HomeMy WebLinkAbout040-1291-10-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 582035
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holdees Name: City Village Township Parcel Tax No:
John & Holly Bjorseth TOWN OF TROY 040-1291-10-000
CST BM Elev: Insp. BMEle ABM Description: 161L) ✓G - Section/Town/Range/Map 24. No:
85 S, v V .28.20.1658
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER ,y~tJ CAPACITY STATION BS HI FS ELEV.
Septic t t^'~ Z ! l 250 Benchmark 171.`1 ~L o 9
&Ostm Alt. BM ~ / 3 7
R6 t'; 6...A. 6 Q -LA- 3.4 Z- y .S
Aeration Bldg. Sewer 5.7- y
Holding St/Ht Inlet 6 - Cp Ste 5 , Z
TANK SETBACK INFORMATION St/Ht outlet
TANK TO I'~ P/L WELL BLDG. ent Air Intake ROAD Dt Inlet
Na f ~L- s uv` \
Septic mo Dt Bottom
Dosing Header/Man.
Aeration Dist. Pipe 541-3
Holding Bot. System $D I to 7Z
PUMP/SIPHON INFORMATION Final Grade TL
Manufacturer Demand St Coverer~
GPM 3 TZ -T 1i7,
Y; I GO
Model Number
T Lift Friction Loss System Head TDH Ft
Forcemain Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3
SETBACK SYSTEM TO ~~OO P/L BLDG WEC LLLrd•" LAKE/STREAM LEACHING Manufactge':
INFORMATION CHAMBER OR
Type Of System 33 / V 71J Model Number:
o,jJ 'D UNIT 4vj i e-2 tep
DISTRIBUTION SYSTEM of3~.. 1~c Gal 5+15-1-1. = $ s
Header/Manifold If Distributio IxHoleSize y, ZaLj x Hole Spacing Vent to Ai Intake
54.5 14 Pipe(s)
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over jxx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
1(\s No Yes Q No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: )nspection #2: n
Location: 331 LINDSAY RD (qwV V~O w ~4
1.) Alt BM Description = t
2.) Bldg sewer length C-L d- y.o e. S a
- amount of cover
7 ~ g a aC.X~L~
Plan revision Required? Yes No
Use other side for additional information `L 64
J
SBD-6710 (R.3/97) Date Insepctor's ignatu Cert. No.
fyAmar~ County
J . r Industry Services Division
S A v 1400P.0. l3ox~ Sanitary Permit Number (to be filled in by Co.)
Madison, WI 537 7- 162 5g 7,63S
Sanitary Permit AppliCat101$T CROIX COUNTY State Transaction Number
in accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form~%WUQP&Qamt AA-
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Address (if different than mailing address)
the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project ses in accordance with the Privacy Law, s. 15.04(1)(m), Stats.
L Application Information - Please Print All Information
Property Owner's Name Parcel #
L -
Property Owner's Mailing A dress Property Location
ZL~ Govt. Lot
City, s Zip Code Phone Number Section
s 5' N R L(cir oef '
II. Type of Building (check all that apply) Lot #
1 or 2 Family Dwelling- Number of Bedrooms L69D Subdivision Name
❑ Public/Commercial - Describe Use 6K Blo
❑ City of
❑ State Owned - Describe Use ❑ City of of
CSM Number
/5 } 6 Town of
IlL T e of Permit: Check o 1 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)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. Type of POWTS S stem/Coln onent/Device: (Check all that apply)
Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound ? 24 in, of suitable soil ❑ Mound < 24 in. of suitable soil
Holding Tank Other ispersal Component (explain) ❑ Pretreatment Device (explain)r1, r~ a
V. Dis ersal/Treatme Area Information:
Design Flow (gpd) Design Soil Application Dispersal Area Required (so Dispersal Area Proposed ( System Elevation
Rate(gpdsO
VI. Tank Info Capacity in , l
Gallons Total # of U 1
Gallons Units n 1Manufa r o ;r g :e
w
New Tanks Existing Tanks in ,09
cn w C7 0.
Septic or Holding Tank / ❑
Dosing Chamber ❑ ❑
VII. Respo sibility Statement- I, the undersigned, assume responsibil' for Installation of the POWTS shown on the attached plans.
Plumbe ame Plumber's Si MP/MPRS Number Business Phone Number
/7
Plumber's Address (Street, City, State, Zip e)
</;XZ
VIII. oun epartment Use Only
Approved sapprove~- Permit Feet Dat Ise ed Issu' t Sign
ven Reason for Denial $ 47 J ` bD ,I x
IX. Conditions of Approval/Reasons for Disapproval t , ~'tank, W a filter and So " t ( V~ 1's , U` A14AJ° G l S teW ft:
al cell J t all be services ! maintained
wipe[ management plan provided by plumber.
P41c"w%o~ keet.Jb 10C, mi:5er-Z as par twde / ordinances.
Attach to complete plans for the tem and submit to the County only on paper not less than 812 x t t inches in size
SBD-6398 (R03/14)
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CONVENTIONAL COMPONENT DESIGN
Residential application
INDEX AND TITLE PAGE
Project
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Name:
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.:.JiT.;{xz}Y•F.••.~•.~;R:Zi1j~.i.}%L;Ji¢!!T
Y, ,.,•,}}:{:;'?.,}:T,F •::.:.v::: _.i:y,:.j.:.::.?i:~ v?:::i::::.:•,:i::}i::.i.:.}y.?-'..•_?--:~f•'•.':'.'.•::: i:-r:i::::.1:
Owner's
W,
Name
Z3
- - - ti:}`•:"v: is '::}''}ry ii:NV:.S:'~
Owner's
Address:
pQ,•~.'... ..X:ii:iii::~.~:;''~';.'~:~v':~'~;r,:::yt{i: }
.,,.:~'S»;}r}::i.:':•:'}i}:::;•:.}:-??}:. _ ~.:.::::iii::":i;':}::: ~::':isi:.:::::::::c::i'i:}:i:;:}v::::::.
i:•M--.:M ti-':~ri:::}:i:i:. - iC\Ktiti}}}`::-: ~.:~i~:i.}}ii}:.i}:;•:
Legal Description: --21r,71 IJ
Subdivision; Lot
Town:
County:
Parcel ID#
Designer/Plumber: License
Signature: Date: /7 i~
Comments
Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0
lndex+Title 2/2/2012
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Soil Absorption System Cross Section
tt
ft
4° Schedule 40 Final Grade
PVC Vent Pipe
With Vent Cap ft
Leaching
Chamber 2
System Elevation
ft ft ft
Soil Absorption System Plan View
ft
ft
a
ft Leaching Trench 1
Chambers
e Dia.
Trench 2 Header
Vent Or Observation Pipe
o~ ~.Jo
Trench3
Leaching Chamber Specifications
Manufacturer And Model
EISA Rating,_ sq ft per chamber Soil Application Rate gpd/sq ft
gpd Design Flow Soil Application Rate EISA = Charpbers
m%
3 rows of chambers each.
Page of
pL&W~,1191, FILTER
INSTALLAWN INSTRUC11ON8
ti _.v,.•~.Y „sx ~S<;~r'.-i:;Y•:?~':"P la"i. i '~i 1_ -
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(A) pt aca€e the a~udet arthe ~ciank A) PBe pkRm-- the (A) eke SO Sw hOn the
fig} PGmwe fonk cover and pump hank liftr houft on to tits ou(W pipe. MEW P%M.
tea ~ratthe~ (B) kt~~ in the
if n Y is posWomd so thetw can be hour .sureis taer
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ma*ftnenceaid sen► o aanjpk*Wfiv9srl9d In the h° `
MAINTENANCE JNSM,- UCtlofia -will 11
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Step 1: ` rr 1•
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^~2.:~3t'•.•;.~ii2.,.~~ ir:t'.`2'•.` 5--32:_x` ~
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Stag 2 Step 3:
Lacab no 0"ofthe sgmctank (A) Remove tank cover and pump (A) buW 'cwVWpbw*
[f tte cy kdD on ff" hwobe mamv
_ f (Bj Pt~U ttt~e ti~'ou€tt+ftt~e tts: t~t'~ p~
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 1:1~of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner _ Septic Tank Capacity gal ❑ NA
Permit # Septic Tank Manufacturer 14il ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA
Number of Bedrooms < ❑ NA Effluent Filter Model 141 ❑ NA
Number of Public Facility Units )9Y NA Pump Tank Capacity gal J'NA
Estimated flow (average) gal/day Pump Tank Manufacturer E3-NA
Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer ;14 NA
Soil Application Rate gal/day/ftz Pump Model 24 NA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit WNA
Fats, Oil & Grease (FOG) :_30 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD5) 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 (BOD5) 530 mg/L 2f In-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L ) NA ❑ At-Grade ❑ Mound
Fecal Coliform (geometric mean) :_104 cfu/100m1 ❑ Drip-Line ❑ Other:
Maximum Effluent Particle Size Ya 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: ❑ 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 years) ❑ NA
JU year(s)
Clean effluent filter At least once every: ❑ month(s) ❑ NA
J9 year(s)
Inspect pump, pump controls & alarm At least once every: ❑ month(s) NA
❑ year(s)
Flush laterals and pressure test At least once every: ❑ month(s) ET NA
❑ year(s)
Other: At least once every: ❑ month(s) ,ANA
❑ Year(s)
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 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 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)
Page _Z_ of
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.
❑ 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.
following removal of
effect at that time, the biomat at the
❑ Mound an surface. at-grade Reconstrruct Reconstructions of such systems bmust comply width place
infiltrative < <WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NO
CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
ENTER A SEPTIC, UMP O OR OTHER A TANK MAY BE DI K UNDER
T OR IMPOSSIBLE.
PERSON FROM THE
ADDITIONAL COMMENTS
POWTS INSTAL E POWTS MAINTAINER
Name
Name '
Phone
Phone ~
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name '
Name
Phone Phone S
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.
Page ~ of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products 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:
X 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 INSTAL E POWTS MAINTAINER
Name Name
Phone S _ Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name
L
Phone Phone S
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.
s
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREE
AND
OV.NERSHtP CERTIFICATION FORM
0Wn=(BUYW J h n i W n I l y BorscLk
Matting $ddr, 313
Property Address 3 L' S
(Verificafm required from P & Zoning for baron.)
ado-]Z°1 C -1
City/State r n Parcel Identification Number ®O 0
MCRIPTIONN -ILI Property Location % , 74 , Sec. T _,~BN RZO W, Towa of
~ ~ Y% Lot#
Subdivision Plat: Iro
Certified Survey Map # Volume . Page #
Wart saty Deed # /r~/ (before 2007)Volume - Page #
Spec house 'o yes~o Lot lines identifiable O no
SYSTEM MAIN'Y'ENANCE AND OWNER CERT CAUON
Improper use and maintenance of your septic system could result in its premature Mure to Dandle wastes, proper
maintenance consists of pumping on the septic tank every three years or sooner, if needed, by a licenaed pumper. What you put into
the system can afrec i the function ofthe septic tank as a treatment stage in the waste disposal system. Owner mairrtrrrance
nespangbilities are specified in ASPS. 38332(l) and in Chapter 12 - St Croat County Saukary Ordinance,
The property owner agrees to submit to St C mix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, j yin plumber, restricted plumber or a licean d puauper verifying that (1) the on-sits
wastewater disposal cyst= is in proper operating coon and/or (2) a$er inspection and pumping (if necessary), the septic tank is
less them b3 fbn of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards stet fortis, herein, as set by the Department of Safety And Professional Services and the Departpme;nt of Natural pjmwccs,
S'tate of Wisconsin. Catificauion stating that your septic system has beean maintained must be completed and refitnuW to the St Croix
Couxo pbuning & Zoning Dint within 30 days of the three year expiration date
Uwe certify that all star ~nts onthis farm are true to the best of my/our Imowledge. Uwe anvare the owner(s) of the
property described above, by vie Are Of a tl~ deed recorded in Rem of Deeds Office.
N f
SI ATURE OF APPLICANT(S) DATE
'Any information that is misrepr esenUed may result in the sanitary permit being revoked by the Planning & Zoning Dot.
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
Ica is made in the mwramy dead.
(REV. 04a2)
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To Whom it may concern -
Dreamstructure DesignBuild gives permission for the sanitary permit to be issued for lot 130 Troy Burne
Village to John & Holly Bjorseth
Sincerely
Jason Johnson
CEO
Dreamstructure DesignBuild, LLC
Wiscon nDepartmentofIndustry, SOIL AND SITE EVALUATIO 'AEPORT ~k Page I of
L;' rand Human Relations
r.Tosion of Safety & Buildings in accord with ILHR 83.05, W' Atirrf Code
r" f COUNTY\
ST-G~LK
Attach complete site plan on paper not less than 8 112 x 11 inches in size. PI n"Rust include, but
not limited to vertical and horizontal reference point (BM), direction and % of slg , scq) qr' PARCEL I.D. #
`j 11
dimensioned, north arrow, and IocaUon and distance to nearest road. , ~
. ~b
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION - REV D Y DAT
PROPERTY OWNER: PROPERTY LOCATION
C r~
114 114;S14 T ?A E( W
`60T , AA G
PROPERTY OWNER':S MAILING ADDRESS. T # BLOCK # SUBD. NAME OR CSM #
\Z3o 1 )~Ul N.~ . Z 3~ - 1'mu'i ULu_f r F1Dt) .
CITY, STATE ZIP CODE PHONE NUMBER LJCITY OVILLAGE NTOWN ' NEAREST ROAD
B ~_rn.nu l , tV S S q,1'4 ( ) T'Q-oY ~t t~~s PM 1~CD
[XI New Construction Use [~Q Residential / Number of bedrooms 4 AdditiQn to existing building
[ j Replacement Public or commercial describe
Code derived daily flow b bO gpd Recommended design loading rate --::-_bed, gpd/ft2 - 6 trench, gpd/ft2
Absorption area required % 5 $ bed, ft2 "1 S o trench, ft2 - Maximum design loading rate - bed, gpd/ft2 - b trench, gpd/ft2
Recommended infiltration surface elevation(s) TM _n' *V ct(l!~lft (as referred to site plan benchmark)
Additional design / site considerations S ~ fy 01'e- -Co LN 51*-LCC Cu`l -C-
Parent material `b\ZSS 0 v%-Z G kA-,j ft-,, Out N5 H Flood plain elevation, if applicable C~ G 3 ft
rsu = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN RLL HOLDING TANK
= U nsuitable foS S EIU CAS ❑ U ®S ❑ U Cl S❑ U as [I U I I] S O U
SOIL DESCRIPTION REPORT
B, ing # Horizon Depth Dominant Color I Mottles I Structure Consistence Earrhry Roots GPD/ft
, I
in. Munsell Qu. Sz. Cont Color F exture Gr. Sz. Sh. B_ Tmnch
Qj-I1Z 3LZ Zrn a-bk 1~ ~g - s ~6
to`'1~z_ -LL Z - siCl -2-M-L~ YhTi C_ S
Ground 3 ~&-38 l bL1R 3(6 - SL CI ZW a-b2 S
elev.
86g.yft y _l~g Is-2 31Y sd6t' a 35
Depth to
limiting
g1
I- F
Remarks:
Bo~i #
1 o-ty t o~1 Q 31 z s t l sb wt~i~ cw s 6
2 f qQ f `t tz 31` Si l Zen S61z ht ~S - • 5 .6
3 uo.ag s 723ly s~G►- v sg I - •-1 tb
Ground
elev.
0'`{~3 4 ft
Depth to
limiting
factor
Remarks:
CST Name:-Please Print Phone:
Arthur L. We erer 715-425-0165
dress: _
egerer Soi Testing & Design Service-P.O. Box 74 River.Falls,WI. 54022
Signature °14 - 2 9 7 - 11 q Date: CST Number:.
220254
4
PROPERTY OWNER (:UKMQkZ*JMV. 'Z~~ZQ - SOIL DESCRIPTION REPORT : P Z
age - of y y;
PARCEL W. # ~e 11.,p) !y G
Depth Dominant Color Mottles
Ber g # Horizon Texture Structure Consistence Bourday Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
z r3?; _Z
t .:C 1 0 3► u Ll VI- 3 L Z
S i z-'Q S b m'P h c-~ - • 5 .6
Ground . 3 6y~~Z W `t. L %4 Ly .54v- SIB s t ( sb
elev. Z ' 3
ft.
Depth to
limiting €
fac6tor ,r
l
Remarks:
Berr~q #
l w-m- 3 Li - s t 1 FRUL
FILL
Ground 3 z$-~S l O `~l 1Z ~-LZ s t c, Z~ s ~1L cw ,`t . S
elev. ft. y 3s-s3 tv~tz 3!6 siCA z sbiz m`P►- ~s - •y .S
S S3-IZl -1 S`1R3LY S G6 V Sg iM - •1 '•~3
Depth to
limiting
factor
?1-ZA~
i
I J
f
Remarks:
B r i #
5i"g
( p~1Z 1p`'llZ 3l Z- - S1, Zv►z S ~j1Z ~S'1 C W 5 •6
<~.,..~:::f~ ~ t,z=3$ ~o ~ R ~l6 - s t ( Zrn Sb1•z wt'Pr• ~ S - • s ► • 6
3 g_I~y -1•34p-3C S1 FL6~. u Sq rat \ - •"1 j Sb
Ground
8~v-g E
it.
r
Depth to
limiting
factor
> 13y !
Remarks:
3ori g #
0-1I tI)L tz 3Lz - st 1 Zwr stilt wt~y e~ - : s .6
S9 4L L D`1 lz 3l L 1 s LIP- sus S, I ! e s 6 - - Z I , 3
around ,
?lev.
'
f t.
)epth to
imiting
actor
SS"
Remarks: _
•r~ no•r rrr •'.r
PROPERTY OWNER GUKJT11J~ruT'tc- SOIL DESCRIPTION REPORT Z `
Page _ of `
PARCEL I.D. I__ t~ 110
Bo y'~g # Horizon Depth Dominant Color Mottles Structure
in. Munsell Qu. Sz. Cont. Color Texture Consistence Boundary Roots GPD/ft
1 0 _i Gr. Sz. Sh. Bed Trerxh
t .;:C 3 t U 3 L Z -
510
w►'P acv - , 5 .6
Z Z3 -64 1y ZLZ - S11 1 Z~ s bk. a -
Ground S
Ly -t.541LSJ8 st( \~-Sb
elev.
!~"•3 ft. I- Z .3
f
Depth to
limiting
factor 6q ~r
I .
Remarks:
B~rr~q #
:;``ll<L 1 a_9 1o~1(Z 3Lz - sit Ft~ z a
.:kl CU
2:= Z 9-Z8 ~u~ttz ~fb sg
r-ILA- C3
Ground 1 L) `l
-~S 1Z zL N l~b- Cl v s
Z s t c.. ~ Z`~ s ~1L
elev. y 3S-S3 I() lZ 3/6 S1C. Zht
Depth to S S3-)Z1 "t•S l lZ 3Ly S eC Gk U Sq
limiting
ft. S "L
factor
>-v I
Remarks:
BMg #
f>,;::,v....: st 1 Zwr s ~1z ~ s h c w ~ , s~ 6
} € tz-3$ Lo4 cL alb st ( Zrn sb~z rn'fi~ ~S _ , s j, b
3 $,13y 7~S~-1 R 3L
Ground S FL 6h 0 al
1M 1 ` - • "1 .43
e ev.
8 g ft.
Depth to
limiting
factor
> 13y ii
!r
Remarks:
3ori g #
F Z 11-ss t u
, ~Z ~-L Z • ~ sit Z►n sbk
'round I C)-t t7- -31 -S LlR. sLS S ,)l
e s 6 - Z, 3
.lev.
t4TS
It.
)eplh to
imiting
actor
SS"
Remarks:.
`h rra•rnrt~ •.r n
° Industry, SOIL AND SITE EVALUATION REPORT Page I of
Labor and Murnan Relations
D vision of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but ST - C-V~ u t,
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # pti-~,~p 1,v
dimensioned, north arrow, and location and distance to nearest road. '
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVI Y DATE
- - - ( 't f~l
PROPERTY OWNER: PROPERTY LOCATION
0-bl-57L J kD~ ~dc~~-tU~►"1 -1- G94. 1/4 1/4,SZ4 T N,R Z.0 E( W
PROPERTY OWNER':S MAILING ADDRESS. T # BLOCK # SUED. NAME OR CSM #
\Z 3 0 l C,1Z f'SL f~U~ ~-3 n - I`TZ o `'f U I l.~.ttG E Prp t~ .
CITY, STATE ZIP CODE PHONE NUMBER (]CITY (]VILLAGE (MOWN ' NEAREST ROAD
s~-n-"ru ,colN -Sq1114 ( ) Ttz_oY aK~pS" C LSD
[XJ New Construction Use [4 Residential /Number of bedrooms 4 [ ]Addition to existing building
j) Replacement Public or commercial describe
Code derived daily flow b b0 gpd Recommended design loading rate - bed, gpd1ft2 .8 trench, gpd1ft2
Absorption area required 8 5 $ bed, 112 -1 S o trench, ft2 Maximum design loading rate - bed, gpd/ft2 -'b trench, gpd/ft2
Recommended infiltration surface elevation(s) 8 b-Z-• O& C$ TM 7TQav ct(lslft (as referred to site plan benchmark)
Additional design/ site considerations s . 1y o*T~ZO 1rJ S *-LQeS-- UQ
Parent material LO~S3 0 V NZZ G UK'`t t v >'C 3 N Flood plain elevation, if applicable % G 3 it
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable fors stem 19S El U (as ❑U ®S ❑U I Ells ❑U ( LAS ❑U I DS ®U
SOIL DESCRIPTION REPORT
Depth DominantColor I Mottles I I Structure I I GPD/ft
B`\ring # Horizon Texture Consistence Ba rcbryr I Roots
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tmrxh
A <F p_~ \z-3[Z Si 1 Zrn a)bk eg - • S -6
'3 Z Fs ~bH~ZLZ - s Z
c► vh '
1 w~ abler t c S • ~ .s
Ground 3 (6 al C.1 Z fn a.be-
tiv1 F 1-- CS • ~l • 5
elev.
B6$ .4 It y' g_11% 7 S`7fZ 3114 s dst~ a s 9 ~^'t< ~ -
Depth to
limiting
factor
Remarks:
Bo~i #
1 o_14 1 ok Q 31 Z s i t sblz `Fig cw s€. 6
r. 8+.~ z 1 y-~a I u ~t ti ,~16 si ~ Z~, sbi~ y~,-~ cs - • s . b
Ground 3 X10.9 3 I -,S `1 R 3/Y S 6h U S g h1 1 - ' -1 f3
elev.
i{ Ll O It
Depth to
limiting
factor
Remarks:
T Name:-Please Print Phone:
Arthur L. We erer 715-425-0165
egerer Soi Testing & Design Service-P.O. Box 74 River.Falls,WI. 54022
Signature: - -°14 - Z 9 7 _ q Date: ' I ZQ ` g G CST Numbec. 2 - 2254
PFl0PEM-,0WNER (ZUK QE*J-rtV, SOIL DESCRIPTION REPORT
Paf;;'EL I.D. # n~ xjp) Iv G Page 3 of
Boring # Horizon Depth Dominant Color I Mottles Structure
GPD/ft
in Munsell Texture Consistence Boundar
Q Z Qu. Sz. Cont. Color Gr. Sz. Sh. Y Roots Bed Trt ndi
10 `-11Z 3 LZ
G =
- s 1 Z-w, sbl.~ r~'Fl~ ck, %
Z qz -2
Ground 3 S-1• -L -1 -5 Li 2 31 - Set 61- u S9 -
elev.
ml ,S3
X6.1 It.
Depth to
limning
factor
L IZ VI
j
Remarks:
Z b -3 0 t o `'l R t - s~i 1 Z to slat 1~V1'F{•• CS - • S
, 3 o i •6
Ground 3 _l37 -1-5`t2 3Gy _ S~G►- S9 , _ g
elev.
t
Depth to
Limiting
'actor ll~ !
Remarks:
o ZY 10 K 2 3 l Z S 11 Z• ~S b~ wt'~'i~ TYt . s -6
Ground ~ S7-MS ~•SYIZ3ly - S~LGr u &i;
yn1 ,Z
ev.
1,22 ft.
:
Cepth to
miting I !
actor i
> to S" ,
Remarks:
3QriW #
< FMCz-11 3ti
S L ground 3 Ly _ S eL G~. O - 8
ev.
a8 ft.
epth to
;ailing
~ 111 ~ ~D
Remarks:
I
PLOT PLAN Page of
SCALE 1"=
/ 01.E 2" \RcY~1 PLDk
kt 86g e
' ~.~-$Zp z
o,1lgEE
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.i' 86i_ B.ttga 2 k t ' asg.
9 ,
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q9-Z9'~-119
OWL, 11-Z.9-g9 (71 ) 4 5 (s
CST Signature Date Signed Telephone No. CST #
PLOT PLAN Page of
a r
SCALE 1"= SD '
x.567 t-I
/ ~ Z-`' ~Rc~1 P lAE
1
. l
' eL 86,1
is. rlq E
~ 86Z_ a.ugq ~ ~
S
a 12 b o o tNrri ►tt 4 t v o
JI yola QL ~Zo --tfiLZ 2h hZ~1t1C-he s
66% 1
~ e.t196~ g•tlgLi
8bi 4
e. I 6-IRb Cj•11gF868 ZL.
tL8b~
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SOU SL Qt_-:PST Lialiksr... pps' -17-4)64 1 sa, s.
~'9-Z9~- llq
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9
(715 ) 4 .5 - n .irsq_ _
CST Signature Date Signed Telephone No. CST #
a► .
Parcel 040-1291-10-000 07/25/2007 11:02 AM
PAGE 1 OF 1
Alt. Parcel 24.28.20.1658 040 - TOWN OF TROY
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
04/23/2007 00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - KLEWICKI, JOSEPH A & TANAE G
JOSEPH A & TANAE G KLEWICKI
257 TROON CT
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 331 LINDSAY RD
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 1.406 Plat: 09/09-TROY VILLAGE 5TH LTS 130/145 40/02
SEC 24 T28N R20W LOT 130 TROY VILLAGE Block/Condo Bldg: LOT 130
FIFTH ADDITION
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
24-28N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
10/04/2005 808440 2902/146 WD
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 04/23/2007
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.406 220,000 0 220,000 NO
Totals for 2007:
General Property 1.406 220,000 0 220,000
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