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HomeMy WebLinkAbout020-1347-00-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No (ATTACH TO PERMIT) 600300 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: Donald Palm TOWN OF HUDSON 020-1347-00-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 11.29.19.1870 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 5~5 1-f Dosing Alt. BM a Aeration Bldg. Sewer H mg TeT TANK SETBACK INFORMATION tr~ 7.02 97-57- TANK TO P/L WELL BLDG. Vent to Air Intake ROAD DF~tiet e~tic t I DfBottom >160 Heade Aeration Holding „`sue Bot. System U PUMP/SIPHON INFORMATION Final Grade •05 Lf I a U5. Manu turer Demand St Cover COL"r GPM- 7" Model Number 76 2- S TDH Lift Frictiowtoss System Head TDH Ft + F in Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width r ILeng t No. Of Trenches PIT DIMEN NS No. Of Pit side Dia. _ th DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAK R AM LEACHING Manufacturer: INFORMATION CHAMBER OR E L)W Type System: ( L UNIT Model Number: t~ -~~U~. 7foo` G DISTRIBUTION SYSTEM Header/Manifold Distribution Ix Hole Size x Hole Spacing Vent to Air Intake It %t pipe(s) Length~_ Dia Length Dia Spacing J' SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Deof, xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil °®4y ❑ Y~ Na Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 746 PACKER DR X4.n 1.) Alt BM Description = e 2.) Bldg sewer length = if - amount of cover = !r/~ 4-15 Plan revision Required? Use other side for additional Yes No U _ information. n. Date Inse ctor Cert. No. SBD-6710 (R.3/97) sr: County a { + Safety and Buildings Division St Croix .i 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) S P Madison, WI 5370 10 y, G 3 60 Sanitary Permit Applicatio d 4 State Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to~propriat ~nnent nit NA is required prior to obtaining a sanitary permit. Note: Application forms for state-own to Project Address (ifdifferent than mailing address) the Department of Safety and Professional Servies. Personal information yo~o or secondary purposes in accordance with the Privacy Law, s. 15.04(1)(m), Slats. 7! Pow~r 1 % 1. Application Inform do - Please Print All Information a-0 1~L Property Owner's Name Parcel # Donald Palm 020-1347-00-000 Property Owner's Mailing Address Property Location 746 Packer Drive Govt. Lot City, State Zip Code Phone Number SE y, SW y4, Section 11 Hudson WI 54011 651 492-3704 29 N; R 19 circle T 11. Type of Building (check all that apply) Lot [VI or 2 Family Dwelling -Number of Bedrooms ~ 20 Subdivision Name Block # Homestead ❑ Public/Commercial - Describe Use ❑ City of CSM Number Village of El State Owned -Describe Use LY' s Townof Hudson EZ 90143 Vol#7 pg#30 Ill. Type of Permit: (Check only on box on line A. Complete line B if applicable) A El New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber List Previous Permit Number and Date Issued ❑ Ye-it Transfer to New Before Expiration Owner 338971 June 7 1999 IV. Type of POWTS S stem/Com onent/Device: (Check all that apply) dNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of s table~pil ❑ Holding an< -th~er Dispersal Component (explain) El Pretreatment Device (explain ) ~ V. Dis ersal/Trea ent Area Informati Design Flow (gpd) Design Soil Applicati Rate(gpdst) Dispersal Area Required (s Dispersal Area Propos (sf) System Elevation 450 0.6 750 750 97.55 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units 2 to New Tanks Existing Tanks w o a; v v ~c b w P (a{C SZS a N Septic or Holding Tank 475 1000 1475 2 Wieser Concrete Dosing Chamber NA Infiltrator VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) P / er's Signature~ y MP/MPRS Number Business Phone Number Darrell Hubbell 'A~~~ ' 221073 715 307-1630 Plumber's Address (Street, City, State, Zip Code) N7988 920th St River Falls WI 54022 VI .Coun /De artment Use Only mit Fee Date ssu ature Per ❑ pprove; Approved D O Reason fo Denial $ I f ~-7 IX. Condit M easo~s for Isapproval + 1 Septic ark, Emt;c .mt 17 El n 3, Q.Q _ ~L Q 'tiisper -A ct li must atl be is _s ' t_ ~J. 1 ss,per giarsyement plan o uJae~1 by piunbe:. U ,WMrnems must ue .:r& il.E'I 2. .i> l>li~,lC fec W per 9Xkrbl1,q cax.'ei ! .1d..^~rn..:... Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I I inches in size SBD-6398 (R. 11/11) -ro E~~b J c~ 5 ,7~ - T `~31 l~ l ~ Cat ~ I C '+tg r~ i k A? 71 , 1 ?1 /i! q 1f ' ! d I):rte -4,4 r4l b''90 k -4 CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Don Palm Owner's Name: Donald E & Kay V Palm Owner's Address: 746 Packer Drive Hudson WI 54016 Legal Description: SE 1 /4 SW 1 /4 S 1 1 T 29 R 19 W Township: Hudson County: St Croix Subdivision Name: Homestead Lot Number: 20 Parcel ID Number: 020-1347-00-000 Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans T; 0h k 5T': c 5 Designer/Plumber: Darrell Hubbell License Number: 221073 Date: 10/24/2017 Phone Number (715) 307-1630 Signature ^ Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 t rr ` 112;,• t'a}-~ r'G <s i .1' ~ s td ~ s it} ~3 1 Iwo irx_f A 1- ..->~C a uhf(; ;e. 131 PCA ~~r-- r ID .0 PAGE 3 OF oa) cif ca 7j5 o m J_ r m °E O .E 0- Q LL E N W L) E CL m : L m O > co z 0 O Y g O c y Q m o C m U m -o M U C: L F U CD N LU Qo m€ o m II c to to U .Q N Lo w r n d m s _ > Q .C .Q a) w m m U U° c 'n ma O E Lo U o i\A o O -Fu > ° a - Q c U rn a? m v „ m co p I (14 E v ~ o cn o > c ° I II I N In 00 a 1 I W h cca r- r0 w > oi I II II a Q 2W I ~ Q U) Z> I r: I o w w Z 7 II I I O cr o U 3 No I I ~ JUG 1= a> ~3a^ I I -a c <W 0 00 a ~3 I I► I O F- a a) CL U) cu 0 LLI 0- 0 CL o m I II I II Q co ~ U o o I I a`~i _I N f I I (Q N U ~ I I$ ~ a U) N Q I 1 ~N I I a O o . fn O td) m I I"' N N M Q N N N J 11 11 1 I I X T T m -E Lo cu 'E J m > > c _ U_0 via I I D) E N j~ II a I I Q C: a a I I O U) ~ N W c I- ~ ~ II I U @) @) C~ O H F~-~~ I W a I I w A co Q L E" o -a a Z U a I I d M C7 -0 U) = I II I W II C) i O Lo Ow ZZ E 0 W Al. a (D w CS) Z0 ¢Qo I II I Z Lol I C o UJZ I I CO + - a- I I `7 ~aT.tir DIVISION OF INDUSTRY SERVICES pV E,b. row, Plumbing Product Review P.O. Box 7302 1 Madison, Wisconsin 53701-2658 i S P TTY: Contact Through Relay 9 ~ S 1, Governor Scott Walker Laura Gutierrez, Secretary March 9, 2017 POLYLOK INC./ZABEL PATRICK MULHALL 3 FAIRFIELD BLVD WALLINGFORD CT 06492 Re: Description: SEWAGE TREATMENT APPARATUS, EFFLUENT FILTER Manufacturer: POLYLOK INC./ZABEL Product Name: (trans id 2918888) POLYLOK/ZABEUBEST EFFLUENT FILTERS Model Number(s): 3014, 30JA:525.3014-625, A100-8X18-VC, A100-8X32-VC, A100-12X20-VC, A100-12X20- VC-BALL, A111-12X28-VC, A100-12X36-VC, A300-8X18-VC, A300-8X26-VC, A300-8X32- VC, A300-12X20-VC, A300-12X20-VC-BALL, A300-12X28-VC-A300-12X36-VC, A600- 8X18-VC, A600-8X26-VC, A600-8X32-VC, A600-12X20-VC, A600-12X20-VC-BALL, A600- 12X28-VC, A600-12X36-VC, A1800-4X18-30142-68, A1800-4X18-VT-835, A1800-4X18- VT-840, A1800-4X22-30142-68, A1800-4X22-VT-835, A1800-4X22-VT-840, A1801-4X18, A1801-4X22, GF10-8, GF10-16, GF10-32 Product File No: 20170078 The specifications and/or plans for this plumbing product have been reviewed and determined to be in compliance with chapters SPS 382 through 384, Wisconsin Administrative Code, and Chapters 145 and 160, Wisconsin Statutes. The Department hereby issues an approval based on the Wisconsin Statutes and the Wisconsin Administrative Code. This approval is valid until the end of March 2022. This approval supersedes the approvals issued under product file numbers 20140195, 20160051, 20160055 and 20160299. This approval is contingent upon compliance with the following stipulation(s): • These products may only be installed by a master plumber or journeyman plumber or plumbing apprentice working under the supervision of a master plumber. • Installation and servicing of these products must be in accordance with the manufacturer's instructions. A copy of the manufacturer's installation and servicing instructions must be given to the owner of the system. • An access opening of sufficient size to allow removal of the filter must be provided over the outlet tee baffle of which this product is installed. This access opening must terminate at or above grade. • Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter will be necessary. • When this product is installed in an interior compartment, the discharge connection must be solvent cemented to a single four inch diameter schedule 40 PVC, plastic pipe (ASTM D-2665 or ASTM D-1785) which is solvent cemented to a four inch diameter schedule 40 PVC coupling encased in the interior wall. • A manhole extending to grade must be provided over the filter. • This product may only be installed in the outlet tee baffle of septic tanks or compartments that have a maximum daily flow rate of no more than: 800 gallons per day for models A100-8x12 and A300-8x12, 1200 gallons per day for models A100-8x18 and A300-8x18, 1800 gallons per day for models A100-8x26 and A300-8x26, 2400 gallons per day for models All 00-8x32 and A300-8x32. SBD-10564-E (N.10/97) File Ref: 17007803.DOC Polylok Inc. March 9, 2017 Page 2 of 2 Product File No.: 20170078 • The maximum daily wastewater flow, which may discharge through these products shall not exceed the manufacturer's published rating. • MAINTENANCE: Clean filter at inspection/pumping interval. The department is in no way endorsing this product or any advertising, and is not responsible for any situation which may result from its use. Sincerely, Glen W. Schlueter Environmental Engineer - Plumbing Product Reviewer Department of Safety and Professional Services Division of Industry Services Bureau of Technical Services (608) 267-1401 Phone (608) 267-9723 Fax glen.schlueter@wi.gov E-mail MANUAL & MANAGEMENT PLAN Page of It POWTS OWNER'S t FILE INFORMATION SYSTEM SPECIFICATIONS Owner Don Palm Tank Manufacturer: Wieser Concrete ❑ NA Permit # (Septic ❑ Dose ❑ Holding Volume: (gal) DESIGN PARAMETERS Tank Manufacturer: Infiltrator ❑ NA Number of Bedrooms: 3 ❑ NA EdSeptic ❑ Dose ❑ Holding Volume: (gal) Number of Public Facility Units: EAA Vertical Distance Tank Bottom(s) to Service Pad: 00804 (ft) Estimated (average) Flow : 300 (gal/day) Horizontal Distance Tank(s) to Service Pad: 3 (ft) Specific servicing mechanics must be provided if vertical is >15 feet or Design (peak) Flow = (estimated x 1.5): 450 (gal/day) if horizontal is >150 feet. Specific instructions to be provided on back. In Situ Soil Application Rate: 0,6 (gal/day/ft) Effluent Filter Manufactur Polyloc ❑ NA Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model: 525 Fats, Oil & Grease (FOG) <_30 mg/L Pump Manufacturer: Biochemical Oxygen Demand (BOD5) 220 mg/L ❑ NA &NA Total Suspended Solids (TSS) :A 50 mg/L Pump Model: High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer: (BOD5) >220 mg/L ❑ NA ❑ NA (TSS) >150 mg/L ❑ Mechanical Aeration ❑ Peat Filter ❑ Disinfection ❑ Wetland Pretreated Effluent Monthly average ❑ Sand/Gravel Filter ❑ Other: (BOD5) <_30 mg/L Soil Absorption System (TSS) <_30 mg/L ❑ NA Fecal Coliform (geometric mean) <_104 fu/100m1 din-Ground (gravity) ❑ In-Ground (pressure) ❑ NA ❑ At-Grade ❑ Mound Maximum Effluent Particle Size 1/g inch dia, ❑ NA ❑ Drip-Line ❑ Other: Other: ❑ NA Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) When combined sludge and scum equals one-third (/3) of tank volume ❑ When the high water alarm is activated Inspect condition of tank(s) At least once every: 3 ❑ onth(s) (Maximum 3 years) ❑ NA [y'year(s) Inspect dispersal cell(s) At least once every: , El [Vyear(s)onth(s) (Maximum 3 years) El NA Clean effluent filter At least once every: 1 t O month(s) ❑ NA Inspect pump, pump controls & alarm At least once every: El month(s) ®'NA ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s) [A ❑ year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS • Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or 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 ponding of effluent on the ground surface. The soil absorption system shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. • When the combined accumulation of sludge and scum in any treatment tank equals one-third (%3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator (pumper) and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. • All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. • A service report shall be provided to the local regulatory authority within 30 days of completion of any service event. Page of C 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 absorption system. If high concentrations are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will be discharged to the soil absorption system in one large dose causing an overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. 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 treatment tanks and soil absorption system: acids, antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, and water softener brine discharge. 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 Wisconsin Administrative Code s. SPS 383.33: • 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 (pumper). • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: (Check all that apply) ❑ 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, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY ✓ RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE. ✓ V ADDITIONAL INSTRUCTIONS: V S T- d 9. 5 L'9 kl k I~ ~l S v r~.h L4>_ n 1-e-ct POWTS INSTALLER POWTS MAINTAINER Name Darrell Hubbell Name Ron's Sewer Service Phone 715 307-1630 Phone 715 749-0153 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Ron's Sewer Service Name 5 TT ' X C U v %2 Phone 715 749-0153 Phone 715- 3~' Y -~10 This form is In compliance with Wisconsin Administrative Code s. SPS 383.22(2)(b)(1)(d) & (f) and SPS 383.54(1), (2) & (3). ~I 13 IM-540 General Specifications and Illustrations A A' The IM-540 is an injection molded two piece mid-seam o plastic tank. The IM-540 injection molded plastic design - 61.7 7~ allows for a mid-seam joint that has precise dimensions o EXT RIOR for accepting an engineered EPDM gasket. Infiltrator's WIDTH gasket design utilizes technology from the water industry to deliver proven means of maintaining a watertight seal. The two-piece design is permanently fastened using a series of non-corrosive plastic alignment dowels and 64-911,6481 EXTERIOR LENGT LIFTING STRAP INLET ( ONNECTION TOP VIEW TMP' locking seam clips. The IM-540 is assembled and sold C through a network of certified Infiltrator distributors. LTYP) INLET CONNECTION Must be backfilled and installed in accordance with lrrPl Infiltrator Water Technologies, Infiltrator IM-Series Septic Tank General Installation Instructions and for shallow ground water conditions reference the Infiltrator IM- Series Tank Buoyancy Control Guidance. 54.6 [1,387) Please visit www.infiltratorwater.com/images/pdf/ EHE G OR ManualsGuides/TANK01.pdf for the latest information. END VIEW Total Capacity 552 gal (2090 L) j 121 [610] diem. ACCESS OPENING WITH LOCKING LID Length 64.9" (1648 mm) Width 61.7" (1567 mm) INLET Height 54.6" (1387 mm) Maximum Burial Depth 48" (1219 mm) Minimum Burial Depth 6" (152 mm) i Maximum Pipe Diameter 4" (100 mm) Weight 169 Ibs (77 kg) SECTION A- A' INUOUS ET TANKTOP HALF SEAM CLIP TANK INTERIOR ALIGNMENT DOWEL 5ANKBOTTOM _ HALF 4 Business Park Road MID-HEIGHT SEAM P.O. Box 768 SECTION DETAIL Old Saybrook, CT 06475 F LT R AT O R ;$~22; 4436 660-577-7001 www.infiltratorwater.com U.S. Patents: 4,759.661; 5,017,041; 5,156,488; 5,336,017; 5,401,116; 5,401,459; 5,511,903; 5,716,163; 5,588,778; 5,839,844 Canadian Patents: 1,329.959; 2,004,564 Other patents pending. Infiltrator, Equalizer, Quick4, and SideWinder are registered trademarks of Infiltrator Water Technologies. Infiltrator is a registered trademark in France. Infiltrator Water Technologies is a registered trademark in Mexico. Contour, MicroL.eaching, PolyTuff, ChamberSpacer, MuIdPOrt, PosiLock, QuickCut, QuickPlay, Snaplock and StraightLock are trademarks of Infiltrator Water Technologies. PolyLok is a trademark of PolyLok, Inc. TUF-TITE is a registered trademark of TUF-TITE, INC. Ultra-Rib is a trademark of IPEX Inc. © 2013 Infiltrator Water Technologies, L LC. All rights reserved. Printed in U.S.A. IM11 1116 • • - - - • - :11 III Pff M- l ATM DIVISION OF INDUSTRY SERVICES Ee Plumbing Product Review off. I P.O. Box 2658 a } OS Madison, Wisconsin 53701-2658 y2 P s TTY: Contact Through Relay Scott Walker, Governor ss,oyP~' Dave Ross, Secretary May 21, 2013 ~ r✓ G~ E'er 1~ ~ . ~j- TUF-TITE TED MEYERS 1200 FLEX CT LAKE ZURICH IL 60047 Re: Description: SEWAGE TANK COVERS, LIDS, RISERS Manufacturer: TUF-TITE Product Name: SEPTIC TANK RISER AND LID Model Number(s): 24" RISER AND LID Product File No: 20130080 The specifications and/or plans for this plumbing product have been reviewed and determined to be in compliance with chapters SPS 382 through 384, Wisconsin Administrative Code, and Chapters 145 and 160, Wisconsin Statutes. The Department hereby issues an approval based on the Wisconsin Statutes and the Wisconsin Administrative Code. This approval is valid until the end of May 2018. This approval supersedes the approval issued on 3/17/08 under product file number 20080159. This approval letter shall be incorporated with your previously approved plans and/or specifications approved under product file number 20080159. This approval is contingent upon compliance with the following stipulation(s): • The manhole cover must be secured to the riser using screws which are not standard or phillips head to be considered an effective locking device. • Joints between riser sections shall be seal with butyl mastic sealant and secured with a minimum of four screws. The department is in no way endorsing this product or any advertising, and is not responsible for any situation which may result from its use. Sincerely, Glen Jones Public Swimming Pool Plan / Plumbing Product Reviewer phone: (608) 267-5265 fax: (608) 266-2602 email: glen.jones@wi.gov SBD-10564-E (N.10/97) File Ref: 13008001.DOC 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 746 packer Drive located at: SE '/4, Sw '/4, Section 11 , Town 29 N, Range 19 W, Town of Hudson , 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 11/15/2017 Did flow back occur from absorption system? Yes No x (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: 1000 Construction: Prefab Concrete X Steel Other Manufacturer (if known): Weser Concrete Age of Tank (if known): June 7 1999 Permit number (if known) 338971 Darrell Hubbell (Licensed Plumber Signature) (Print Name) 221073 (Title) (License Number) MP/MPRS 11/15/2017 (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 WWIM IN/N'31•! U.p• 1 1Nhf'N7 i.u' A ~ 1 ANDS IpiN LINE Or 7Nt5 1V2 SWIM ® $89'35'50'E 2 /i:,a D?1 20 b, Wr am i ~ sties 31C 3'L ~s 1N.oJ1 10. K t , t162 10.17 ) • 09 13.24 AC.~ 141, Z59 SQ IrT.) Ito. JS (Of 4~ \ U a3. .Y so R ~ 1 Or I S or A[ 1 F4 8 ~I,ti OP ~ '+.w•p1.w ~ \ 111071 .>L, 19 y rsf .cAlEs IT Y w...e 1a R / , Ir 2-34 111010 IT 18 22 r 1p1.1at1o 2t am. 0030 IQ rr 2W AOM r I D 0 w ' b / 9%iv 70. rL NUI Q f J 41." AC.) N p~ 05,202 33* 23. WAD" - 7qf - - 317 65 1 _--._,n~.10 •M•O3'W 723.03' _ • / ~~s 1t ' PACKER-----;- p• Cy us y .o, NI 7r 1.N• 20.~a W 04 t7 - r AOi.M _ J ( »b J 23 ~w G14 { I c r-- 1/) 2r. 8 24 2.30 can r • _ 12 i tv / R 4 603,506 70. K 1 IM,171 !0. FT 042 US 047 SP. T. 104.230 m r1. f 01 IN3.p lay'u 03 w Al cw \al 8 Ivor sl / / M.OI ♦01 -1171.or- Ll 319.41• ♦ 1 U10 I ' N89.29'03' W 2378.39' So1RN 4A OF, THE 11101N \ s Ir < LoBa1~;~ RCUC ` senor O FRC)POSE,; PLAT OF GRASS RANG. \ 7 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Don Palm Mailing Address 746 Packer Drive Property Address 746 Packer Drive (Verification required from Planning & Zoning Department for new construction.) City/State Hudson WI 54011 parcel Identification Number 20-1347-000 LEGAL DESCRIPTION Property Location SE '/4, SW '/4, Sec. 1 1 , T 29 N R 19 W, Town of Hudson Subdivision Plat: Homestead Lot # 20 Certified Survey Map # 590143 , Volume 7 , Page # 30 Warranty Deed# tQ ~ 64~ ~ 061% (before 2007)Volume 1168 Page #294 , Spec house DyesDio Lot lines identifiable 0 yesEj 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(]) 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. Uwe certify that all statements o this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a arranty deed recorded in Register of Deeds Office. Number of bedrooms 3 Q_ j - 1010 / 17 SIGNATURE O APPL NT(S) DATE ***Any information that is misrepresented may cult 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) OWNER Sens ' rod HOMESTEAD LOCATED IN THE SEI14 OF THE SWI14 AND IN PART OF THE SWI14 OF THE SWI14 OF SECTION II, T29N, RI9W, TOWN OF MASON, ST. CROIX COUNTY, WISCONSIN. soAVA M- r A Rtr im-! - 1. Douglas J. Zahlec. Registered Wisconsin land _ that in full cuevllancs Nith the provisions of Map; ; t, be~~ certify firm IR mm 01 am CNN »f )Ilmt nxm Statutes, and under the direction or Su Nillerr 23 eor the CLOC°nas°d 10. f~lII 16L1 11 1tI1L iOGII IJt5i1 IYt16 lath Nacrihee m this plat, I have .erl•eyed, divided and mapped Bolo gttb. rant eh plat eorrectly r presmta Cho exterior houv0aries•aM the euhaiviaim I 1f 11.11' fl%x• N2°I1'II.5'1 111.55' 21°11'09 NI%{414 of the land surveyed; and that this plat is located in 561/4 of the SN1/°{ t » II.N' tl°»'ll' rs]%1'12.1 ln.n' 111.11' fl/h{'11•[ 'Psl'IS•i and in part of the M/4 of the SMI/4 of Section 11, 1'29A, A19M, 7b1)n of f If II.N' 118°18'51' 21°51'11.59 121.41' IN./f' 21%1'lS'1 1°tl'N•1 R,Wem, St. Cmix CoontY. Nipoonain; further, deacrihed as folleua: c 11 18.11' ]Yls'I1' of%4'11.59 11.11' 11.11' t//%1'119 tll%f'»9 1 11 II.11' ]l°11'11' ill°»'S1'I 41.15' 1{.)1' nl°J!'119 tN%{'li9 ~ASAafIIe at the Si/4-COrmea f motion 11; Chmee N89o29.03 •N, loop the [ 21 1)1.11' It°SC'SI• 144°51'17.1 31.14' 11.11' ill%{'ll•I tllht']I9 sooth line of the 6741/9 no id coon, ]378.39 feet; thence 1102°2B•06•N, f 16 H' N%{•3l• N{°/1'Sl.f'i 1{.11' 1{.11' III%15.1 III°71'It•I 1332.62 feet to the rth line [ the Sl/2 of tJMn/4, thence [ 14 2.18' It%1'D• 151°1!'71.]'1 15.51 ».N' 111%1'11.1 N191'IS•t 5.90356, along id north line, 2x18.54 fseU to the north _ oath 1/4 L » N.N' IS%1'71• NI°l7'I{'1 71.54' ».I1' NI%1',s't 771°1/'/l't line; thence SOO0034.16•N, long said mrth - 3/4 line, 1325.66 feet t » ILM' »5%!'m' U6025-17.1 111.!!' 111.9' nt°N'll•1 B701-34 to the point of beg5ming. ],hove deacrihed parcel cantaid 73.32 3leipa f 1S II.N' I2°n'1]' n3hl•14'I I4S.17' 115.12' tf]%1')1'/ iN%2'n•1 (3,193,654 Sq. R.) t » 18.11' SihPII• ilfhperv 77.18• HAP 11I°32'13•1 i48°4 4'18.1 [ ! » 1.11' )Ih171' NI°I{'/f9 lSf.n' 155.11' 10°41.'Ir1.12211:"T., :20103 M-1 r f 11.11• 11%1'77` .12.5.1 1{.11 I{.IS' 2!%111 oft'11 I 1 11.11' ]t%1`ll• p1%11 18.14' 1L'1' N195'll•[ p1 ►/COs 1 / ILN• Ill%1'51' 2!%1.51.1 111.11' ISLN' I/l°l1•Il'i t4s%r»v 1 11.18' II{%1'11' t»°]{'31.59 771.11' 111.11' NSht9p1 NW25'S5'ISl a 1 / N.N' Nh/']p f11%7'/1•[ It.fl' 47.11' NI%5'55.1 t»%1'11.1 n f 1[/.18' n%f'/1• tl{%1'51'1 {7.11' {1.31• 775%1'119 tll°I3`139 ISm ASOmff LDM (BRAKn 0 a DIBTmm) ul.n' 0 2MN'm9 ].4s• q~23~98 0 21°Ire9 4.18' 1 218°11.159 rsLU• I MINVN9 1f.23' I 111°11'11.1 Ln' 1 Newlin ».18' 1 111011-189 VALPLATTED LANDS eon" raa a< r"t al.z or rla zel.. ® S! 35'50'E 2448.54' 21 20 9 4~• s 3F"F°gg F:~ =-=-16 a ` F ga S4 n3,b399.fT / a ,r$9=J r1ey ~2 I 3 06 x160. / CDZ 2M. 113,113 rt.l IC n ` ~ ~ ~ a r~41` epP / zz.2y. •>'a grQt'w r'~~e \ Iev°)) /\z/J~~`•~ ~e~~• e $ $ In ggeZ ~a ~m~l+ go 19 \ It, 5i P, µ9m go r~ a f / 17 r = ~I- N~ oQ~ 22~ / M1F~ of a' ) Iasi slze.frl 21~ _ ~a '~'sa m 33• m.ro f 50, _ 317..3 - / / S~ ~F $ nN•3e 773 . _ ~ ~ _ - a - - PACKED- ° ~~s~e / ° ~ '1-q E• {V - - a 4300.00' 11 a a ag~ i o o/ 23 I m4 0""~ o s• i 41 I a a ~ I I rJ~ ~xa I 26 ~ a / I 25 24 n 3.18 K1F5 r.9) stela C ~ gl I lxgax7 su. rt. zs aIe 2 m leases m R Yo'S.azo of 6 ~ 2 II / Iaa2N wL ~-ce ` ~4s 1 0 z97•: e2o.••)m aela I 4oe.zz• -`760 ft~• aeaez 9 K . 183. 110.0" NTW 192a 1 ~N89'29'03'W 2378.39' san"ua sr,e slw cmel 1-\\ LA BARGE ~-~-C saTUl n PkDF1aEC PLAT OF GRASS RA SCALE IN FEET 1' • 100• SHEET 2 OF 3 SHEETS Wisconsin Department of Safety an ofiessional Services Division of Industry Services SOIL EVALUATION REPORT Page 1 of 2 UAa in cord ce with SPS 383, Wis. Adm. Code ~County ST. CROIX plete site pla ape Unan 8 1/2 x 11 inches in size. Plan must not limited to: a ontal reference point (BM), direction and Parcel I.D. e, scale or diI rth arrow, and location and distance to nearest road. ZQ Se print all information. Revie by Date '''J ormation 0 rovide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). r Property Location 1~<'l{Ll~ ~'A LAS Govt. Lot 1/4 Sam/ 1/4 S t T ~ N R E (or)® Property Owner's Mailing Address Lot # Block # Subd. Name or SM# City State Zip Code Phone Number ity ®ViIlage Town Nearest Road n New Construction UseE] Residential / Number of bedrooms -3 Code derived design flow rate GPD 19 Replacement ® Public or commercial - Describe: Parent material Flood Plain elevation if applicable PI n ft. General comments and recommendations: 7D MDVS Sys M lZ~i~i~tc ivtGA1 171 Boring # J3 Boring Pit Ground surface elev. 99 J` G~ ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox De GPD/ff Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 D-4 75YiZZ,16- - L - - hG d.b' 2 t~ Z~ ~sY,'~ 3/5 s~ z 6K ds q 34-V7 7,5Y< - /~,b,< js a- 0,1/ o~~ O,q 0,6 Boring # -71 Boring h 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 * Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signatur CST Number MARY JO HUPPERT Hollister's Soil Testing&Design) ~ 224832 Address Date Evalua ' n Conducted Telephone Number W9875 690th Avenue, River Falls, WI 54022 12 - 06, 2017 715-426-1775 SBD-8330 (807/13) jq,,;",e5rqo1 64W r»e J v } j rte. it q V ,r (3'Z t fH AL q , t' ~yol F~ Page Wisconsin Department of Commerce SOIL AND SITE EVALUATION 1 Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code Attach complete site plan on paper not less than 81A x 11 inches in size. Plan must Fftrmcel ty include, but not limited to: vertical and horizontal reference point (BM), direction and $t CIO1X permit slope, scale or dhnemsions, north arrow, and to cation and distance to nearest road. I. D.# - APPLICANT INFORMATION - P lQi~ilao 'on. Personal i &wsh- you provide may be used for , purposes (P~J; `@• 15.04 (1) (m)). ttlod ✓✓►G~ Prpperty O- WM- r '°perlX Location MILLE SAM . Lot SE 1/4 SW 1/4 S 11 T 29 N,R 19 W Property Owner's Maling Address L t # ;Block # Subd. Name or CSM# TROUTBROOK RD '498 J20 HOMESTEAD City Statel Zip Code r City ❑ Vllaae ®Town Nearest Road Hudson WI zc)R Hudson LABARGE New Constlrucliort oonas ~Addfon to ex4" Wil tg Replacement Use. Publicbe 0 Code Derived dally flow 4503 gpd Recommended design loading rate t bed, gpdNF. G lrenck gpdW Absorption area required 9W bed, fls 750trench, W Maximum design loading rate 0 bed, gpd/ff'trench, gpolfF d r Recommended infiltration surface elevation(s) 3 r~cc(cs of y u ft (as referred to site plan benc T. ^ ~I Additional design / site consideration t o ( ~S Parent material /0 '0 5 -S otzm Flood lain elevation, if applicable ~y It S--Suita for sws'tem C 'nil ! Gtwu P Me AT Cade ! sysste;r in Fll Haig Tent: IU=Unsubble for system 4 is M U , s A U S Z U O s E u ❑ s ®u O S® U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/fF HOt 9n in. Mrmsel i Qu. Sz. Cant Color Texbure) Gr. Sz. Sh. Consistencel Boundary. Roots Bed` ; Trench 1 1 4- I /0 ra? I { f t1 2 r /0 I. ~ ~(o 2 S73rc /o yr V/10. It , my ~ Ground 3 3 - q (f Y i S ! U S ct') ' elev 4 ya- CLJ .7 5 8-5'/, J. S r Depth'tD limiting tactor 7 -.q 7,5 Remarks: i.A0y'('7 ! ° 7 , c , ' !i t f Ii In Ur 2 1 i7r 2 4lfliP Ground 3 r f Cs S r 7 i Depth to 5 f limiting factor S 1 Remarks: \ _ - CST Name (Please Print) Signature: Telephone Thomas C. Nelson 715-246-2454 Address Environmental By Design Date CST Number Ref # 1432 120th Street, New Richmond, WI 54017 8/20/98 227387 59 i PROPERTY OWNER: MUER. SAM _ SOIL DESCRIPTION REPORT ® Page 2 of PARCEL LOS Environmental Des' Horizon Depth Dominant Color ' Mottles structure nsistence Boundary ! Roots GPDM in. j Munsell Qu. Sz. Cont Color Texture I Gr. Sz. Sh. ~Col i I Bed : Trench eiev 3 S 1.5; .f ©s C' ' ev L?p.,Qtlt-ZD ~ . ' iimfing factor 7 . - i - i Remarks: 4 1 10 rj 2 Al ( 2 ;r_ ,s Ca _0 lin 5A Ground 17- 0 4 7.2 -7)-ia 11PIPI-f 's o2 r w S C Depth to factor 6 . . - ~IU I ! qQy. j I j Remarks: t 0-.9 /o 5 Q j Z mu r Z, s 2 1/0 lmf~k n.; el~ 3 4r~v 7.S 2 ,f 4 Depth to 5 i limiting facto' 6 Remarks: i i Ground elev Depth to faclorg Remarks: i ~n+ /l7 t~LiL N~~t sTt d b Lod 'x z..o ~,4cKEII (~!1/V,E sysrt~►.. 9$,tj0 eA c r,4/_ a TAX* C' 20- 13W 7-oo-oo0 '71c ry~+ Q~ Z 2 Sp 3 C. t 3 z o. moo' ~iVa S[,4 c.. E J-1 w Q =b s ro , ,J t (1 14 e- k/ -rO T A L D L lS 7' -E C M, A 73 c MirN slDr- "Tp 1 E lZ tow EN JD V it t~s REE ~i :y LOT 2 I T Soo 4f ' t i3 M - + ;.zy~4c ToP of I ` t +PE 19 it f=~- fpa.pa kJ3 19 y ~s -r r