HomeMy WebLinkAbout040-1193-10-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division Sanitary Permit No:
INSPECTION REPORT 572831
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:-7 Gamache, Gabriel & Cheryl Troy, Town of 040-1193-10-000
CST BM Elev: Insp.BM Elev: BM Description: Section/Town/Range/Map No:
6- / cabT 24.28.20.867
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURE CAPACITY STATION BS HI FS ELEV.
Septic T..n. O' Benchmark 9 ZL /49. /�
f�ILv. /•S /� a� 7
F'1 ! o ID �jZ S Alt.BM , 6 4,G2
Aeration Bldg.Sewer ,61 A'/- 17
Holding St/Ht Inlet `•.73 16Z• S
SVHt Outlet 7 33 �1fl,9Z
TANK SETBACK INFORMATION !'
TANK TO P/L WELL BLDG. ent t Air Intake ROAD Dt Inlet
Septic Q , /� �G / Dt Bottom
Dosing N 8 Header/Man. b Z
Aeration Dist. Pipe 'A
Holding Bot.System ,Z a q
Final Grade ,
PUMP/SIPHON INFORMATION 7. o /4 2 - Z
Manufacturer Demand St Cover'
GPM
Model Number
TDH Lift Friction Loss System Head TDH Ft
Forcemain Leng Dist.to well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width r Length No.Of Trenches ' -AA PIT DIMENSIONS No.Of Pits Inside Dia, Liquid Depth
DIMENSIONS 3 -76 Z t rtv�.�G.>t+�J� L_ t_
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: LL �
INFORMATION CHAMBER OR
Type f System: LL� � �� G4 � UNIT Model Number:`�
�Qh✓v"vf�1 ww
DISTRIBUTION SYSTEM ( 06i- /1e,'' 15 17 t 7
Header/Manifol� Distribution x Hole Size x Hole Spacing Vent to`A it Int e S
Pipe(s) "" � �
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth o jxx Seeded odded xx Mulc ed
Bed/Trench Center.��/1 Bed/Trench Edges Topsoil Yes [� No No
COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2:
Location: 206 Plainview Drive ever Falls,WI 54022(SE 1/4 SW 1/4 24 T28N R200W) Croix Ridge Lot 21 Parcel No: 24.28.20.867
�`11 (jC✓'Cis 4iw LO G./C. G
1.)Alt BM Description
2.)Bldg sewer length= Z L
-amount of cover
Plan revision Required? Yes 1 7
o
Use other side for additional information. /
Date Insepcto Signatur Cert.No.
SBD-6710(R.3/97)
i N4 County
Safety and Buildings Division S�,
201 W.Wasb ngton Aver P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.)
C3��GO�eO adis�dr;�`.��,//1370�-7162
� loN a� �.G� o���y s 7 o 3
Sanitary Permit Application State Transaction Number
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit
is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address)
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. �D/ %J 1 D
I. Application Information-Please Print All formation W ,✓
Property Owner's Name Parcel#
t3 Yo 93 oa o
Property Owner's Mailing Address Property Location W-,7
9 a(rte 4LL,�J� Govt.Lot
City,State Zip ode Phone Number 1 1 a
p /<, 5 Ll.( /<, Section
- circle one
H.Type of Building(ch"'e"'ck�k all that apply) Lot# T�N; R�E o�
Off 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name P
El Public/Commercial-Describe Use
City of
f� ❑
❑State Owned-Describe Use ` 6� 5 CSM Number El Village of T
Z w ' Town of /
III.Type of Permit: (Check only one box on line A. Complete line B if applicable) e
A' X New System ❑Replacement System
❑Treatment/Holding Tank Replacement Only El other Modification to Existing System(explain)
B. ❑Permit Renewal J0 Permit Revision El Change of Plumber 11 Permit Transfer to New
List Previous Permit Number and Date Issued
Before Expiration Owner
IV.Type of POWTS System/Component/Device: Check all that ap 0 '
JKNon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil Plis C 5
Holding Tank Other Dispersal Component(explain) ❑Pretreatment Device(explain)
V.Dispersal/Treat t Area Information:
Design Flow(gpd) Design Soil Application Rate(gp f) Dispersal Area Required(sf) Dispersal Area Proposed( System Elevation
0 7 � Y 680
VI.Tank Info Capacity in Total #of Manufacturer
Gallons Gallons Units 2 o
New Tanks Existing Tanks
D 'D rG 5Z5 a` U° va Cn w
Septic or Holding Tank / ► ��
Dosing Chamber ! l
VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumb s Signa e MP PRS Number I Business Phone Number
EW/ W6-�ARLI) A /e��z >31 5
Plu er's Address(S eet,City,State,Zip Code)
4113 f/1, &1WT s 706
VIII. oun /De artment Use Only
pproved appro
Permit Fee Dat Issue u Issuing o nt Signatur
en Reason for Denial $ 15 ' / � 1
IX.CondiW&TG~EWReasons for Disapproval
1•:"°Septidtank,effluent filter and'
dispersal cell must all be services I M611bi'uted
as per management plan provided by plunger.
2. AS seosck requirements must mwl"(
its per 40c biiccds7"i 6liii
Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size
SBD-6398(R. 11/11)
,f
rp f
�0 u-u�
T� l
T-a
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3 6 3
boo
ds X6
� ,
Soil Absorptions Cross
lb % ft
4"Schedule 40 Final Grade
PVC Vent Pipe po
With Vent Cap /S+r� ft
Leaching - 1►
Chamber
.� System Elevation
ft ft
Soil Absorption}System Plan View
ft NHS
3 ft
i
ft Leaching Trench 1
Vent Or Observation Pipe Chambers
4°Dia.
Trench 2 Header
Leaching Chamber Ssecifications
Manufacturer And Model
EISA Rating sq ft per chamber Soil Application Rate gpd/sq ft
gpd Design t=tow ',< 7 Soil Application Rate ; c�O EISA= Chambers
z
'12 rows of 17 chambers each.
i
Page of
s. ar
7��Gr� 5�-�tc."w►nN�c� b c�ays�- e� ��,tee.aC�-�. ,
3
Wis.Dept.of Safe,> rofessional Services SOIL EVALUATION REPORT Page of�
Division f dings '"`} " —`
in accordance witkSPS.$$,d s Aclm.jode
>' County �.j `'
A'tach com Igtg § an on paper not less than 8 1/2 x 11 inches-in-sizw v i I 7�
(31st
ipnclu NoLJi -ited to ertical and horizontal reference point(BM),direction and Parcel I.D.
erc o `,s e ii s, north arrow,and location and distance to nearest road.
w��Please print all information. Re by Date
,, I if J
P r�s thformation you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)).
Property Owner Property Location
tLot# t 1/45 ttJ1/4 S y T a 0 N R E(ore
Property Owner's Mailing A ress Block# Sub d.Name o CSM# p 0. o 1 145 + o F CRD s ?A R 1-
City State, Zip Code Phone Number ®City ❑Village EATown Nearest Road
N L C6 tj IT 5 00 D i b Y -1
I hrl'a h)t'j e4-3, Dr, C
New Construction Use:151 Residential/Number of bedrooms _ Code derived design flow rate GPD
❑Replacement ❑ Public or commercial-Describe:
Parent material 0 to *-S Flood Plain elevation if applicable ft.
General comments �'f 1`Gw1 �$ t•-73
and recommendations: -+
Boring#
I ® Boring
Pit Ground surface elev. I Ob.7 ft, Depth to limiting factor � fl� in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft s
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 " ff#2
0-13 11 o 5 L-- Q f 5 bit. 0 9F 6 0
i o�t Qs/ C&S L sb f` w F I.D
qX/oo 5YPAt- 77 1,Le
p
1D
® Boring# Boring
Pit Ground surface elev. Oft. Depth to limiting factor � in.
Soil Application Rate
Horizon -Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 ° ff#2
0-1Y --)F5144 rnFv-
1 -
3C 7. 5 YIRs/ ---w-- o S L ca f5 bk. p,J ✓- c F 1,h Ila
Flo c
"Effluent#1 =BOD .>30<220 mg/L and TSS>30 <150 mq/L Effluent#2=BOD <30 mg/L and TSS <30 mg/L
CST Name(Please Print) 30
�1 !` CST Nu
& a�f[,.. tuber
Address
O prh s..F
1
a7 L Date Evaluation Conducted Telephone Number
a.'
-- - ao�y st►-a 39- y�
SBD-8330(R1 1/11)
Cnery L d
Property Owner �m ja&L-, o• Parcel ID# Page of
T Boring# ❑ Boring
fj$ pit Ground surface elev. tO0.74 ft. Depth to limiting factor too in.
=oil Application Rate
Horizon Depth Dominart Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 ff#2
0 -10 16 yA3/3 S L a w 1 Fs,k M v- a o1 a Lo A
b•� ,SYR 'y` 5L AFVa v- OW I F to /,v
elbo 7�5` AV6 S Ih L. 1 b
Boring#
❑ Boring
❑ pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots GPD/ft 2
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. -ff#1 In
i
❑ Boring
❑ Boring# Ground surface elev. ft. Depth to limiting factor in.
❑ Pit
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 ff#2
"Effluent#1 =BOD ,>30<220 mg/L and TSS>30 <150 mg/L 'Effluent#2=BOD 5<30 mg/L and TSS <30 mg/L
'The Dept.of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to
access services or need material in an alternate format.contact the department at 608-266-3151 or TTY through Relay.
SBD-3330(RI I'H)
Cjr Q6 -F `eery L
Property Owner &Q m j2t-A, �« Parcel ID# Page of
F3-1 Boring# Boring /
Pit Ground surface elev. X00�7g ft. Depth to limiting factor 1,170 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft a
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 ff#2
1
0 -6 D YR3/3 s a FsSk M ►^ a Ld 01 c Lo
SL FS�a4 r^� v-
M L.
Boring#
Boring
pit Ground surface elev. ft. Depth to limiting factor in.
Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. Zff#1 *f#2
i
� I
I
i
Boring
❑ Boring# Ground surface elev. ft. Depth to limiting factor in.
pit Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 ff#2
f
"
Effluent#1 =BOD 5>30<220 mg/L and TSS>30 <150 mg/L Effluent#2=BOD _<30 mg/L and TSS <30 mg/L
The Dept.of Safety and Professional Services is at: equal opportunity service provider and employer. If you need assistance to
access services or need material in an alternate format,contact the department at 608-266-3151 or TTY through Relay.
SBD-5330(RI 111 I)
4a6G' '� ►°r L -
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County
Safety and Buildings Division
201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.)
Madison,WI 53707-7162
gol
it Applich ico State Transaction Number !4
In accordance with S $8 )'Code,submission of this form to the appropriate governmental unit l i AI
is required prior to o permit Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) 1L
the Department of and Professional Servies. Personal information you provide may be used for secondary A �`✓L,
purposes in accordance with the Privacy Law,s.15.04 1 m,Stats.
L Application Informati n—Please Print All Inf rmatio
Property Owner's Name '� I Parcel# `
b - /f 3 - oa
Property Owner's Mailing Address Property Location
t ,� l
x Govk Lot
City,State Zip Code Phone Number '! �fl�'/, Section-,2 —
(circle one
II.Type of Building(check all that apply) Lot T-�-G�--N; R�E qt
W1 or 2 Family Dwelling-Number of Bedrooms � Subdivision Nam;
# U
❑Public/Commercial-Describe Use Uh�tPA
❑City of
❑State Owned-Describe Use CSM Number ❑Village of
2 C J�.Town of
III.Type of Permit: (Check only one box on line A- Complete line B if applicable) 2, X
A YNew System ❑Replacement System ❑Treatment/Iiolding Tank Replacement ❑ Other Modification to Existing System(explain)
i
I
B- El Permit Renewal ❑Permit Revision ❑Chang f umber to New List Previous Permit Number and Date Issued
Before Expiration ! /� r
W.T of POWTS Sy stem/Com onent/Device: Check all t -7 154-.-,1Q11rj 1604
Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Gr]r ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil
❑Holding Tank ❑ er Dispersal Component(explain) ❑Pretreatment Device(explain)
V.Dispersal/Treati4ent Area Information:
Design Flow(gpd) Design Soil Application Rat f) Dispersal Area Required(s Dispersal Area Proposed sf) System'Ele anon
1 . 7 G o
VL Tank Info Capacity in Total #of Manufacturer
Gallons Gallons Units a o ti v
New Tanks Existing Tanks d
a U in ii C7 C,
Septic or Holding Tank Moo
oo U� <
Dosing Chamber
VII.Responsibility Statement- L the undersigned,assume responsibility for installation of the PO'%`TS shown on the attached pleas
Plum s ame )' Plum Sign MP/MPRS Number Business Phone Number
Plum 's Address(S City,State,Zip Code)
® O ' S7o Alf
VIII un !De artment Use Oni
proved app Permit Fee Date su)j4 Issuing t Sign
even Reason ial $ � 'Oa J�
I7s CondTilA1,Q�easons for Disapproval
C.'Z*tfc tank,effluent finer and .
dispersal cefl must all be services/malntained
as per management plan provided by plumber.
2. All s4iack requu'remenis must be-mailrl>Zal cl
as per appllc"coda 'Odkuriicw
Attach to complete plans for the system and submit to the County only on paper not less than 8 in z 11 inches in size
SBD-6398(K 11/11)
i
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: G
Owner's Name: CrD.J� puyv
Owner's Address: '�- '�/
Legal Description: sl- - S l u — S,a
Township:
County: j; C/Lo—t-w—
� a
Subdivision Name:
Lot Number: p�
Parcel ID Number: D
Page 1 Index and title
Page 2 Plot Plan
Page 3 System Sizing &Cross-Section
Page 4 Filter Specs
Page 5 Maintenance Information
Page 6 Management Plan
Page 7 St. Croix Cty Septic Tank Maintenance Form
Page 8 Warranty Deed
Page 9 CSM or Plat
Attachments: Soil Test& House Plans
Designer/Plumber: 139A Y aazy wicense Number:
Date: /O —�s=/ �f Phone Number
7/s-- ��a°oy��6
Signature -------
Designed pursuant to the VGround Soil Absorpt n C mponent Manual for POWTS Version 2.0 SBD-10705-P(N.01/01).
Page 1
keyta / 3 - lam
6-o,�Yw� 3q
f
/uo
/000 7eA
T-1
T=a 70 . / 0
e ilk o� .40 ro7ocy l /°UL
�DC°
l�
l
1
Soil Absorption System Cross Section
bo� ft
4"Schedule 40 Final Grade
PVC Vent Pipe
With Vent Cap /D ft
Leaching
Chamber /o ft
System Elevation
ft ft
Soil Absorption System Plan View
70 ft
ft {
Leaching
Vent Trench 1
Vent Or Observation Pipe Chambers '
4"Dia.
Trench,?, Header
2 aching Chamber S ecifica lone
Manu"rerAnd Model
EISA Rating q ft per chamber Soil Application Rate ° 7 gpd/sq ft
/�� gpd DesignY' 7: 'Soil Application Ra EISA 32, /Chambers
r2 row cha
s of 1 7
x ad
'u
x _
of
Page
s
r
property Owner Jeff Schoen Parcel[D# 040-1193-10-000 page 2__of 3
F Boring# ❑ Boring
3 ® Pit Ground surface elev._ 99.30 ft. Depth to limiting factor +120" in.
Sal licatbn Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Root GPDflf
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. •Efr#1 •Efr#2
1 0-12 10 r4 3 none S1 2m r mvfr qw 2f .5 .9
2 12-35 10yr4/4 none ms Osg ml CrW if .7 1.2
3 35-120 10yr4/4 none co s Osg ml na na .7 1.
Boring# Boring
❑
F-1
❑ pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Root GMT
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. •Eff#1 •Eff#2
J-7
F-1 Boring# E]❑ Boring
Pit Ground surface elev. ft. Depth to limiting factor in.
Soft Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Root GPD1tf
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. •Eff#1 •Eff#2
Ef fluent#1 =BOD6>30:!220 rmg1L and TSS>30<150 mg1L 'Effluent#2=B005<30 ng/L and TSS<30 mglL
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.
sBn.aaso rx.sroo>
L
`7
` SOIL EVALUATION REPORT Page 1 of 3 `�pY
Avmmdn oeparanent of Commerce
owtshm of Bs1*and BuMnes
in accordance with Caren 85,Wis. Adrrt. Code CaurttY
St. Croix
Attach complete alts plan on paper not bas than 8112 x 11 inches in size.Plan trust
inotrde,but not wed lo:vertical and Horizontal referenoe point(BM),direction and Parcel I.D. 040-1193-10-000
perow t dope.scale or dimensions,north arrow,and ooatiort and distance to nearest road. Data
please print all,infarmdon.
Personal k*wmaaon You ProvWa mY b*used norseoaWarirpWP""(Privacy Law.6-15.04(1)(M)). '
Properly Locadon
PropertyOwner SE 1u SW 1u s 24 T 28 N R 20 ii:(or)W
Jeff Schoen
RopWybjnWx Addrr� /�(, '2 E?rC/d tot# Block# Subd.Nerve or t �Wyt,Q
EyF 2 na Croixridge
MAI
Sbte City ❑11Nleige aTown Nearest Road
Burnsville, MN 55337 612) 590-8865 Troy Plainview Rd.
O New Conamjdion tJse:®RestdentW/Nurrlber of bedrooms 4 Code derived design flow rate 600 GPD
❑ReplamnOrt ❑ Pubk or connwrdal-oesatbe:
p%rwt rrletatlsl outwash Flood Phdn elevation if appble na ft.
Ganwal comments
and re'"'wne^ ' trenches 4.00' below grade
a # ❑x Groundaurbm ebv. 102.80 q Depth to*MM fa W +110 in.
❑ Pit � Rate
Horizon Depth DamirwA Redox Desaiption Texture Structure Corlsiatence Boundary Roots GPM
in. WrAd chL Sz. Cone.Color Gr.Sz.Sh. "Eff#1 *002
1 0-9 10yr4/3 none sl 2mgr mvfr gw 2f .5 .9
2 9-19 10yr4/4 none cQ1 s Osg ml gw if .7 1.6
3 19-11 10yr4/4 none ms Osg ml na na .7 1.2
0 Boring#' ® Ground suMm eiev. 102.80 ft. Depth to WnMv fie W +110 im Sol Applicollon WM
Hod= Dsp1h Dominant Color Redox Descriptlon Texture Struck" Comics Boundary Roots GPDNF
In. mans" Qu.Sz. coat Color Gr.Sz.Sh. Mimi "m
1 0-14 10yr4/3 none sl 2mgr mvfr gw 2f .5 .9
2 14-3 10 r4/4 none c Os ml gw if .7 1.6
3 32-11C 10yr4/4 none ms Osg ml na na .7 1.2
i )
Efllu"#1=BOD >301 MO mot.and T,%;,,,V E 150 RM& 'E =BQD `30 and _<30 mpfL
Nurr>be�r
CST Hems(Pieame Ptht) 8
Gary L. Steel TetsptwnsNumbat
Address
1554 200th. Ave. , New Richmond, WI. 54017 8-3-2000 715-246-6200
property owner Jeff Schoen Parcel ID# 040-1193-10-000 page 2 of 3
Boring# ❑ Boring „
F3 ® Pit Ground surface elev. 99.30 ft. Depth to limiting factor +120 in. Sod Application Rate.11
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
I
1 0-12 10 r4 3 none S1 2m r mvfr qW 2f .5 .9
2 12-35 10yr4/4 none ms OSg Ed I CrW if .7 1.2
3 35-120 10yr4/4 none co s Osq ml na na .7 1.6
F-1 Boring# ❑ Boring
❑ pit Ground surface elev. ft. Depth to limiting factor m. 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.
Sod 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 =BOD6>30 220 mg/L and TSS>30:<150 mg/L `Effluent#2=BOD5 130 mg&and TSS<—30 mg1L
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.
STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 Jeff Schoen SE4SW4 S24-T28N-R20W New Richmond, WI 54017
MPRSW-3254 town of Troy (715) 246-6200
lot #21-Croixridge
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1"=40'
BM.= top of 1" pvc pipe C el. 100.00,
Alt. BM.= top of 1" pvc pipe C el. 97.60'
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f��•30
Gary L. Steel
8-3-2000
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Septic Tank Capacity (fib gal ❑ NA
Permit # rr', 2 Septic Tank Manufacturer CV_,&,AcR,_ ❑ NA
DESIGN PARAMETERS Filter Manufacturer ❑ NA
Number of Bedrooms —3 ❑ NA Effluent Filter Model Al $—pl ❑ NA
Number of Public Facility Units ❑ NA Pump Tank Capacity — — gal -�'NA
Estimated flow (average) 30 O gal/day Pump Tank Manufacturer NA
Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer NA
Soil Application Rate s 7 gal/day/ft2 Pump Model *NA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit IVNA
Fats, Oil & Grease (FOG) :530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BODS) -_220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) -.5150 mg/L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD5) 530 mg/L In-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound
Fecal Coliform (geometric mean) 510° cfu/100ml ❑ Drip-Line ❑ Other:
Maximum Effluent Particle Size Y8 in dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other: ❑ NA
*Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: 3 ❑ month(s) (Maximum 3 years) ❑ NA
year(s)
Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 ears) ❑ NA
3 Z year(g)
y
Clean effluent filter At least once every: onth(s) ❑ NA
3 ❑ year(s)
Inspect pump, pump controls & alarm At least once every: ❑ year(s)s) NA
Flush laterals and ressure test At least once ever ' ❑ month(s) 4(f NA
P Y ❑ year(s)
Other: At least once every: ❑ month(s) NA
❑ year(s)
Other: AKNA
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 Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one-third (Y3) or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of:0 2 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
Page Z of y
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and/or damage the 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 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, overloading the cell(s) and may result 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) 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
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a 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 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 that time.
❑ 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.
T
alua ' �Ogrl�
be ' e ai e ?F DgI'5>� fbR- A/�✓ CaNST72t1�
❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
<<WARNING>>
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO 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 IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name Name
Phone �® — �j Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY /
Name Name ST. GI�Q( (�(1N 20llf 1A J
Phone Phone "�/S— 3�(p— &P D
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) &(3),Wisconsin Administrative Code.
QuicM Plus—Series
Quick4 Plus Standard Chamber
.... .... .... .. .... .... .... ....
r7Z
1 1 2"
— 48"
34* — EFFECTIVE LENGTH
Quick4 Plus All-in-One 12 Endcap
PRESSURIZED PIPE DRILL
POINTS LOCATIONS
(2 PLACES) A18"
13' 8'INVERT
-- I — i
33'—
FRONT VIEW SIDE VIEW
INFILTRATOR SYSTEMS,INC.STANDARD LIMITED WARRANTY
Quick4 Plus All-in-One Periscope (a)The structural integrity of each chamber,endcap and other accessory manufactured by
Infiltrator("Units"),when installed and operated in a leachfield of an onsite septic system in
accordance with Infiltrator's instructions,Is warranted to the original purchaser("Holder")against
QUICK4 PLUS defective materials and workmanship for one year from the date that the septic permit is issued for
ALLAN-ONE PERISCOPE the septic system containing the Units;provided,however,that If a septic permit is not required by
(360-SWIVEL) applicable law,the warranty period will begin upon the date that installation of the septic system
commences.To exercise its warranty rights,Holder must notify Infiltrator in writing at its Corporate
Headquarters in Old Saybrook,Connecticut within fifteen(15)days of the alleged defeat.Infiltrator
will supply replacement Units for Units determined by Infiltrator to be covered by this Limited
Warranty.Infiltrator's liability specifically excludes the cost of removal and/or installation
of the Units.
12.7"INVERT (b)THE LIMITED WARRANTY AND REMEDIES IN SUBPARAGRAPH(a)ARE EXCLUSIVE.
THERE ARE NO OTHER WARRANTIES WITH RESPECT TO THE UNITS,INCLUDING NO
IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE
(c)This Limited Warranty shall be void if any part of the chamber system is manufactured by
anyone other than Infiltrator. The Limited Warranty does not extend to incidental,consequential,
special or indirect damages.Infiltrator shall not be liable for penalties or liquidated damages,
Including loss of production and profits,labor and materials,overhead costs,or other losses or
expenses incurred by the Holder or any third party. Specifically excluded from Limited Warranty
coverage are damage to the Units due to ordinary wear and tear,alteration,accident,misuse,
abuse or neglect of the Units;the Units being subjected to vehicle traffic or other conditions which
are not permitted by the installation instructions;failure to maintain the minimum ground covers
set forth in the installation instructions;the placement of improper materials into the system
containing the Units;failure of the Units or the septic system due to improper siting or Improper
9. sizing,excessive water usage,improper grease disposal,or improper operation;or any other
event not caused by Infiltrator. This Limited Warranty shall be void if the Holder fails to comply
with all of the terms set forth in this Umited Warranty.Further,in no event shall Infiltrator be
responsible for any loss or damage to the Holder,the Units,or any third party resulting from
installation or shipment,or from any product liability claims of Holder or any third party.For this
Limited Warranty to apply,the Units must be installed in accordance with all site conditions
required by state and local codes;all other applicable laws;and Infifirator's installation instructions.
(d)No representative of Infiltrator has the authority to change or extend this Limited Warranty.
No warranty applies to any party other than the original Holder.
The above represents the Standard Urnited Warranty offered by Infiltrator. A limited number of
4 Business Park Road states and counties have different warranty requirements. Any purchaser of Units should contact
fit P.O.Box 768 Infiltrator's Corporate Headquarters in Old Saybrook,Connecticut,prior to such purchase,to
Old Saybrook,OT 06476 obtain a copy of the applicable warranty,and should carefully read that warranty prior to the
NFILTRATOR* 1-800-2
11611-577-7021-4436 00-F.x 860-577-700I purchase of Units.
I
systerns Inc. www.inflitratorsystems.com
U.S.Patents:4,759,661;5,017,041;5,156,488;5,336,017;5,401,116;5,401,459;5,511,903:5,716,163;5,588,778;5,839,844 Canadian Patents:1,329,959;2,004,564 Other patents pending.
Infiltrator,Equalizer,Quick4,and SideWinder are registered trademarks of Infiltrator Systems Inc.Infiltrator is a registered trademark in France.Infiltrator Systems Inc.is a registered trademark in Mexico.
Contour,Microl-eaching,PotyTuff,ChamberSpacer,MultlPort,Posli-ock,QuickOut,OuickPlay,SnapLock and StraightLock are trademarks of Infiltrator Systems Inc.
Polyl-ok is a trademark of PoiyLok,Inc.TUF-TITE Is a registered trademark of TUF-TITE,INC.Ultra-Rib is a trademark of IPEX Inc. PLUS05 0713
0 2013 Infiltrator Systems Inc.All rights reserved.Printed in U.S.A.
sx :CROIX COUNTY
MAINTENANCE AGREEMENT
AND
OWNE SW CERTIFICATION FORM
Owner/Buycr V
Mailing Address &,
Ptolemy Addrt?ss Z P �t/1✓�e,� _ -
(Verificatixm required from Pivoting& AD artxnettt for dew truction.)j'
C;ty!Statt ��� .211� �, Parcel Identi calla,Number ��/ 3
LEGALR]E ;1TIQN 7�
Property Localion `/. . Y,.Sec. ,TN R�"—W,Town of_
Subdivision Plat:
, Lot# .
Certified Surrey Map# , Volunx ,Page#
Warranty Creed#� � (before 2007)Volume Page t$
SpCc h2.c` s� Lot lines identifiablekyus t3 ao
SYSTEM M, A;jNTE;tiAN!QE AND)OWNER CERTIFICATION
Improper use and mainvena me of your UP&SWIM covid result in its prettaattue failure to handle wastes Proper
maintenance centrists ofpumping out the septic tank every tt mw years or sooner,if needed,by a li d pumper. What you put into
the system can affect the function of the septic t wk as a treatatent stage in the waste disposal system. owner maintenance
respor;sibili,its axe specified in§Cornet. 83.52(1)PAW in Chapter 12-St.Croix County Sanitaay Ordinance.
The protwrty ownet agrees to submit to Sir Croix County Planning&Zoning€ epartanint a certification form,signed by the
owner and by a rraster plumber,journeyman+phtirA 6r,tescricted plumber or a licensed pumper verifying,that(1)the on-site
wastewater disposal system is in proper operating,condition aatd/or(Z)riftcr-Inspection and pumping(if jecessary i_the septic tank is
less rhan )il Nl)of sludge.
i/we,the undersigned have read the above requirements and agrcc to maintain the pnvale sewage d49poul system with the
standards set fort!,_herein.as set by the Dgmrmient of Commerce and the Department of Natural Resources,State of'Wisconsm
Certification stating that your septic System has been maintained must be completed and miumed to the St. Croix County Planning
Zoning Deparatneat within 30 days of the three year expiration date.
f/we certify that all statements on this f are mia to the best of my/our krmwledge. I/we atn/are the owner{s)of the
property describei above,by virtue of a warrsn deed recorded in Register of Deeds Office.
Nun er of b drooms
• s2G Or APPLICANT(S� D E
tJR
"Any informai,on that is rnisrepresented may result in the sanitary permit bcuig revoked by the Planning&Zoning Deptutnitat.
include with this application n recorded wiuranty decd from the Register of I)ends Office and a copy of the certified survey reap it
inference is made iii the wan-anty deed.
(RF_.V.08/05)
1003458
BETH PABST
State Bar of Wisconsin Form 1-2003 REGISTER OF DEEDS
WARRANTY DEED ST. CROIX CO., WI
RECEIVED FOR RECORD
10/27/2014 11:54 AM
Document Number Document Name EXEMPT # NA
REC FEE: 30.00
THIS DEED, made between Jeffrey L. Schoen ("Grantor," whether one or TRANS FEE: 185.70
more),
PAGES: 1
and Gabn 1 G. Gamache and Cheryl A. Gamache,joint tenants with the right **The above recording Information
of survivorship n ee; a or more . verifies that this document has
been electronically recorded
Grantor, for a valuable consideration, conveys to Grantee the following •returned to the a"bmitter
described real estate, together with the rents, profits, fixtures and other
appurtenant Interests, in St Croix County, State of Wisconsin ("Property") (if. Rewrding Area
more space is needed, please attach addendum):
Name and Return Address
Lot 21,Plat of Croixridge Subdivision,Town of Troy,St.Croix County, Partners Title,LLC
Wisconsin, 659 Blelenberg Drive
Suite 100
Woodbury,MN 55125
040-1193-10-000
Parcel Identiflcatlon Number(PIN)
This is not homestead property.
(is)(is not)
Grantor warrants that the title to the Properly is good, indefeasible in fee simple and free and clear of encumbrance
except:
Dated October 15, 2014
/ '-"' (SEAL) (SEAL)
JWdyKJ Schoen
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin
SS.
authenticated on October 15, 2014 St Croix County
I
* Personalty came before me on October 15, 2014, the above
TITLE: MEMBER STATE BAR OF WISCONSIN named Jeffrey L. Schoen to me kn o be the rson(s)
(If not, who executed the-foregoing acknow ged a same.
authorized by Wis. Stat.§706.06)
THIS INSTRUMENT DRAFTED BY: *Lor' De Ma
Bruce Clark -� No ry Publi of onsin
l.OFiRIE G• QE�VjA4�5 Commissl plies: March 20,2018
NOTARY PUBLIC
STATE OF WISCONSIN
(Signatures may be sumenticated or.nolmowledged. Both are not necessary.)
NOTE:THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM$WOULD BE CLEARLY IDENTIFIED.
WARRANTY DEED 2003 STATE BAR OF WISCONSIN. FORM N0.1-2003
•Type name below signatures.
File No.:23645 Page 1 of 1
2 o N 840 44' E
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N 89°57'31"W! 1295.12'
NORTH -_LINE OF THE W 1/4 OF SE'C'TION. 25
UNPLA TEa . LANDS OWNED BY ROBERT FULTO
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oil
Parcel #: 040-1193-10-000 03/07/2014 09:22 AM
PAGE 1 OF 1
Alt. Parcel#: 24.28.20.867 040-TOWN OF TROY
Current 1X ST. CROIX COUNTY,WISCONSIN
Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type #of Units
00 0
Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner
O-SCHOEN,JEFFREY L
JEFFREY L SCHOEN
18602 EUCLID PATH
FARMINGTON MN 55024
Property Address(es): '= Primary
206 PLAINVIEW DR
Districts: SC=School SP=Special
Type Dist# Description
SC 4893 SCH DIST RIVER FALLS
SP 0100 CHIP VALLEY VOTECH Notes:
Legal Description: Acres: 1.700
SEC 24 T28N R20W PLAT OF CROIXRIDGE LOT
21 Parcel History:
Date Doc# Vol/Page Type
01/31/2000 617686 1487/259 QC
01/31/2000 617685 1487/258 WD
07/23/1997 1169/432 LC
Plat: "=Primary Tract: (S-T-R 40%1601/.) Block/Condo Bldg:
*04-012-CROIXRIDGE 040-75 24-28N-20W LOT 21
2013 SUMMARY Bill#: Fair Market Value: Assessed with:
235862 63,700
Valuations: Last Changed: 11/09/2009
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.760 72,600 0 72,600 NO
Totals for 2013:
General Property 1.760 72,600 0 72,600
Woodland 0.000 0 0
Totals for 2012:
General Property 1.760 72,600 0 72,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch#:
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00