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030-2153-15-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division Sanitary Permit No: INSPECTION REPORT 600248 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 Township Parcel Tax No: KOSS CHRISTOPHER TOWN OF SAINT JOSEPH 030-2153-15-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 1/66-371 / 65 T 20.30.19.3085 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ; C~~ ! Benchmark G #Z.1 Dosing ,L Alt. BM ' 1_ Bldg. Sewer ~4, 6 . 1~ , t • a Holding St/Ht Inlet St/Ht Outlet K TANK SETBACK INFORMATION S ~7 A ~D TANK TO P/ WELL BLDG. Vent to lyr Intake ROAD Dt Inlet 60 Septic ✓ / F Dt Bottom S Dosing Header/Man. Aeration Dist. Pipe 9~~/ 163.3 Holding Bot. System 9.g /dz. 7T Final Gr de ~a5• Z PUMP/SIPHON INFORMATION Manufacturer GP ^and St Cover 1Z •T A6 . 6 Model Number f /a, U /S - r TDH Lift Friction Loss System He TDH Ft d 13S Q Z-1 7 Forcemain Len a. Dist. to Well 16-651,14Z.27 SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIIIQENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS Ly 3 e-Ae, SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: r O ^ I X) UNIT Model Number: 1 64 DISTRIBUTION SYSTEM G~ 2 Header/ManifoljJ l Distribution x Hole Size x Hole Spacing Vent 15,% Length Dia At Pipe(s) 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 2-75 Bed/Trench Edges Topsoil Yes 0 No Yes ] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection 42: c Location: 1473 46TH ST " CaL 1.) Alt BM Description = 2.) Bldg sewer length = Za L ~ aY - amount of cover = #Z D J s Plan revision Required? Yes/ & 54 ELI /j7 L4 PI-7 T Use other side for additional informat Kono Date Insepcto Signatu Cert. No. SBD-6710 (R.3/97) / ~O~YAH7.\rF,'lj County - 3 f% ~O - o S Industry Services Division St. Croix CE f VE® 1400 E Washington Ave Sanitary Permit Number (to be filled in by Co.) P.O. Box 7162 P S Madiso lpll 5 07-7162 STO it Applica loll 7 7 6 State Teflon Number in accordance v~ ( tt`s'.`Adm. Code, submission of this form to the appropriatecovePit}111'~ta] unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address-( f diIT a than mailing address) the Department of Safety and Professional Services. Personal information you provide may be used for secondary Law, s. 15.04 1 m). Slats. 1473 46 Street purposes in accordance with the Privacy O( a~ 1. Application Information - Please Print All Information Property Owner's Name Parcel # Koss Christopher (I" Choice Builders LI,C.) 036-2153-15-000 Property Owner's Mailing Address Property Location Q 1473 46°i Street (3ovt. Lot City, State =54025 Phone Number NW 1A, NE Section 20 Somerset, W l cle one) T30N R19E W II. Type of Building (check all that apply) ®1 or 2 Family Dwelling - Number of Bedrooms 15 Subdivision Name Pioneer Ridge ❑ Public/Commercial - Describe Use Block 9 ❑ City of ❑ State Owned - Describe Use El Village of CSM Number ~ ® Town of *6Wea*1 i velrdek.l III. Type of Permit: (Check only one box on line A. Complete line B .if applicable) A. m ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) ❑ Permit Renewal ❑ Permit Revision ❑ Chanue of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Olvner IV. Type of POWTS System/Component/Device: (Check all that apply) 4Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 i of suitable soil _ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) ~t'' 44b( V. Dispersal/Treatment Area Information: Design Plow (gpd) Design Soil Application Dispersal Area Required (st) Dispersal Area Proposed (sfJ System Elevatio 600 Rate(gpdsf) 1200 1200 102.50, 101.75'. 101.00' 0.5 Vl. Tank Info Capacity in Gallons Total tt of -0 c~ ~ n 2 Manufacturer .r 11 Gallons Units o - New Tanks Existing ranks Icy = U ✓ v c U Septic or Holding Tank 7 1250 I Wieser Concrete ® ❑ ❑ ❑ ❑ Dosing Chamber El E] El El ❑ V1 1. Responsibility Statement- I, the undersigned, assume responsibili", for installation of the POINTS shown on the attached plans. Plumber's Name (Print) Plum Si ature F /MPRS Number Business Phone Number John Schmitt '1~~2 zw~ z 760 715 760 0486 Plumber's Address (Street, City, State. Zip Code) 616 150`1' Ave. Somerset. WI 54025 VIII. County/De artment Use Only ssui g A- t Signature Issue l Approved Isapproved Permit Fee o ~z C, 01r, O L 00 wneson o enal ,lT Ia. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER: 1. Septic tank, effluent filter and dispersal cell must be_serviced maintained as per management plan provided by plumber. Se aC regUlrer $ tblt ~eR}j ~h6ktRlFfh system and submit to the County only on paper not less than 8 Ill x I I inches in size cs per applicable code'r,,,ilranrr. SBD-6398 (R03/14) CONVENTIONAL COMPONENT DESIGN Re's dei"tI nr^IIl;;7t(oim, INDEX AND TITLE PAGE Project Name: 1st Choice Builders 4 Bedroom Septic System Owners Name: Christopher Koss Owner's Address 5660 Memorial Avenue N Stillwater MN 55082 Legal Description: NW1/4, NE1/4, S20, T30N, R19W Township St. Joseph County: St. Croix Subdivision Name: Pioneer Ridge Lot Number: 15 Block Number Parcel I.D. Number 030-2153-15-000 Plan Transaction No. Page 1 Index and title Page 2 Plot Plan Page 3 Septic Tank Specifications Page 4 Effluent Filter Information Page 5 System Sizing & Cross Section Page 6 EZ Flow Information Page 7 & 8 Management and contingency plan Page 9 Septic Tank Maintenance Agreement Page 10 Warranty Deed Page 11 CSM or Plat Attachment 1 Soil Evaluation Report Attachment 2 House Plans Designer: John Schmitt Licnese Number: MPRS 223760 Date: 10/23/2017 Phone Number: 715-760-0486 Signature: fG'zT In-Ground Soil Absorption Component Manual Version 2.0 SBD-10705-P (N. 01/01) Page 1 PLOT PLAN N Project Name. 1 St Choice Builders 4 Bedroom Septic System Legal Description: NW114, NE1A S20, T30N, R19W P. 1. D: 030-2153-15-000 Subdivision Name: Pioneer Ridge Lot 15 SCALE: V=so' Township: St. Joseph Parcel Size: 3.00 County: St. Croix _ System Elevation: T1= 102.50 Pro osed 80.00' EZ Flow Trenc Slope: 12% T2= 101.75 Pro osed 80.00' EZ Flow Trench BM1 Elevation: 100.00' To of 2" PVC pipe T3= 101.00 Proposed 80.00' EZ Flow Trench BM2 Elevation: 95.45' To of 2" PVC Pipe ■ Backhoe Pits: Septic Tank Wieser Concrete WLP1250-MR See Plat Map for complete view of parcel Effluent Filter POLYLOK 525 4 inch Sch 40 -ASTM D2665 4 inch 3034 - ASTM D3034 O c, ~t r c u L Sr n j V\ ~ zxz~ .r4 i3J4J Z ZII/ 1 - - - Page 2 PREPARED FOR: COUNTY PLAT OF: PIONEER RIDGE NaoEST cararu_ Lrc S1~J n512W A'.CeWE THE NE1/4 OF THE NE1/4, NWi/4 OF THE NE1/4, SE1/4 OF THE (au} ~a-seo. u u" 5315° NE1/4 AND THE SW114 OF THE NE1/4 OF SECTION 20, T30N, R19W, ''+>nux.Jt1 PREPARED BY: ,j:;. TOWN OF ST. JOSEPH, ST. CROIX COUNTY, WISCONSIN. SbN L,NO J.:R`F r.NO u;.. '.92C :,W CV: $111;;1 y5()5 Nt:C.~rr'. 'N 5M.15 LOT 26 PREPARED BY: I LOT 2] NITF CC1,1 ;1PLrT 7, °•tnrE 1°i ~ 1 ~ - LOT 26 1 l T C1O s'o"~ LOT 29 ax ~ r LEG µ I SEE 9N / LOT ]O LOT 5 c~ e' - YENU _ .,2 6,471 - - 149TH A n,+a LOT 10 LOT 12 ~ LOT 2a [n :d j uc LOT 14 T Y ~ wx>-..ten n,au, 9 - .e LOT 23 .;--_41 ` y ti 7 vA 9'c+ W LOT 21 nL ~j LOT 10 ❑6}INAOE ~j 3~~r r/(( })NA EASEMENT ~I. -T T- T OLe e' 1 f LOT 9 LOT 22 LOT 18 '1y 4 iE, G riz t T q J f / N~ LOT 8 ~ \1 LOT 11~ t y T' \ i LOT AREA TABLE . LOT z0 .R.:-~ o w ,A, , ENT - T ~ TnnLE O LOTT N xas ~K LOT16- y7 LOT 18 'milt ~nJ / Y28 z~ scA;E w r " °TYVr K LOT 8 ' r '1r 5 Po 14- i ~ u 'se9aoxwrol6 ar owvnoE - n k M ct_ 2.. EASEMENT TAFLE 'N - 'l xD l' S yt~ Xc tv ]MKS u t -..-i. ro.t 033 6 rtiR 1 ,Wrp a,y~u .I.a. Ax v...,u.J~ v)[. v/Ca(ro:; F[.ui. ie,YO» SNEET 3 01 J SETS Pace 11 air-09ZIdw :3~ij 95 8-SZ~-008 0 \ :dnOd-1SOd •31VO 00/00/00 :-1 09L46 IM 'NOOJ N3OIVW OL WH Sn 9L42M ~vnNVN OIlcd]S w o 00d-38d „O-,L=„4 L 31VOS dOM J.8 NMVaO 313801100 13531M 6w_05Z~dl, 0 W x ~ ~Q W d z mo I1 CY J z o Of W o 0 V) a t~ aC:: W z m d. m o D O w O X0L~,,11 ~ LL w_ V) d ° U W F- _J J H Of Cf) J 'S m o F- 0!o Li0- X O ~ Z o o z om o¢ z w~ Q H O > Z to O U F- J z 2 N :2 m t- 3 o a F :D c~ > u 1- a o 0 oow a¢o ¢ Zo a o d 0 ~p O mcn Jww (_D \ Ozv~i U ¢ a ° M Ci O d c cU m q Q 11 d a0 J r O Z Y c U -N\~dr7J W I QmW(n WCa Q -00O z O o o~ I Lf) ~ U) M W a ao a° U \W NN0c WWLO WQU LLJ } od U O= c)z Y~ D V) N~ OQ W O OW Q ZI- J (n WU pW F ..0~ t- ?i0 Y QWQ W mF O~ VI (n 0 1-- J OQOOQL~wwMWC07w <t z~0 v O~C~> O QLJ :2 Q§ No d C~ Nle, z3co0 J3mJ~ ~ F- o zo< Z U ci~.. :20 z J J Q Y Y in Q 0 Z Z < U< U J a W i d I r H- U w <t o ~ z W M w D K J I N Ow Q Q I U w Li !~j V) o ( cn I I Q o I w Q t O „S x ci ~ w W HI w N U J d Z D z (1b32J „ti8 Sd ,~ZS a V) Y z a Page 3 of 1 ~~~t 3 x 41 ti PL-525 Effluent Filter G~ it atrons i+~ PrceasC Draa t c Zabel " sPa"Idfer Prd¢cPSi,S A Divislan of Falylak Inc. The PL-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 Polylok PL-525 has an automatic shut-off ball installed with every filter. When the filter is removed for cleaning, the ball will float up and temporarily shut off the system so the effluent won't leave the tank. Rated for 10,000 GPD v~ Alarni Switch (gallons per day). (optional) 525 linear feet of 1 X16" filtration. Accepts "t" PVC Accepts 4" and 6" SCHD 40 pipe. ( Extension Handle Built in gas deflector. Automatic shut-off ball when filter is removed. &Ited for Alarm accessibility. ~i 10,000 GPD Accepts PVC extension handle. I 1~ a Ideal for residential and commercial waste flows up to 525 Linear Ft. of 1/16" Filtration Slots 10,000 gallons per day (GPD).-' 1. Locate the outlet of the septic tank. 2. Remove the tank cover and pump tank if necessary. Accepts 4" & 6" 3. Glue the filter housing to the 4" or 6" outlet pipe. If SCHD 40 pipe the filter is not centered under the access opening use a Polylok Extend & Lok or piece of pipe to center filter. 4. Insert the PL-525 filter into its housing. ~ P Certified to 5. Replace and secure the septic tank cover. NSF/ANSI Standard 46 ~t ~1.rt1 if I-ialI'.4'i The PL-525 Effluent Filters will operate efficiently for several years under normal conditions before requiring cleaning. It is recommended that the filter be cleaned every time the tank is pumped, or at least every three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the filter r~Gas Deflector needs servicing. Servicing should be done by a certified septic tank pumper or installer. Automatic - Shut-Off 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. 6. Insert the filter cartridge back into the housing making C7rrtcionr nn;rttiPer :`41arn; Extend ~ Lok0v sure the filter is properly aligned and completely inserted. Polylok, Zabel & Best' est filters accept Easily installs 7. Replace and secure septic tank cover. the SmartFilte t, switch and alarm. into existing tanks. Polylok, Inc. 3 Fairfield Blvd. Wallingford, CT 06492 Toll Free: 877.765.9565 Fax: 203.284.8514 www.polylok.coni Page 4 SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT Project Name: 1st Choice Builders 4 Bedroom Septic System Gravelless Leaching Unit Specifications Manufacturer Model Laying Length EISA Rating EZ1203H-5ft 5.0' 25.0 Infiltrator EZ1203H-10ft 10.0' 50.0 System Sizing 0 EISA Rating per Foot of EZ Flow ft2 Soil Application Rate 0.5 gpd/ft2 600.0 gpd Design Flow _ 0.5 Soil Application Rate . F-5-1 EISA = 240.0 Feet of EZ Flow trenches 80 feet long each 3 No. of Cells 8 Per Cell 3 ft Cell Width 24 Total No of 1203H 80 ft Cell Length 400 sq ft EISA Per Cell 3 ft Cell Spacing 1200 sq ft Total EISA Typical Cross Section Finished Grade 105 ft Observation Pipe with approved cap or vent I Soil Backfill Geotextile Fabric 36 inch >3 ft U-5D > 3ftSlotted and Anchored Vent/Observation Pi 12 inch ~ with Cap O -T 102.50 ft. r O >36 inch 101.75 ft. 101.00 ft. Infiltrative Surface Plumber/Designer Signature: License MPRS 223760 Date: October 23, 2017 Page 5 Installation Instructions for o #Ow Systems in Wisconsin Z fllyFILTRATOR Wisconsin Department of Commerce, Safety and Buildings 5. The Absorption area (SF) necessary for a given site shall Division, has reviewed the specifications and/or plans for this : be sized based on maximum daily sewage flow (GPD) and product and determined it to be in compliance with chapters the Permeability for the site. If certain criteria is met, the Comm 82 through 84, Wisconsin Admin. Code, and Chapters EISA sizing can be used in Wisconsin, resulting in a 40% 145 and 160, Wisconsin Statutes. All sites must meet the Site smaller drainfield. & Soil Conditions & Locations & Isolation distances as noted in local regulations. 6. Place EZflow bundle(s) in the EZflow configuration ap- proved by system design permit specified for the particu- The approved products bundles with pipe in lar site. The top or center-most bundles containing pipe are 1 203H (3-12" center bundle in 5' or 10' lengths) and 1203HP (3-12" bundles are joined end to end with an internal pipe coupler. Any with pipe in each bundle in 5' or 10' lengths. additional aggregate only bundles that may be required, • should be butted against the other aggregate-only bun- A single pipe bundle contains a four inch perforated pipe sur- dies and do not require any type of connection, rounded by EPS aggregate and is held together with poly- ehtylene netting. A single aggregate bundle contains aggregate 7. The top of each GEO cylinder contains a filter fabric pre- only and is held together with polyethylene netting. manufactured in between the netting and aggregate. The fabric is inserted to prevent soil intrusion. The installer Materials and Equipment Needed shall make sure the the GEO is positiioned upward and is • EZflow Bundles in contact with the fabric contained in the adjacent cylin- • EZflow Geotextile Fabric ; der before backfilling. • EZflow Internal Pipe Couplers • Pipe for Header and Inlet 8. The EZflow Drainfield Systems should be installed in a • Backhoe/Excavator 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 instructions for installation of EZflow products are given adjoining 10-foot cylindrical bundles placed end to end, below. This product must be installed in accordance with state : with central bundle distribution pipe interconnected, rules defined in chapters Comm 82 through 84, Wisconsin Ad- without any dams, stepdowns or other water stops. ministrative Code, and Chapters 145 and 160, Wisconsin Stat- utes, as well as the local health department's current design 9. The trench top shall be graded such that water will not manual. pond. Backfill should be seeded or sodded immediately after completion to reduce erosion. 1. After the local health department has determined sizing, configuration, and layout for the EZflow systems, stake 10. EZflow EPS bundles are flexible and can fit in curved or mark with paint the location of trenches and lines. Be trenches as may be necessary to avoid trees, boulders, or careful to set correct tank, invert pipe, header line or dis- other obstacles. tribution box and trench bottom elevations before instal- lation of pipe bundles. 1 1. EPS aggregate is lighter than water, therefore, it might be expected that natural buoyancy forces would tend to 2. Remove plastic EZflow shipping bags prior to placing : cause EZflow assemblies to float out of ground when bundles in the trench(es). Remove any plastic bags in the pending occurs. Field experience has shown, however, trench before system is covered. that this is not a problem when systems have a minimum of 6" of soil cover as recommended by manufacturer. 3. This product must have geotextile fabric that meets re- quirements of s. Comm 84.30 (6) (g), Wis. Adm. Code, installed directly on top of the product and extending 1203H-GEO down along the sides of the product to a point at least six inches from the bottom of product, , _ Geotextile W`Barrier Material { 71, 4. When installed in a trench, the trench should be dug to • t? ha ii ni i il~i w - rni~iY~uli I a width of 36 inches. This not only saves labor in excava- ~ tion, but also provides better load-bearing capacity after backfilling is complete. •a-- 36' Page6 POWTS OWNER'S MANUAL & MANAGEMENT PLAN FILE INFORMATION SYSTEM SPECIFICATIONS Owner: Christopher Koss Tank Manufacturer: Wieser Concrete fl NA Permit # ❑ Septic ❑Dose ❑-iolding Volume: 50 PP DESIGN PARAMETERS Tank Manufacturer: Wieser Concrete NA Number of Bedrooms. 4 ❑ NA ❑ Septic ❑Dose ❑iolding Volume: gal Number of Public Facility Units: ❑ NA Vertical Distance Tank Bottom(s) to Service Pad: ft Estimated (average) Flow: 400 gal/day Horizontal Distance Tank(s) to Serivice Pad: ft Design Flow = estimated x 1.5: 600 gal/day Specific servicing mechanics must be provide if vertical is>15 feet or if In Situ Soil Application Rate: 0.50 gal/day/ft2 horizontal is > 150 feet. Specific instructions to be provided on back. Standard Domestic Influent/Effluent Monthly average Effluent Filter Manufacturer: POLYLOK ❑ NA Fats, Oils & Grease (FOG) 530 mg/L Effluent Filter Model: Biochemical Oxygen Demand (BOD5) <_220mg/L ❑ NA ump anu acturer: Total Suspended Solids (TSS) s150mg/L Pump Model: High Strength Influent/Effluent Monthly average Petreatment Unit NA Fats, Oils & Grease (FOG) s30 mg/L Manufacturer: Biochemical Oxygen Demand (BODs) 5220mg/L Q NA ❑ Mechanical Aeration ❑ Peat Filter Total Suspended Solids (TSS) 5150mg/L ❑ Disinfection ❑ Wetland Petreated Effluent Monthly average ❑ Sand/Gravel Filter ❑ Other: Biochemical Oxygen Demand (BOD5) 530mg/L of sorption ystem Total Suspended Solids (TSS) s3omg/L 121 NA 7 In-Ground (gravity) ❑ In-Ground (pressure) Fecal Coliform (geometric mean) 5104cfu/100m1 ❑ At-Grade ❑ Mound Maximum Effluent Particle Size: Aa in dia. A ❑ Drip-Line ❑ Other: N Other: ❑ NA Other: ❑ MAINTENANCE SCHEDULE Service Event Service Frequency When combined with sludge and scum equals one-third (Y3) of tank volume Pump out contents of tank(s) When the high water alarm is activated At least once every: 3 month(s) Maximun 3 Years) El NA Inspect condition of tank(s) year(s) month(s) Maximun 3 Years) El NA L_j Inspect dispersal cell(s) At least once every: 1.5 ❑ ears (month(s) ❑ NA Clean effluent filter At least once every: 1.5 year(s) month(s) Q NA Inspect pump, pump controls & alarm At least once every: years month(s) Q NA ear s) month(s) NA year s) 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 Insepector, POWTS Maintainer; Septage Servicing Operator (pumper). Tank inspections must include a visual inspeciton 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 a check for any back up or ponding of effluent on 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 indicated a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumualtion of sludge and scum in any treatment tank equals one-third 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 Admininistrative Code_ All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, petneatment units, and any servicing at intervals of <_12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 30 days of completion of any service event. (Rev.2/05) Page 7 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 soil 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 extended 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 and may overload them resulting 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) 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 out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide the opportunity to obtain a sanitary permit for a code compliant replacement system: ® A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated 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 locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. WARNING: 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 ai CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK IS VERY DIFFICULT. ADDITIONAL INFORMATION: POWTS INSTALLER POWTS MAINTAINER Name: John Schmitt Name: John Schmitt Phone: 715-760-0486 Phone: 715-760-0486 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name: Owners Choice Name. St. Croix County Zoning Phone: Phone: 715-386-4680 This document is intended to meet minimum requirements of Ch. Comm 83.22(2)(1b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. I Ica of this rlnrumant rinac not nijgrnntPP.. the nerformance of the POWTS. Paee 8 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Christopher Koss Mailing Address 5660 Memorial Avenue N. Stillwater, MN 55082 Property Address 1473 46th Street (Verification required from Planning & Zoning Department for new construction.) City/State Somerset, V V I Parcel Identification Number 030-2 1 53-1 5-000 LEGAL DESCRIPTION Property Location NW NE '/a ,Sec. 20 T 30 N R 19 W, Town of St. Joseph Subdivision Plat: Pioneer Ridge Lot# 15. Certified Survey Map Volume Page # Warranty Deed # (before 2007)Volume Page # Spec house ❑ yesE1o Lot lines identifiable ElyesE]no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1 /3 full of sludge. I/we, 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 must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms 4 rf, 10/23/2011 SIGNATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) Page 9 Visconsin SOIL EVALUATION REPORT #1 in accordance 'h Comm 85, Wis. Adm. Code Page 1 of 3 ,o Department of Commerce 3 Schmitt Soil Testing, Inc. Division of Safety and Buildings County Attach complete site plan on paper not less than 8'/2 x 11 inc in s an must St. Croix include, but not limited to: vertical and horizontal reference poin M), io nd Parcel t. percent slope, scale or dimensions, north arrow, and location and ' tance are t road. O 3lJ -'5- 5 / s-co() Please prim all InREADEW E D Revi By Date Personal informabon you provide may be us 9d for secondary purposes (Privacy w, s. 04 (1) (m)). / z / B o V- I Property Owner 2006 roperty Location Golden Harvest Capital, LLC ovt. Lot NW1 , NE1/4, S20, T30N, R19W Property Owner's Mailing Address ST. CROIX COUNTY of to Block # Subd. N e or CSM# 14906 Blakeney Road 15 Pioneer Ridge City State Zip Code Phone Number City Village R Town Nearest Road Eden Prairie MN 55347 (612)202-3234 St.Joseph 50Th St. New Construction r Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD Use: 1 Replacement LJ Public or commercial - Describe: Parent material Outwash Flood plain elevation, if applicable na ft. General comments and recommendations: Area os suitable for a conventional system with a 0.5 9pd/sgft. Possible system elevation for Area 1 (step trenches) is high renc 102.5', low trench 101.0'. Boring # ❑ Boring ,~d pit Ground surface elev. 106.37 ft. Depth to limiting factor 106+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/M 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 1 0-7 10yr4/4 none sl 2fsbk mvfr cs 2vf .6 1.0 2 7-13 10yr4/6 none grsl 2msbk mf gw lvf .6 1.0 3 13-24 10yr5/6 none ft Osg ml cs .5 1.0 4 24106 10yr5/4 none grcos Osg ml 7 1.6 Boring # N Boring N pit Ground surface elev. 106.37 fl. Depth to limiting factor 110+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consisten Boundary Roots GPDM2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •EH#1 'Eff#2 1 0-6 10yr3/3 none I 2fsbk mvfr as 2f,2vf .6 .8 2 6-12 10yr4/4 none grsl 2fsbk mfr gw 1vf .6 1.0 3 12-34 10yr4/4 none grsl 3fsbk mfr gw 1vf .6 1.0 4 34-62 10yr5/4 none g6s lcsbk mvfr gw - .7 1.6 5 62-72 10yr6/4 - --none Ifs lesbk mfr gw .5 1.0 6 72-110 10yr5/6 none , grs Ogg ml - .7 1.6 /oz' z• 'Y Effluent #1 = BOD? 30 < 220 mg/L and TSS -36<150 mg/L ' Effluent #2 = BOD5 <_30 mg/L and TSS <_30 mg/L CST Name (Please Print) Signature: _ CST Number Thomas J. Schmitt t ate- ruo 227429 Address Schmitt Soil Testing, Inc. Date Evaluation Conducted Telephone Number 1595 72nd Street New Richmond, WI 54017 8/4/2006 715-247-2941 sap-8330 (x.07/00) Property Owner Golden Harvest Capital, LLC Parcel ID # Page 2 of 3 I ' ]Boring # D Boring J ® pit Ground surface elev. 103.37 ft. Depth to limiting factor 108+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIft' in. MunseH Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eft #1 'Eff#2 1 0-8 10yr4/3 none grsl 2msbk mfr as 2f,2vf .6 1.0 2 8-31 7.5yr5/4 none grcos Osg Ml Cw ivf .7 1.0 3 31-45 10yr5/6 none ifs icsbk mvfr 9w .5 1.0 - .7 1.6 45-108 1 4 none ricos lcsbk mvfr 4 9 i 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/ft' in. MunseH Ou. Sz. Cont. Color Gr. Sz. Sh. 'Efr#1 'E j Boring ng Soii A lication Rate Ground surface elev. ft. Depth to limiting factor in. pp F-1 Boring # LI Pit Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDfft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#t •Eff#2 Effluent #1 = BOO5> 30 < 220 mg/L and TSS >30 a 150 mg/L ' 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 (R.07/00) Schm tt Sol TMUN, Inc. Page 3 of 2 Conducted by: Conducted For. 'Schmitt Soil Testing Inc. Name: Goklen Harvest Capital, LLC Thomas J. Schmitt, CST 227429 Address: 1440 Arcade St.. N 1595 72nd St. City, State, Zip: St. Paul, MN. 55105 New Ricbmond, WI. 54017 Phone: 715-247-2941 Subd.Name: Pioneer Ridge Lot No.: Legal Description: %6tl 1/4 NE1/4 S20 T30N R19W Backhoe pit Township, County: St. Joseph, St. Croix ® Bench Mark EL 100.00' Top of 2" pvc pipe. d Alternate Bench Mark EL Top of 2" pvc pipe slope= Contour Line Contour Line Length Scae 1" = 40' r ~~RQr r ~ .~f ~~?v ~ I y8 Th&SeiMaiSiDBVMW&dnVMOMMpiMWOMM" a=MftjvVb=WLljwWorMyndb&MkCld MW*2WrWWL i r: - a o n. S - - - - - - - - ry N " II I 1° L N N O DRAWING-S PROVIDED BY. Ukr+t lrvonnrilpn PrcperSJ lnlamalian NO. DESGRIPTtON 8T DATE rn A ° D Arcola Design LLG. ~n'i rn w rn Ron Johnson New Home Design 3 mda 651-271-0193 2150 5q. Ft. Nvisconsin SOIL EVALUATION REPORT #1464 Department of Commerce in accordance with Comm 85, Wis. Adm. Code Page 1 of 3 Division of Safety and Buildings 3 Schmitt Soil Testing, Inc. Attach complete site plan on paper not less than 8% x 11 inches in sib'] an must County St. Croix include, but not limited to: vertical and horizontal reference point-(13M), ho nd - percent slope, scale or dimensions, north arrow, and location and distance are t road. Parcel I. Please print all i►REQrM4VED Reviled By Date Personal information you provide may be us ad for secondary purposes (Privacy L w, s. 04 (1) (m)). Z $ O Property Owner 2006 roperty Location Golden Harvest Capital, LLC ovt. Lot NW1 NE1/4, S20, T30N, R19W Property Owner's Mailing Address ST. CROIX COUNTY of # Block # Subd. N e or CSM# 14906 Blakeney Road 15 Pioneer Ridge City State Zip Code Phone Number City Village Town Nearest Road Eden Prairie MN 55347 (612)202-3234 St.Joseph 50Th St. New Construction Use: Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD Replacement Public or commercial - Describe: Parent material Outwash Flood plain elevation, if applicable na ft. General comments and recommendations: Area os suitable for a convent~ion_allssvstem with a 0.5gd/sqft. Possible system elevation for Area 1 (step trenches) is high rrenccF 102.5', low trench 101.0'. Boring # _ -1 Boring i Pit Ground surface elev. 106.37 ft. Depth to limiting factor 106+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistenc Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-7 10yr4/4 none sl 2fsbk mvfr cs 2vf .6 1.0 2 7-13 10yr4/6 none grsl 2msbk mf gw 1vf .6 1.0 3 13-24 10yr5/6 none fs Osg ml cs .5 1.0 4 24-106 10yr5/4 none grcos Osg ml .7 1.6 Boring 2 Boring # Pit Ground surface elev. 106.37 ft. Depth to limiting factor 110+ -in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistenc Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-6 10yr3/3 none I 2fsbk mvfr as 2f,2vf .6 .8 2 6-12 10yr4/4 none grsl 2fsbk mfr gw 1vf .6 1.0 3 12-34 10yr4/4 none grsl 3fsbk mfr gw 1vf .6 1.0 4 34-62 10yr5/4 none grls icsbk mvfr gw .7 1.6 5 62-72 10yr6/4 none Ifs 1csbk mfr gw .5 1.0 6 72-110 10yr5/6 none grs Osg ml .7 1.6 /6 Z - - 7 Z-10 * Effluent #1 = BODS> 30 < 220 mg/L and TSS >36< 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS <30 mg/L CST Name (Please Print) Signature: CST Number Thomas J. Schmitt 227429 Address Schmitt Soil Testing, Inc. Date Evaluation Conducted Telephone Number 1595 72nd Street New Richmond, WI 54017 8/4/2006 715-247-2941 SBD-8330 (R.07/00) Property Owner Golden Harvest Capital, LLC Parcel ID # Page 2 of 3 F3 ]Boring # Boring Pit Ground surface elev. 103.37 ft. Depth to limiting factor 108+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 1 0-8 10yr4/3 none grsl 2msbk mfr as 2f,2vf .6 1.0 2 8-31 7.5yr5/4 none grcos Osg ml cw 1vf .7 1.0 3 31-45 10yr5/6 none Ifs lcsbk mvfr gw .5 1.0 4 45-108 10yr5/4 none grlcos lcsbk mvfr .7 1.6 u 2 ❑ Boring # Boring I 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/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 F-1 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/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 " Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 <150 mg/L ' 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 (R.07/00) Schmitt Soil Testing, Inc. Page 7 of 2 Conducted by: Conducted For. Schmitt Soil Testing Inc. Name: Golden Harvest Capital, LLC Thomas L Schmitt, CST 227429 Address: 1440 Arcade St. N 1595 72nd St. City, State, Zip: St. Paul, MN. 55106 New Richmond, WI. 54017 Phone: 715-247-2941 Subd.Name: Pioneer Ridge s ~2 chu~~` Lot No.. A Datc C6, Legal Description: 5W 1/4 NEl/4 S20 T30N R19W i Backhoe pit Township, County: St. Joseph, St. Croix A Bench Mark EL 100.00' Top of 2" pvc pipe. © Alternate Bench Mark EL ..S _VS- Top of 2" pvc pipe Slope= /a? Contour Line El. A114 Contour Line Length N Scale I"= 40' l~ r J 17us Soi and Site Ew>uaboa aas compieted to fitti a maiog se at it nary craw am be is a location soil" for YOW use.