phase systems. i I • Double piggyback variable level float switches are available 4` for variable level long and short cycle controls. - i I • Sealed Qwik-Box available for outdoor installations. See 111,116 121;8 FM 1420. • Over 130"F (54°C) special quotation required. ; L 41516 _ i s3fa i _ SK2444 SK2064 151/152/153 MODELS ! Control Selection Model Yolis-Ph Mode Amps Simplex Duplex N151 115 1 Non ' 6.0 1 2 or 3 BN151 115 1 Auto 6.0 Included 2 or 3 E151 230 1 on 3.2 1 2 or 3 BE151 230 1 Auto 3.2 Included 2 or 3 "EaS assembl " N152 115 1 Non 8.5 1 2 or 3 Y Y BN152 115 1 Auto 8 Included 2 or 3 (pump 8 discharge pipe not included.) 4E152 230 1 Non 4.3 1 2 or 3 BE152 230 1 Auto 4.3 included 2 or 3 N153 115 1 Non 10.5 1 _ 2 or 3 BN153 115 1 Auto 10.5 Included 2 or 3 E153 230 1 Nat 5.3 1 2 or 3 BE153 230 1 Auto 5.3 Included 2 or 3 1. Single piggyback variable level float switch or double piggyback variable level float switch. Refer to FM0477. Reduces potential clogging by debris. 2. See FM0712 for correct model of Electrical Alternator E-Pak. Replaces rocks or bricks under the pump. 3. Variable level control switch 10-0743 used as a control activator, specify duplex Made of durable, noncorrosive ABS. Raises pump 2" off bottom of basin. (3) or (4) float system. Provides the ability to raise intake by adding sections of 1'/2" or 2" PVC piping. IA caurloN « Attaches securely to pump. Accommodates sump, dewatering and effluent applications. NOTE: Make sure float is free from obstruction. For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. © Copyright 2008 Zoeller Co. All rights reserved. POWTS OWNER'S MANUAL AND MANAGEMENT PLAN FILE INFORMATION SYSTEM SPECIFICATIONS Owner Tid orrES a r r, Se tic Tank Ca aci SD al ❑ NA Permit # Septic Tank Manufacturer E E',c f"et. ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer EST ❑ NA Number of Bedrooms 104 d/bedroom) Effluent Filter Model 6i-/p ❑ NA Number of Commercial Units - Pum Tank Ca achy SO al [3 NA Estimated flow (average) Pump Tank Manufacturer Design flow 5~0o aUda L✓ESE~e Z",e r-1 NA (DWF estimated x 1.5 a al/da Pum Manufacturer ZoEtt E.c ❑ NA Soil Application Rate Pum Model o al/da S/ ❑ NA Influent/Effluent Quality (NA❑) Monthly Average Pretreatment Unit WNA Fats. Oil & Grease (FOG) ~ C] Sand/Gravel Filter C1 Peat Filter Biochemical Oxygen Demand (HODS) 30 mg/L El Mechanical Aeration [3 Wetland Total Suspended Solids (TSS) < 220 mg/L ❑ Disinfection ❑ Other: 5 150 me Manufacturer: Model: 'retreated Effluent Quality ❑ Monthly Average Soil Absorption Component Biochemical Oxygen Demand (HODS) < 30 mg/L ❑ In-ground (gravity) ❑ In-ground (pressurized) Total Suspended Solids (TSS) ❑ At-grade ffMound Fecal Coliform (geometric mean) < 30 mg/L ❑ Drip-line El Other: _<10 cfu/100m1 ❑ Dispersal Units - Manufacturer Maximum Effluent Particle Size 1/8 inch diameter ❑ Aggregate Cell(s) Model calculations: Soil Dispersal (EISA) or DWF Application rate = Area Required _ (Aggregate Trench Width) = # Units or Total Length of Agregate Trench(s) Goo - o - Goo 7.8 = 77 lESIGN CRITERIA ❑ "Design of Pressure Distribution Networks for Septic Tank-Soil Absorption Systems" Publication 9.6 (SSWMP Manual) ❑ "ICC Flowtech Mound Component Manual" Version 1.2 ❑ "EzFlow Mound Component Manual" Version 8/20/2007 ❑ SBD - 10854--P (R.1/12) "At-Grade Component Manual Using Pressure Distribution" Version 2.0 ❑ SBD - 10705-P (N.01/0I) "In Ground Soil Absorption Component Manual" Version 2.0 ,X-SBD - 10691 P (N.01/O1) "Mound Component Manual" Version 2.0 ❑ SBD - 10657-P (8..6/99) "Drip-line Effluent Disposal Component Manual" , SBD - 10706-P (N.01/01) "Pressure Distribution Component Manual" Version 2.0 ❑ Other - :AINTENANCE MONITORING SCHEDULE - MAINTENANCE AND MANAGEMENT Service Event 3 Vr S Service Frequency im /ins ect tank(s), inspect dispersal cell(s), clean filter At least once eve : X 13 months OF 3 ears spect pump & pump controls, alarm, pretreatment unit At least once eve ❑ Other ush and pressure test laterals ❑ months 3 ears ❑ NA At least once eve : ❑ months 3 ears ❑ NA ART UP AND OPERATION: For new construction, prior to use of the POWTS check treatment tank(s) for the presence of inting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations detected have the contents of the tank(s) removed by a septage servicing operator prior to use. stem start up shall not occur when soil conditions are frozen at the infiltrative surface. e property owner is responsible for the operation and maintenance of the POWTS and submission of required reports. The quantity J quality of the wastewater stream will affect the performance and longevity of your POWTS. The installation of water-saving 31iances and fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine or waste from water teners, iron removal units, other clear water treatment devices and foundation drains should be discharged to the ground surface enever possible. Note: this does not include laundry waste, showers, dishwater, etc. is system is designed to handle domestic strength wastewater, however the disposal of food based greases and oils, vegetable/fruit ;ls and seeds, bones, and food solids such as those produced by a garbage disposal should be minimized. Toilet tissue is the only )er that should be discharged into the system. Other non-biodegradable items such as baby wipes, tampons, sanitary napkins idoms, cigarette butts, dental floss, and cotton swabs should not enter the system. Chemicals such as petroleum products, paint, Page 7 of disinfectants, pesticides, antibiotics, solvents, etc., should not be flushed into the system as they can seriously damage your POWTS and contaminate your drinking water supply. Maintain a regular steady flow by spreading laundry washing throughout the week. Avoid vehicle traffic over all system components. Compaction of snow over the dispersal unit may cause it to freeze up. INSPECTIONS & MAINTENANCE: Inspection shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Maintainer or Septage Servicing Operator (per the attached Maintenance Schedule). Tank inspections must include a visual inspection of the tank to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and check for any backup or ponding of effluent to the ground surface and test all electrical equipment such as pumps and alarms. Any defects shall be promptly corrected. Exposed openings greater than 8 inches in diameter shall be secured with effective locking devices to prevent accidental or unauthorized entry the tanks. When the combination of sludge and scum in any tank exceeds one-third (1/3) 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 NRI 13, Wisconsin Administrative Code. The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to manufacturer's specifications. Solids washed from the filter shall be retained in the tank. Filter cleaning may be necessary at more frequent intervals than stated in the maintenance schedule to keep the system operating. Alarms should be tested on a regular basis by the home owner. If an alarm sounds, contact an individual licensed to service POWTS, There is normally a I day reserve under regular operating conditions, however water should be conserved until any problems with the system are corrected to prevent back-up of sewage into the dwelling or surfacing. ABANDONMENT: When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to ensure that the system is properly and safely abandoned in compliance with Ch. SPS 383.33, Wisconsin Administrative Code. - All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. - The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. - After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or other inert solid material. CONTINGENCY PLAN: If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ 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 render it unusable. Replacement systems must comply with the rules in effect at the time of replacement. 0 A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. j~ 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. c<WARNING>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTIAN LETHAL GASSES AND/OR INSUFFICIENT 3XYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR 'MPOSSIBLE. kDDITIONAL COMMENTS `OWTS INSTALLER POWTS MAINTAINER lame roll d ELKE /JP-,?.~/3yG Name 72),#,j El E ELXE lc. ,si,✓t 'hone )r/s' 67.? - "C4 Phone /S G7.2-s,246 ;EPTAGE SERVICING OPERATOR um er - CIA41 rA0w.J LOCAL REGULATORY AUTHORITY lame Agency i ~o oN D j/tE 'hone Phone S .38L 90 Page 8 of 9 • ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer ' ' I r Mailing Address—707 CoA4A.N► .r-Ge % • c ►49 4(0 k co4ir rAA Al Property Address 9 7 0 pro MA.;(tia.a.C-� Lg _ _ (Verification required from Planning&Zoning D artment for new construction.) rp City/State -. -I-v e Sa ti-, Parcel Identification Number 040- 131 8-00—o S-7 LEGAL DESCRIPTION Property Location 5■AI 1/4,A.( 1/,Sec. ( ,T 29 NR (°1 W,Town of I ro Y Subdivision Plat: i I ( s 0 I roy ,Lot# 57. Certified Survey Map# ((S3753 / ,Volume /(o ,Page# 433 2- Warranty Deed# (r) -1 2 L (before 2007)Volume ,Page# Spec houseees 0 no Lot lines identifiables 0 no • SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner,if needed,by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in§SPS.383.52(1)and in Chapter 12-St.Croix County Sanitary Ordinance. The property owner agrees to submit to St.Croix County Planning&Zoning Department a certification form,signed by the • owner and by a master plumber,journeyman plumber,restricted plumber or a licensed pumper verifying that(1)the on-site • wastewater disposal system is in proper operating condition and/or(2)after inspection and pumping(if necessary),the septic tank is less than 1/3 full of sludge. Uwe,the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the • standards set forth,herein,as set by the Department of 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. Uwe certify that all statements on this form true to the best of my/our knowledge. Uwe am/are the owner(s)of the property described above,by virtue of a warranty de d recorded in Register of Deeds Office. Number o ooms 4 • 7 /21/13 NATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning&Zoning Department. ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if • reference is made in the warranty deed. • (REV.04/12) • `l H V v a R m {0-' Z :T' r c a =mar i c > 0 /off <t m Q) - .O N f0 C . ~ i Rf 4~ ZI m R w q a E pl O Y ra _ a ~ m o a N i -1 QO N r, u y i w s„a a cVIta ~t3°s ~s ~N e rne" 4 t b- E a yv~ q W -0 .U a-+ t0rnD* a15 iw '4-A w n o ca . 0 Q A Ij u Ul CL u 0, T y C m m W a u~i » m ~D u E 42 g LL! > o m E c ili v« rn 4- t-A -d Z2 > ^ m acx L J! W 0. ~fI 4 a ~s "d E f~S d J N a CL'a a Q N v 1 3 C a r- 0 E ~ you m in o 4 Q W u 4-4 M W ~Mc CL .0 a 1 ov=maCtd O „ o v o .t0 V a- rT , E -o s - ate, 3 0 cr CL c y,Qa11n~ mo 3~0.. r 0-.,u 02 WE .2 tef w c n O O l z Y c= o W « 0.3 -x J45 L r t• t .o.. 7 0 aa.. , j 7 iF g a { - G Y N o C jy a s _ N O V a+ aa -0 L N m t E # C. ~f~ w Q• pox '1 a V z3 i m 6 N..3-9tE F. a 1 axis ~ ~mwamom P E~ ;3 I~1 0 R« g i O T4,1 U i+V a i ..i. L N a ei a N ( °'ca ~o~w r L I ° 3 acs ° T" .,Q - tZ 4- rn a a -o a,a a.a=tr f y'~ 41 q) 8 1 4 7 9 0 4 State Bar of Wisconsin Form 6-2003 Tx: 4120163 SPECIAL WARRANTY DEED 976926 BETH PABST Document Number Document Name REGISTER OF DEEDS ST. CROIX CO., WI THIS DEED, made between BMO Harris Bank National Association, successor by 04/16/2013 11:52 AM merger with M&I Marshall & Ilsley Bank EXEMPT#: NA ("Grantor," whether one or more), and REC FEE: 30.00 Creative Home Construction Investments, LLC, a Wisconsin limited liability TRANS FEE: 2025.00 company ("Grantee," whether one or more). PAGES: 3 Grantor for a valuable consideration, conveys to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property") (if more space is Recording Area needed, please attach addendum): 3 Name and Return Address a See attached Exhibit A. o E I e ive o e C~istt~ tthtn vesffirem, LK.C I 6 ri gl Drrve Land T~T't" 2 h< . Ho to , 082 r' C, ~c.~S Sc" itt~MN Sr4 See Exhibit A Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Grantor warrants that the title to the Property is good, indefeasible, in fee simple and free and clear of encumbrances arising by, through, or under Grantor, except municipal and zoning ordinances and agreements entered under them, recorded easements for the distribution of utility and municipal services, recorded building and use restrictions and covenants, general taxes levied in the year 2013, and Permitted Encumbrances described on the attached Exhibit B. Dated February 28, 2013 BMO H S BANK NATIONAL ASSOCIATION, succes th &I rshall & Ilsley Bank (SEAL (SEAL) * * B S. autze , President (SEAL) (SEAL) * * By: AUTHENTIC otSAR Y "gtil ACKNOWLEDGMENT Signature(s) r k F C., +r STATE OF WISCONSIN j ss. authenticated on L = MILWAUKEE COUNTY ) r+ T~ V Personally came before me on ti 2013 + the above-named Gary S. Kautzer, ice President of BMO TITLE: MEMBER STATE BAR bR., SIN Harris Bank National Association (If not, to me known to be the person ) who executed the foregoing authorized by Wis. Stat. § 706.06) trument d ac wl a the me. THIS INSTRUMENT DRAFTED BY: *Carol Lee Hopkins Marvin C. Bynum II, Godfrey & Kahn, S.C. Notary Public, State of Wisconsin My Commission (is per rent) (expires: April 6, 2014 ) 9003373_2 (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. SPECIAL WARRANTY DEED 2003 STATE BAR OF WISCONSIN FORM NO. 6-2003 * Type name below signatures. i EXHIBIT A Legal Description Lots 2, 11, 13, 14, 15, 16, 17, 19, 24, 25, 26, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 48, 52, 53, 54, 55, 56, 57, 58 and 59, Plat of Hills of Troy in the Town of Troy, St. Croix County, Wisconsin. Parcel ID Nos.: 040-1318-00-002 040-1318-00-011 040-1318-00-013 040-1318-00-014 040-1318-00-015 040-1318-00-016 040-1318-00-017 040-1318-00-019 040-1318-00-024 040-1318-00-025 040-1318-00-026 040-1318-00-032 040-1318-00-033 040-1318-00-034 040-1318-00-035 040-1318-00-036 040-1318-00-037 040-1318-00-038 040-1318-00-039 040-1318-00-040 040-1318-00-041 040-1318-00-042 040-1318-00-043 040-1318-00-044 040-1318-00-048 040-1318-00-052 040-1318-00-053 040-1318-00-054 040-1318-00-055 040-1318-00-056 040-1318-00-057 040-1318-00-058 040-1318-00-059 EXHIBIT B PERMITTED ENCUMBRANCES 1. Any encroachment, encumbrance, violation, variation, or adverse circumstance affecting title to the Property that would be disclosed by an accurate and complete land survey of the Property. 2. Easements or claims of easements which are not shown by the public records. 3. Any lease, grant, exception or reservation of minerals or mineral rights appearing in the public records. 4. Subject to the building set back lines, utility easements, drainage easements and wetland areas as reflected on the recorded plat. 5. Subject to the terms and conditions as shown on the recorded plat of Hills of Troy. 6. Restrictive and protective covenants as recorded in Document Number 816569, amended by Document Number 841464. (These restrictions contain no forfeiture provision.) (Omitting any covenants or restrictions, if any, based upon race, color, religion, sex, sexual orientation, familial status, marital status, disability, handicap, national origin, ancestry, or source of income, as set forth in applicable state or federal laws, except to the extent that said covenant or restriction is permitted by applicable law.) 7. Subject to the terms and conditions of the Landscaping Easement in favor of Hills of Troy Homeowners Association, Inc. as shown as Document No. 816571. 8. Subject to the terms and conditions of Conservation Easement recorded on July 1, 2005 in Vol. 2834, pages 155- 173, as Document No. 799119, amended in Vol. 2937, page 68-77, by Document No. 813315. i b P OI ~ I a11e1`~ ~d qq 's \D ~ c~ ~ ONd7 0311V7dN/1 ilbl~l r--- io . W "'Wj ~ g~~ 2 ~ a6i =~w „~a~ " g~g=» x pgy_ ExAi a yS"~ " g "S y asab S ~I 101 I i ? b (~.aees'~i.s~ ° ~ atria _ F ~z"- a d H~' a 3a - - -----Win.-H-.L*o ling I Q o2 NI x= 8~ ~P~a~yY j~3gpw ~c°ss rn I r .w II\I7' _ r w s ~ V a s tai a ad€ a ' 3l tltl i -~W~I~wOIO a j a N i"1 p $ UJI t i aw s J~I01 g z 0 a zr ~8 ' d m ? ° Y> z s n 4 j O.tG N-W -----W 1~. 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F W U) OWZ?Z LLWLL U)~ 20 Wp so O U)Zmx~ ~C7W ma ZZ M d~ o } 0- p0 W W OO O0 o Z'-CL 9 30 o~00K O¢O Wa C N Z 0 W W HUJ ~U UW 00 J L) 0~ aE 3o a.. W o~ OW WW O Z O Z- Nm U)U)U) Www ~H- , U W co ~W W W W W W U) N U) ¢ F- C7 } V) U) LL 2 za 000 O ¢O }W m5Z O rnwN 00000 aaa =U 0W OWo z>N Zzzzz 000 LL >~p WW wa0 ¢ z ?i O _Y K} 000000 aaa 4.aii t~iT u) p } z~ 0EEN V ra°O~ U WjvOi ON~ wp0 Z10 W2(W V a' W_ J W Z a¢ W v) 7 x> LL =w}O ~ N >O> SVU) U) 0~ Wwgmw ( 0N0 W WN0 i:LL 0 p Z 4~ aF=Omrn NM .0.0O a'-Z NO > VW) {11 g J p pZ W W oN ~ x 00 0 R p F W U) p¢ F AA-- < ~X 000 W N N xFm ~F3 a ¢ U a ¢ag aU°3m En. Y ~N )1 i .00 Ze[ _~a r 1 / $ .o ",mow ii W m Z Z 1- W w U) o w w } O v 0z W N y £ ~ 4L L M `~O.Ob,I[ S too ri w- J y a W r N Z"W s ~ y~ .002£L W Q 1'L m f0 M'0blL S. LL W N O O' A U I ~ a p t ~ Wisconsin Department of Cornea.. SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings s_,~ .~in.accordar a wlf>> 136 AAlrs-Adm,_ Code County ST. CROIX Attach complete site plan on paper not less than 8 12 x 11 Inches in size Flan must include, but not limited to: vertical and horizontal reverence point (BM), direction and Paroel I.D. parcent slope, scale or dimensions, north arrow, and locatigr} and distance. to nearest oad. Q 7 '+i Please print all information. Revi ed by Date Personal information you provide may be used for seconklary puipbstwi ROVAco-arl~)-15.04 (1 (m)). [ 6 Property Owner %Property ovation LEONARD & MARGARET DELAURIERS x Govt. Lot SW 1/4 NW 1/4 S 11 T 28 N R 19 E (or) Property Owner's Mailing Address Lot # Blodc # Subd. Name or CSM# 706 Coulee Trail N57 Hills of Troy City State Zip Code Phone Number ity village ■ Town Nearest Road Hudson, WI 54016 ( ) Coulee Trail New Construction LlseE] Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD 0 Replacement Q Public or commercial - Describe: Parent material loess over till Flood Plain elevation if applicable rT n ft. General comments Mound System 1.00 ft. sand fill 0.6 loading rate and recommendations: _7taq„~'~/1,~/ alums 0't (If pre-treatment - below ground drip irrigation system 0.8 loading rate) Boring # 0 Boring m pit Ground surface elev. 1070.86 ft. Depth to limiting factor 25 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 0-3 10YR3/2 - sil 3fgr&abk mvfr as 3vf-m 0.6 0.8 2 3-9 sil 3fgr&abk mfr as 2vf-m 0.6 0.8 3 9-15 10YR3/4 - sil 3fabk mfr cs 2vf-m 0.6 0.8 4 15-25 7.5YR4/4 mvfr as lvf-m 0.2 0.6 5 25-37 7.5YR4/4 c2f7.5YR3/4 fsl Om mfr lvf-f 0.2 0.5 Some gr in all horizons; few cobbles. B Boring # El Boling 1073.93 36 1 Pit Ground surface elev. ft. Depth to limiting factor in. Soil liption 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 1 0-4 10YR3/2 sil 3fgr mvfr as 3vf-m 0.6 0.8 2 4-12 10YR3/2 sil 2fgr&sbk mfr as 2vf-m 0.6 0.8 3 12-20 10YR3/4 - sil 2fabk mfr as lvf m 0.6 0.8 4 20-24 7.5YR3/4 - fsl lmsbk mfr as lvf-m 0.2 0.6 5 24-36 7.5YR4/4 - ? Is lmsbk mvfr as lvf-m 0.7 1.6 6 36-40 7.5YR4/4 f2f7.5YR3/4 ~C(1~ Is Om mvfr lvf-f 0.7 1.6 Horizons 4,5 & 6 have some gr. " Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effl ent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature Lk CST Number Ma Jo Hollister S 224832 Address Date Evaluation Conducted Telephone Number W9875 690th Avenue, River Falls, WI 54022 05 - 05 - 05 (715) 426 - 1775 R r k DeLauriers (Lot N57) Paroel ID # (Pending) Page 2 of 3 Property Owner f. Boringfl Boring 1071.23 Q Pit Ground surface elev. ft. Depth to limiting factor ~3 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 0-4 10YR3/2 sil 3f-ma&sbk mvfr as 3vf-m 0.6 0.8 2 4-12 10YR3/2 sil 2f-ma&sbk mfr as 2vf-co 0.6 0.8 3 12-17 10YR3/4 sil 2fabk mfr as lvf-m 0.6 0.8 4 17-33 7.5Y 3/4 fsl Om mfr aw lvf-f 0.2 0.5 5 33-39 7.5 R4/4 c2f .5YR3/4 fsl Om mfr 0.2 0.5 ❑ 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/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 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 * Effluent #1 = BORS > 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-8330Tmt (R.07/00) - o Tro Plot Plan for Halls of y Page 3 of3 Town of Troy, SL Crok County, Wisconsin Lot .5-7 1" = d0 fl. ~w` -AND - 2 ft. contours Legal Descriptaon ~vw'Iy e~ ,E e ► zZ- . 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