HomeMy WebLinkAbout040-1236-10-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No 600282
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:
Thomas & Melissa Dress 7 TOWN OF TROY 040-1236-10-000
CST BM Elev: Insp. BM Elev: BM Description ection/Town/Range/Map No:
(1 cv 03.28.19.1187
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration ` Bldg. Sewer
Holding V St/Ht Inlet
TANK SETBACK INFORMATION S t/ Outlet
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD t Inlet v
Septic Dt Bottom
Dosing Header/M
Aeration Dist. Pipe
r, 3
Holding Bot. System
Final Grade .e^
PUMP/SIPHON INFORMATION /
Manufacturer DPMand St Cover
Mode umber
TD Lift Friction Loss em Head TDH Ft on
2.01 //0 .7
1 _Ox
Forcemain Dia. Dist, to Well _ (^I /
SOIL ABSORPTION SYSTEM -i -f
BED/TRENCH Width 11-ength j, No. Of Trenche3 PIT DIMENSIO No. Of Pi Inside Di Liquid De~Eh
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer INFORMATION CHAMBER OR
Ty e Of System: UNIT Model Numb
DISTRIBUTI SYSTEM or,44, (0 ei D ~4 f'Yoirt Piec~
Header/ old Distribution x Hole Siz x Hole Spacing Vent to Air Intake Q
1,~ r /I Pipe(s)
Length Dia Length Dia Spacing C
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
C/ Depth Over t Depth Over 1xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Cent I1 Bed/Trench Edges I zit Topsoil Yes ~ No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 528 GILBERT RD d ~ej, rS/ f, 61k,
1.) Alt BM Description Sq-6 -
2.) Bldg sewer length = C" • q,// 0
- amount of cover S ( Nv ~Ue
CC.~~ ! n s~ hv sv' ~.S
Plan revision Required? ]Yes No ~l7
Use other side for additional information. ' /
Date In is Signature Ce t. No.
SBD-6710 (R.3/97)
Q SAN -,3a ► -7 , qd/
County
Industry Services Division St. Croix
Ixir`t Q $ NQ V I to, 1400 E Washington Ave Sanitary Permit Number (to be filled in by Co.)
P.O. Box 7162
'i P S ;CROD(COU14TY disc , WI 53707-7162 O
~}NITY DEVELOPMENT
Sanitary Permit A cation State 'I'ransacti umber
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form 1T~*~ 9rt1iental unit
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned PO S are submitted to Project Address (if different than mailing address)
the Department of Safety and Professional Services. Personal information youu provide may be used fof seconda . 528 Gilbert Road
purposes in accordance with the Privacy Law, s. 15.04(I)(m), Stats. y
1. Application Informa Please Print All Information
Property Owner's Name Parcel
Dress, Thomas & Melissa 040-1236-10-000 • p
Property Owner's Mailing Address Property Location O
528 Gilbert Road
Govt. Lot
City, State Zip Code Phone Number SE '4, SW '14, Section 3
(circle one)
Hudson , WI 54016 T28N R19EorlY~
II. Type of Building (check all thjat Lot n
® I or 2 Family Dwelling- Number 5Subdivision Name
Country Wood
❑ Public/Commercial - Describe UsBlock #
❑ City of
F-1 State Owned - Describe Use ❑ Village of
SM ~LllmbCr
®Town of Troy
3
~'b 4J
III. T e of Permit: (Check onl Zone box on line A. Complete line B if applicable)
A. ❑ New System ® Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
B. Before Expiration Plumber Owner 268594, 8/15/1996
- -
IV. Type of POWTS System/Component/Device: (Check all that apply)
® Non-Pressurized In-Ground ❑ Pressurized ln-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
Holding 'lank t ler ispersal Component (ex lain) ❑ Pretreatment D - ice (explain)
V. Dispersal/Treat nt Area Information: a
Design Flow (gpd) Design Soil Application Dispersal Area Required st) Dispersal Area Prop ed (sf) System Elevation 0
450 Rate(gpdsf) 900 900 X
0.5 i
VI. Tank Info Capacity in o a ~U
Gallons Total # of
Man facture5r ' 8 v
L ZS a U )
m
New Tanks Existing Tanks Gallons Units ~ (7 v
Septic or Holding Tank 1000 1000 1
Dosing Chamber 1 ❑ ❑ ❑ ❑ 0
VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name Plumb- s igt 'tire MP/MPRSNumber Business Phone Number
(Innt)
223760 715-760-0486
John Schmitt
Plumber's Address (Street, Cit}, State, "Lip Code)
616 150`h Ave. Somerset, WI 54025
VIII. -County/Department Llse Only -
Approved Permit Fee Date sued ISSLlin° ent Signature
S'
~M r GFiven Rcason for Denial S ~ Z 17
,uteasasfor disapproval
IX. Condit nopt'fi'rN1T
V. EFn: u . rn Mss
J
(Asper -o cell oust all be s=ic s ii
as per iTlar.3gement plan p o %iaed by plumber. &r-.,
2, y~('(~(~M9S".k11~'S dT11~1f%.rie40Sti 11`:E
Attach to complete plans for the system and suit ro the Cou t' ly un paper not less than H V2 r 1 I inches in size CY\
SBD-6398 (803/14) Ljen"~- Q r
CONVENTIONAL COMPONENT DESIGN
INDEX AND TITLE PAGE
Project Name: Dress 3 Bedroom Replacement Septic System
~I
Owners Name: Thomas & Melissa Dress
Owner's Address 528 Gilbert Road
Hudson, WI 54016
Legal Description: SE1/4, SW1/4, S3, T28N, R19W
Township Troy
County: St. Croix
Subdivision Name: Country Wood
Lot Number: 50 Block Number
Parcel I.D. Number 040-1236-10-000
Plan Transaction No.
Page 1 Index and title
Page 2 Plot Plan
Page 3 Effluent Filter Information
Page 4 System Sizing & Cross Section
Page 5 EZ Flow Information
Page 6 & 7 Management and contingency plan
Page8 Existing Tank Certification
Page 9 Septic Tank Maintenance Agreement
Page 10 & 11 Warranty Deed
Page 12 CSM or Plat
Attachment 1 Soil Evaluation Report
Designer: John Schmitt Licnese Number: MPRS 223760
Date: 11/15/2017; f Phone Number: 715-760-0486
Signature:
~L r
AQ
In-Ground Soil Absorption Component Manual Version 2.0 SBD-10705-P (N. 01/01)
Page 1
PLOT PLAN ~T
Project Name: Dress 3 Bedroom Replacement Septic System
Legal Description: SE114, SW114, S3, T28 N, R19W P.I.D. 040-1236-10-000
Subdivision Name: Country Wood Lot 50
Parcel Size 2.09 Acres SCALE: 1^=50'
Township:, Troy
County: ISt. Croix
System Elevation T1= 107.30' Existing 50.00' Rock & Pipe
Slope: 6% T2= 105.54' Existing 50.00' Rock & Pipe ly,
A BM1 Elevation: 108.48 Septic Tank outlet T3= 103.30' Existing 50.00' Rock & Pipe L~
BM2 Elevation:) T4= 5 0' Proposed 60.00' EZ Flow Trench 3
® Backhoe Pits: T5= 10 30' Proposed 60.00' EZ Flow Trench {rrr~TTT"' ,
T6= 1 3. Proposed 60.00' EZ Flow Trench r`Q
Existing Tanks Midwest Precast 1000 alto 1 (1~4 %'AlblX, a tA- u4
~b~ ffluent Filter Polylok 525
E~ 4 inch Sch 40 -ASTM D2665 t
inch 3034 -ASTM D3034 i I~
Div r T~ i
0
A
v /
f-t'wSc ~S "
d
Page 2
PLOT PLAN N
Project Name: Dress 3 Bedroom Replacement Septic System
Legal Description: SE114, SW1/4, S3, T28N, R19W P.I.D: 040-1236-10-000
Subdivision Name: Country Wood Lot 50
Township: Troy Parcel Size 2.09 Acres SCALE: 1^=50'
County: St. Croix
System Elevation: T1= 107.30' Existing 50.00' Rock & Pipe
Slope: 6% T2= 105.54' Existing 50.00' Rock & Pipe
BM1 Elevation: 108.48 Septic Tank outlet T3= 103.30' Existing 50.00' Rock & Pipe
BM2 Elevation: T4= 1,05/0' Proposed 60.00' EZ Flow Trench 3,
® Backhoe Pits: T5= 10 30' Proposed 60.00' EZ Flow Trench
T6= 163.40' Proposed 60.00' EZ Flow Trench ~.ccA Existing Tanks Midwest Precast 1000 gallon ~,f►ti►►~fi a eJ~.
ffluent Filter Pol lok 525
4 inch Sch 40 -ASTM D2665
4 inch 3034 -ASTM D3034
Z4) )-7
°
0I'M i
° VN
f~I~NSc "
W EtA-
UP~P~G
r
O
1
~v
~V
Osage 2
( d( 7
An'
E'"' €nr„"3'ttil 812 1
a
v,r; 1" ill Cr in :f Zabel
,...;ct. P A D,,ic;cr of P klul, 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 autornatic 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.
features: 1/16" 1"iltra ion slo"s j
Alarm Switch
Rated for 10,000 GPD (gallons per day). a (optional)
525 linear feet of 1/16" filtration.
Accepts 1" PVC
Accepts 4" and 6" SCHD 40 pipe. Extension Handle
Built in gas deflector. ,
Automatic shut-off ball when filter is removed.
Rated for
Alarm accessibility. 10,000 (-',PL)
yak
Accepts PVC extension handle. i
4ntiS:lll ltii; E_: E i at'~ ~ afi m~
525 Linear Ft.
Ideal for residential and commercial waste flows up to of 1/16"
10,000 gallons per day (GPD). r--~ Filtration Slots
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 Lxtend & Lok or piece of pipe to center filter.
4. Insert the PL-525 filter into its housing.
Certified to
5. Replace and secure the septic tank cover. NSF'/ANSI Standard 46
'z'1--.'3 '..°5 1i~9ckt?3It'truilie; _C_)_MEz=
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 filters Gas Deflector
needs servicing. Servicing should be done by a certified l
septic tank pumper or installer. Automatic
Shut-Off Gall
1. Locate the outlet of the septic tank.
2. Remove tank cover and pump tank if necessar}'.
3. Do not use plumbing when filter is removed. r.
4. Pull PL-525 cartridge out of the housing. ''U
5. Hose off filter over the septic tank. Make sure all '
solids fall back into septic tank. l'
6. Insert the filter cartridge back into the hOUSIn akin
g m g ti; i [Filie~ ? AtOlni t{xtrnd e: Lolc
C?utrloz~r
sure the filter is properly aligned and completely inserted. Polylok, Zabel & Best fitters accept Easily installs
7. Replace and secure septic tank cover, the SmartFiltc b switch and alarm. into existing tanks.
Polylok Inc. 3 Fairfield Blvd. Wallingford, CT 06492 Toil Free: 877.765.9565 Fax: 203.284.8514 www.polylok.com
Page 3
SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT
Project Name: Dress 3 Bedroom Replacement 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
EISA Rating per Foot of EZ Flow ft2 Soil Application Rate 0.5 gpd/ft'`
450.0 gpd Design Flow 0.5 Soil Application Rate = E-5-1 EISA = 180A Feet of EZ Flow
trenches 60 feet long each
3 No. of Cells 6 Per Cell
3 ft Cell Width 18 Total No of 1203H
60 ft Cell Length 300 sq ft EISA Per Cell
3 ft Cell Spacing 900 sq ft Total EISA
Typical Cross Section
Finished Grade 108 ft Observation Pipe with
41
approved cap or vent
Soil Backfill
Geotextile Fabric
36 inch ~ ,
>3 ft
O ' > 3ft Slotted and Anchored VentJObservation Pi
12 inch II with Cap
O
- - 105.10 ft.
104.30 ft/ O
>36 inch
103.40 ft. Infiltrative Surface
Plumber/Designer Signature:
License MPRS 223760 Date: November 15, 2017
Page 4
Installation Instructions for
boy' Systems in Wisconsin 4J by INFILTRATOR
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 Gaily 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 anc 160, Wisconsin Statutes. All sites must meet the Site smaller drainfield.
& Soil Conditions & 1-ocations & 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 are 1203H (3-12" bundles with pipe in lar site. The top or center-most bundles containing pipe
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 recuired,
• should be butted against the other aggregate-only bur-
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 anc 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 Bundlcs ; in contact with the fabric contained in the adjacent cylin-
• EZtlow 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 o= 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.
tr&tion box and trench bottom elevations before instal- '
lation of pipe bundles. 11. 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
9 ( Barrier Material
• Iv i
4. When installed in a trench, the french should be dug to
-
lit lira 11)"
s labor in excava : e Tz3~ `~rr',~ ~
a width o; 36 inches. This not enly save ~t ,
tion, but also provides better load-hearing capacity after
bdckfillirig is complete,
Page 5
POWTS OWNER'S MANUAL & MANAGEMENT PLAN
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner: Thomas & Melissa Dress Tank Manufacturer: Midwest Precast ❑ NA
Permit # 0 Septic ❑Dose E]-lolding Volume: 0 gal
DESIGN PARAMETERS Tank Manufacturer: Q NA
Number of Bedrooms: 3 [vJ NA E Septic ❑Dose ❑-Iolding Volume: gal
Number of Public Facility Units: E21 NA Vertical Distance Tank Bottom(s) to Service Pad: It
Estimated (average) Flow: 300 gal/day Horizontal Distance Tank(s) to Serivice Pad: ft
Design Flow= estimated x 1.5: 450 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: PDLYLOK ❑ NA
Fats, Oils & Grease (FOG) s30 mg/L Effluent Filter Model:
Biochemical Oxygen Demand (BOD5) !Q20mg1L NA Pump Manufacturer:
Total Suspended Solids (TSS) 5150mg/L Pump Model:
High Strength Influent/Effluent Monthly average Petreatment Unit / NA
Fats, Oils & Grease (FOG) s30 mg/L Manufacturer:
Biochemical Oxygen Demand (RODS) _220mgIL NA U Mechanical Aeration ❑ Peat Filter
Total Suspended Solids (TSS) s150mg/L ❑ Disinfection ❑ wetland
Petreated Effluent Monthly average ❑ Sand/Gravel Fitter ❑ Other:
Biochemical Oxygen Demand (BOD5) <_30mg/L of sorr~tion ystem
Total Suspended Solids (TSS) 530mg/L ❑ NA J In-Ground (Gravity) ❑ In-Ground (pressure)
Fecal Coliform (geometric mean) 5104cf1Ji100m1 ❑ At-Grade ❑ Mound
Maximum Effluent Particle Size: % in dia. -TIA ❑ Drip-Line ❑ Other,
Other: ❑ NP Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
When combined with sludge and scum equals one-third of tank volume
Pump out contents of tank(s) When the high water alarm is activated
Inspect condition of tank(s) At least once every: 3 moearnthh(s) (Maxlmun 3 Years) El NA
Inspect dispersal cell(s) At least once every 1.5 month(s) (Maximun 3 Years) El NA
ear(s)
At least once every: 1.5 month(s) ❑ NA
Glean effluent filter years)
❑
Inspect pump, pump controls & alarm At least once every: month(s) NA
ear s)
month(s) NA
Rest T1, T2 & T3 5 ear(s) ❑
Alternate between T1, T2, T3 and T4, Annually month(s) E] NA
T5, T6 annually or as indicated by ear(s)
inspection
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 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 a check for any back up or pending 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 (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
Admininistrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, petreatment 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.2105)
Pagl
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 riot 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
v 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 Jo hn Schmitt
Phone,715-760-G486 ~PName
he 715-760-0480
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name: Owners Choice Name: St. Croix County Zoning
Phone: Phone: 715-38611680
This document is intended to meet minimum requirements of Ch. Comm 83.22(2)(b)(1)(d)&(t7 and 83.54(1), (2) & (3), WiF-nzin Administrative Code.
Use of this document does not guarantee the performance of the POWTS. Page 7
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer-Torn Dress
;Mailing Address 528 Gilbert Rd
Property Address 528 Gilbert Rd
(Verification required from Planning & Zoning Department for new construction.)
City/state Hudson, Wl Parcel Identification Number 040-1236-10-000
LEGAL DESCRIPTION
Property Location ''A , SW '/4 , See. 3 T 28 N R 1 9 W, Town of Troy
Subdivision Plat: Country Wood , Lot # 50
Certified Survey Map # Volume Page #
Warranty Deed it (before 2007)Volume Page #
Spec house ❑yes[Dno Lot lines identifiable ❑yes0no
SVS'FEIVI 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.
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 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 Kr's"Ity orm 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 deed recorded in Register of Deeds Office.
Number of bedrooms 3
11/07/17
1S URE 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.
(NEV.04/12)
Page 9
I
j7_ 7, M: w 110 Z5
.7 Ll
4
_ 2,37 AC. f 1 41 2.02
nmmmogmdsm~c boa ~ tl
" 0 103,073 S.1FT. / I I 88,00
0 a 0+ , , „ , d 1.87 AC. EXC. ESMT/ I Y/ ' I
" m m o 0 o n 1 'h 81,453 SO. T. i ne na ca r:a rA w s~i cCOn s^., L1J1 STS oOT' f f 1 it 'r/
44"~ / f r
m o ~I r / S84° 11'50"E
iZ l °o \ / 3~ r 3g c\j 51
„ ..-.o
r~NONa~ 2.59 AC. 47
g 112,947 SO. FT. 2.03 A
in .Gl,~ / ~l r! / 88, 261
/ V
1.62 AC. EXC. ESMT, ~ r
~"~G,o,-wn'+o_r+MF +.5, _t 79,414SO.FT.
7,3. 14.
_ E. .
0 00- o - - _ H SsT44~ ~ 5Q06~~ ~ 1/ /
w o n n rn a. /
a r~ o o a o k /2l
r~d~~ oQOO W 48
- -
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o°°Zi50 \ IA r ~ 2.53 AC.
Z9 Zz N / T \ / r ss%/. 110,261 SO. FT.
' .a 2.09 AC./- / / /1 F 41+
7A wo,
0 90,870 SO, FT. t rot '3
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p 1.03 AC. EXC/SM?
_ 44,897 5/FT / 61
/s 64,
r/ 49
2,09 AC.
r
91,053 SOFT.
1.98 AC, EXC. TEMP. CUL-DE-SAC
86,136 SO, FT.
N89'09'24"E 2A I N ( - 695.30'-
214.66' 66_.21' 615.30'
1322 17' 80' RADIUS TEMPORARY N89°09'24"E 976.17' sou'
„ CUL - DE -SAC TO BE a
REMOVED UPON ROAD _
EXTENSION IJN LA I I ED LAN^S
z~ 300 400 SHEET 2 OF 4 SHEETS
Page 12
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lrh ; and H.'Ir:ran Rc tte s s r r n aro L A v~ii~44F [ E §H9 Y
Sat E .y arch dt s. Divrslort INSPETCi ION REPORT ST. CROI X
' `3'TA i R ) 771 itar~ na;r rn IF F",-)
6s'E&TB6 RA ii_5g'eaP ca k zysg•ii,ri 43114 04
Permit Holder's Name: El Cry 1,1 `Village Town of State Plan tD No.:
DRESS, TOM F MELISSA ( rppnv
CST 8V ~lev : In;p SM Elev.: SM Description: Parcel Tax No
TANK INFORMATION EL_1d~TA~C~ A]AT~i A9600295
1 T~J.C3~ 11en n~r~cnrz-~~nr„ - -
u . runrn %.F r k-iI'Y ~IAIIUJV BS HI ES ELEV.
Se tfc ~f Benchmark I /f
p-------.•--.-,-~A~4_.l i.JT_°tZ.I'". i . !~/~~.~~..e!I_.'~✓ 1 ~ c~~~ ~ ± /1_.~ 3
Dosing
AG'fdttC?R v r e s Ftt•ri~ 4Pwcsv t r e
Holding St / Ht Inlet ~
Septic T o , NA Dt Bottom
3• ~s' r n s p'
Dosing NA Header/Man.
Aeration NA _ Dist. Pipe 06. -
6 Y' '7
Bot. System A-1-11-31 ' ~vs:sv; 1 0 8-3
SAP0o'tt`ON i$+$FO$iMAi $ON - final Grade
Manufacturer Demaritt
r
GPM
TD H t i f`t htr frict'it~ri ~,siem i Tr - - 1
i
~ D tH
1" -E
frsr'ee~~t~air5 ~ Length
fi n.'AS0OZ F 0y''1~Ya~ eY};
t
E ~.r ssir~mti__--_ 3"d~ rrr ens J# C ti r 5"
l r > r C, ~i~ rt~itle (:tin q rd ~ [ .h
- - - t. u i ert E
` r}T iv
Y` ur j 1 rL 1 r la ~C
1 'd Cads c
A~~Ev TM" s? : TYUL~
r A i av ter ~lys,+, {'ten / ) ; i ; Ai1r33T2EAM fa t s
r s
t - . 1 h ti. i 15.4
1
r~,n.a+r~a-.n..e- Dra d.rn iun P~neS} lr. F?p) 5L4: 1 xllr)! 5[. c,nC +/eni To Air Mttae~
g - gth fJ;a Spacing } I
r art x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over i xx Depth Of xx Seeded/ Sodded xx Mulched
i5 Y Epti ) I rPnrr) f a'+nYnr p .t S'..... w f 7 f
j, j
LOCATION: TROY.3.28.19W, SE, SW, TOWER RD
-PI AYY f'f35JiClYrfl ron. urnr79 •W tn~ r r--'-,-~
Use other side for additional in-formation.
L~Ll rT 1 ~t j~` „ (r~ (i~+ th f
I S2C3.6 '".0 fH. U5~3t7~"~ _
cert NO
Wisconsin Department ot Industry,
Labor anct Human Fialati9etions SOIL, AND SITE EVALUATION REPORT Page of 3
Divisiarf of 9a ty S 8ui'd rgs in accord with ILHR 83.05, Wis. Adm. Code
Attach .arnpleta sift} plan on paper not less than e tf2 x 9 t inches in size. Plan n9vst irrc-iude, bit
-r*, iii"n, vV I~Y4t an-4 yVt~-IL~ri~NC~Ft 1 olcl ~al,WV ( Il,t u,j
, W116Vt1 11 QI Hi o vi awpnc, ...aiv
dimensioned, north arrow, and location and, distance to nearest, road. St. Croix _
APPLICANT ,NFOR ATION--P FAST i RINsT ALL INFl'`PMATYf.3M PI NMEttgy OaTE
r~~'J1tvER
PROPER
a e R7.ci"iar,- S'GJZ,.- GOVT. (}T esV Sa ,
9 ~ ~ C~ t AU #del's: ✓
MNUNG xMRF&S j.,~ll i{ I BL6(`11_(4 I~t'itUBD, ai G _ .-1 A ,f I
i ~ .
€ 1353 r v a tu e r'1 ~ ! i C313P 1-CITY, STATE 21P CODE PH0NENUM3ER -("ITY DV. LUfGE a--AMN
Hudson, WI.. 54016 (7151 549-6731 Troy Tower Rd
12j New Construction Use (c 1 Residential f Number of bedrooms 3 [ 1 Addition to existing building
L) Replacement- ( I Rubficar commercial describe
Code derived daily flog 450 gpd Recommended design loading rate. 5 bed, go/f12 .6 trench, gpd/ft2
Absorption area required 900 tied, 142 750 trenrb, tt2 Maximum design loading rate .5 tted. Clod/ft2 .6 trench. gnd/ft2
ti Recommended infiltration surface elevation(s)- 100.65 ft (as referred tosite plan benchmark)
Adtlitiona! design I site considerations alt site trenches n 103.171&101.641 el.
Fat€nt'na.eMi ni treo _O t wau; € , a 1r, Hoed plain evasion it applicable na tt
S ISUltei, , lzl ySiaii I t3lf~f,Yrf9 X s,~{~ Ih nl .~}1 ac. . ct~~'1= r1.S'ST921 IAt (-r+ 1_ t HCyl_Tuta TAM
U= Urtswta tie tttr svstern } S Q U i S 1 Li ) ❑ U I M- S❑ 0 IN S 13 U- 0 S A U
G Depth I Dominant C^'tcr I t'o?tes n Structure ~ GPD/ff
5oriny IGrizon tttn elf s c u z Ccta,. f.'.~r`~r ( Teyture Cr. . SI1. Cans fence ~ s Y f~aeta F?n T!± .
a
'Oy 2-_} none 1 a2rnc,b: mfr
2 115-40 10)K4 j t`r~?t?2 ~sil ) T bc_ - Mfr 1 qw _ if ) .2 s
' - lr.!=b1~ rn'i,= p1 rl?. { .5 .6
f.2rt?C.ind r lL'} g~ _""r4/6 none
107.3 Ic'U: t~ S t 1 ~ )
a f
Depth to
fQ4.lUi ~ t
+85" -
, t
I
ILE
Poring #
i i 0-1? f 10vr2,/2 r~crte ? 1 2nfs lc mfr if 1 .5 ' .6
L 7.L-3 i SLtVrc}p rl ztE? I ci i ;r , i tlrr i t I ,i
I lc~l~lt [1f Y ~ Y2ct 5 ' .6 n
3 38-'82 10,
Y 4jL4 12t e1F i f__
elev.
Npib !14
limiting
factor
+821,
Q I I I i A
Remarks:
CST foam:-p,o? jn. Ps rt yi ors
711 24U-6200
/arlr
y 6 tt 7 AnNt,( N`ew Rc17r o- nd, tvTT 5~i0 m02298
C'STfJlurr"-_,:
4-24-96
PROPERTY OWNER H].C11ard_Stout SOIL DESCRIPTION nEPORT rage 2 of 3'
FIiRC EE.1.6.... pending Lot#54
Boring # l Horizon Depth k;3minant Colo,,
iV % jTextura ucture CDnsiS rtC2 -Boutay Roots '3PC1.11-
~i,. ivi 6li,,A7Gii ~.p1. ,.J1.• Vtl, i4 UaviVi l]t. J6. JIi. boo Irenm
1-10 X14 r2?__ _
4 t S ! ! j
10-21
i
I ,
c. ~ ~1-35~ ~_GVz '4 1 b~K~n~ r ?rsibtr j Tm fr ! crv , I
' C'z o 5 ft. j 39-84! I0 Zit/4 ifs j
£3SL IYIC L r1 Y2a- , .6
t th to i
` I t ; r ` r
-
dacIff
t 1 '
j
Rernarks:. _
u>,tttifi ~ _ 7 ! ( 1 !
1 t7-18~ 10
~1'212,_~ 2 2msb3c i r c
-~rw 5 5
1 Ovr414_ Fzn I s?~.it3 mir i cox i i .2 ,3
e s :30-14! '-10; {G ~77 f r r >sca c 7 5.,c
Ground ~t_ SC l ii v's _Cal .4 )
10 -1 s j 7 . ~i~~r4,l~ I ncz~~ s o~ ~~~vr r_a ~ na
'14-34
Depth io j ~
i« ds -
„ I I
x
Remarks:
~ a
1 -18 ? fl r2,/2 1 t2r -r-- I LrA X3% _ refr c 1 5 .6
5Y ~ L Si :L if sb'c # mfr if 2 ~
3 131-10
IC7t y ~ C 730a1C I _us I 1 CSb3: i nft { s, Ri ~ 4 R
1 40-80i 10 r4/o nc,~ ~ __1 ifc j Osq MVi"r na na .5 ` .6
101.07 - r I 1 - -
a
--1-------~r-----F-
i,~jr!~~
.
a
31
GrGurt ~ I 1 -•--f-_______,_ _ _
Depth to 1_ -
t=iam~nc~~:
pj,.lR?yGWNF-R Richard. Stout $OIL DESCRIPTION REFORT rage a-Of-4___
~a,,t,,,.
rte. ~ Cord
bong 0 mullzur i. 1n. MuflSeil 4du. . . ~/ok t?~. J~. 'J11. .L~2'f32 IIL7 ii7
mfr 2f .5 <6
1 2msbk 914
1 0--13 10yr2/2 none _
6 2 33-95 10yr4/4 I none sit I~lfsbk mfr 9w if
w, .M r .w
f
107. H.
limif~Rg -
`I
< t !'t'7 tr
HemarYs:
I mfr .5 ,b
2~zsbfr ~ #@
, 9w
Berm 0-24 ~ 10yr2/2 2f
t 2 24-52! 10y X4,/4 none si 1 f =bk r mfr acs 1 r f 2 3
3 152-96 7.Syr4/6~ none a rs I us ttty,"r ra ,~a ,
c3rnu~ti` I~ ~
Dopm to
facwr
-
L
N
Remarks:
Boring ft I I 1
i'
Ground
1 N
to # ~ i j t i r f ~ -a
t
I ~
WRe a0x',~:
m
,u
....-.-•..~-~..-o.....m........._.,....~.«. r....w-...~..w.«,,..n.,.....n+xn*..~.wwe.:r:.rnu a:..xsa,:,xP'aa..s.a.Sh~.:£A;;s~iY..;h4'Fad.K:edihR.bT,:ea;:tDw"~i~a4.r u..r.S3krrii.E3..Fat-J*.'v::
+~=~.~....-R{~.'.2~"4-as-x~Y-
STEEL'S SOIL SERVICE
Gary L. Steel
Richard sTout 1554 200th Ave.
CSTM2298 SE-IsSWk S3-T28N-R19w New Richmond, WI 54017
MPRSW-3254 town of Troy (715) 246.6200
t lot #50-Country Wood
1"=401
BM.= top of SW lot stake el. 10011
t
4
2-7 /?3
3ti ~
Ao~
Gary L. Steel
8-6-96
r
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the following residence:
(Street address) 528 Gilbert Road located
at: SE SW '/4, Section 3 Town 28 N, Range 19 W,
Town of Troy , St. Croix County Wisconsin.
Upon inspection, I certify 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
Did flow back occur from absorption system? Yes No
(if no, skip next line.)
Approximate volume or length of time: gallons nunutes
Tank Capacity: 1000
Construction: Prefab Concrete X Steel Other _
Manufacturer (if known): Midwest Precast
Age of Tank (if known): 21 years
Pert-nit number (if known) 268594
John Schmitt
(Li ensed Plumber Signature) (Print Name)
MPRS 223760
(Title) (License Number) MP/MPRS
2
(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
Page 8