HomeMy WebLinkAbout020-1119-30-000
VVsconsin Department of Commerce PRIVATE SEWAGE SYSTEM COL.nt; St. Croix
Safety and Gu, ding Division
INSPECTION REPORT Sancary Permit No
ATTACH TO PERMIT) 584733
GENERAL INFORMATION State Plat) ID No
Persona irtormahoo you provide may be used fnr secondary purposes (Pnvacy Lay, s 1504 (1};m)I
Permit I-older's Narre City V age Township Parcel Tax No
Ronald & Kathyrn Smith TOWN OF HUDSON 020-1119-30-000
CST BM =1ev Ipso. BM Elev. jwv Description n SectiorTen n;Range'Map NO:
CH k7 J C-sT 17.29.19.510
TANK INFORMATION ELEVATION DATA
TYPE MAN.IFACTURFIR CAPACITY STATION BS HI FS ELEV.
,
Septic Benchmark / qq Q
G;"► Pa 1 o k Alt. BMi~~4- e7
Aeration Bldg. Sewer 73 cf'1` 35
Holding SUHt Inlet sar T3. ?'7
TANK SETBACK INFORMATION SO It Outlet
TANK TO P;L WELL BLDG. ventt 'ir Intake ROAD Dt Inlet
~ ` r Dt Bottom ~
Septic 73 7 ' '7
Dosing _ p ~Q, Header!P.1an. r I Tf , 63
Aeration Dist. Pipe
z5 $9" V3
Ho ding Got System Beby
/ti r3 Tit , ( 0
Final Grade
PUMP/SIPHON INFORMATION 5.6 03
Manufacture' Demand St Cover 9 7, it
_ GPM
Model her
TDH Lift Friction l css Pad R
Forcemain Length Dre. D st to Yveu
SOIL ABSORPTION SYSTEM
BED/TRENCH LNdth I-ength INo Of Trerrhes PIT DIMENSIONS `.o Gf P Is Inside Dia. Ligjid Depth
DIMENSIONS 3 114:5
SETBACK SYST Eh9 1 U ICJ P(L BLDG / If WELL LAKEiSTREAM LEACHING Manufacturer //b
INFORMATION CHAMBER OR G 1~
Type O ~v~ste ~ y I 1 j /1 UNIT Mode Number
66 i 6 ~/DLf ~~JA
D,,J~„~ S S
DISTRIBUTION SYSTEM CACJC 6'
Header;hlanifo'd I D siritut or x Hole Size x -ole Soaring Vent t" it Irta`D
LDia ~ ILencth. Ga` Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth of xx d l, xx Bed!Tieici'.)enter C"2 BedrTrench Edges 'opsod ~ Ves No Yes :Mulched
NO
COMMENTS: iInclude eccode discrepencies, persons present. etc.) Inspecticn #1 Inspection #2:
Location: 385 BROOKbVOOD OR
1) Alt Bf,4 Description = F,- %
2) Bldg sewer length = 3-7
amount of cover =
142 6v-1- 0_~o
Pl
LO 441 ~ I
an revision Required Yes No Use other side for additi onal informal'. n Date Insepctor's Si ature Cert. No.
SBD-671 ;R 197)
~ unarm? Count)'
/ St. Croix pit #0w, IRE Industry Services Division
D
1400 E Washington Ave Sanitary- Permit Number (to be tilled in by Co.)
S P P.O. Box 7162
r S APR Madison, WI 53707-7162 4) ~ 7 41-733
ST r,wrl sib.
COMM~NUYtw~yt. t • Application vans n Number
In accordance with SPS :8; 211?:, \k is Ailm Code• st: ion nl this term In the appropriate govcmmcntal unit I
N
is required prior to obtaining a +anitan pcrntil. Note: Application forms for stale-owned POW "I'S are st:hntitted to
the nep-rimeni of Safetq and Professmnal Serv ices Perrnnal information you prrn,ide may. be used for seeondury' Protect ess (if different than mailing address)
Same
Purposes a ac.ord rncc with the Plis~ } L!ns- . I~ Q4(I1(mL Stars #
1. Application Informatio - Please Print All Information cl~V( ki~J ~J
Property Owner's Manic 1 Parcel
Smith. Ronald & Kathryn / 02n-1 119-;o-non
Property Owner'; Mailine. Address Property Location
385 Brookwood Drive C
Govt. Lot
City. State L.ro Code Phone Number - NC :4. SE Section 17
1ludson , W1 s4016 'circle one)
129N R19Etit 11. Type of Building (check all that apply) ? -
®1 or 2 family Dwclline -Number of Qcdro,nis > I Subdivision Nanie
Trout Brook %Volxis Addition
❑ PubliclContmercial - Descrihe Ilse ~Gt t.tM~ Block tt
❑ Coy of
❑ Stale Oswied Describe Use
CSA1 Number ❑ Village of
~ ~ 1~ t~ 7•~} i ~ ~7~~ ❑ •fostiro of I[udson
111. Type of Permit: (Check nh' one box on line N. Complete line -R if applicable) A ❑ New System Q Replacement Sy tent ❑ "freaunentil folding Tank Replacement Only ❑
Other Modification to Existing System (explain)
B. ❑ Permit Renewal El Permit Revision -E] Change of ❑ Permit Transfer to New List Pre\ ious Permit Number and Date Issued
Before Expiration Plumber Owner 49416 277!1984
IV. Type of POWTS System: Com onent'Device: (Check all that apply)
® Non-Pressurized In-Ground- ❑ Pressurized In-Groutnd ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound 24 in. of suitable soil
o m, : wtk Other Dispersal Component {ecpluin) ❑ Pretreatment Device )explain) C~ Jn
V. Dis ersal/Treatme t Area Information:
Design flow ;gpd'r Design Soil Application Dispersal Area Required isf Dispersal Area Pr osed (sf) System Elevation
450 Rate(_pdsf) 643 675 89 On'
0.7
VI. Fank Info Capacity in -
:J
Gallons Total ii of s '
- Manufacturer y L ~`z y
New Tanks ExlstingTnnl Ciallims Units ?
Septic or Holding Tank 1000 1000- I ~Viescr Concrete ® ❑ 0 ❑ ❑
Dosilta Chamber ❑ ❑ ❑ ❑ ❑
VI1. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the PUN~'I S shoal on the attached plans.
r
Qusmcss I
Plumber's Name (Print) I'lumhcy_ igl urc \ti"~'I'RS Number 'honc Number
John Schmitt Lt( t1C~- 1 123760 715-760-0486
Plumbcr's Address ;Street, Cltc. Stale. Lip Codel
616 151Y Ave.'oinerset. NVI 54025
X711. punt y!De partnient Use Only
4pproved i - Permit Feee4e, Da Issu 1 Issuine enl Signature
Ow ner ea_son fir trial ~ ~ J • ~ ~ /
IX. Condit ff&: 9K Reasons for Disapproval ) ~I
1. Septic ark, eill nt finer and 3 l 'ej C~-'V
disper:zii cell must all be services ! rn~inta'nec I'a"
as per management plan pro-nded by plumber. 2. AI salt * requirelawAs must be maintzir~d as per applicable code J ..rdinance3.
littnch to complete plsnc For the ssdem and suhmit lu file ( uull" sins nn paper not less than N 1 : x I t inches in siie
SRD-01qS (Rh3 141
PLOT PLAN
Pro;~~. Name Smith 3 3edrocm Replacement Septic System
__gat Description NE114, SE1l4, S17, T29N, R19W P I D 020-1119-30-000
Subdivision Name. Trout Brook Woods Addition Lot; 7
Towrsrip. Hudson Parcel S;ze 1.74 SCALE: _
County: St. Croix as
Systerr Elevator. T1= 89.00' Proposed .00' EZ Flow Trench
Sicoe ^ ;T2= 89.00' Proposed _45. 0' EZ Flow Trench
FS' Eievation: 98.04' Walkout Door Sil 'T3= 89.00' Proposed 45.00' EZ Flow Trench
3rV,2 Elevation:i iExistin Drainfield 12' x 52' Bed
6ackhoe bits Tarks!Wieser Concrete WLP1000-MR
Fite- fol lok 525
See CSM or Plat for complete view of parcel
14 i-)ch Scr 40-ASTM D2665
4 inch 3034 - ASTM D3C34
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CONVENTIONAL COMPONENT DESIGN
INDEX AND TITLE PAGE
Project Name: Smith 3 Bedroom Replacement Sept c System
Owners Name: Ronald & Kathryn Smith
Owner's Address 385 Brookwood Drive
Hudson, WI 54016
Legal Description: NE1/4, SE1/4, S17, T29N, R19W
Township Hudson
County: St. Croix
Subdivision Name: Trout Brook Woods Addition
Lot Number: 7 Block Number
Parcel I.D. Number 020-1119-30-000
Plan Transaction No.
Page 1 Index and title
Page 2 Plot Plan
Page 3 Septic Tank Specifications
Page 4 Effluent Filter Information
Page 5 Valve Information
Page 6 System Sizing & Cross Section
Page 7 EZ Flow Information
Page 8 & 9 Management and contingency plan
Page 10 Septic Tank Maintenance Agreement
Page 11 Warranty Deed
Page 12 CSM or Plat
Attachment 1 Soil Evaluation Report
Designer: John Schmitt Licnese Number: MPRS 223760
Date: 4/25/2016 Phone Number: 715-760-0486
Signature:
In-Ground Soil Absorption Component Manual Version 2.0 SBD-10705-P (N. 01/01)
Page 1
PLOT PLAN N
Project Name: Smith 3 Bedroom Replacement Septic System
Lega! Description: NE114, SEV4, S17, T29N, R19W Rl D: 020-1119-30-000
Subdivision Name: Trout Brook Woods Addition Lot # 7
Township: Hudson Parcel Size: 1.74 SCALE: 1"
40'
County: St.-Croix
System Elevaton T1= 89.00' Proposed NOW EZ Flow Trench
S ope 41% T2= 89.00' Proposed 45. 0' EZ Flow Trench
A BM1 Elevation 98.04' Walkout Door Sil T3= 89.00' Proposed 45.00' EZ Flow Trench
BM2 Elevation: Existing_Drainfield 12'x 52' Bed
■ Back7oe Pits Tanks Wieser Concrete WLP1000-MR
Filter Pol lok 525
See CSM or Plat for complete view of parcel
4 inch S& 40-ASTM D2665
4 inch 3034 - ASTM D303t
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Page 3
PI)LIA AOX Inc,
zatel' PL-525 Effluent Filter
IT-;25 'Filter
The P1.-525 Filter is rated for 10,000 GPD (gallons per day) making it one of the largest filters in its class. It has
525 linear feet of 1;16" filtration slots. Like the Polylok PL-122, the Pohrlok PL-525 has an automatic shut-off hall
installed avith every filter. When the filter is removed for cleaning, the gall will float up acid temporarily shut off
the system so the effluent iron't leave the tank.
fi-atures: ltW' Filtration Slots
• Rated for 10,000 GPD (gallons per day). r Alarn, Switch
10,000 GPD (optiunal)
• 525 linear feet of 1; 16" filtration.
• Accepts 4" and 6" SCHD 40 pipe. A(copl, I" PVC-
Extension t landle
Built in gas deflector.
• automatic shut-off ball when filter is removed.
s,-a
= Rated for
• alarm accessibility. u,taoGPD
• Accepts PVC extension handle.
I' L-525 Instillation:
Ideal for residential and commercial waste flows up to 525 Linea,- Fi.
10,000 gallons per day (GPD). - h1tration Slots
I . i .ocate the outlet of the septic tank.
Remove the tank cover and pump tank if necessary.
& h"
.Accepts -t"
3. Glue the filter housing to the 4" or Ei" outlet pipe. If scxD to pipe
the filter is not centered under the access opening use a
Polvlok Extend & Lok or piece of pipe to center filter.
4. Insert the PL-525 filter into its housing.
Certified to
5. Replace and secure the septic tank cover. :0: NSFANSI Standard 46
IT-525 Maintenancc:
The P1.-525 Fffluent Filters ivill operate efficiently for
several years under normal conditions before requiring
cleaning. It is recommended that the filter be cleaned W 4f~~
every time the tank is pumped, or at least every three z ' T
years. If the installed filter contains an optional alarm,
the o4vner will be notified by an alarm when the filter-
needs servicing. Servicing should be done b_y a cerli I icd Gas Defluctor
"
septic tank pumper or installer. Automatic
phut-Dff Ball
1. Locate. the outlet of the septic tank
2. Remove tank cover and pump tank if necessary.
3. Do not use plumbing when filter is removed.
4. Pull PL-525 cartridge out of the housing.
5. Hose off filter over the septic tank. Make sure all
solids fall back into septic tank. r
6. Insert the filter cartridge back into the housing making
Outdoor tiniaithltee :Alarm Extend & Lolc"'
sure the filter is properly aligned and completely inserted. Polgiok. Zabel & Best filters accept Easily installs
Replace and tiecllre septic tank cover. the Smartrilteris, switch and alarm. into existing tanks.
Polylok. Inc. 3 Fairfield Blvd. ~t<tllingfori;. CT ('10492 "lull Frcc: '877.765.9565 Ftix: 203,254.8514 %,.ww-.polylok.cnm
Page 4
American Manufacturing Company Bull Run Valve Page I of 3
w~rr
i-Home About Site Map Order Info Training Videos Contact Drip sy
I
Treatment Controls Products Downloads Design Guidance
HE BULL RUN'"" VALVE
- ~
OIL
' YMTER-TIGHT'
ACCESS CAP
RI SER CAP
ADAPTER
RISER
TUBE
VALVE DIRECTION
144 i^DLE
The Bull Run Valve„'' is designed to split flows to septic
fields or systems. In addition to the advantages of 4' OUT PORT
longer life and easier installation it is the most public T OUT PORT
health safe alternating device available for wastewater
disposal applications. The use has absolutely no contact
with wastewater due to the valve's leak-proof and
external operating characteristics. The change over from C INPORr
one drainage field to another can be accomplished in
less than a minute by simply turning the valve without
digging or contact with wastewater, The Bull Run Valve is available in 4" sch 40 pvc
and is suitable wherever septic disposal systems
are used - in commercial, industrial, and
residential applications.
OPERATING THE VALVE
The direction control handle should be rotated
7on Field V periodically to direct effluent to one or the other
No.2 of two septic fields. After removing the screw
cap at the top of the riser tube, the valve handle
can be turned with the valve key furnished.
Ped BULL RUN VALVE
oa No. 1 . 3
g Complete Valve Kit
Od Years Septic Septic Even ~a Contains
Tank Tank 1. Bull Run Valve body
2. 28" Valve Key
3. Riser Cap Adapter
ITEM DESCRIPTION 4. Watertight Access Cap
BRV4 BULL RUN VALVE 4"
Page 5
file:lilC:li:sersiJohn°-o20Schmitt,Desktop./Johnr`American°-o20N,1anufacturing°02OCompan~:°'"O?0--qb!-O LIII'-U~... 4;'2 12016
SOIL ABSORPTION SYSTEM DETAIL 1 GRAVELLESS LEACHING UNIT
Project Name: Ronald & Kathryn Smith
Gravelless Leaching Unit Specifications
Manufacturer Model Laying Length EISA Rating
FZ120?1-1-Eh j E 0' 250
Infil:ratc•
EZ12c31H-10f. .0 01 50 0
System Sizing
EISA Rating per Foot of EZ Flow 5 ft` Soil Application Rate 0.7 gpdift'
450.0 9pd resign Floc; = 0.7 Soil Application Rate _ F-5 ] EISA = 128.6 Feet of EZ Flow
2-
trenches 45 fe t long each
<j L1
3 No. of Cells X4.5 Per Cell 69
3 n Cell Width 3) 15l Total No of 1203H
45 ft Cell Length 225 sq It EISA Per Cell
3 it Cell Spacing 675 sq ft Total EISA
Typical Cross Section
Finished Grade 96 ft Observation Pipe with
approved cap or vent
Soil Backfill
36 inch a Geotextile Fabric
o ■
12 inch II II MO I Slotted and Anchored Vent/Observation Pipe
with Cap
\ 89.00 It Infiltrative Surface
>36 inch
86.OOft
. .
Plumber/Designer Signature:
License MPRS 223760 Date. April 25, 2016
Page 6
Installation Instructions for EZ owTM
EZ;flo Systems in Wisconsin by1NFILTRATOR
'viscorsin Dep=,rtrrert c Commerce, Safety aid Buildings : E. Tr-e AbsorpbDfi area (SF) rece~:s.ry for a give- si,e shall
Divsior, has revie,,ved the specificatic-s and%or clans for th s be s zed based on maximum daily sewage flew (GPD) and
product arc determines t to be in compliance with chapters ; -he PermeabJit, fcr the site. If cerain criteria is me.. the
Gomm 82 throigr 84, W scorsin Adrni,~. Code, anc Chapters FISA sizing car be used in Wisconsir, resulting in a 40%
145 anc 160, WViscons n Statutes. Al sites must meet t.-e Site smaller d,ainfield,
& Soil Conditions & Locations & Isola_ti_or_ distances as nosed in
local regulations. 5. Place EZflow bundle(s) in the EZf ow configuration ap-
prcved by system des gn pe,m't specified for the particu-
The approved products are 1203H (3-12' bundles with pipe in lar six, Trc top or center-most bircles cortain'ng pipe
center bundle it o' or 10' lengths; and 1203HP (3-12" bundles are je ned end to end i,, th an internal oipe coupler. Ary
vJ-h pipe in each buncle i- 5' or 10 lengths. adcitienal aggregate only burdles that may be required,
should be outtee against tre other aggregate-only bun-
.4 single pipe bundle co-tams a four inch perforates pipe su - dies anc do rot regjire any tyoe of connection,
rourded by LIPS aggregate anc is held togcthe- witf poly-
ehrdlene retting. A s'ngle aggregate bundle conta ns aggregate : 7. The top of each SEC cylinde, contains a filter faor c pre-
only and is helc togethe-,vith polyet'rvlene ne`.6ng. manufactured in between the re.ting anc aggregate. The
fab,ic is nserted to prever- sor intrusion. The installer
Materials and Equipment Needed shall make sure the the GEC is pcs~tiicned upward and is
• EZf o,,,; B:,rdIF= ; in contac*, with the fabric cortained in the adjacent cylin-
• EZflow Geotextde Fabric ; der before bacKfilling.
• EZflow Internal Pipe Cor.plers ;
• P pe for Heade- and Inlet 8 The EZf'ow Drainfield Svstems should be installed in a
• BackhaaiExca:atnr level trench in all directions (both across and along the
trench bottom) and should follow the contour of the ground
Installation Instructions ; surface elevation (uniform depth). with all continuous
The ins-ruc-ons for ins-aliation of LZfoN,,; products a -c giver adjoining 10--cot cy'incrical bundles placed end to end,
below. Tris product must be insta lec in accordance wish state v i-h centra' bundle d stribut on pipe irtercornected,
rules defined i- chapters Comm 82 trirough 84, Wisconsin Ad- without ary cams, stepdor.•ans or other water stops.
ministrative Coce. anc Chapters 145 and 160, Wisconsir Stat-
ues, as well as the Iota' health depa-tmen.'s cirrert ccsigr 9 T-re trerch top s'-all be graded such that water vvil not
manual. : pond, Backf ll should be seeded or sodded immediately
after completion to reduce erosion.
1. After the local health department has determined sizing,
confguratior, and layo-t for the EZfow systems, stake 10. EZflow EPS bundles are flexible and car fit in curved
or marK with pain- -he location of trenches and lines. Be trenches as rray be necessary -o avo,d trees, boulders, or
areful to set correct tank, irrvec pipe, header line or dis- other obstacles.
t- bution box and trench bottom elevations before instal-
at c- o~ p pe bundles. 1. FPS aggregate is lighter than water, therefore, it migh.
he expected that natural bucyanq forces would tend to
2 Ec r io,. e plash:: EZflow sh pp ng bags p- or x placing cause EZflow assemblies to f oat out of ground when
nJie i- e trer::Hes). Remove any p astic bags in -he poneino occurs. Field experience has shown, however.
to lr tle'("r = -.=tom is covered. -hat this is ro- a prob em N,vhen systems have a minim_im
• c' 6" o` soil cc,/er as reccr-merdec b`; rranufacturer.
. •
J Trrs produc n r,s- nave geotex,ile fabric that meet: re-
cuiremerts o= s. Comm 84.30 15) (g), ,'Wis. Adm.:;oce.
rs-alled directly on top of -he product and extencing 1203H-GEO
:mvn along the sides of the product to a poirt at least six
inches from -he bcttorr o' product.
4. WI-en installed in a trench. -he trench shou d be dug to _
a v.,idth of 36 inches. This not only saves labor it excava-
tion, bus also provisos bc-ter'oac-bearing cap ad-,'Y after
backfilling is complete.
Page 7
POWTS OWNER'S MANUAL & MANAGEMENT PLAN
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Ronald & Kathryn Si Tank Manufacturer: Wieser Concrete ] NA
Pemtit * , Septic ] Dose CHolding Volume 1000 gal
DESIGN PARAMETERS Tank Manufacturer: Wieser Concrete NA
Number o' Bedrooms 3 L NA. ❑ Septic ] Dose ❑ lolding Volume: gal
Ni of Public Facility Urits: NA. Vertical Distance Tank Bottom(s) to Service Pad ft
Estirr-ated (average) Flow 300 galday Horizontal Distance Tanl l to Serivice Pad: ft
Design Flow = estimated x 1.5: 450 gavday Sppcitir servlrinq merhan rn mAst he provide rr v!In¢::¢I is-1e lI d
In Situ Soli Application Rate: C.7 ga ldav,ft2 hrrz7r- s > feet Specfc nstn^tions t^ he 3rerdedn-i hrr,
Standard Domestic InfluentlEffluent Monthly average Effluent Filter Nlanufal POLYLOK L NA
Fars, O & I s30 item Effluent Filter Model: 515
Biachem cal Oxygen Cemand (60:)s) s22(l L NA Pump anu actu'er:
Total St speeded Solos (TSS) 51 Kn-g,L Pump Mcde -
High Strength InfluentJEffluent Monthly average Pe.reatrient Unit L NA
Fats. Oils & Grease (FOG; 53C rr,q+L Aganufa urer:
Biochem,cal Oxygen Demand (1300s) s220mg L L NA ❑ 10.0ilrieat Awal ❑ Peat amine'
Total Suspended So As (TSS) 5150mgiL nisinrection 71 Wetlaru
Petreated Effluent Monthly average ssnn; aye ~iuer ] ocrc
Biochem ral Oxygen Demand (BODS) 530ri of sor t Crt ystem
Tctal Suspended Solids ;TSS) <3)l C NA :1-31 Cara tit In- i c d re e
Fecal Coliform (geometric mean] s1 J4cfu/100m1 ] At-Grade ] %Urld
Maximum Effluent Particle Size: Y. in dia. L_JNA ] onp-_i,e ❑ n: e
U;her: Othe-: L NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
When combined with nudge and scum equals one-third ,'h) of tank volume
Pump out contents of tank(s) When the high water alarrr is activated
Inspect condition o` tank{sj At least once every: 3 monthisl (Maximun 3 Years) ❑ NA
st once every: 1.5 5 110fitl'I'I Maximun 3 Years ❑ NA
Inspect dispersal celbs) ry. L .rar
Clean effluent filter At least once every: 1.5 NA
ar ti
"°"tfI''I ❑
Inspect pomp, pump controls & alarm At least once every: NA
j_ ear s
monthl• I ❑ NA
ear's'
monthl_I NA
ean's'
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an r dual :.arryirg ore of the fc9owiny licenses cr certil bons master
P umber Master Plumber Pestricted Sewer POWTS Irseoectol PO1N-S Maintainer: Septage Servicing Cperator (pumper; Tank
nspectiors must include a visual inspection of the tank(s) to dentify any missing or broken hardware. identify any cracKs or leaks,
measure the volume of ccmbmed sludge and scurn and a check for any back uo or pording of effluent on ground surface The
dispersal cells} shall be visually inspected to check the ef`luert levels in the observation pipes and to check for any pondmg of effluent
on the ground st.lace. The pondmg of eff cent ci she grOr.nd surface may indicatec a failing conditic•i and requires the irr•neciate,
notification of the local regulatory autnority.
When the combined addunn ion of sludge and scum in any treatmem lark equn s one-!hind (YS) or more of the tans volume, the entire
contents of the tank shall be removed by a Seotace Servicing Operator and disposed of in accordance with chapter NR 113. Wisconsin
Admininlstrative Code.
Al other services. including but i limited to the servicing of effluent filters, rrecnanical or p•essurzed components, betreatment units,
and any servicing at ntervals of 512 months, shall be performed by a :ertlied PO`+'dTS Maintainer.
A. service repel shall be provided to the local regulatory authority w th n 30 days of completion of any service evert
Page 8
page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products. solvents or other
chemicals or sediment that may impede the treatment process and/or damage the so-l discersal cell(s). If high concentrations are
detected have the contents of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During extended power outages pump tanks may fill above rormal highwater levels. When power is restored the excess wastewater will
be discharged to the disoersal cell(si in one large dose and may overload them esul:ing in the backup or surface discharge of effluent.
To avoia 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
I
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 so I absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance arc prolong the life of the POWTS:
antibiotics; baby wipes; cigarette butts, condoms, cottor swabs; degreasers; dental floss; diapers, disinfectants fat, foundation drain
(sump pump) discharge; fruit and vegetable peelings: gasoline; grease; herbicides; meat scraps medications; oil: painting products;
pesticides; sanitary napkins tampons, and water softener brine.
ABANDONMENT
When the POWTS fails and/or is permanently taken ou: cf service the following steps shall be taken to insure t'nat the system is ,=erly and safely
abandoned in comp) ance with chapter Comm 83.33, Wisconsin Administrative Code
• All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed.
• The contents of al. 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 wish sod,
gravel or another inert solid material
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide the opportunity to obtain a sanitary permit for
a code compliant replacement system
❑ A suitable replacement area has oeen evaluated and may be utilized for the locat on of a replacement soil absorption system.
T,ie 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 evalua:ion to establish a suitable replacement area. Repiacemen: systems must comply with the rules 'r effect at the t me of their
permit issuance
❑ A suitable replacement area is not available due to setback and/or soil limitations If the soil absopition system cannot be
rehabi itated and barring advances in POWTS technology, a holding tank may be installed as a last resort.
The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation
must be performed to ocate 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.
❑ Mourd and at-grade soil absorption systems may be reconstructed in place following removal of the ciomat at the infiltrative
surface. Reconstructions of such systems must comply with the rules in effect at that time.
WARNING: TREATMENT TANKS AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES AND LACK SUFFICIENT
OXYGEN TO SUPPORT LIFE. NEVER ENTER A TREATMENT TANK OR HOLDING TANK UNDER ANY
r CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK IS VERY DIFFICULT.
ADDITIONAL INFORMATION:
POWTS INSTALLER POWTS MAINTAINER
Na" Johr Schmitt Nara, John Scimitt
~)horc 715-750-0485 Pnore 715-760-0486
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Na•re Owners Cho;ce Name' St C'oix CoLn,.y Zoning
Phone. Phone: 7'5-386-4680
This document is intended to meet minimum requ remen:s o` Ch. Comm 83.22{2)i,b)(1)(d)&(f) and 83.54(1), (2) & 1;31, Wisconsin Administrative Code.
Use of this document does not guarantee the pe formance of the POWTS.
PaSew 4,cs)
ST. CROiX COUNTY
SEPTIC "DANK MAINTENANCE AGREEMENT
AND
OkVNERSHIP CERTIFICATION FOR\4
0W11,r/B,,y;et. Ronald & Kathryn Smith
Mailing Address 385 Brookwood Drive
Property AddreSy 385 Brookwood Drive
(VC1 ifiCA011 required from planning &c Zoning Depanment for new cons-.ruction.)
CityiStdic Hudson, WI Parcel Identification Number. 020-1119-30-000
LEGAL DESCRIPTION
Property Location NE NE " 4 , Sec 17 T 29 N R 19 W, Town of Hudson
Subdivision Plat: Trout Brook Woods Lot i-4 7
Certified Survey Map # VOILtinc Page #
'Warranty Deed # - (before 200 7 )Volume Page #
Spec house ❑yesEbo Lot lines identifiable ❑yes0no
SVSTEINI :MAINTENANCE AND O«'NER CERTIFICATION
Improper use and maintenance of your ~cptic sy,.cri cnuld recta in its hrcnuiture failnrc- to handle a~-'.es. 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
rcNponsibilities arc specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property oa ncr agrees to submit to St. Croix County Planning R Zoning Department a certification form, signed by the
o" tier and by a master plurnbrx. journeyman plumber, restricted plumber or a licensed pumper verifying than ( I ) the on-site
wastewater disposal system is in proper operating condition andior (2) after inspection and pumping (if necessary), the septic tank is
less than 113 full of sludge.
liwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources,
State of Wisconsin. Certification stating that your septic system has been maintained rrrtrst be completed ar.d returned to the St. Croix
County Planning K Zoning Department within 30 days of the three year expiration date.
irwe certify that all statements on this form are true to the best of my/our knowledgc. live anu'are the owner(s) oft he
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms 3
SIGNATyyyvVVURE OF APPLICANT(S) DATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.
Inclt:de with this application a recorded warranty deed from the Register of Deeds Office and a copy of the ce: tified survey_ map if
reference is made in the warrant} deed.
(REV. (14!12)
Page 10
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DEPAR b OF REPORT ON SOIL BORINGS AND SAFETY & B DIVISI
INDUS INDUSTRY Y DIVISION
N
LABOR AND PERCOLATION TESTS (11~y ' xAMS~'i B° 53707
HUMAN RE"4TIONS
(H63.09(11 & Chapter 145.0451 ~j
IO 'n F.:
=AOII`JTV• CT-0N- ATI'NJ' ,2W H P,,'[, rdICIPA' 1 1 . RI K
1/1 ~41"' 6 /T 9 N/R=OE lo;, t±~ v.c ^s 6 /moo vy
Ok'At ' Rt: FP'S NAME MAIL Nei -A DD ROSS:
-il 1/rE,?C GCTc 2 z 'Pe0
USE OA SERVATIOASI
IND. B COMrn EA . A S .R TION: ~Mpr' A E TS:
~esidz~ca i ~ ~ ~ ~~New ❑Replace I ~,t , '
5'CS I
RATING: S= Site utitable for system U= Site unsui to ole for system Tvp sn fT
CONvE`l' ONAI: MOUND. IN-GRUUN;i S "STEM - - ILLHOLDING TTAA%K:RECOMMENOEO SYSTEM. ioptiona0 r
~ S❑ U ❑ S EU ES [U S❑ U C S E X I I C'ovc urvti ai U P,~p"u . S e. /y x 7y
SuPf ~f£ !tl- r _
I P r,v +tion Tests are NOT-1 uirad DESIGN RATE i ! If r; P - the teet•d a•ea is in the N
order s.Nn3.(K!;SY151, ,rdicate' F ndn rn.f care rloodplafn a e+rotwr, r~
Mf PROFILE DESCRIPTIONS
RORINGI TOTAL DEPTH TO GF U ^'NATEP-IN' ' CHARACTER OF SOIL d/ITH THICKNESS. COLOR. TEXTURE, AND DEPTH
I NUMBER DEPTH ELEVATICti OBSERVE D HEST TO BEDROCK IF OBSERVED ISEE ABBRV. ON VXK.1
4v~niF :&V /,.5 uc, rl' R'. is-S
- r /"I,,' ZY/_1/„ GS 7S'G77%~r 51 67i~ c,P..'S
B- 2 y
, Yb Ar1 >/o, o tf w; + 2otS'
~f ? vEj' s
L5, e",F /3,V SL, •SS~~ ~'%s'!/ %h C' ,S •Sr
dv 5-/ w {c ok m0f-c rr S4vP Cc, At,
i~0 17/ ~Z y i 3'dJ-Gr G33" ~r~. /,r:
13-
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PERCOLATION TESTS "tr
T FS_ DEPTl V:4-FR IN HOLE IESI WA UPOP INWATLR LEVEL-IWHIS HAPL%SINUTES
NUMBER IN. r, AFTER 3V'E_LIV? i%TEPVAI -fv11N o P- 2 p _ PER IN;'7H
13
~ i -
12-
r-
PLOT PLAN: Srtusv locations of uarculat Dn test;, soil horings and the r'imersions of suitable :oil areas. Indicate scale or distances. Describe what aru tlia hurl
zonal anc v2,ti^3l clcvatinr rc'erenca pd its and shorn their location on the plot plan. Show the surface elevation at a I borings and the direction and percent
of la nd sepc_
%-;-7 i 0 1 Oc Bi. C t:.~c'~f1.'3 Tfr~ %"c ~~t :9 i'71 ~/D• t; rr
SYSTEM ELEVATION '.'4 7 le 4) 6,c- 17y
4 L..,,t y'. Z- l.Y
t. v
Vltrw~t d.-,__ ,
f S lN~ ✓~c~L ~T~ST" i
_,i1P1'fcx11.,7fli "s~t L?t'!Clva[ To wAs CvT
1 J1 r / /'o
LO(C Al SL-C' J f Q tJ avu-
5 ~JC;T/o U 1Ch4 S !7e !G co t£ caJt LJ 1901P7 T ~i
i rw0` '0/0 6 Lr
v /It _ U f~C 711!r ~fL~-tt ;k741f✓ SD/L t t' S'T
4p/,0,gL, 7£E 7, o,f NdGrr z e) 7- M6-7- piA;;A,oti•l
~oiJE S 0,~ ' ~t1. S~ f1/-9 Tf . DT A rO.tt L'E tt T"/02` ~ E~T1 C S'` "re A-? 4c, r-f ~c r
/U70 ~'~~b'/~ ~.,'!Ar>Q.U,. _ Df~ .~!L rnr-7f~-2 G~~f{rf.JJl d r
l6' Rt TLii!rYt h` r'l tl r - 12
" = - 1 ±r, s/o~F 4J~F S i4 t rr E' G~
1, ;•ie urdersignod, herabv oert0y that the soil tests topur tad on I'm `urn Nare rnaide by me in acourd with tha procedure; arD net'h--pest floc in the .!'iscu n;i~
Administrative Cude• a,iJ that th•e~- cant,. recorded and the loc_atior of the tests ire correct to the best of rrty knowlenge end xlic'.
hi ,y~-'- E TT • L c
NAME lurint : TENS 0JERE COMPLE-EC 0".
f.DDRESU: `t CEPTIFI :ATION NI_JmacR: 1?HONE N'Ur,.1 ,R,ERlops hen I
w•. .t wiiJ. v.%:iJ CST SIGNATURE:
wr:ur~,e TEST co.vp.rotis S~~vu yr
DISTRini mnN- n . o Ln^al au;^nnty, 4nner•y Own=r and Sn-I Te.•rr. G
7. F S FR A10 14~005 7- -Q IC /Z-
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AS BU IL f :;AN 1'I'ARY Sy'; I LM RI.VOR I
tJ7QA~~~ ~ r
~`~W vl~~e Q O W N 1111 If!.a SLC lT N-It OW rd r:l< pp p
AD1)t( l:tia tkU1X IUUN't'Y, W15lUNS1N
L'lill I V I I~)V ~F'', R'3C,[ I.U'1' LOT 51LL'
III nN VIEW
1)IsLa[Icu6 au~i dIIIIL.:LL Jto IL S L0 lilt: ct iuyuirumuuLs kit' 1163
,;UUW E'VEKYTHLNG WITHIN IUU FELT O ~iY~,"LM
I
I ,
I, ~Ii. iL N )r h rr~ w
t
BENCHMARK. (Yerillallunt rulururnt•c Voiut) Huscribb1e:
Lievatlon of vyrL [cat rul-arum L• fi44111C • ~lopu aL bILu
SEPTIC TANK: ManuJaCLUrut: r~SKw.'~T~a~.-~Uiyuid CapaeiLy:_ /0 - - Number of r1uF,6 kill cuvur j f'I'ailk- maliholia c:uver elevaLiun:
Y'an-k Ii I l K I c vat luiI ~U. Tuuk Uutlut_l levatluu:
PUMP CHAMBER IVA-
NlallutauLuLul. : Nuiuber of ballona
Number of gal. bump aet for a c:yclc ~allu[is; '1'utal capacity Of
(Ilbtributloba L Hies gal tun: size. of pump- _ liuad; r,,allun per wtnutu hurbupuwur ;brand name of pump
Lind u►udul number
type of war[r:ir►g device _ _ _ _
HOLDING TANK: Mal[ulal LurutA ~ Nulllber of gallons
EIevaLtun oi- manho)e cover Type ut warning dui ice - - - '
--Nuu,bur of tcet diameter lue~'. id depL11 seeTage piL iulel pipe-elevation
I utCuui kit scupal;u lit ulcvatiuu _ feet. s r/
SLEPAC; BED S]ZL: uwiber ul LInes- widtb~ `lenbCb ile dept
_ Af4 imOm AfrFf CurTiJG- SLLYAGL•' TREN,A; width _ leug[-h
_ 11LItCULATION (A'Tl:_h? ICliA 1cLl~UIRLUGi~} AREA AS BUIL`I'6 30
~,~c~s• Ns l'l:t: rl;Il
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DEPARTMENT OFF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
@ABOR & HI.IMAN RL`LATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7.969 BUREAU OF PLUMBING
MADISON, WI 5:3707
CONVENTIONAL ❑ALTERNATIVE sl~laP_,LD v mix,
n1 a„Ip~IVJI
Holdlnq Tank In-Ground Pressure Ll Mound
rJaM1 ~I* PFI: MIT 11111 FFH
~CCHESS :F P, Rtd1T NOLGEH INSPECTION D:11E
Evan Vienegge R42, Box 91A, Hudson, W7
-
Lll H MaH•:. IF. .~nI ,.1 4„. i, liE SP: iFF IF I, F: c.:i :
. T FHCI:I FL.4f. REF PT EIEV T•1 HEt F1 _L.
NE SE,Sec.18, T291N-R20W, Lo.t#7,Tltou.tBA.o0k,` Town o~ Hudson
u,.,l..a \iP HVHj:\r . I1.- ,
R•ichahd Hopkins 1059 S~. cto.ix 49416
SEPTIC TANK/HOLDING TANK:
MANLI 11P I,: I:, I:APACITY _ANK Ir.I F_ EI F: I-ANK FIIITI =T ELF'V IS'a RNINL: LAHF1 LOCKING C'CVLH
FH IJI IF I, !'-'I
V JlL
U ~t 5 (9"L c / YEs s NO YES -NO
BEUUIhI_ vent U,14 VV A NUMBER 'F Ronc: -iPROPER 4ELL BI_IL~II N1, ~VFr.T TO P3=;H
a.l aVtM1' Lln A19 INI ET
FEET
S - NC 61 _ _ JYES F-INO NEAREST- /L f
DOSING HAMBER:
II 1,'a`J.1=.:i:11 HFi BECL'INC, : ;17i PUIlP MODEL P'J tv SI'HFiN INAFNING LABE.. LOCKING COVER
PROVIDED PROVIDEC'.
-:]f~,,, ❑YES CINU i ~JVFS LINO YES -N0
GALLONS PER CYCLE. P PI 7P r+IFs'uL ;;PLRAIIONAL NUMBER O~F v rn•u+rv tveL_ R., 1 In;: 'RENT roFRES
IDIFFERENCE BETWEEN Zk'h FE ET FROM v1 IR INLEr
PUMP ON AND OFF) YES ❑NO NEAREST
-Ti A V
SOIL ABSORPTION SYSTEMCh esole o'stureat the depth of plowing H Fred- [IA'LPIALAnC%+ARKINts
Or rxcava'lun. {If ,nil can tie rolled into a wire, Construction shall cease until FFOFCE the
soil s hrv' encigh to continue.} V
CONVENTIONAL SYSTEM:
';+II_li~l -r~F-^.~~ti1 r.C I'I DIS~R FIP: sP ACIN~~, ~-'1',~I_ - ivI L1L L;IA ft Vll:i I In1/1D
BED/TRENCH HLr,:,ne, i tJfl ` PIT aFPTH
DIMENSIONS /_2
(JF 'F. I1F=-'1 ItI (IFHT/ I`TII III'I_ r,157F PIPF MATFF•IAI_ N I• NUMBER OF PFC'PERT'i (SELL Bl.'ILDI`JG '.EVT T1, FRESH
EEI - C' N 1 F. 1 r•:771) a Llr. y.~ f l R I L-
FEET FROM 3'~
. ~ ~ NEAREST 2P MOUND SYSTEM:
Mound s.te plowed perpendicular to slope Check the texture of th fill material f PROVIDE A DIAGRAM OFSYSTEM
and furrows thrownupslope' mound systems to J31-d e~certdin tl it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria foi ed lm sand' TIONS MEASURED.
DYES ONO
SOIL COVER TExrIJHE i A" -,TV
~Y S uG .L ivalrJ>J :vI I1.
-NO ❑YES ONO
I)III I T;iFN<Ii HFn 19,1, ::vi 11 TfiFN(F- RIT I (JEV-H,)F T")F II F:iFF ? `OFF I'.F F:' MJLCHFD
C~YI S L NO F IYtS LINO OYES CNO
PRESSURIZED DISTRIBUTION SYSTEM:
0.IUIIi iL Fr., Tl. NO. OF LA t EHAL SPACIM1G -;RA•✓ELU PTF- HzL^V:v F L_ DEPTH ABOVE I'O'v F•
BED/TRENCH 1HLNC11 S
DIMENSIONS
MANIFOL-I PIMP IAANIF1-11 -1 DISTR PIP/NO n MA Ii )STNIBJTION PIPE FA i.I-FFV EI Ev FAA E_EVFIPELEVATION AND
DISTRIBUTION
INFORMATION 'il_/E VA`IUL_U VLR MA II AL vERTICAL UF-CaRRESVONDS'o APPROVED
PLANS
CJYE nYES NO
COMMENTS: PERMANENT MARKERS oesERVA-or. WEL _s: NUMBER OF YHUPCI+TY fFt L Rllll DING.-.
_ FEET FROM I INF I
_ YES NO -YtS /No NEAREST 1
Sketch System cr R in in county file for- audit.
Reverse S de. -
SI~^J!i TITI F
DILHn SBD67'C IR. 01;821
APPLICATION FOR SANITARY PERMIT
~ DILHR COUNTY
(PLB 67) HNIFORM SANITARY PERMIT #
Ir1C111 ;TRV. I FPC1F HUTG'l 4ELFTOnS ~ ~ I
-Attach complete plans in accurd edit- s. H 63.05, Wis. Adm. Code for the Iysem, on paper riot less than 8'.2x 11 inches in size.
See reverse side for instructions for completing ,his application. PLEASE PRINT
PROPERTY OYdNER//. MAI ING A-7DRESS
T
t1 4/ 2
PR PERTY LOCATION (7 Or v G!~ S
1/ L 1/4, S T.~ `l N, R 22) It (or) W TO u
I OT NUMBER BLOCK NUMBER SUBDIVISION NAME VyROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
"I rr46 / O /DQ Gli ^ /i/~
7 !i r
TYPE OF BUILDING OR USE SERVED
~1 or 2 Family Numbe- of Becroorns. [J Public (Specify):
THIS PERMIT IS FOR A:
X New System _ Tank Replacement L Repair
Replacement Su I AusurpLun System Revision L. Privy
Alternate System L- Reconnectinn F-1 Petition for ,Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK
Seeuaye Bcd C-I Seepage Trench U Seepage Pit Holding Tank
System-In-Fill L_-1 In-Ground Pressure J Vault Privy Pit Privy
Existing, For Which A Previous Permit lb On File, Permit #o~ issUeo
_ An Existing System That Has Been Inspected And Is Compl~ant As Far As Snil Conditions. 1114
Tota #of Prefab. Sul.
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tark Capacity Ll
Lib Pump Tark,Siphon Chamber
Holcing Tank capacity
Manufacturer: yj~ L
IF THIS IS AN ALTERNATIVE SYSTEI'd COMPLETE THIS BLOCK: Mound -11In Ground Pressure
Total #o' i ab v Site.
Gallons Tanks Cencre.e Constructed Steel F berg ass Plastic
Septic Tank Capacity
Lift PumprSiphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AFEA V,jATER SUPPLY:
IP,9isper inch): PEQUIRED l9qu.:re Feeti 'ROPOSEU l5qurae Feetl:
I' ~ / 51 i ;-I_ L u Private - Joint ~ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
NaX/ f Plunni (Pr nr)S gnat MPRSW No. Phone Number:
e_ X 4 f c C /Sr y6 ~y
Plumber's AAddress: / / S Naar • rf Design.
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent re,- Dale-
Disapproved
-1 Owner Given Initial
Approved Adverse Determination
4 X Reason for Disapproval
Alternate cou-se(s) o- Action Availab e:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: O-iginal to County, One Copy To; Bureau of Plumbing, Owner. Plumber