HomeMy WebLinkAbout040-1252-80-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 605061
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:
Craig Davis TOWN OF TROY 040-1252-80-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
19.28.19.1329
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
q
Dosing Alt. BM
r
Aeration
Holding Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG. vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing Header/Man.
i
Aeration Dist. Pipe AA,,
Holding- Bot. System ~0.~ .~~~((OJJ C l -11_0 1: 2 Final Grade
PUMP/SIPHON INFORMATION OV, Cna.-E°~C a• $D 9 .Dv
Manufacturer Demand St Cover
PM
Model Number
TDH Lift riction Los Sy t m H TDH Ft ( .00
Forc Dia. Dis.to
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length 1 No. f Trenches PIT DtfAENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LA S M LEACHING Manufacturer
INFORMATION CHAMBER OR
Type Qf System: UNIT Model Number:
Gov) L,~.J
DISTRIBUTION SYSTEM jJ~-143fi1
Header/MaInifold Distribution _T Ole Size x Hole Spacing Vent to Air Intake
U Pipe(s) f _
Le_ 1 Length Da 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 ~5I (f f „G Bed/Trench Edges Topsoil Yes D No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 291 ST ANDREWS DR ll
1.) Alt BM Description = ST~
„p,,.__,/
2.) Bldg sewer length = Glcj_ a6Neon rwcv~,
- amount of cover = kJ 111 calms
Plan revision Required? ❑ Yes ❑ No /
Use other side for additional information. b ~J
Date Insepctor's Cert. o.
SBD-6710 (R.3/97) e
~a~wtrnrryr ' County
Safety and Buildings Division
201 W. Washington Ave., P.O. Box 7162 Sanitary Permit umber (to be filled in by Co.)
r~ J\ ,1018 ' ' Mad" W1~370 . 71
FDA
Oq=
~L
State Transaction Number
it Applica 1
In accordance `rkitis :SIPS ~ls • s. Adm Code, submission of this form to the appropriate governmental unit
is permit Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing g address
required P s rioitto a sanitary
y~
)
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law, s. 15. 1 m), Stats. 19 ` ft A
t S
L Application Information - Please Print All Information C~V-1e
Property Owner's Name Parcel #
Prop owner's Mailing AddrProperty Location q j V IQ .
4 /'T GovL Lot 0
i r
City, State R Zip Code Phone Number Section
}
L 4 pe of Building (check all that apply) Lot # T ' N; R ME
y
Family Dwelling-Number of Bedrooms Subdivision Name
c
Block#
❑ Public/Commercial Describe Use ❑ Ci
State Owne" d -!t)~""bey clf/S W CSM Number ❑ Village of Use
TH*4 05J Of. L
I
III. Type of Permit: eck only one box on line A. mplete line B if applicable) zot)
A. p .
na Sys e, System reatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
R. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued
on Owner y~j 3 3Z p 2 Zt'70$-
ype ofPOWTS System/Com onent/Device: Check all that a I
pn-Pressurized g_PAsurizodln-Ground In-Ground ❑ At Grade El Mound >24 in. of suitable soil ❑ Mound < 24 in. of suitable soli
-he T~lw
Hol g Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dispersal/Treatment Area Information:
✓ r
ign Flow (gp Design Soil Ap on Rate(gpdsf) Dispersal Area Requir Dis Py~sed (sf) System Ele , j
4,:3 . ife, Mrn 1A91
VL Tank Info Capacity in Total # of Manufactiffer
Gallons Gallons Units
New Tanks Existing Taa1¢
w/2 _ he / /,~~~V o ° 'r " m ne
nU ~P C7
Septic or Holding Tank
I i
Dosing Chamber
VII. Responsibility State nt- 1, the undersigned, a, { e responsib i or installation of the POWTS shown on the attached plans.
Pluyiber's Name (Print) PlinyG Signature MP/MPRS Number Business Phone &N111DCr
7- Z
PI her's Address (Street ity, State, Code)
Zr ,~-o
V I S i~)i 7
Countv/De attmeat Use On}
V141 6
Uir
ed ❑ Di Permit Fee Date Isssuue Issuing Agent Sign
❑ en R or Denial / W • i "
#c,1-7ec po"la sju *Pool wS f,~e V1 if
Ws ti€M OWNERvat/ReasonsforDisapproval
1. Septic tank, effluent filter and T
dispersal cell must be serviced / maintained kr(/
as per management plan provided Ly plum' er.
2. All setback requirements must be maintained
as per app llcableAmq @4gs for the system and submit to the County only on paper not less than 8 i2 z 11 inches in size
SBD-6398 (RL 11/11)
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi 54017
715-246-4516
Date: 6/21/18
Owner:Craig Davis
Location: NE 1/4 NW1/4 S 19 T28N,R19W 291 St. Andrews Drive Troy
Manuals Used: In-ground absorbtion system (version 2.0)
Page#
1. Cover Page
2. Plot Plan
3. Chamber Cross Sectio
4. 6. Maintance and Conti e y Plan
7. Existing Septic Tank
Ar`
Signature-
- License numbe 26900
Cross Section of Quick 4 Standard Leaching Chamber
Typical cross section for 2 of 3 cells
r Quick 4 Standard
Leaching Chamber with
20.0 ft2 of Area per
Chamber 5.6ft^2 pair of end plates To be >1' above grade
Finish grade elevation
Typical Installation 96.5'
Av,ent Grade ~ Vent
4" 4'
~30/34 Septic Tank
5 4' Long 1
Grade at System Elevation
34Grade at System Elevation 34"
Spacing 5'
3-3' X 62' Cells
Observation tubeNent
Same on other end To be located on end of Cells
%A
B
System elevations: C
A-90.3'
B-90.2'
C90.11
15 chambers per cell
System PLOT PLAN
-PROJECT Craia Davis ADDRESS 291 St. Andrews Drive Hudson Wi 54016
NE 1/4 NW 1/4S 19 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX
SYSTEM ELEVATION 90.3/90.2/90.1 6' below B-3 DATE 6/21/18 BEDROOM 4
CONVENTIONAL AT-GRADE ` CONVENTIONAL LIFT XXX HOLDING TANK
MOUND SEPTIC TANK SIZE fpMgallons LIFT TANK SIZE800 DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 916 # of chambers 45
BENCHMARK V.R.P. Top of steel fence post ASSUME ELEVATION 100' Filter Zabel A-100
❑ BOREHOLE O WELL *H.R.P. same as benchmark
Property Line
B.M.*
Scale is 1" = 40'
unless otherwise
noted 75
B-1 25, Vents B-4
0,
3-3' x 62' cells with >3' spacing
I
1% Slope 60'
i
25'
B-3
B-2
60, 60'
Existing 4
Bedroom Combo Tank
75' House 20' Valve
Property Line
30'
- / 3 TrenchesFailed
Well
St. Andrews Drive
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE t'iGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer et"t
Z~4
Mailing Address
Property Address
(Verification required from Planning & Zoning Department for new construction.)
City/State Parcel Identification Nutaber -gv
LEGAL DESCRIPTION
Property Location 1/4 ,,4 M 1t)/a , Sec_ , TzN R W, Town of 1 %
Subdivision w T 0 Lot #
Certified Survey Map # Volume age
Warranty Deed # A < - Volume C `Page #
r
fr
Spec house yes no Lot liner identifiable yes
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, ii 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 §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zon ing Department a certification form, signed by the
owner and by a roaster 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.
1/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 Commerce and the Department of Natural Resources, State of Wisconsin.
Certification stating that your septic system has been maintained tnust 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/otur knowledge. I/we am/are the owner(s) of the
property described above, by virh , of rranty deed recorded in Register of Deeds Office.
Nutfier of bedrooms
SIGNATURE OF APPLICANT(S) DATE
***Any information that is misrepresented may result in the sanitary permit being ftwoked 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. 08/05)
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Septic Tank Capacity r al ❑ NA
Permit # Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer ~K ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model
❑ NA
i Number of Public Facility Units NA Pump Tank Capacity al ❑ NA
j Estimated flow (average) gal/day Pump Tank Manufacturer ¢ ❑ NA
i Design flow (peak), (Estimated x 1.5) v avda Pump Manufacturer , ❑ NA
i
Soil Application Rate Pum Model
a- NA
uda /ft' p j ] (.S Z 13 i Standard Influent/Effluent Quality Monthly average` Pretreatment Unit
Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD5) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) _<150 mg/L E7 Disinfection ❑ Other.
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BODs) 530 mg/L In-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L A ❑ At-Grade ❑ Mound
Fecal Coliform {geometric mean} 5104 cfu/104m1 ❑ Drip-Line ❑ Other.
Maximum Effluent Particle Size Ya in dia. ❑ q Other: ❑ NA
(Other: A Other: ❑ NA
"Values typical for domestic wastewater and septic tank effluent Other ❑ NA
IAINTENANCE SCHEDULE
Service Event Service Frequency
❑ month(s)
(Inspect condition of tank(s) At least once every: 22 94eaqs) (Maximum 3 years) ❑ NA
(.Pump out contents of tank(s) When combined sludge and scum equals one-third (X) of tank volume ❑ NA
ilnspect dispersal cell(s) At least once every' 11 month(s)
year(s) (Maximum 3 years) ❑ NA
months ❑ NA
Mean effluent filter }
At least once every: years) }
Inspect pump, pump controls & alarm At least once every: ❑ onth
~ r(s(s) ❑ NH
19ush laterals and pressure test ❑ month(s)
At least once every: ❑ year(s) ❑ NA
ether. ❑ month(s) NA
At least once every 0
year(s) NA
I6ther:
NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master
Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must
include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of
i~-ombined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be
[visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface.
The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local
-egulatory authority.
When the combined accumulation of sludge and scum in any tank equals one-third (X) or more of the tank volume, the entire contents of
I:he tank shah be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin
Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units,
And any servicing at intervals of <12 months, shall be performed by a certified POWTS Maintainer.
ik service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
Page of
START UP AND OPERATION other chemicals tt><jt
For new construction, prior to use of the POWTS check treatment tank(s) ~>hthe presence det~ctedacts or have the contents of thi:
may impede the treatment Process and/or damage the dispersal cell(s).
tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when =1 conditions are frozen at the infiltrative surface. restored the excess wastewater will be
During power outages pump tanks may fill above normal highwater levels. VVhen power is
or surface discharge to effluent.
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup
To avoid this situation have the contents of the pump tank removed by a Septage Servicing operator prior to restoring power to 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. the area within
Do not drive or park yehkks over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact,
15 feet down slope of any mound or at-grade soil absorption area.
Reduction or elimination of the fdlowittg from the wastewater stream may improve the performance and prolong the life of the POVVT$,
- disrnfec~nts; ~ foundation drafin
antibiotics; baby vvipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers,
(sump pump) water fruit and vegetable peelings; gasoline; grease; herbicides; meat soaps. medftfions; oil; Ping producils;
pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT shall be taken to insure that the system is propefily
When the POWTS fails and/or is permanently taken out of service the following steps
and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:.
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space fined with soil,
gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS falls and cannot be repaired the foliowing measures have been, or must be taken, to provide a code compront
replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption systelm.
The replacement area should be protected from disturbance and compaction and should not be infringed upon by requbied
setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the neled
for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in
effect at that time.
❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a
holding tank may be installed as a last resort to replace the failed POWTS.
as
site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a sal and site evatuat!
ledi as
must be performed to locate a suitable replacement area. if no re~acement area is available a holding tank may be instal
a last resod tu replace the failed POWTS.
❑ Mound anti at-gnsde soil absorption systems may be rec~.structed in place following removal of the bionrat at the in6ltralive
at that time.
surface. Recenstn rc:tions of such systems must comply with the rules in effect
<<WARNING>>
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TAN UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE O~ A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS -1 a
, ? 5 (Zf,1 -
POWTS 1NST ER POWTS MAINTAINER
-
~ . Name , <<Ct
L Name
Phone j )r- Phone
SEPTAGE SERVICING OPERATO UMPER LOCAL REGULATORY AUTHORITY
Name Name
Phone _
Phone yr '
This doasneM was drafted in compliance with chapter SPS 383.22(2)(b)(1)(d)S(1) and 383,54(1), (2) & (3), Wisconsin AdminWtrative Code.
ST. CROTX COUNTY
CERTYPIC ZONING QFFICt
FOR UTILIZATION C3F•TION STATEMENT
EXIS'r,XC SEPTIC
PYris ~s to NK
-,'rvi ce.t-tifY that I haVe n
g the J~ inspected the septic tank preset
i t_ 1. y
residence
_-1k Alh ectYc~n - T dence located
s--'~L , R
the t Upon inspection w' `fowl-' c; f
n and baffles to be I certif
functionin in good condition, Y that I have to
9 properlyo ttrjd
it appears to be
r..~ast time
serviced. - p14 and
1?~-d flow back
occur trom
Yes absorption
Na system?
(If no, Tine}.
APproximate volume or skip next
length
Capacity: of tine: gallo
nS tjp
Construction: Prefab
Concrete
11 r~1- 11uf_acturer: Steel Other
(It known) ; -
Age of T (I 1~~6
known).: ure) >
N ) Please
~ ~ print-----
to
('c~r7n to be co
Statutes mpleted by licens
or
L' ed
c
Code) erased Disposer (NR p113 Wisconsin 5*06, Wiscons~r~
Administrative
umber (applying for sanitary Permit) Certification:
Condition g the above sta
' I tement re
conform to the that the tank to g h ding existing septic, tank
e re est of m
i aspect i on openi rements of ILHR 83 Y knowledge wi).1
g over outlet m. Code
Nance r baffl (except for
Signa t
MP/MPRS
O -
Wisconsin Department of Commerce
PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and BuildinZj Divisio??•
INSPECTION REPORT Sanitary Permit No:
463320 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Davis, Craig & Jane Troy, Town of 040-1252-80-000
CST BM Elev: Insp. BM Elev: BM
/~JU• a D p ption. Section/Town/Range(Map No:
/6-0 v lly~,t {Ydri~ C14- 19.28.19.1329
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION~ S HI FS ELEV.
Septic IX/ ~O Benchmark 1 _ J 108
Dosing Alt. BM B b~^ r p G
Aeration r Bldg. Sewer s,` 4 (0
/ ! 2
Holding SUHt 1 b Q• / !/s •
C
St/Ht OOU&t
TANK SETBACK INFORMATION 10.5 13 9 ~•9
TANK TO P/ WELL BLDG. vent to Air Intake ROAD Dt Inlet 6 • p
t Bottom AS 6~
Septic 7-75 10 ( kW
eader/Man. ~W
14o, -ZID osmg y H
A e ation Dist. Pipe / 2 • y
T- 9!i
Holding Bot. Syste Z /0 S O
Final Grade
PUMP/SIPHON INFORMATION dy2L ' f •o
~ rn 3
Manufacturer Demand St Cover
Model Number 3/ / ~ Z 319"5 -T3 f _
44 System Hd TDH Ft I 0
TDH Lift Friction Loss V
Forcemain Length • / Dia. Dist. t j ell ` Q ?
SOIL ABSORPTION SYSTEM Q l
BED/TRENCH Width Length l No. Of Tr es PIT DI NSIONS No. Of Pits Inside Dia. Liquid th
DIMENSIONS 3' 1 2•
SETBACK SYSTEM TO P/L BL WELL LAKE/STREA LEACHIN Manufactur ~~"S,~y)
INFORMATION OR rev GP-
Ty9 Of System: HUNIT Model Number 51'D i
Ad
DISTRIBUTION SYSTEM fiv"Wtala S~ AM"
Header/Manifotd Distribution x Hole Size x Hole Spacing vcnl io Air ntake
- i N Pipe(s) .j ! fj(it~T
Length Dia Length Dia Spacing--y-
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over -TT
Depth of xx Seeded/Sodded 4,o--
Location: Bed/Trench Cente O Bed/Trench Edges psoil Yes Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: In/ / G291 St. Andrew's Drive Hudson, WI 54016 (NW 1/4 NW 1/4 19 T28N R1 9W) Troy Village
2nd Addition Lot 78 Parcel . Parcel No: 19.28.19~.1.329
A ~
1.) Alt BM Description = SX.Wr~ Q ~t~lN /St( `-~Q2 Z `J -1 7:51-1 w / J '50 E 4 !~"tN'~}
-
2.) Bldg sewer length = 12/ ~(o- ~D(. oZ /tDYe+ r IiY~Cr~L~G/ elf Q~ T~ 1~ - 3 !
amount of cover= ! 5y5~Piyr.. ,5 _ &q
t7~I / I U ~ G~~ U - Req Plae othe~ls de foruadd Gonal ormation No Z,4z- -
- 1
Date Insepctor's n urG ~ Cert.No
SBD-6710 (R.3,`97) ~~I `"U ` V' Cr7 w• Pl `UJ ~P o4 A-r a, r
Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162 5,7~- l f v~
V~sconsin Ma ' n, WI r_ r Sanity y Permit Number (to be fill by Co.)
Department of Commerce 8) 2 -3151 "M-1 EV 7 (p~3a0
Sanitary Permit A i ti tState tan LD. Number
In accord with Comm 83.21. Wis. Adm. Code, personal r *tion provide
may be used for secondary purposes Privacy Law, sl 1) T. CROIX COUN ~ rojec Address (if different than mailing address)
1. Application Information - Please Print All Information S-f >~nd rC{~~ ~Y/
Property Owner's Na me Parcel M Lot # Block k
Cry :4 Qne Da vas a - la S a - - cxx~ . 13
Property O is M ailing Address t4. ' Property Location
LI+./ ~J Q
110 O(~)~d~ 74vc t 'A, ~W Sd,Section f /
City, State Zip Code Phone Number
/ KC Zany m 1,J tJ sv//~ ~p (circle one)
11. Type of Building (check all that apply) 7 T O(A N; RE
El 1 or 2 Family Dwelling - Number of Bedrooms ~'a Subdivision Name CSM Number
❑ Public/Commercial - Describe Use T(b Villa-76 ZM r~
❑ State Owned - Describe Use ❑City_❑Village Yfownship oftrYL4
111. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. VZNew System ❑ Replacement System El g Y Treatment/Holding Tank Replacement Only Other Modification to Existing System
List Previous Permit Number and Date Issued
B. ❑ Permit Renewal Permit Revision ❑ Change of ❑ Permit Transfer to New /
S~
Before Expiration Plumber Owner z ~ 3 3,) a/ IV
IV. Type of POWTS System: ( heck all that a I) er %re /6 ~n L
Non -Pressurized In-Ground ❑ Mound > 24 in. of suitable sot < 24 in. of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter
❑ Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter
❑ Recirculating Synthetic Media Filter Leaching Chamber Drip Line ❑ Gravel-less Pipe ❑ Other (explain)
V. Dispersal/Treat ent Area Information:
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) Svstem evation /
g~~ 35
0
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Seel Filer Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
Septic er--~nk o°C I
e1
-
0-T-teeinw"I 14 oo e~ cam
it
Dosing Chamber 7 fo 75-0 ( ' ` rC
VII. Responsibility Statement- 1, the u» d Igned, assume responsibility for Installation of the POWTS shown on the attached plans.
Plumber's Na the (Print) P mbes Si gnatur MR4APR9-'idamber Business Phone Number
?ttul- ez ae,4r K o?o?S S I '7!S- yZS SSz/`~
Plumber's Addre ss (Street, City, State, Zip Code)
N ga 3o 9g6YA S-~- ~►ycr Falls, w-T 5L10ZZ-
VIII. unt /Department Use Only
nitary Permit Fee (includes GUndwater Date Issued I mg Ag t Signatur o Stamps)
a
El Disapproved PSS
EaXpproved urcharge Fee) n~
❑ Owner Given Reason for Denial v (O 11 J !i
IX. Conditions of Oproval/Reasons for Disapproval
d4l
t ~
..nom g(o.
Attac complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size I
SBD-6398 (R. 01/03)
PUMP CIIAMIIF11 CROSS SFCT1011 Atli) SPECIFICATIONS
Vent Cup
Wenthty Proof Approved Locking
n-F •
Junction Box Manhole Cover
12" Min
Vent Pipe
Final 4" Flin
Crnde '
Conduit 18" Min
18" Flin
Approved
+
Inlet Joints u/
C . I . Pipe
Extendiar:
4pproved
3 ' Onto
Joint w/ Solid
;.I. Pipe 1
E x t e n d i n g A Ground
I' Onto Alarcn
io lid .'b
,round
On j
+ ,Yump____~ Off Concrete Block SPECIFICATIONS
TANK PUFI1'
lanufacturer: LUei e✓. Manufacturer: oe,(le/ IJ
rank Material: Hod aI Numt+ur:
rank Size: Callonu Switch' Typo ADaf-
Total Dynamic Ilead: Ft.
CAPACITIES pump 1) iacharge Rate: yp GPM
Total Daily Effluent: 000 Gallons
or ~.i Oy Callons Number of Uoues Per Day
I~~r or 0 Gallons Dose Volume:' 1~ Z Gallons
:e- or _ /021 . (e8 Callons Notes: 1. See pump curve [or
" or . 3(o Callona additional performance
otal Tank information. 77 :opacity Required Cnllona 2. Pump and alarm are to be
inatrilled on ucparat,! circull
ALARM au per I LIIR 16.19 NAC.
fnnuf neturer Ley c l
,w1 t ch Type.
page of
HEAD CAPACITY CURVE
MODEL 152/153
ry
LJ
L.LJ
L1
l G
50
153
12 40 152
0
w
30
Q 8
z
0
20
0
4
1 n
0--
20 0 60 80 100
GALLONS
LITERS 0 80 60 240 320
FLOW PER MINUTE
CONSULT FACTORY FOR SPECIAL APPLICATI
• Timed dosing panels available.
5 z 260.00
s 1/4 CO
SECTION 1
o ° 0 79 F T28N. R 19
00 o a, o { 46775 S.F. N 21' IRON P
{ o { - o { 1.074 ACRES o 0
o o 0
{ N 86°51' 48" W o
335.23' ES o
0
N { N W { -
n 0p { m
O
63097 S.F. °
1.448 ACRES ° N 83°00' 00" E
7.96'
o
S.F.
ACRES . 0
{ 20.1 9 4
?6 73 °
00 w-- C 10 19,
E 338.28' a°,
00
COU ITT C9 N 84° 19' 00" E 318-90' S 07°06' 32" E -
n 58.07' M
77
N
-'179.3 { 45947 -S.F.
C)O,. E 224.471 0 1.055 ACRES
0
r-
N 88°00' 00" W
^ 9 0 W 318.00'
46291 F.
1.063 CRES 0 o° 76
0
00 44520 S.F. o ~
N 1.022 ACRES r N
- M
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N
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3
o
W o° ! .318.00'
° 3
0
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Property Owner _ Parcel ID # Page of
Boring # IS] ❑ Boring J1
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
G L "'ice
irk, j~
L r.. ~ ,7 r - 1
# /ry C 7
[q]Boring
Boring
it Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2
❑ Boring
Boring # Ground surface elev. ft. Depth to limiting factor in.
F-1 ❑ Pit
Soil Application Rate
Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2
Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg1L ' Effluent #2 = BOD, < 30 mg& 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.6100)
Property Owner _ Parcel ID # Page of
❑ Boring
1
Boring # pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2
- SY /
LJ I Boring # ❑ Boring
I / I it Ground surface elev." ft. Depth to limiting factor ~ in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2
77-
L
F-1 Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2
` Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD, < 30 mg/- 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.
SBD4330 (R.6Po0)
Soil Test Plot P
Project Name Craig Davis n r
Address 291 St. Andrews Drive 3 et
Hudson Wi 54016 "S-TM #226900
Lot 78 Subdivision Troy Village 2nd Add to 6/21/18
NE 1/4 NW 1/4S 19 T 28 N/1319 W Township Troy
❑ Boring 0 Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of steel fence post
System Elevation 90.3/90.2/90.1 *HRPSame as Benchmark
Property Line
B.M.
Scale is F = 40'
unless otherwise
75
noted io, B-1 B-4
25 10'
1% Slope
60'
B-3
'
` B~-2 5
~Do 60
Existing 4
Bedroom Combo Tank
75 ~ House 20' Property Line
30'
3 TrenchesFailed
Well
St. Andrews Drive