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040-1312-02-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 592180 GENERAL INFORMATION 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 Township Parcel Tax No: Dennis & Kelly St. Aubin TOWN OF TROY 040-1312-02-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: f 04.28.19.2032 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER J CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer r ~-J,t. 0 Holding St/Ht Inlet r' TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet y Septic Dt Bottom a I Dosing Header/Man. Aeration Dist. Pipe Holding - Bot. System r PUMP/SIPHON INFORMATION Final Grade Manufacturer Demand St Cover . GPM Model Number ~J i t0 TDH Lift Friction Lo System Head TDH a Ft Forcemain Length Dia. Dist. to Well ! /t SOIL ABSORPTION SYSTEM ~l BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS . ' SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of System: CHAMBER OR . , UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold, Distribution x Hole Size ` x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia -Spacing _ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only i" - - Depth Over Depth Over xx Depth of Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil T 1;j Yes No F] Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 516 EDIE CT h - , 1.) Alt BM Description = k I 2.) Bldg sewer length = / A V - amount of cover = J t f Q p" p Plan revision Required? `O Yes U No + ! Use other side for additional inf6rmation.3.J SBD-6710 (R.3/97) Date Inse or's Si ture Cert. No. ~FS•xTar~ r ww County C; I _ Safety and Buildings Division 201 W. Washington Ave., P.O. Box 7162 Sanitar} Permit Number (to be filled in by Co.) T p.F pS Madison, WI 53707- 7162 g G/ / L A State Transaction Number J t Sanitary Permit Applica In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to me applvy....... is required prior to obtaining a sanitary permit Note: Application forts for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04(1)(m), Slats. l_ L Application Information - Please Print All Information C Property Owner's Name Parcel # Property Owner's Mailing Address Property Location vq j 9 Q0 3.-)- .,t (k Govt. Lot City, State Zip Code Phone Number Aj ~V 1/a' 5 y<, Section ? Z p (circle one) II. Type of Building (check all that apply) Lot # ❑ 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name d~ Block# 67 ~ F~f G tc~46 ❑ Public/Commercial - Describe Use ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Villa--e of 4Nb I✓ ~•z ZZ G Town of G~ tZ III. Type of Permit: (Check onl one box on line A. Complete line B if applicable) A. New System El Replacement System El TreatmentlHolding Tani: Replacement Only ❑ Other Modification to Existing System (explain) List Previous Permit Number and Date Issued B. ❑ Permit Renewal Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New Before Expiration Owner IV. Type of POWTS System/Component/Device: Check all that apply) 14 Non-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: Design Flow (gpd) esign Soil Application Rate(gpdsf}~ Dispersal Area Required (sf) Dispersal Area Propos d (sf) System Elevation \ 7_~ VL Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units U v New Tanks Existing Tanks ar E Septic or Holding Tank 4 Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's ignature MP/A946 Number Business Phone Number Plumber's dress (Street, City, State, Zip Code) 1 1 ~/c' P VIII. County/De artment Use Only ❑ Approved ❑ Disapproved Permit Fee Date ued Issuing nt Signature ❑ Owner Given Reason for Denial IX. Condi lgh4pVNEhWeasons for Disapproval 7. ,Sepbi tank, eifltx;n: ilte- <<nd diwl'ems,i cell must all be s r ic-mss?r)ainte`r:ec As per rrlaragement plan p: o rider) by plumbef. Z -AW a ldcrac{tllreraens mtr t,k,o ri intzired as per rVp1 0* rode / ,:rdinanaes Attach to complete plans for the system and submit to the County only on paper not less than 8 1n 1 11 inches in size SBD-6398 (R. 11/11) >t ©A✓/q`S~ C11 CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Owner's Name: Owner's Address: / Z •4 Vf7 Legal Description: N Q) L'l1 f JL 1-e ! Township: ~d y County: GPL.OJ'L Subdivision Name: G©Y/~--O er Lot Number: Parcel ID Number: © °Z ! Q4e,~) "w- Page 1 Index and title SEI (G A) Page 2 Plot Plan t l QE~Ic~~ LJi%]tk/~t~ CPage 3 System Sizing & Cross-Section (Z ~G~P f ~}itJ K Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber: License Number: J~ z7- Date: Phone Number ~l'✓~ ~l 5~f S Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 County is • o fro Safety and Buildings ulvision G'2~ p ni W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) R Madison, WI 53707-7162 D lONil State Transaction Number Sanitary Permit Application in accordance with SPS 383.21(2), Wis. Aden Code, submission of this form to the appropriate governmental unit regitrttl.prior,tta c;htaiaing a sanitary permit Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) e,f~3r~ardm06t 4Safe~ ant] ~~ofessional Servies. Personal information you provide may be used for secondary purposes in accor~arice with'tiie'Privac Law, s. 15.04 1 m „Stats. L Application Information - Please Print All Information Parcel # Property Owner's Name ~J Property Location t 2 Property Owner's Mailing Address (J,J 8 'r U& Govt. Lot Zip Code Phone Number -i / Section City, State gf' (circle one) II. Type of Building (check all that apply) LSubdivision Name 1 or 2 Family Dwelling - Number of Bedrooms Block #C~-~1 ❑ Public/Commercial - Describe Use `0 4 ❑ City of CSM Number ❑ Village of ❑ State Owned - Describe Use Town of T O 2 t✓ ZZeZZ G III. Type of Permit: (Check only one box n line A. Complete line B if applicable) d A. Xew System L1 Replacement System 11 Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) ❑ Permit Transfer to New List Previous Permit Number and Date Issued B. ❑ Permit Renewal Q Permit Revision ❑ Change of Plumber Before Expiration Owner t!/ r N. Type of POWTS System/Component/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 soi El Holding Tank 11 Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treat ent Area Information: Desi Flow (gpd) Design Soil Application Rate(gpds Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation, CJ~c1' rJ- VI. Tank Info Capacity in Total # of Manufacturer ` Gallons Gallons Units U U Un s, E o New Tanks Existing Tanks 'C[V()/ ~ y1 o ;3 2 ~ .n cc cd (J a. U v~ h cn w C7 c. 01 Septic or Holding Tank Dosing Chamber VII. Responsibility Statement- I, the undersign ssume responsibility for installah of the POWTS shown on the attached plans. Plumber's Name (Print) P~ ber's Signature MP/I Number Business Phone Number 2- 7:3 ~Pl ber ddress (Street, City, State, Zip Code) oun /De artment Use Onl Permit Fee Date,Asue j Issuing em Signature/ Approved ❑ $ - er Given Reason for Denial IX Condit easons for Disapproval I M /tee f ~ ' --'~ptu~ ~ltllts5rm tilte* 2nek ~ ~ vc+ • ~s7 tiiYp6mi cell must all be srRicb s ! m7ynt_±rec' aspef r0nagement plan provided by plumber. 79114 b c;k rex ijrertents must t o maintz in d as Per a wlicable God: / .'rdinance3. Attach to complete plans for the system and submit to the County only on paper not less than 8 lrz z 11 inches in size SBD-6398 (R. 11/11) plot plan v _ Properly fawner le a s J< t--LL)( -STA ug A/ I"-40ft Legal Description z, CM ,,ACO5{AJ 4xC,ej!t where note of -r~~ sw~ - • ~"{T~4 , R fritx i 'TOtyS~ 9Z s~ El = Backhae pit Ct:CiX ~C WI~CD . 0 kelmi .North S l Lx. Cl Iv 6' Y ASP i 1 \ Tj) 'Z~ FOI^^ DR~NF,ELp \ Site Location: ' J 5 cS VV ~ ~~i J; icy I- or 2- Family Dwelling In-ground Soil Absorption System (2-cell Conventional) Daily Wastewater Flow (DWF) _ # of bedrooms x 150 gal/day/bedroom = 60 gal/day Design Loading Rate (DLR) or Soil Application Rate = gpd/ft2 (per SPS Table 383.444-1, 2, or 3) Required Distribution cell area = DWF gal/day = DLR gpd/ftz ftz # Chambers = Required Distribution cell area ftz _ a ft2/ unit EISA = _7- . Chambers Chamber Manufacturer and Model: t1 r T1~ 2 Q t L IC / f zu S Actual Distribution cell area = Required cell area V ftZ + ft2/ unit EISA End Cap Pair= Cross-Section In-ground Soil Absorption System (2-cell): c'( C~,iu ACS 4" Schedule 40 PVC f~ vent pipe with vent cap ~I 12 inches minimum 12 inches minimum i i z; inches Soil Cover Trench 1 Sys- tem Elevation inch Chamber Height l' II ~Mt Trench 2 System I' Elevation 4~-- ft _ ~ft Trench Separation Leaching Chamber Width ~ Ir ~~ft to limiting factor Plan View In-ground Soil Absorption System (2-cell): Trench 1 ~ Modify ft header/ design as ft ~ Leaching Chambers 14 ~ needed. Trench 2 4 inch Header Sch. . 3& ft with end camps Draw 0 for a Vent and 0 for Observat ion Pipe above. They will be located 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 Plot Plan Property Owner Dwvis s r. USuJ 1~=4Qf~ Legal Description l 'of z~ Cc~rq AACDAC016 (except where note . d) Backhoe pit CP,C()f tOOLVVY W~ScD , J.0 4etmi o ,3lz-M--M North m\ e N 'F4 fJ 1-4 SU- kT v, L. 'To ~p 5 FRp ~ Z N ;r-o pR~ Site Location: It h1 ~ aX jfr Combination SepCa.c; Tank and j Z PUMP CHAMBER CK055 SECT10KI AMD SPECIFICATf0~1S WCATHE yE1JT CAP. K PI(o0F • JUJJCTIOQ 5OX ti'C.I. VENT PIPC APPROVCD LOCKIM(; hSAJJHOLE COYER r1-1l '-I0' FROM DOOIL, yuAR~JIlJG LP.6EL. ; woow OR FRCSH S c~~u~r ~r~sP o>J 1' IpE ASR aiTAKE ~I W%w, a j I `(~KI1J. ~•LOOT I , 16.'/'511.1. • ~.c PROVIOE I IIULE T AIRTIGHT SEAL I Ilj ' ~ I I I I A . I I APPROVED JOIu APPKOYED JOINT ZP18~L Prll I I I w~C.T. f IPE P W/C.I. PIPCDR Tank constlruction I III J ALARJ shall comply with TLHR ()3.15 and 33.20 Js I II • I i oJJ . ~ •I I I PUF1P-~ -_J OFF O C0IJCKETE cz zl.J ! 6~OGS( 3" APK-: RISER EXIT PERMITTED 01JLy IF TAIJK MANUFACTURER HAS SUCH APPROVAL BEDDING scPrlc F SPECIFICATIOUS DOSE 1n1~5~ ~ C TA i.1K MA)aUFACTURCR. 1 : _ IJUlr5f3ER OF DOSES: V PER p,►,~ TA1JK SIZE : d' Z ~'LhgLLOhJS DOSE VOLUME tt// ALARM rlA1JUFAC7URCFZ: S,5 ,EL~-rCTftO SLffl (3 IWCLUDIJJ6 OAr-KFI.OW: ~Y i Z GALLONS MOOCL DUMBER: - I Ol Nw CAPACITIES: A IUCHCS OR C `r l W GALLOIJS SWITCH TyPr: . B = IUCHES~OR ell, ~Z~ ~-G~LLOUS Pump MAIJUFACTURCR: ~LC _ 1-1) C r-,-IUCHES OR `fir, ALLOUS MODEL JJUMDER: cZ,/ Dc INCHES OR ~GALLOJJL SWITCH TYPE: IJOTE: PUMP AMD ALARM ARE TO pC MINIMUM-DISCHARGE RATE GPM INSTALLED OQ SEPARATL CIRCUITS VEKTICAL DIFFERENCE DETWEEQ PUMP OFF AUO•.015TR18UTIOW PIPE., i/ 1C hEET t nlulrtuM NETWORK 5UPPLV PRE55URE FCET FEET OF FORCE f1A►N X Fo fLFKICTIO►J.FACroR.1-L FEET J TCYTAL OyQAMIC HEAD FEET As Per. Manufacturer. b gal/in. APR-12-2005 16:28 FERGUSON ENT HUDSON 715 386 6144 P.01 HGOULDS PUMPS Submersible 3 Effluent Pump PE 4kVfNT Pump SPECIFICATIONS MOTOR FEATURES Pump - General; General: ■ Corrosion resistant • Discharge: 114" NPT • Single phase construction. • Temperature: 104°F (400C) t 60 Hertz ■ Cast iron body, maximum, continuous when • 115 and 230 volts 11 Thermoplastic impeller and fully submerged. • Built-in thermal ovedoad pro- cover, • Solids handling: 14" tection with automatic reset ■ Upper sleeve and lower maximum sphere, • aass B Insulation. heavy duty ball bearing _APPLICATIONS • Automatic models Include a • Oil-filled design. construction, float switch. • High strength carbon steel n Motor Is permanently Specially designed for the t Manual models available. shaft, lubricated for extended following uses: • Pumping range: see PE31 Motor service life. • Mound Systems performance chart or curve, • .33 HP, 3000 RPM ■ Powered for continuous • EfFluent/Dosing Systems PE31 Pump: • 115 volts operation, • Low Pressure Pipe Systems_ • Maximum capacity: 53 GPM • Shaded pole design ■ All ratings are within the f - Basement Draining • Maximum head: 25' TDH PE41 Motor working limits of the motor. • Heavy Duty Sump/ PE4.1 Pump: • .40 HP, 3400 RPM ■ Quick disconnect power Dewatering • Maximum capacity: 61 GPM • 115 and 230 volts cord, 20' standard length, • Maximum head: 29' TDH • PSC design 1hea 15 or 230 1613 e, with PE51 Pump: PE51 Motor: plug volt grounding • Maximum capacity: 70 GPM .50 HP, 3400 RPM ■ Complete unit is heavy duty, • Maximum head: 37' TDH 115 and 230 volts portable and compact. METERS FEET ' PSC design ■ Mechanical seal is carbon, 40 ceramic, BUNA and stainless QE51 I ( I ! -1 I MODELS: PE31, Pf41, W steel, 35 I r I I I ! HR.33, .4o, so ■ Stainless steel fasteners, 10 ` r I 1 -a Z GPM l 1' 1 Ii I 30 •FEa t , I AGENCY LISTINGS o I. I 1 _7 I 1FT ' I 1 X 25 e~ 1 - I r I I I I I i 1 1 lJ I 7 1 I I 0 I( i! I i , 1 I' ~ 1 I I Q 20 I ! I ' I i 11 I I- ) I I I C us c I ' I I a - . t I (I • ' Tested to UL 778 and 1 s I' I I I I I I I I _j_ I I I{ I f CSA 222108 Standards p I , I- I ByCaracrwStandards Anotiavon i I i I 1. 1. I I- i I rite #tR38U9 1 i ; „L I I ! I. 4 • I Gourds Rungs IS ISO 9001 Registered I• ! I I 64 0 00 ~IIt 10 20 30 40 50 60 70 GPM 80 0 $ 10 15 m3/h Goulds Pumps ® 2004 ITT Water Technology, inc. CAPACITY EffedivJunt, 2 ooa ITT Indu fiYE3 i/41 stri es Wisconsin Department of Safety and Professional Services Division of Industry Services SOIL EVALUATION REPORT Page I of 3 in accordance with SPS 383, Wis. Adm. Code County 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. 040 - 1312 - 02 -000 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Revie by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 1Z 7 Property Owner Property Location DENNIE & KELLY ST. AUBIN NW 4 28 Govt. Lot 1/4 SW 114 S T N R 19 E (or) W Property Owner's Mailing Address Lot # Block # Subd. Name o CSM# 2 Cottage Meadows City State Zip Code Phone Number []City Village Town Nearest Road ( ) I Troy Edie Court a New Construction Use[D Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD o Replacement Public or commercial - Describe: Parent material sandy Flood Plain elevation if applicable NA ft. General comments Conventional In-ground trenches 0.7 loading rate and recommendations: Property Address: 516 Edie Court 1❑ Boring # 11 Boring El Pit Ground surface elev. 99.00 ft. Depth to limiting factor >96 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 1 0-12 10YR2/1 1 3fabk&gr mvfr cs 2vf-m 0.6 0.8 2 12-18 10YR2/2 sil Ifsbk mfr cs lvf-m 0.4c 0.6 3 18-26 l0YR3/3 Is Osg m1 cs lvf-f 0.7 1.6 4 36-96 10YR3/6 s Os d1 0.7 1.6 F2 Boring # Boring ❑ 100.30 >100 ' Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-6 IOYR2/1 I 3fa&sbk mvfr cs 2vf-m 0.6 0.8 2 6-16 10YR2/2 sit 2fabk mfr cs Ivf-m 0.6 0.8 3 16-26 10YR4/4 sicl 2msbk mfr cs 1 0.4 0.6 vt=f 4 26-36 1OYR3/3 Is Osg m1 cs lvf-f 0.7 1.6 5 36-100 1 OYR3/6 s Osg dl 0.7 1.6 ' Effluent #1 = BOD > 30.< 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signa CST Number MARY JO HUPPERT Hollister's Soil Testin &Desi' G / 2 L 224832 Address Date Evaluation CbAducted Telephone Number 28497 King Arthur's Court, Danbury, WI 54830 11 - 02 -2016 tz-Chit; 715-426-1775 SBD-8330 (RO7' t 3 ) L Property Owner ST. AIJBIN, Dennie & Kelly Parcel ID # 040 - 1312 - 02 - 000 Page 2 of 3 3 Boring # El Boring 100.70 <96 Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0-19 IOYR2/1 sit 3f msbk mfr es 2vf-m 0.6 0.8 2 19-39 10YR4/4 Cl 2fabk mfi es lvf-m 0.4 0.6 3 39-46 IOYR3/3 Is Osg ml gs 0.7 1.6 4 46-96 10YR3/6 s NO - dl OJ 1.6 4] Boring # Boring Pit Ground surface elev. I UZ. `bU ft. Depth to limiting factor qd in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 t 0 cj ,c V9 Z/r s; Z-~-YK5bK ; r 6L -5 zv -,n 2 -I YK 313 (s ~s r e s 1 t, 4, 17-~1C 3 S (js Il riot Ab"- A,-[ Boring Boring # ❑ Pit Ground surface elev. t C Z, ft. Depth to limiting factor in. H Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 i 0-~s .c YIZ z z - ~~1 insk~~ t5 z~'ra Z-' _ ! lv ro v'PZ 3/3 (s bK mJre^ C I -ri, L . / . 1 T- * Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L SBD-833 0(RO713) c Plot Plan Page Hof Property Owner s l<L-,LLy sT A tie ~----1 1"=40ft Legal Descriptio,, z. c'c r,tcc mDt wr,` A, vi '1q (except where noted) c9r .two F f r~~L rF r►ec = Backhoe pit IC cv .,3~z-North Icz. SC ~ 2 I •e0 ~Q ~x o' " ; 6D ~o onv~y ~~LL To I*: SEfT,e 1 AAK Z5 rF PM DPANF~gU~ 7 $0 Site Location: J O TD RD, rC County 17- C~ Safety and Buildings ivl ion ~ pf" 0 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) Madison, WI 53707-7162 ` P; ! ` U T ~ c ~MIJHH y J ION A~ State Transaction Number Sanitary Permit Application t t z in accordance wi6 SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit gtgtjprior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) d ~ p eftt of Safety and R~qfessional Servies. Personal information you provide may be used for secondary purposes to accordance with'tPrivac Law, s. 15.04 1 m , Stats. ZJ/ 1. Application Information - Please Print All Information ~J / fj T Property Owner's Name Parcel # 47' / /I z. -o Property Owner's Mailing Address Property Location Z Govt. Lot Zip Code Phone Number /V W y '/y, Section City, State ✓'/el.t al lleon(3 T ~ N; R/ Eo II. Type of Building (check all that apply) Lot # Subdivision 1 or 2 Family Dwelling - Number of Bedrooms Name Block # ~ ~ ~C~,e4-,41 r~5 ❑ Public/Commercial - Describe Use 0 4. ❑ City of Number ❑ Village of ❑ State Owned - Describe Use CSM ~'2Z ~ ~ A Town of T AC~j ~ 1 11 III. Type of Permit: (Check only one box in line A. Complete line if applicable) d stem ❑ Treatinent/Holdin placement Only ❑ Other Modification to Existing System (explain) ❑ g Re A. ew System Replacement Sy List Previous Permit Number and Date Issued B. ❑ Permit Renewal Permit Revision Change of P Permit Transfer to New Before Expiration Owner tf 6-4~ W. Type ofPOWTS System/Component/Device: C ec hat a 1 Non-Pressurized In-Ground ❑ Pressurized In-Groun ❑ -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soi ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersal/Treat nt Area Information: Des Flow (gpd) Design Soil Application Rate(gpds Dispersal Area Required (sf) Dispersal Area Proposed (st) System Elevau VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units n U y 2 New Tanks Existing Tanks y o 2 9 ro U v5 n u' ~7 a Septic or Holding Tank `7 Z ~fcz?~L_ Dosing Chamber G~ VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MPRAPPe r Number Business Phone Number - /0 C17~ SLR Z 2b ~ 7/S~Z7-?~f~ Plu ber ddress (Street, City, State, Zip Code) r✓ ~~G- f i:~JC~ .l` ~ f-C ~ C VIEJ,<oun!yTepartment Use Only Approved ❑ Permit QFee. Date sue Issuing ent Signatur -6 er Given Reason for Denial IX. Condit easons for Disapproval r_ 1. SopW tank, effluent fine. a„il 3> ~G Sef , dis}~ Mstl cell must all be sp.vics F ! nu!et= rec' f as:per Mr~agement plan provided by plumber. 2. AU eetbetsk nequjrements must,t a maintr ined ss per apFkAW code I ~ rdinance::. Attach to complete plans for the system and submit to the County only on paper not less than 8 to z 11 inches in size SBD-6398 (R 11/11) CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Owner's Name: QIAJ Owner's Address: 4 Ve7 _A--i~V 027:W 6 -NJ / Z 'Z Legal Description: A J Q) L21 s / ~7 Zq ze_-- Township: County: ~ - C J ~L. Subdivision Name: CDC Lot Number: Parcel ID Number; Page 1 Index and title to K Page 2 Plot Plan i L tu(;r ~f iN~ Ilfiii4`f~ Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber: ~ ~ ,(1~LS~kf License Number: Zoo Date: Phone Number Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POwTS Version 2.0 SBD-10705-P (N.01/01). Page 1 Plot Plan v Property Owner Dex iv t t--t-LY STr411g kV Legal Descepdon Letz Cor-r,,c,~ nn 40ft (Cwxpt where noted) of -r+r~ -w;i s~.nl' R ,ter ~aJ~ Tbw y ~r • = Backhoe pit ~zotx ec W~ -t 0 3 ©~oar3~z-az- North h ~x SU- } `6 1 A ~ Ids O 1 , Apt< -To >z5 r;Z ' Site Location: 150 7 Taw ~ J, or 2- Family Dwelling In-ground Soil Absorption System (2-cell Conventional) Daily Wastewater Flow (DWF) # of bedrooms x 150 gal/day/bedroom = ~ gal/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 r gpd/ftZ = e' I y ftZ # Chambers = Required Distribution cell area ftZ _ G d ftZ/ unit EISA -Chambers Chamber Manufacturer and Model: fOz.1 -l;-el 2 Q L'L C IC 7 ~'G~t S Actual Distribution cell area = Required cell area ftZ + ftZ/ unit EISA End Cap Pair= / Dit2 Cross-Section In-ground Soil Absorption System (2-cell): 4" Schedule 40 PVC vent pipe with vent cap 12 inches minimum 12 inches minimum I 1069, 7 G a ,v' 70 inches Soil Cover Trench 1 Sys- tern Elevation inch Chamber Height FY, Ift 7ft Trench 2 System I' ♦L.. Elevation ft -ft Trench Separation Leaching Chamber Width / ft to limiting factor Plan View In-ground Soil Absorption System (2-cell): Trench 1 Modify ft header/ design as ft ~ Leaching Chambers /4 0 needed. Trench 2 4 inch Header Sch.3&1933t` ft with end camps Draw O for a Vent and for Observat ion Pipe above. They will be located 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 L m Fp N m .1 c p t r .L., .L., ry C i. O (D ID C •E ' c c L C U s 0 on). t4= ~ cmED m t It omcv~m~c ~•9 3 N L a LL R a C Y 11 aci Yrkk c 0 o f m m ° ' m 'C LL 7 m }t' yt Y o c I L 9 0) ; m O m .~0.. CO 8 b n Ct m m' O N OL « C m -C y a° c Fwt.L ~r Y~ a Y- m L m d E mL mm 1 15 _v~t 3m°E~m c tmj L (n O W W ~x L N f E N c' 10 N N m 9maV o` °-C -o 2 C > 'O E - [F G N - W Cm O C 2 U 8 i m m ma Y°° o p E m°° E s CD tp ` 01 a W l0 G m m •a Sfi c F N N m L o C to -do, OS ~5 I C O N mt m N •4. $ i ` p w e' C lD N _ N ~ EE aI ° m m G 3 .6 NS~- m N m m C •H L O m _m D L t 'OO m E 0 kEY 01 m m Z~ «CoYEmN o D E m E b o` 3Y ai 3 o S ~j C p Y O 4. w a C m V m m 0 o m _o y cm_ o~ r, c L W m 16 m~N LL 1]U LL NON C d Co CT o f m m~ d m m~ m~ E Ti w L~Ij CD CD E 0 Q F•- 3 E C 5 F- w V> v F C N N C ~i u Y r~Gu~ ~qWp ~ ~ ~ E JS ~ ~d E ~,~W 1 V yy~ ~ ~ 511 ~~H6tt ~ G ppN~~ MkSY ~,a «~g3 c SQ ~N F ~2 :'`C'° tic p"'6 O 3€Q e v 8 co D u o 1.9 0 ° S a n . O ti~,;~ r v s A 1r~' ~ 2mEm W u° c fir m Q . t'~ _ ~ ~ mu e E v ~ f m VE aim -1 x n 4 a F i7iTq a r~ x 7A K Yr ~I1~ acv m rya °5. if K g k~ .old I ! <; ~ ~ e nL All Z {7 a Y f `~„'Fwheft~s6~l' POWTS OWNER'S MANUAL MANAGEMENT PLAN FILE INFORMATION SYSTEM SPECIFICATIONS Owner 0/ Septic Tank Capacity , gal ❑ NA f ' I A -A/ :~:l Permit # Septic Tank Manufacturer W I Sr- ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units ,14 NA Pump Tank Capacity iai ❑ NA Estimated flow (average) ~QO gal/day Pump Tank Manufacturer ? ❑ NA Design flow (peak), (Estimated x 1.5) (,on 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 (BODs) 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 (BOD.) 530 mg/L ❑ In-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade 13 Mound Fecal Coliform (geometric mean) 510' cfu/100m1 ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y. in dia. ❑ NA Other; O NA Other. ❑ NA Other: ❑ NA 'Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA j MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: 3 ❑ month(s) (Maximum 3 years) ❑ NA D ear(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA -3 ® year(s) Clean effluent filter At least once every: O month(s) ❑ NA ® ear(s) Inspect pump, pump controls & alarm At least once every:❑ month(s) ❑ NA 3 J9 ear(s) Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA 91 ear(s) Other: At least once every: ❑ month(s) ❑ NA ❑ ear(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; POINTS 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 4II(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) I.l 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 chemical; 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 ba 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., 0 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 sultable 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 recbristructed 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 PROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name p 2 C L S OnI E Name Phone -7 1 S - Z 7 3 - (r!!r Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name, I :'o H Vv 5,6},vr fit frv Name ; S4 CdldlX Z0~! i Phone 7~5 Z 73 " Phone - - `~"39k'16,1U This document was drafted In compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.5401, (2) & (3), Wisconsin Administrative Code. e x >x r nL F h ~w uick4 Pius Standard Chamber Side and End Views ;i i 48" (EFFECTIVE LENGTH) 12 34"~ y' ,Eyi , t 4. I ii as III-ire-one 1 Encap Front, Side and E rid Views 1, .2" k 13" 8" INVERT 8" INVERT 5.3" INVERT ~--18.2" 33" uick4 Pius All-in-One Periscope QUICK4 PLUS AL41N-ONE PERISCOPE (360-SWIVEL ) t ENDCA 8 12.7" INVERT QUICK4 PLUS ' ALL-IN-ONE 12 ENDCAP Quick4 Plus Standard Chamber Specifications _._-_a ) I Invert Height 0.6 5.3 8.0 1 Size (WxLxH) 34" x 53" x 12" (86 cm x 135 cmx31cm ) ; y Effective Length . 48" 122 cm (1.5 cm, 8.4 cm, 18,5 cm, - 222.6 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. (b)THE LIMITED WARRANTY AND REMEDIES IN SUBPARAGRAPH (a) ARE EXCLUSIVE. THERE ARE NO OTHER WARRANTIES WITH RESPECT TO THE UNITS; INCLUDING NO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE (c) This Limited Warranty shall be void if any part of the chamber system is manufactured by anyone other than Infiltrator. The Limited Warranty INFILTRATOR does not extend to incidental, consequential, special or indirect damages. Infiltrator shall not be liable for penalties or liquidated damages, c V t'i; 1 (1 C . a including loss of production and profits, labor and materials, overhead costs, or other losses or expenses incurred by the Holder or any third party. s Specifically excluded from Limited Warranty coverage are damage to the Units due to ordinary wear and tear, alteration, accident, misuse, abuse w 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 c, he Units: failure of the Units or the septic system due to improper siting or improper sizing, excessive water usage, improper grease disposal, Old Saybrook, CT 06475 or improper operation; or any other event not caused by Infiltrator. This Limited Warranty shall be void if the Holder fails to comply with all of the . terms set forth in this 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 y apply, the Units must be installed in accordance with all site conditions required by state and local codes; all other applicable laws; and infiltrator's 800.221 .4436 installation instructions. (d) No representative of infiltrator has the authority to change or extend this Limited Warranty. No warranty applies to any party other than the 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. ~ f~a xs1 4 ~ t'~-~tY,M'& C e~~.z *S:`H~gY L , r*~y~ ?~:~!`eh'~r4 a«n~ i ~•:~§~~ik~~, e,..~i 4~~'f~! t,~w '~t 5, -,alb x ¢k u~ y r e ds4ir ~ tt.r T~pr Ky~'~~ r~°~g b+ ~t. ➢ i t9',) n~, 4 1as 6R ,:cif 1 2r - ,ry 1 b _ I 1 red y ~ t§ ~(4 ~ ~ 9 B ~ ~ s r U~S."Patents: 4,759,661; 5,017,041; 5,156,468: 5,336,017: 5,401,116; 5,401,459; 5,511,903, 5,716.163; 5,588,778; 5,839,844 Canadian Patents: 1,329.959: 2,004,564 Other patents pending. Infiltrator, Equalizer, Quick4 and Ouick4 Plus are registered trademarks of Infiltrator Systems Inc. Infiltrator is a registered trademark in France. Infiltrator Systems Ina PLUS0510101Si-2 is a registered trademark in Mexico. Contour Swivel Connection is a trademark of Infiltrator Systems Inc. ©2009 Infiltrator Systems Inc. Printed in U.S.A.