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HomeMy WebLinkAbout040-1304-20-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 578952 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: Precision Builders JP2 LLC Troy, Town of 040-1304-20-000 CST BM Elev: Insp. BM Elev: BM Description: Sectionfrown/Range/Map No: DM&7 08.28.19.1826 TANK INFORMATION ti ELEVATION DATA TYPE MANUFACTURER PACITY STATION BS HI FS ELEV. Septic , _ + 12-S Benchmark f~ ^ D N I G5 are., Alt. BM -1 U ~w 9071-2 3 Aeration Bldg. Sewer em-NA 8.-%CL1 9 Holding Sb*4Hnlet Z.S TANK SETBACK INFORMATION StNitUutlet 'jb7.73 TANK TO P/L~ WELL BLDG. Vent to Air Intake ROAD Qtlnle.L Lap Septic 22hh G Dosing ea /Man. Aeration 1071 Dist. Pipe W 3$ 90 .3-4-, Holding Bot. System ~ l .3 PUMP/SIPHON INFORMATION Final Grade 9bS~ p Manufacturer D nd St Cove by.p GPM 9b . 4 Model Number TDH Lift Fric ' oss System Head T 5H Ft 74 Force Length Dist. to well SOIL ABSORPTION SYSTEM ZZ t Z BED/TRENCH Width ~ Length n ~ ~ No. Of Trenches ^ PIT DIMENSIONS No. Of Pits i Inside Di T quid Depth DIMENSIONS -t(/ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR l Nral + T R5 Of System: UNIT ~.n+1 ~ V G Model Number n W Y DISTRIBUTION SYSTEM e 0&+ Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake L4 IC, Pipe(s) Length Dia Length is Spacing 7t11 (]J SOIL COVER IAJ X Pressure Systems Only xx Mound Or At-Grade Systems Only f~ IJJri Depth Over Depth Over / xx Depth of xx Seeded/Sodded xx Mulched Bedfrrench Cente 3. lBedrrrench Edges G/ Topsoil Yes 0 No Yes ~ No COMMENTS: ( clude code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 449 Sunrise Cir Unknown (Unknown 8 T28N R1 9W) Sunset Valley Lot 20 Parcel No: 08.28.19.1826 1.) Alt BM Description = -qi l Cu V "1'~ 2.) Bldg sewer length = ,~L G I S (/V( wS UStXit - amount of cover = J J AA rrII ..n,, 11 QQ Plan revision Required? ❑ Yes No Use other side for additional inform /On. SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No. • County f r Safety and Buildings Division C Rlo f~ 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) t GeV _0 0S 1'1 Madison, WI 53707-7162 78q.sZ P' A; ti~15 PA 1 5- State Transaction Number s~ ermit Application in accordance with SP S Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obt2ng 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 C p C L purposes in accordance with the Privacy Law, s. 15.04 1 m , Slats. qql `r I „ 1 fl( I. Application Information -Please Print All Information fI/tly K Property Owner's Name Parcel # 40 9'~6 - 0 -2©-o c, R ~S O 1~ L Din- S LG Property Owner's Mailing Address Property Location Govt. Lot City, State Zip Code Phone Number LA) 6 ~ y, Section (circle one H. Type of Building (check all that apply) Lot# Q Subdivision Name X1 or 2 Family Dwelling -Number of Bedrooms I ❑ Public/Commercial -Describe Use ❑ City of CSM Number ❑ Village of C1 State Owned -Describe Use Town of T Y III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. )(New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) ❑ List Previous Permit Number and'Date Issued B. El Permit Renewal ❑ Permit Revision Change of Plumber ❑ Permit Transfer to New Before Expiration Owner W. Type of POWTS System/Component/Device: Check all that apply) XNon-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. Dispersal/Treatment Area Information: q G~uaK+ Design Flow (gpd) Design Soil Application Rate(gpdsf) - Dispersal Area Req 'red (sf) Dispersal Area Proposed (so System Eleyta onn A a `Z > VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units a t j y y New Tanks Existing Tanks u c a aU v~ m w w3 P. Septic or Holding Tank no Dosing Chaznber ✓ VII. Responsibility Statement- I, the undersigned, assume responsibility for' stallation of the POWTS shown on the attached plans. MP/Irfi4~6 Number Business Phone Number Plumber's Name (Print) / Plumber's Signature 12Z16 ie,77 ~7/2_ 2-7-3 Plumber's dress (Street, City, State, Zip Code) C-, L w VIII. Coun /De artment Use Only Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature , ❑ Owner Given Reason for Denial 1X. INMpasons for Disapproval f. $eptktlanh, effluMitlow bid dispersal cell mutt aill,be o s I maintained as per managemenCplan provided by plumber. 2. AR setback requirsawlis must be maintained as per applicable code / ordinances Attach to complete plans for the system and submit to the County only on paper not less than 8 t72 x 11 inches in size SBD-6398 (R. 11/11) l CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: GDNki j/VVZOa^rp Owner's Name: ~C f/ o..*J f~ i ()C X~ C~ S r~ L C Owner's Address: 7 ~O Z 41Z, sc o71- r ~5rO z Legal Description: Township: T l~ 0 County: C R o 1' u Subdivision Name: 5ut jf~5* Yj,5 Lot Number: Z Q Parcel ID Number: bqo - 3Q. - 20 --clQ<7 Page 11 ' Index and title Page 2! Plot Plan Page 3 System Sizing & Cross-Section 3q QtA.t ctc tfa~ 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 / 3;-6 N-1 r- 4 A Designer/Plumber: p%G-!? fUtt. d;I / License Number: -44 Z Z Date: Phone Number 77 gZ 4C~~ ~1 Signature Designed pursuant to the In-Ground Soil Absorption Component manual for POWTS Version 2.0 SBD-10705-P (N.01101). Page 1 f ID LL tik Lti~ w D 1f, b-2o c V~ 6uoaK /j pli-fiAR44J f - ~ a Ktf6 C(~G 4-6 L L, 701 ecAlvel'L 1 I- or 2- Family Dwelling In-ground Soil Absorption System (2-cell Conventional) Daily Wastewater Flow (DWF) # of bedrooms x 150 gal/day/bedroom = ~al/day Design Loading Rate (DLR) or Soil Application Rate •gpd/ftZ (per SPS Table 383.44-1, 2, or 3) Required Distribution cell area = DWF gal/day _ DLR gpd/ftZ ftz # Chambers = Required Distribution cell area ftZ + ftZ/ unit EISA = Chambers Chamber Manufacturer and Model: 1/U16,,X 6putt C-lc I/ l'oCttS (~7 Actual Distribution cell area = Required cell area ftZ + ~r Z ftZ/ unit EISA End Cap Pair= ZftZ Cross-Section In-ground Soil Absorption System (2-cell): 4" Schedule 40 PVC vent pipe with vent cap L 12 inches minimum 12 inches minimum inches Soil Cover Trench 1 Sys- tem Elevation / Z inch Chamber Height V V / I5ft Trench 2 System i4 Elevation b -ft ft Trench Separation Leaching Chamber Width ft to limiting factor Plan View In-ground Soil Absorption System (2-cell): Trench 1 Modify ft UN~E: header/ design as ft Leaching Chambers 0 needed. Trench 2 4 inch Header Sch.1 ~J • ft with end camps Draw O for a Vent and 0 for Observation Pipe above. They will be located T ft from the end of the cell. Vent pipes shall be Schedule 40 PVC and extend at least 12 inches above finished grade. Observation pipes that extend above finished grade must also be 4 inch Schedule 40 PVC. Page of r ~~t Quick4 'Plus Standard Chamber Side and End Views T r 48" (EFFECTIVE LENGTH) 34" - ~I a 12 Encap Front, Side and End Views ai~;le.4 Plus All 1.2" 13" 8" INV1 ERT 8" INVERT 5.3" INVERT 33" -1 Quick4 Plus All-in-One Periscope z k DUICK4 PLUS ALL•tN-0NE PERISCOPE---,,\ 560 SWI VEL ) Z 6- .r' 12.7" INVERT QUICKIPLUS ALL-INANE 12 15" I 9"~ ~ ENDCAP -+1I Ir h Quick4 Plus Standard,Chamber Specifications Size (W x L x H) 34" x 53" x 12" (86 cm x 135 cm x 31 cm) Invert Height....,,., 0.6", 5.3", 8.0", 12.7x' (1.5 cm, 8.4 cm, 18.5 cm, 22.6 cm) Effective Length 48" (122 cm) INFILTRATOR SYSTEMS, INC. STANDARD LIMITED WARRANTY (a) The structural integrity of each chamber, end plate, wedge 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 defective materials and workmanship for one year from the date that the septic permit is issued for the septic system containing the Units; provided, however, that if a septic permit is not required by 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 defect. 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.j (b)THE LIMITED WARRANTY AND REMEDIES IN SUBPARAGRAPH (a) ARE EXCLUSIVE. THERE ARE NO OTHER WARRANTIES WITH RESPECT y 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 INFILTRATOR does not extend to incidental, consequential, special or Indirect damages. Infiltrator shall not be liable for penalties or liquidated damages, systems inc. 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 6 Business Park Road • P.O. Box 768 3 the Units; failure of the Units or the septic system due to improper siting or improper 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 Old Saybrook, CT 06475 } terms set forth in this Limited Warranty. Further, in no event shall Infiltrator be responsible for any loss or damage to the Holder, the Units, or any 860.577.7000 • FAX 860.577.7001 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 slate and local codes; all other applicable laws; and Infiltrator's installation instructions. 800.221.4436 7 (d) No representative of Infiltrator has the authority to change or extend this Limited Warranty. No warranty applies to any party other then the www.infiltratorsystems.com original Holder. The above represents the Standard Limited Warranty offered by Infiltrator. A limited number of states and counties have different warranty requirements. Any purchaser of Units should contact Infiltrator's Corporate Headquarters In Old Saybrook, Connecticut, prior to such purchase, to obtain a copy of the applicable warranty, and should carefully read that warranty prior to the purchase of Units p fj~ y a 4p d'i nt 0~~* t, adf 19~f HQXEu a ~G 9 D a r T' G iR~ t1 • t~ 4) t µ € -a ' .b 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, Ouick4 and Qu1ck4 Plus are registered trademarks of Infiltrator Systems Inc. Infiltrator is a registered trademark in France. Infiltrator Systems Inc. is a registered trademark in Mexico. Contour Swivel Connection is a trademark of Infiltrator Systems Inc. 0 2009 Infiltrator Systems Inc. Printed in U.S.A. PLUS0510101SI.2 A10013001600m~12 series A The original ZABEL® Disc Dam Filter was patented in 1959. The 12" series filters have been filtering wastewater longer than any filter in the wastewater industry. In 2000 Zabel made the best even better by introducing a complete redesign of the original with more great features and fi evels of filtration. A 100-12T M Series The A100-12 is the commercial filter chosen by more engineers and installed in more localities than any other filter on the market. The reliable performance and flow rates from 3000-6000 gpd allow this filter to be utilized in almost every application. The new ZABEL Versa-CaseTm is available with built-in reducer and outlet hub that accepts either 4" or 6" SCH 40 pipe. The A100-12 Series is also popular in many areas for residential use due to its high quality effluent and large capacity. Independent research has shown the A100-12 decreases TSS by 50-90% and CB0D5 by 20-40%. 1 /16"Flltration or-,! k I I Available lengths 20", 28" & 36" A300-12T M Series Long heralded as the ultimate grease trap filter, the A300-12 provides 1/32" filtration and has been shown to reduce FOG by as much as 50-98%. The A300-12 is also used for onsite wastewater systems which require a finer level of TSS removal, such as laundromats and dog kennels. As with all ZABEL Filters extra filter l_ cartridges are available to speed service time and allow offsite cleaning of the used cartridge. 0011/32"Filtration Available lengths 20", 28" & 36" A600-12T M Series The newest addition to the ZABEL Filter line incorporates the proven performance of the disc dam design with the finest level of filtration available on the market. The 1/64" filtration of the A600-12 provides optimal filtration levels for those unique applications with very fine particulates and suspended solids. Every A600- 12 Series filter includes the exclusive SmartFllter® Alarm switch to alert the owner of required maintenance. 1/64"Flltration Available lengths 20" 28" & 36" For further technical information: www.zabeizone.com 050,03.244 POWTS OWNER'S MANUAL MANAGEMENT PLAN FILE INFORMATION SYSTEM SPECIFICATIONS s Owner Septic Tank Capacity 12f© al ❑ NA Permit Septic Tank Manufacturer (.l.) IIrSBIZ ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model A100 ❑ NA Number-of Public Facility Units }$i NA Pump Tank Capacity ❑ NA Estimated flow (average) V60 gal/day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) > (000 gal/day Pump Manufacturer ❑ NA Soil Application Rate al/da /ft2 Pump Model ❑ NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD.) 5220 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 (BODE) 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 Ye in dia. ❑ NA Other: ❑ NA Other: [I NA Other: (7 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) 0 NA 9 ear(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: .3 ® month(s) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: ❑ month(s) ❑ NA ® year(s) r Inspect pump, pump controls & alarm At least once every: ❑ month(s) [I NA 3 H ear(s) ❑ NA Flush laterals and pressure test At least once every: ❑ month(s) year(s) Other: At least once every: 0 moot ►(s) ❑ NA Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; 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 opll(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 512 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. GMW (4/01) START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or othe chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents a 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; ,-,L 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. ❑ 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> > 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 ~ p tZ C-L So/V Name Phone S- Z 7 3 7` T Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name 3n~NSa~J y'.6}~r'fh o°'✓ Name _ Sf CIQd/X Z0 f Phone 7/5 Z 7 3 Phone 3adV/ 90 This document was drafted in compliance with chapter Comm 83.22(2)(b)0)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT / AND OWNERSHIP CERTIFICATION FORM Owner/Buyer ~n C ! 5/0 ~l '5LA c <-0 cc~ 5, ~P Z t^.C L Mailing Address Property Address ! L E (Verification required from Planning & Zoning Department for new construction.) City/State Parcel Identification Number 0 K0 /30 Y' Z0 - 6 O LEGAL DESCRIPTION Property Location E: %a , S UJ 1/a , Sec. g , T 'Z $ N R- W, Town of 4- oy Subdivision !~U, NS'~5-4- MC-054. Lot # Certified Survey Map # , Volume , Page # Warranty Deed # 1001-731 , Volume , Page # Spec house yes no Lot lines identifiable yes 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 §Comm. 83.52(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 Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe 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 deed recorded in Register of Deeds Office. Num r f b ooms - 61711,5 SIGNATURE 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. 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Plan must include, but not limited to: vertical reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location an/3 d U / informationDate Please print al Personal information you provide maybe used for secondary purposes ( /4 05 Property Owner Properly Location ❑ S ARTHUR & N ARIYLN FEYEREISEN Govt, Lot - %P- 1/4 SW 1/4 S 8 T 28 N R 19 E (or) W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 420 Townsvalley Road 20 - Sunset Valley City State Zip Code Phone Number DCity [:]Village • own Nearest Road Hudson, WI 54016 ( 715) 386 - 2122 Townsvalley Road 0 New Construction UseE] Residential / Number of bedrooms 4 Code derived design flaw rate 600 GPD ❑ Replacement ❑ Public or comnerdal - Describe: Parent material outwash/sandstone Flood Plain elevation if applicable N k ft. General comments Conventional In-ground trenches - to be designed by instal Z and ~,!^•k~ UG2e2 ~ 0.5 loading rate_ -P'j'~ E B:- Boring # ❑ Boring Q Pit Ground surface elev. 906.151 R Depth to limiting factor 61 in. Sol Appkation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Rods GPDNF in. Mumsefl Qu. Sz. Court. Color Gr. Sz. Sh. 'Eff#1 °0102 1 0-4 IGYR2/2 - 1 3f-lsbk mvfr cb 3vf-m 0.6 0.8 2 t OYR2/2 - I 2f-mabk mvfr cb 2vf-m 0.6 0.8 3 210YR3/4 4V1 V 1 2f-msbk mfr aw 2vf-m 0.6 0.8 4 24-33 10YR3/6 - s Os dl aw 2vf-m p,7 1.6 5 33-37 10YR4/4 s & gr Osg dl aw 0.7 1.6 6 37-61 1OYR4/4 - fs Osg dl as - 0.5 1.0 7 61-64 10YR4/4 c2f IOYR4/6 fs Osg dl - - 0.5 1.0 1i Boring # ~ ~nrg 909.27 <110 B El Pit Ground surface elev. ft. Depth to limiting factor in. SO Rate Horizon Depth Dominant Colo Redox Description Texture Structure Consistence Boundary Roots GPD11P in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0-3 10YR2/2 - 1 3fabk ds cb 3vf-m 0.6 0.8 2 3-12 10YR2/2 - 1 2f-mabk ds as 2vf-m 0.6 0.8 12-25 IOYR3/4 - 1 2f-mabk dsh as 2vf m 0.6 0.8 4 25-37 10YR3/6 - s Osg dl gs - 0.7 1.6 5 37-110 10YR5/4 - s Osg dl 0.7 1.6 ' Effluent #1 = BODS > 30:5 220 mg/L and TSS >30 < 150 mg/L ' Eflhie(M #2 = BODr,< 30 mg/L and TSS < 30 mg/L CST Name (Please Print) nahare G/WiJ CST Number Ma Jo Hollister 224832 Address Date Evaluation Conducted Telephone Number W9875 690th Avenue, River Falls, WI 54022 01 - 13 & 07 - 09 - 04 (715) 426 - 1775 Property Owner FEYEREISEN, Arthur (Lot 20 Parcel 1D # ) (Pending) Page of 3 a goring # Boring 904.65 Pit Ground surface elev. fL Depth to limiting factor >90 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz Cont Color Gr. Sz" Sh. 'Eff#1 `Eff#2 1 0-3 IOYR3/2 - 1s Ifsbk ds cb 3vf-m 0.7 1.6 2 3-13 IOYR3/2 - A 2f-msbk ds as 2vf-m 0.6 1.0 3 13-25 10 3/4 s Osg dl gs 0.7 1.6 4 25-40 lOYR5/4 s Osg dl - 0.7 1.6 (Horizons 1,2 & 3 have some gr.) goring # 11 goring Pit Ground surface elev. ft. Depth to limiting factor in. Soo ication 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 Found surface elev. ft. Depth to limiting factor in. Sod Application Rate Horizon Depth Dominant Col Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'EfT#2 f°+nicia° _ :sous % ,xi < ccv ,Tay'ii es+w i aSi:'.~ %.3i~1i < i,`snr ,Tiyi " ineucsN #2 = BW, < 30 mgh. and TSS _ 30 mg/L 11ccil Illuicilai ill aiii a!H [risk' 3SP ma'.i. jPk:aar: PWr P~AN p~~5 BM-11--we OF 1' 3XON ,PES 12"o R . ~ E SLR. q TROY, st C s N. ®-50L i W/ MWa NO COMM 83 "M MUMM 1.502 gees I _ I LOT 20 J N ell N 3 :912.56000' B-2 C I Q) B-20 909. 7762' M 74>0 SLOPE d.. I N v 1 ' 9?OS~ .1 047914 $c' u eY % 0~ X Ro. ~~-11GJ UGI I'~HL o' RED BRICK I ADDI TION ~ 9G ICL1 T R R SI r E 900.4 TIAL - - - - - + - - - - ~ x 70.8 EAST-N~FST AN L l E ' 14" E 13 .11' ~ - .66' .29' 913 3 22 .73' ,Q p F910.5 LOT 19 ' OD `o .604 ACRES o co QT 2 s 6 ,875 S.F. N N 1. ' A S 50 65,4 S.F. I rn I X896.8 N °4 ' 4' E /913.3 a _ I p~ B 19 0. 0 S's ~v 3.~~ X 5 % 0~ OiyO * ^h 911. coo t1~ C7~ `C> F C? I lr- ~o L 1 f c ~r 1 5 0 E =80' 00 N `6 3 6 CD N °18'3E I 987.04' W ' N I n ~ x r 905. 1 x ' \ O 895. J r 903.0 O N 7 O 00' If W 7S, x ad 00 C S 6' 81. 9 ' I tp_ r 9 .F ~ cQ Q~ 1.570 ACRES ' C9~ S.F. I % ~I I O p O ~ ~ I I ~ 71. 5' 50 0 i 3 2 .2 ' 000 O° to 896.5 256.53' s 9 °00 00" 1 050 ' 00" E 06. 4'. I z cn C'bl -7-7-7- N °00' 00 W 574.39' 87 0.0 I UT OT 1 E, _ c _ O .62 CRE _ w 2 04 ,206 S.F. o L T ' 50' N (LBO=888.0 w o 0 1.506 ACR S/ B- 7 65,624 S.F. 0 8 f~ ti N .75ARS 893.0 7 ,8 .F. % cr_ rn ti 9.2 ° ` /90 i vvisc onsin Department of Commerce SOIL EVALUATION REPORT Page I of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code COY ST. CROIX Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. yo - 176q- z1) - Coo 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 ~ ❑ ARTHUR & MARIYLN FEYEREISEN Govt. Lot NE 1/4 SW 1/4 S 8 T 28 N R 19 E (or) W Property Owner's Mailing Address Lot # Block # Subd. Name or CSW 420 Townsvalley Road 20 Sunset Valley City State Zip Code Phone Number ihr 3~Ilage Town Nearest Road Hudson, WI 54016 ( 715) 386 - 2122 Townsvalley Road 1WY E]New construction useEl Rewentiat / Number of bedrooms 4 Code derived design flow rate 600 GPD 0 Replawnent Q Pty or oonfr wcial - Describe: ft• Patent material outwash/sandstone (=food Plain elevation if applicable NA- General continents Conventional In-ground trenches - to be designed by installer and 0,1 qffloadingrate C-~R 2G",3.c,d 1b S~wk~l rA a~ ?md#wr P13- Boring # [a] Boring o Pit Ground surface elev. 906.151 ft. Depth to limiting factor 61 in. Sol Appkation Rate Horizon Depth Dominant Color Redox Description Textile Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cortt. Color Gr. Sz. Sh. 'Etilkt 'Eff#2 1 0-4 10YR2/2 - I 3f-lsbk mvfr cb 3vf-m 0.6 0.8 2 4-14 I0YR2/2 - I 2f-mabk mvfr cb 2vf-m 0.6 0.8 3 14-24 10YR3/4 - I 2f-msbk mfr aw 2vf-m 0.6 0.8 4 24-33 10YR3/6 - s Os dl aw 2vf-m 0.7 1.6 5 33-37 10YR4/4 s & gr Osg dl aw 0.7 1.6 6 37-61 10YR4/4 - fs Osg d1 as 0.5 1.0 7 61-64 10YR4/4 c2f Ik1YR4/6 fs Osg dl - 0.5 1.0 B ] Boring # Boring 909.27 <110 Pit Ground surface elev. ft. Depth to lirr~ting factor in. S~ Rate F Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munseff Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2 1 0-3 I0YR2/2 - I 3fabk ds cb 3vf-m 0.6 0.8 2 3-12 I0YR2/2 - t 2f-mabk ds as 2vf-m 0.6 0.8 3 12-25 10YR3/4 - I 2f-mabk dsh as 2vf m 0.6 0.8 4 25-37 10YR3/6 - s 0sg di gs 0.7 1.6 5 37-110 I0YR5/4 s Osg dl - 0.7 1.6 I ` Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 ffxA ' Effluent #2 = BM, :5 30 mg/L and TSS < 30 mg/L CST Name (Please Prim) Sign CST Number Ma Jo Hollister 224832 Address - Date Evaluation Conducted Telephone Number W9875 690th Avenue, River Falls, WT 54022 01 - 13 & 07 - 09 - 04 (715) 426 - 1775 D,t-- V1 POf PLAN Ma'5a -~5 OF rP~ urr E S• q 0 sr,C l 1 5 ®-501. i W1 PALM NOCOMMM"AXMMM LS4'L ~e~s I LOT 20 N. I 30 i I 1:912.56000' B-2 0C :9 4. 94 Q) I C B-20 I: 909. 7762' 7ero I c, B-P21 90 . WDSR 06.1 AN 7 14 ' . se ,ytu~1 3 X Ro. ~ -/S~ /S ~4,~~r,►-cam: Os 0 SOIL PROFILE DESCRIPTION Owner: FEY~R E (S~~ CST: 1)4hizY jo ~-IuPg-gT//-1Oc/i/STS System Elev. Proposed: ft Syst. Range_._fdZ_ft to faAaft Ld Rate: • 7 # Elevation: g09 3D # 13 Elevation: 9d 9 L 7 # 6 Elevation: poY o Boring o Boring o Boring o Pit o Pit o Pit !/O QOg ~ 104 ~`µy -~a 6 90,7 ----AM - ~.l 1 ilk 6 VVX