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HomeMy WebLinkAbout040-1255-70-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 597385 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: Victor Genco TOWN OF TROY 040-1255-70-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: '193, 6% t & f'fw-- 30.28.19.1354 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic \ r Benchmark 3 J]cciag~ Alt. BM ♦ i V Aeration Bldg. Sewer "e, 6 Holding St/Ht Inlet 41- TANK SETBACK INFORMATION St/Ht Outlet -7• Z $ TANK TO P/L WELL BLDG. it Intake ROAD Dt Inlet Septic l d4 + Dt Bottom Dosing ~ `O Header/Man. Q~ Qp Aeration Dist. Pipe T17. TZ Holding Bot. System p QQ++ a / ~v~o• V dk ~j PUMP/SIPHON INFORMATION Final Grade 5 1 Manufacturer Demand St Cover _ PM Model Numb TDH L" Friction Loss System Head rlll~ Ft - Forcemain th Di ist. to well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS _~Z~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Ce Av'd 16 ~6 //D Model Number: ~ A -L f DISTRIBUTION SYSTEM Sp„~~•~.. 9 } / Header/Manifold/ Distribution ix Hole Size re Spacing Vent Air In ke Q" Pipe(s) *__1 Length V Dia Length Dia Spacing s SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only '066 /8 Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched h Bed/Trench Center 1. Q Bed/Trench Edges Topsoil Yes No es No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 198 TROY GLENN DR CN 0.~( S de,I•S Ova 1.) Alt BM Description = &L reLTx- Ci0(Aa/\, ff 2.) Bldg sewer length = /x; ~ ,{►1 ~ ~ ~ - amount of cover Plan revision Required? ❑ Yes No ~ 1-7I Use other side for additional information. J Date Insepctor's nature Cert. No. SBD-6710 (R.3197) I V t.> County r1 < 8 Safety and Buildings Division - fl 1 JUN 2 2u, } + 201 W, Washington Ave., P.O. Box 7162 Sanitary Permit umber (to Madison, 53707-7162 be filled in by Co.) ,rt? qT CROIX COU S / c7 j0M tAry ermit A State T 'o Number In accordance with SPS 383.21(2), Wis, Adm- Code, submissio is required prior to obtaining a sanitary permit Note: Appbcation the Department of Safety and Professional Servies. Personal information fo ~rovide Project Address (if different than mailing address ores in accordance with the Privac Law, s. 15 1 m), Stars. YOU P may be used for secujn_, ) L A lication Information -Please print nformation Property Owner'S Name C~ f st ! t I Parcel Property Owner's Mailing Address t°/y Z -c/ operty Location O 1 9, 13 City, tare / '4 Zip Code I Govt Lot _ Phone Number _1 L 2'14, Section II. pe of Building circle (check all that appl T y Lot N; R g fur i amily Dwelling - Number of BCdr00 j• i Subdivision Name T ❑ Public/Commercial - Describe Use /bCL~ B o / 40 y L City o State Owmed - Describe Use CSM Number 3 ❑ Village of ~L of III. Type of Permit: (Check only A. one box o line A. Complete in B if applicable) #;Iew System Replacement System ❑ Treatment/Holding Tank Replacement 0111Y ❑ Other Modification to Existing system (explain) B- ❑ Permit Renewal ❑ Permit Revision Before Expiration Change of Plumber El Permit Transfer to New List previous Permit Number and I?are Issued Owner IV. T e ofPOWTS System /Com onent/Device: Check all that apply &.0 ^got n-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil 11 Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) Devi V. Dis rsal/Trea ent Area Information. ❑ Pretreatment ~ Design Flow (.pd Design Soil Application Raz f) Dispersal Area Required (s Dis d 's Penal Area Pr sf) Syst Elevatio VL Tank Info Capacity in O N: L' Total # of Manufacttner Gallons Gallons Units New Tanks e o g TanlS • m v U Sep= or Ho! o r m ding Tank o U v X-43 p Dosing Chamber VII. Responsibility S t ment- 1, the undersigned, u e responsibility 's Name (Print} at for installation of the PORTS shown on the attached plans „ PI er' Signature MPlIvfPRS Number Business Phone Wilber Plumber's (Street, City, stare, 'p ) G~ 7 f J J' atvlDe artment Use Only " v l G~ Approved pt Permit Fee Da Issu Issuin ent Signature I Own rven Reason for Denial 1191."D G )-7 DL CouditiM~ ` ~rb3l ons for Disapproval 1 Septe'tank', m iilt r,i 3 (ii51.12f1 .su cell must t all be ic?s , r ec J • M e,/~`. 3s per ,rnacagemeW pl. n p! c. iiae 1 by ,olumbe:. 2• AW. Jc require r en,s must Le ;r'tc ive i as iW PXTI ~abla cn0enI rdinanr,,._. 1 Attacb to plans for the SFstem and submit to the County only on paper not less than 8 1r_ z I1 inches in size SBD-6398 (R 11/11) Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County l J 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 LD. tr . " S * , "f s / percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Revie by Date 4" Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location l V ; (of) W Govt. Lot 1/4 /4 S ,~7 T ~N R 2E Property Owners Mailing Address Lot Block # Subd. Name C 199 Tr, AA City S// a Zip Code Phone Number ❑ !City ❑ village own Nearest Road j 6A, ❑ New Construction Use' or, Residential / Number of bedrooms - Code derived sign flow rate 1 GPD eplaeement ❑ Public qr commercial - Describe: Parent material Flood Plain elevation if applicable - ft• Z .6 General comments A t j t and recommendations: PC. VVI System Type System Elevation Boring M Boring # ❑ p it Ground surface elev? r' C Depth to limiting factor in. Pit 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 A 0, "34 1- V 6 F1 Boring # Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor inSoil licabon 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 Effluent #1 = BOD. > 30 < 220 mg/L and TSS >30 < 150 ' Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) S• CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 11 1432 120th St, New Richmond, WI 54017 4~~I' 6 ; ^ ; - 2 715-246-4516 Property Owner _ Parcel ID # Page of ❑ Boring # ❑ Boring ❑ 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 F-1 Boring # ❑ Boring ❑ 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 ❑ Boring F-1 Boring # Ground surface elev. ft. Depth to limiting factor Pit in. ❑ Soil Application Rate Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 mg/. ' Effluent #2 = BODS < 30 mg/l- and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (8.6/00) System PLOT PLAN PROJECT Victor Genco ADDRESS 198 Trov Glen Drive River Falls %Vi 54022 NW - 1/4 NW 1/4s 30 /T 28 R 19 W TOWN Troy COUNTY ST. CROIX SYSTEM ELEVATION 886.4/886.2/88, 4' below 6/21/17 4 DATE - BEDROOM CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK l 250 LIFT TANK SIZE DOSE TANK SIZE S HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 900 # of EZ-Flowsl 8 BENCHMARK V.R.P. Top of survey iron ASSUME ELEVATION 890.18' Filter Lifetime Filter -[:]BOREHOLE O WELL *H.R.P. same as benchmark Scale=1/4"=10' Vent >6" Quick4 Standard of Cover Leaching Chamber with 20.0 ft2 of Area 5.6f A2/pair of end caps 12" 4' Long Grade at System Elevation 34" Existing 4 well Bedroom 0 All piping shall be ASTM SDR 30/34, within House 10' of tank, piping shall be ASTM F891 60' B-7D 30' B-7B 60' ST O ' Existing system completely filled in by B-7E ' gophers, not worth installing a valve. 0 Vents VB-7CC 65' B-1 B-7F 2-3' X 90' cells with >3' spacing 35' 0' 60' .M.* 85' 110' ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing s ptic and/or dose tank presently serving,the ollowing residence: (Street address)_ I q located at: I.J 1/a,V 1/a, Sectio Town~N, Range W, Town of St. Croix County Wisconsin. Upon inspection, I ify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service 7 Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: 12 (Jb Construction: Prefab Concrete Steel Other Manufacturer (if known): Age of Tank (if known): Permit numbe if known) (Lime ed Plumber Signature) (Print Name) Title) (License Number) MP/MPRS (Date) Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 System PLOT PLAN PROJECT Victor Genco ADDRESS 198 Trov Glen Drive River Falls Wi 54022 NW 1/4 NW 1/45 30 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX SYSTEM ELEVATION 886.4/886.2/886.0 4' below DATE 6/21/17 BEDROOM 4 CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK r MOUND SEPTIC TANK SIZE 1250 LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 900 # of EZ-Flowsl 8 BENCHMARK V.R.P. Top of survey iron ASSUME ELEVATION 890.18' Filter Lifetime Filter ❑ BOREHOLE O WELL *H.R.P. same as benchmark SIrQIG ~ I %L^t~~ = I Vi Vent ~6>> Quick4 Standard of Cover Leaching Chamber with 20.0 ft2 of Area 12 5.6ft^2/pair of end caps r 4' Long Grade at System Elevation 34" xisting 4 well Bedroom All piping shall be ASTM SDR 30/34, within House 10' of tank, piping shall be ASTM F891 60' B-7D 30' B-7B r ST 60 O 15' Existing system completely filled in by G' gophers, not worth installing a valve. B-7E 45' 0' • 30' 65' e B-7C WTB7 d(,P 3-3' X 60' cells with >3' spacing 3 5' 0' 60' .M.* 85' 110' t Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 6/21/17 Owner:Victor Genco Location: NW1/4 NW1/4 S30 T28 N,R19W 198 Troy Glen Drive Troy Manuals Used: In-ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. EZ-Flow Cross ction 4-6. Maintanance el Contin ncy Plan i Signature License num 4226900 System PLOT PLAN PROJECT Victor Genco ADDRESS 198 Trov Glen Drive River Falls Wi 54022 NW 1/4 NW 1/4S 30 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX SYSTEM ELEVATION 886.4/886.2/886.0 4' below DATE 6/21/17 BEDROOM 4 CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK r MOUND SEPTIC TANK SIZE 1250 LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 900 # of EZ-Flowsl 8 BENCHMARK V.R.P. Top of survey iron ASSUME ELEVATION 890.18' Filter Lifetime Filter ❑ BOREHOLE O WELL *H.R.P. same as benchmark Scale = 1/4" = 10' r Vent >6" Quick4 Standard of Cover Leaching Chamber with 20.0 ft2 of Area 5.6ft^2/pair of end caps 12" Long 3411 Grade at System Elevation Existing 4 Well Bedroom 0 All piping shall be ASTM SDR 30/34, within House 10' of tank, piping shall be ASTM F891 60' B-7D 30' B-7B T O Existing system completely filled in by gophers, not worth installing a valve. B-7E 0' 60' ;tB-7C ' 65' Vents B-7F 3-3' X 60' cells with >3' spacing 35' 0' 60' .M.* 85' 110' by bj c fl_. 3 O d co a) C LL N m O 0 x E ~..r 0 LL O C7 cn O . . Q ~ C U _ Ns ED O c N (D U- . . a~ E Ibc NUS ..:u o m . . . CL > o . c (0 l a .10 3 Q °o-0 n 00 W (8 U E V Q O O c4 O C~ O CO N lf) O O o 0 ; 'O z N O W cD W d"..". V c E (0 Cl) in O. O m. ca O t o L v Ez a O Q w C~ N rn LL O U) POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of lL.E INFORMATION SYSTEM SPECIFICATIONS Owner lJ i C Septic Tank Capacity al O NA Permit # Septic Tank Manufacturer ❑ NA 3ESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model O NA Number of Public Facility Units ]NA Pump Tank Capacity al NA j Estimated flow (average) al/day Pump Tank Manufacturer NA 7-0 g ki i Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer NA Soil Application Rate aUda ifl2 Pump Model NA i 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) 420 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 (BODs) S30 mg/L -Ground {gravity} ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ' ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 5104 cfu/100m1 ❑ Drip-Line ❑ Other: !Maximum Effluent Particle Size Ya in dia. ❑ NA Other. ❑ NA Qther. Other: A ❑ NA "Values typical for domestic wastewater and septic tank effluent Other ❑ NA AINTENANCE SCHEDULE Service Event Service Frequency linspect condition of tank(s) At least once ever ❑ month(s) y' JZLyears (Maximum 3 years) ❑ NA (Pump out contents of tank(s) When combined sludge and scum equals one-third (36) of tank volume ❑ NA [Inspect dispersal cell(s) At feast once every: j ❑ onth(s) (Maximum 3 years) ❑ NA ar(s) ~ month(s Clean effluent filter At least once every: year(s) ) ❑ ) ❑ NA nspect pump, pump controls & alarm At least once every: ❑ month(s) El NA year(s) f=lush laterals and pressure test At least once every: ❑ month(s) NA ❑ year(s) )they. At least once every: ❑ month(s) NA ether: ❑ year(s) 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 oombined 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 Iegulatory authority. I,Nhen the combined accumulation of sludge and scum in any tank equals one-third or more of the tank volume, the entire contents of j:he 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 <12 months, shall be performed by a certified POWTS Maintainer. l~ service report shall be provided to the local regulatory authority within 10 days of completion of any service event. pap of START UP AND OPERATION nt tank(s) for the presence of painting products or other chemicals thOt Fix new construction, prior to use of the POWTS chethe ck dtreatrrue cell(s). If high concentrations are detected have the contents of thO may impede the treatment process and/or damage P~ 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. will bie During power outages pump tanks may till above normal highwater levels. When power is restored or the surface excess discharge wastewater will bi. discharged to the dispersal cell(s) in one large dose, overloading the (ell(s) and may result in the backup To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to it* 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. the area within Do not drive or park Vehicles over tanks and dispersal kegs. Do not drive or park over, or otherwise disturb or compact, 15 feet down slope of any mound or at-grade soil absorption area. life of the POWT_ Reduction or elimination of the following from the wastewater stream may improve the performance di and s~nfe~r+ prolong ants; the fat: foundation dram antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; dicrtions; oil: painting iondu~; (sump pump) water; fruit and vegetable palings; gasoline; grease; herbicides; meat scraps; 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 prope(iy 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 shag be excavated and removed or their covers removed and the void space filled with Soil, gravel or another inert solid material. CONTINGENCY PLAN code compliant If the POWTS falls and cannot be repaired the following measures have been, or must be taken, to provide a replacement system: replacement soil absorption system. ❑ A suitable replacement area has been evaluated and may be utilized for the location of a rep The replacement area should be protected from disturbance and compaction and should not be infringed upon by requitled setbacks from eunsting and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the r*ed for a new soil and site evaluation to establish a suitable replacwment area. Replacement systems must comply with the ruulet in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technologN a ng tank may bs 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 nstal{e0 as must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be 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. ReconStnuctions of such systems must comply with the rules in effect at that time. «}IVARNING>> ENTER 0 A SEPTIC, PUMP A SEPTIC, PUMP OR OTHER TREATMENT TREATTANKS MA CONTAIN LETHAL ANDR INSUFFICIENT MENT TANY UNDER ANY RCCI UAMSTANCES. DEATH MAY RESULT. RESCUE ENTER PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER ` Name Name , C 6L Phone ~ 7 Phone l SEPTAGE SERVICING OPERATOR (PUMPER LOCAL REGULATORY AUTHORITY Name Name ~ J-71 Phone Phone This Bras drafted in compliance with chapter SPS 383.22(2)(b)(1)(d)&(f) and 383..54(1), (2) & (3), Wisconsin Adminwa ive Code. ST CROIX COUNTY SEP1%ANK. MAINTENANCE AGREEM6 AND OWNERSHIP CERTIFICATION FORM Owner/Buyer V i C-r o R- M • G NCV ¢ . Mailing Address __%LH1TF--MjL- X212- Property Address Mg V (Verification required from Planning Department for new construction) City/State7Uk1N OF 33EO"f V-M Parcel Identification Number nod' 11*5- '70 ' 000 LEGAL DESCRIPTION Property Location MW 1/4, NVJ Sec. '30 . T 2. N R 19 W, Town of "TROY Subdivision 77-0N CaLNEi-l . Lot # 7 Certified Survey Map # e>(6CQQ-7 . Volume 2 . Page # 3u~ Warranty Deed # Volume . Page # Spec house 0 yes Ono Lot lines identifiable yes 0 no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature fai =to. handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the fuaction of the septic tank as a treatment stage is the waste disposal system. The property owner agrees to submit to St Croix Zoning Department a certification form, signed by the owner and by a masterplumber, joumeymanplumber, restrictedpiumber ora licensedpumperverifying that (1) the on-site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary); the septic tank is less than 113 full of sludge. Uwe,. the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has eea maintained must be completed and returned to the St Croix County Zoning Office within 30 days of the ear date. • CANT r DATE OWNER CERTIFICATION I (we) cethat all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property dews ed a e uy virtue of a warranty deed recorded in Register of Deeds Office. A0 T OF APPLICANT DATE A Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed NEW-- Wisconsin Department Commerce PRIVATE SEWAGE SYSTEM County St. Croix Safety and Building Division t ' INSPECTION REPORT Sanitary Permit No: 420523 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)). Permit Holder's Name: City Village X Township Parcel Tax No: Genco, Victor J. Jr TroTownshi 040-1255-70-000 CST BM Elev: Insp. BM Elev: BM Description: 1 ' )g O • l ~v c CSt- gw~ TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Et 62... Z~ T W ` S'Q0.1 ~ Dosing Aft. BM Aeration StJ "3 Bldg. Sewer G i f • TO o • b0 ` Holding St/Ht Inlet -T-8z' B&9•Sb r TANK SETBACK INFORMATION St/Ht Outlet LL $~1. /4 f TANK TO P/L WELL BLDG. Vent to Air intake ROAD Dt Inlet Septic Dt Bottom 25 Dosing Header/Man. Aeration • 93 ~ Dist. ipe •tx t Holding Bot. ystem 866•x3` PUMP/SIPHON INFORMATION Final Grade +t kL 4. Manufactur Demand St Cover M Model Number TDH Lift on Loss System Head 5TDH Ft Forcemain ength D1 . Dist. to well SOIL ABSORPTION SYSTEM BED/TRENCH Width yj ngth No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Die. Liquid Depth DIMENSIONS .3 I ) S y ar r SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer. . INFORMATION Type Of System: CHAMBER OR p v . 3or by I) r.s- UNIT Model Number. ~ ~.prr DISTRIBUTION SYSTEM Header/Manifold u Pipe(s) x Hole Size x Hole Spacing Vent to Air Intake ll-ength~Dia (a) ~ r Length Dia Spacing ' SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil [J Yes ® No Yss ® No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: 11 / M / 02- Inspection #2: - J a Location: 198 Troy Glen Drive Hudson, WI 54016 (NW 1/4 NW 1/4 30 T28N R19W) Troy Glen Lot 7 Parcel No: 30.28.19.1354 gat 1.) Alt BM Description = set R,(,o~ , C "A45 ' 2.) Bldg sewer length = 3 2.1 76P5 _ Sufi - amount of cover d^ n Plan revision Required? ® Yes X No I to. ~I !rr I Yersi.d for add ition I ' i n. F1 1 Z2- Cert No. PC- 677) Im ~1• Date Insepctofs Signature ` Softy nd fddlop Dwsin comm ST. CROIX Viscootsin col W. w Ave-, P.O. Box 7162 ldcdbm wf 33707 - 7162 no wadm.e Department of Commerce 198 TROY GLEN DRIVE Sanitary Permit Appll Patmit Natt*a 1a acowd wit Goan t3.21, ara. Adm. code, Puu,d 61 _ Cheek i Fe irlon be =W for uw-ju-04diia:s noomim Puna L AppBattis Btbe~ - !knee Kist Ag lledae md= ltca I.D. Noodw Pt "nv owner's lisae c Roamer BRUCE LENZEN HOME - VICTOR M. GENCO JRC~ Papa4Y Owaer'c ~ Addraa Petpergr Laud= 3 502 SECOND ST., STE 204 NW IA NW s 30 J8 FA; N CSg. Slice Zip Code PI Nwobw Lot KNEW Xwk Nwxi w HUDSON, WI 54016 7 715-386-5050 Swb6vicioa Ncae cou Nanba TROY GLEN 560007 OCk II. Tate Of bilifts (&a* al that appy) fl 1 or2F=ftDwdts- Nmer [Bdm4 0 PuWioWm=w cW - D,,I, U. ` OVEW TROY 0 Safe owmd lieatett Road MAXANICKIE DRIVE III. Type Of ra(Cbeclt 0* ase boa as Bat A Wmba9sp .theme tae Wwad are). Complete Bat E if Wg=We) A. 1,.8 New 2 0 >ittp)ammeet &jam 3 ❑ For Cti~ sea lteplaoeoeet of 6 ❑ Add4isa b Tdt 1. 0 caboo f smduty Pbtnit F1 Moody bread iwat+t Number Dace leveed t 1V- T3Pe Of reemit: (Chak all dot app13)Uroobairj ad ow is ter bctend arc) 44,2 Non -Ptaari wd k*.. d 210 M&M 47 0 Send Pd1er SO 0 Conoacmd WedaW 4 22 ❑ Peecrariacd in1'ytv®d 410 HoWior Tack 42 0 Side Pw 510 Drip Lies l~A 4s 0 Monde 46 0 Aerobic Trwaart unit 49 0 Rahadafra 30009M 1 O b f Ff .c am V. AreaYdrrmtlm .•S Dectp Plow Wo Dbperad Arse DLpeng Area Son Applieadoe PwceoWioe Beee zwvwl= Plod ands 600 imquked Ptopaed lttce((ide /Dayc/Sq R) (biioJloei) Hlevadoa 857 ,85T- 7 -7 6 VL Taalt Yale CAP@* is Taut Naebw !fan Pttxab &eo Seed PBer Plastic swft Gal= Gas= of ilrb Coectace Gbasaesd Glow lie. flcitthe ara0m0s X 1250 1 WEISER X tlociae olrrmer vm - 1. tie atetace Aw ImtailcdM dde P0WU tire..- M tie alttdwd FWN* r'c Nape (Fdoo 1ip/IdpltB Number Bacio n Phone Naebw TODD FEATHERSTONE, 242514 715-381-1704 AZW7. Aft= (SuaL OW. Sucv. Zip Code) P.O. BOX 467 HUDSON, WI 54016 VOL up o Dk*pwvad Saaice7 Pmdt Pee (iicceMes Cteaedwaler Due Ismed Apt- Sieeame (NO Stempc) ❑ voce. 0irra iridd Ad.etae A4tpraral/Rassoas for Ac A, • Aroma.eve.l~trer~4~b)etrrrt~r.aotrparwla.ttarrlnaAtaiccYt`. SB"99 (R. 05101) V104w4wAn Oopw s Y ! SOIL AND SITE EVALUATION REPORT pap_. of 3 labor and Human Rstaao~auonu oivaan of Safety a Bwldugs in accord with ILNR 83.05. Wis. Adm. Code COUNTY Attach complete site plan on paper not leas than 8 1/2 x 11 inches in size. Plan moat include, biit not linated to vertical and horizontal reference point (Stu), direction and % of slope, scale or PARCEL I.O. K dimensioned. north arrow, and location and distance to nearest road. 6%y'-p Z APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION I R I BY DATE , PROPERTY OWN:: PROPS;IY LOCATION IQV LeWZ?A1 OIyES G. GOVT. LOT NW mt N#J114,0o T Z8 N.R ! -t" W 4OZ GO A00 r 2O ¢ ~ LOT s BLOCK s SYN. NAME OR ~ CSbt~A y 444*01 ~jG STATE 23P CO E PHONE NUMBER CITY ILLAGE OWN NEAREST ROAD CrLY, ~/OSA,v GU/ Sod/ t>'l G - 50 o N/ New ConsUttctian Use Residential / Number at bedrooms (1 Addition to ens*V btnOM L 1 Replamnent I 1 Public or coinnuircial dtrscribe Code derived daily flow Q_ gpd Rewymiended desigrt loading ran _I bed. 9polR2j Uench, WdR2 AbstlrOM area required >36r7 bed, ft2 SO far ch, tt2 Wixitrim design baling rate A..:? _bed. gNM2 e• 8 Ir nck gpM12 Reoomtnertded infiltration surface elevation(s) .C/N/1' 06C AZrft (as refefred to site plan benchmark) Additional design / site consideratkm /i9L. G = Z X 7~~ 8 N/T/A,G a o v Parent material 14u. yenIA7 a,4A41 1_ DUTIUf L5*-toed plairt elevation, if applicwe R S - Suitable for SyStem CONVENTIONAL MOUNO IN•GROUNO PRESSURE AT-GRADE SYSTEM IN FILL HOLOING TANK U.I.InSt miefor I ®S pU I a'S QU as ❑U ffS oU OS ®U QS ®U SOIL DESCRIPTION REPORT ;4Z!;. ,tt.4,`T ll '1 Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. SL Cont. Coker Texture Gr. Sz. Sh. C'am' Roots bed Trer>dt 1 D-/Z D 51Z k ~v D• 5 A 4 ~ /Z- DY 3 ~ si/ Z ~ 6~ als~C Z✓~ D. 5 .G . s Grotred elev. ft C -8¢ oY/-7 s 6 - s sa d~ - IVA 0-7 0,8 Depth to limiting >4y i Remarks: Boning # /D /o YX 2L - y, f Z~rsG.E ash aW c / > 8 /o- D ,e ¢ s•/ '71k .015k t4 cv Z✓F D.S o.G .s' :5 epsoi, Gmtmd D'v k I 7 Depth to lettntirtg ~-oi S '.p r3 t ~°I Lo. 2 ~~F orx / > o'' F7 N7 -y Remarks: r 4 CST Names-Phase Print JAIIAES b. FILKINS Phone: I (715) 4 d , !j_'k'Z, Ad*nr OGDEJN SING CO., 113 WEST WALNUT ST., RIVER FALLS, WI 54022 Dan: CST Number 222952 AROPEIMOWNER ~ SOIL DESCRIPTION REPORT Page 2 of 3 PARCEL I.D. II Depth Dominant Color Mottles Texture Structure Cam ecurtoy GPD/ft Boring # Horizon in. Munsell Qu. SL Cont. Cola Gr. Sz. Sh. Roots Bed MOM -4p-? Id YW .3 Z t5';/ I 0kS,4 d AW Zr~ D. S l D• . r- 9-Z/ 7 ,Y o /cA6k AA w v~ 49. ¢ 8 c ,e ~'Z t/-¢ IDY,e ¢ /s D dl Cw Zr~ 0.7 1 0 7ft G ~Z-9m Of' SG - s s dl r~ o. 7 o.S 080 to 1664 Remarks: Boring # O- DYE 3 z g i/ Zosbk 'w/f Aw MAP D.Sv. G -r 8 -/8 /10 Y19 - s./ Zirrabk ask el an Zvl o•S~-~ .s lel -4Z O X S~ S d/ 14 r ur l 1t ~Z ¢Z- or'Z ',/G o.~ d.9 . A C6 46 tin ring y oy ~(v Remarks: Boring # n S O 3 ew A.5-:4"4" 8 /5-ZG oY/L Ground C Z6- AM -if- G 9r, I ft. Depth to limiting Remarks: Boring # am~ Ground elev. Dow to lining factor Remarks: seo-a~o(aos~o~ i PAGE 3OF3 SITE PLAN NOTE: DRAINFIELD TO 13E A MOWMIJM OF: 25' FROM DWELLING; 50' FROM WELL. 5' FROM LOT UNE. ©7- -Ti2O Y ~G.EN c 7p SCALE 1 50' n ® 7G i /SON I OGDEN ENGINEERING CO. JAME . Fil-KINS, 222982 Civil Engineers i4 Land Surveyors DATE 'f ZS'<98 113 W. Walnut St. River Falls. WI 54022 (715) 425-7631